Time to take the American Medical Student Association (AMSA) to task again

I've blogged many times about the AMSA and its promotion of quackery in medical education. I did so with the thought that the best way I could fight quackademic medicine was to expose it. The extreme woo promoted by AMSA made great fodder for ridicule with little elaboration or work required on my part. It pretty well spoke for itself. I gave it a rest a year or so ago though because I thought I had covered most everything and, after they redesigned their web site the woo became much harder to find. They've either toned it down or buried it deep, deep within their site, I thought. Whatever the case I even wondered if I deserved a little credit for AMSA's woo assuming a lower profile.

After reading Orac's recent update and doing a little digging of my own it turns out that AMSA's still pushing the same old woo; they've just adopted a smoother approach and made it a little more palatable. I thought this would be a good time to post my own update.

First a look at Orac's post. It was prompted by AMSA's upcoming International Integrative Medicine Day (the link is from last year's event). Here's a sample from this year's event:

During the Happy Hour, clinical services to be offered include: Acupuncture, Massage, Chiropractic, Energy Healing, and more.

Classes from 4:15 - 11PM include Ambient Music, Yoga, Meditation and Qi Gong, Community Drumming for Wellness, and Salsa Class & Dancing.

This page documents AMSA's role as a partner in the event, alongside a virtual parade of stars of woo.

Now for a recap on some of the material I've posted before and what I dug up today. It seems that the promotion of woo on the AMSA web site is organized around four campaigns: ICAM, EDCAM, HUMED (I'll explain about those three in a moment) and, more recently, a strong and rising interest in naturopathic medicine.

ICAM stands for AMSA's initiative for integrative, complementary and alternative medicine. In its present form it's basically a repository for various woo promoting documents and links. There you'll find, for example, the CAM Pocket Handbook. It contains promotional, credulous statements about acupuncture, Ayurvedic Medicine and, yes, that woo of all woo, homeopathy, describing it as “very cost effective over the long term.” Polarity therapy, Reiki, reflexology get similar credulous treatment.

HUMED stands for humanistic medicine. The old HUMED page redirects here. A current focus seems to be student wellness and self care but again, it's another repository of woo. For example, there's the Complementary Therapies Primer which contains the same old woo, including a particularly non-critical view of reflexology, along with several types of woo I had never heard of. It also claims that large doses of vitamin E are useful in Parkinson's disease. You'll also find the claim that fasting eliminates pesticides and other toxins from the body. Finally, it says chelation therapy (no, I'm not making this up) is beneficial for arthritis, scleroderma, lupus and spider bites.

EDCAM, which stands for Educational Development for Complementary and Alternative Medicine, is a completed project in which the AMSA Foundation, with funding from the NIH and the NCCAM, introduced and developed CAM, including a lot of woo, in the curricula of 14 medical schools. In an article published in the journal Academic Medicine (which none of the aforementioned organizations will likely want you to read) reviewers from Baylor found the teaching material to be devoid of supporting evidence and concluded:

By tolerating this situation, health professions schools are not meeting their educational and ethical obligations to learners, patients, or society.

I blogged about the whole thing here.

Finally there's the Naturopathic Medicine page, which says that the AMSA aims for collaboration with naturopathic medical students. This page has lots of dubious links and a recommended reading list of promotional material for all sorts of woo. I won't go to the trouble of fisking it here. This post is getting long and the list speaks for itself.

In my blogging career I've gotten into many discussions about the rise of quackademic medicine. A common theme is speculation as to why, and it seems inscrutably hard to determine for some. Sure, the money behind it is one element. But after following quackademic medicine closely for several years (although it was a few years later that I coined the term, my first post about it was here) I am of the opinion that the AMSA has been a major driver, perhaps the major driver of this trend.

Eleanor Roosevelt's tuberculosis

This Medscape article chronicles Eleanor Roosevelt's illness. Eleanor Roosevelt carried a diagnosis of aplastic anemia for two years, for which she received multiple transfusions and was given prednisone. It was not until two weeks before her death that her final bone marrow specimen grew out tuberculosis.


When I was a medical student the story was circulating around that Eleanor Roosevelt had died of miliary Tb that had long been misdiagnosed as aplastic anemia, but I didn't know if it was really true. The Medscape piece, which draws on information from Roosevelt's medical record, is the best account I've found.


This was a popular topic when I was a medical student. One of our most esteemed and feared Internal Medicine mentors, Thomas E. Brittingham, always encouraged skepticism toward accepting any diagnosis of an incurable disease, particularly if an infectious cause could be sought. He was particularly negative about diagnosing patients with idiopathic inflammatory diseases and treating them with immunosuppressives and was fond of presenting patients long diagnosed with such diseases as systemic lupus, Wegener's granulomatosis or inflammatory bowel disease and ultimately discovered to have tuberculosis or a fungal disease.

Renal manifestations or rheumatoid arthritis

Via Renal Fellow Network.

JAMA commentary proposes adding emotion and passion to scientific articles

Some medical journals such as JAMA and the Annals of Internal Medicine occasionally publish emotional articles that convey the human side of medicine. Many journals, NEJM notable among them, also weigh in on political issues. Appropriately, the emotional and political content is clearly compartmentalized from the scientific content. A commentary writer in the December 8 issue of JAMA seems to think that may not be a good thing:

What if science were presented in the same passionate, emotional style as in those accounts of personal experiences that moved the physician who wrote them? Instead of requiring a science article to have the standard introductory, methods, results, and discussion sections with a certain number of words and a certain number of tables, science articles should perhaps include cartoons, pictures, or emotional images that contain meaning and require the use of both the right and left brain. Perhaps permitting the personal would not degrade the scientific process but rather increase the likelihood that the information contained in the journals would actually be read, absorbed, and used.

Apparently the author, Robert H. Brook, MD, of the Rand Corporation, thinks the dispassionate language of scientific papers is too dry to be useful. Earlier in the paper he wrote:

...scientific articles are written in a manner that, in many instances, adopts a bland, somnolent tone. The language has no passion, conveys no emotion. The words stimulate no visual image. Physicians have been taught to present their science in what is called a “flat manner”: let the facts speak for themselves.

That's what Dr. Brook thinks is wrong with scientific articles. What nonsense. Steve Milloy, in his book Junk Science Judo, wrote, on page 46:

...keep the slow, steady ho-hum scientific method in mind. Boring? Sure. Tedious? You betcha. Slow and deliberative? Be grateful.

Dr. Brook seems to start with a faulty premise: that the purpose of a research article is to persuade. Wrong. Persuasion is an art which almost by definition introduces fallacies. That's what Aristotle laid out in his textbook on Rhetoric. He described the three elements of persuasion: ethos, pathos and logos. Scientific papers confine themselves to logos. Bring in the other two elements and you introduce all sorts of emotionally driven fallacies such as appeals to fear, passion and belief. More than that, allowing an author's emotions and passions in a scientific paper would deliberately permit and even introduce bias.


It's true that doctors need to be persuaded to incorporate the best evidence into practice. But please, not in original scientific papers. There are other appropriate places and methods to accomplish that. Imagine if clinical investigators passionately spun the results right in their own research articles! It would make a joke of scientific journals.


As an aside I note this little gem of an observation Brook makes midway through the paper:

However, the world of communication has changed. Today, the Internet, Facebook, LinkedIn, and all sorts of connected devices allow humans to immediately share photographs, emotions, thoughts, and passions. It is difficult to imagine a young physician growing up in this communication environment, trying to focus his or her brain on science studies that seem to be written in a language as foreign as medieval English would be to modern inhabitants of the British Isles.

Here Brook comes dangerously close to saying that social media has dumbed down science education for a whole generation of students! Could it be? I'm not sayin'. U r free 2 read n 2 that what u want 2 LOL.

Rescue therapy for refractory hypoxemia in ARDS

I recently highlighted this as one of the top issues in hospital medicine for last year. Although I missed this review in JAMA from December 8 when preparing that post, many of the same points were made. The review is in a Johns Hopkins Grand Rounds format and the full text (which is unfortunately behind access control) is worth reading in its entirety. It provides a nice overview of ARDS.


ARDS is hypoxemic respiratory failure. Despite this, as is pointed out in the article, only a small minority, on the order of 10-15%, of the mortality is attributable to refractory hypoxemia. The remainder is due to failure of other organs.


General supportive care is the mainstay of management of ARDS with only one specific modality known from research evidence to decrease mortality: low tidal volume ventilation. Multiple other modalities which in studies have not been shown to decrease overall mortality but can improve oxygenation are considered rescue therapies, examples of which are prone positioning, heavy sedation with paralysis, high frequency modalities, high peep and recruitment maneuvers. Rescue therapies, while not “evidence based” in the strict sense, may offer the patient's only chance for survival in desperate situations involving refractory hypoxemia.


Which rescue therapies to implement depend in part on local expertise. Provision of rescue therapy will require some preparation, particularly if the patient requires transfer to another facility. This underscores the importance of early severity assessment which facilitates planning for possible rescue therapy.

The decline effect

---refers to a waning of the magnitude of positive research findings over time. In other words while initial research may lead to a slam dunk conclusion subsequent attempts to replicate it, though sometimes positive, are often less robust. Other times, of course, they don't stand up at all. Such was the topic of a recent piece in The New Yorker.


Aside from a few flaws in the article (its implication that early popularity of HRT was bolstered by randomized controlled trials, credulity towards acupuncture and a statement that research on cardiac stents suffered from the decline effect) it did a fair job of illustrating some of the booby traps of conducting and reporting research.


The article explored several explanations for the effect including regression to the mean. No single one is adequate. There are probably many contributing factors. Initial research findings may be more likely to suffer from investigator and publication bias than those of subsequent investigations, which may bring more skepticism to the picture. Sometimes initial studies have design issues that make them unsuitable for generalization or widespread change in practice such as small size or anomalies in the sample that was studied. Early studies on glycemic control in hospitalized patients and perioperative beta blockers come to mind.


So do we throw evidence based medicine (EBM) and science based medicine (SBM) out the window? Not at all. This is just a reminder that though some science is for practical purposes settled, much of it is tentative. That's why EBM regards the most current evidence as an important attribute of best evidence.


Related content at DB's Medical Rants.

Megyn Kelly handles Sheriff Dupnick

---and exposes his foolishness. Deferentially and with respect.



OK, back to regular blogging, punctuated if the need arises by updates on this topic.

After Arizona shootings the political vultures swoop

I've tried to make it a rule to confine political blogging to issues of health policy. Today I'm breaking that rule. I don't want to, I have to. I simply can't contain my outrage. So let's start with this piece from NRO:

Very few Americans are fans of both The Communist Manifesto and Mein Kamp, as the Tucson killer, 22-year-old Jared Lee Loughner, apparently was. Fewer still post on the Internet fears about “brain washing,” “mind control,” and “conscience dreaming”; have a long record of public disruption and aberrant behavior; were expelled from community college; or were summarily rejected for military service.

No matter. Almost immediately following Loughner’s cowardly murdering of six and wounding of 14 including Rep. Gabrielle Giffords, pundits and some public figures rushed to locate his rampage, together with his paranoid rantings about government control, within the larger landscape of right-wing politics — especially the rhetoric of the Tea Party and Sarah Palin.

And rush they did. Almost immediately after it happened Paul Krugman, admitting he didn't know if the shooting was political, blamed the Right anyway.


Upon first learning of this tragic shooting I suspected something like this would happen but I had no idea of the degree of political opportunism that would follow. Disgusting.

Internet addiction and depression

A study out last year from the journal Psychopathology found a relationship between excessive Internet use and depression. It was based on an online questionnaire sent to 1319 respondents. Here are some selected portions of the abstract (my bold):

There is a growing awareness of a psychiatric construct that needs to be better defined and understood: Internet addiction (IA)...

Three scales were included: the IA Test, the Internet Function Questionnaire and the Beck Depression Inventory (BDI). 1,319 respondents completed the questionnaires, with 18 (1.2%) identified as falling in the IA category...

Across the whole data sample, there was a close relationship between IA tendencies and depression, such that IA respondents were more depressed; there were also significant differences between the sexes, with men showing more addictive tendencies than women. In addition, young people were significantly more likely to show addictive symptoms than were older people. There was a significant difference between the IA and the NA group in their levels of depressive symptoms, with the NA group firmly in the non-depressed range, and the IA group in the moderately-to-severely depressed range (F1, 34 = 22.35; p less than 0.001). In terms of the function for which they used the Internet, the IA group engaged significantly more than the NA group in sexually gratifying websites, gaming websites and online community/chat websites...

Related content at Clinical Cases and Images.

Acute respiratory failure complicating obesity hypoventilation syndrome

Review in Current Opinion in Pulmonary Medicine.

What have we learned about fluid therapy in septic shock?

From a review in Current Opinion in Critical Care:


Front load it and titrate it early to hemodynamic goals.


Although starch preparations have been associated with renal harm in some studies the type of fluid didn't matter in this literature review.

What is an internist anyway?

One time years ago, when it came out in conversation that I was a doctor, a lady asked what kind of a doctor I was. “An internist,” I said. “Are you learning a lot?” she asked. From that moment on I never told anyone I was an internist. My usual answer became “I am a specialist in internal medicine.” Clearly internal medicine struggles with its identity.


The other day DB did a little experiment. He asked readers to submit answers to the question “What is an internist?” He got eleven replies, mainly from internists, and nobody seemed to nail it.


In a follow up post he reflected on the difficulty we have in defining our specialty. He had this to say about what an internist is/does:

I like the comment about diagnostician, because in my experience that is the crux of the issue. Our job always involves diagnosing the patient, whether diagnosing a disease, the severity of disease, the response to medication (including unacceptable side effects), the patient's goals of therapy, or the social situation. Internists diagnosis and then appropriately treat adult patients. The location of our practice or the scope of our practice (generalist or subspecialist) does not change with that definition. Excellent internists order diagnostic tests (laboratory tests, observation over time, imaging studies or even referral to a subspecialist) in order to help the patient receive the most desirable outcome. That outcome depends on our diagnosis of the patient's desires.

True enough, but isn't that what every good doc does regardless of specialty? Does it explain the uniqueness of IM? Well, only if it means, at the substantial risk of sounding elitist, that internists are superior to other specialists in diagnosis and appropriate treatment! That may not bother our orthopedic colleagues (“I'm just a dumb bone cruncher”) but how would it sit with others? The true notion of IM is about expertise at a special level of complexity in diagnosis and treatment.


Sapira's Art and Science of Bedside Diagnosis, on page 7, defined it thus:

(1) (Obsolete) That nonsurgical medical specialty concerned with clinical diagnosis and scientific therapy. Previously a secondary-care consultant specialty, it underwent crisis by lysis in the late 1960s; (2) (contemporary) a biopolitical consortium of balkanized tertiary nonsurgical subspecialties, which, oxymoronically, claim it to be a primary care specialty.

Definition 1 gets close to the true notion of IM. It truly is a secondary-care consultant specialty. (Well, yes, it's devolved considerably form that state, but that's the original idea). This is not easy to define and requires elaboration. I attempted to do so in a Medscape Roundtable piece a couple of years ago. I reviewed the history of the specialty, hoping that would add clarity to the true notion of IM.


Rather than elaborate on what I said there, let me recount my own journey. I was profoundly influenced by my dad. He was an old fashioned GP in the suburban fringes of St. Louis. He had great admiration for internists. He had always wanted to be one, but when he started his IM training WW II got in the way. After the war he was ready to come home and hang out the shingle. Though a skilled diagnostician himself, he had a special regard for internists. He held them in awe. Whenever he had a really really tough case he called the internist.


When my mom developed a mysterious illness he called a colleague he considered one of St. Louis's finest internists. When she was finally diagnosed with Graves disease things didn't get any easier. The tests used to monitor thyroid treatment in those days (the BMR and PBI) were crude and required a great deal of clinical skill to use. During the difficult course of her illness there were many encounters with the internist. By the time she recovered I knew that an internist was a specialist.


Fast forward to medical school. Every department had its outstanding mentors, but clearly the master clinicians were in the department of Internal Medicine. The exemplar was Thomas Brittingham. His teaching rounds were awe inspiring. Brittingham didn't promote IM over other specialties but through his teaching I learned that an excellent internist was not only a medical detective, but also the one you called for severe illness and very difficult management situations.


Our professional organizations need to do a better job of defining and promoting the specialty. The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade?

The provision on reimbursement for end of life counseling

---What does would it add?


As I've explained before, we've always had reimbursement for end of life counseling. I've availed myself of it many times in my career. Before we ponder the inscrutable question of what the measure would add it might be useful to take a closer look at the counseling provisions already in place. First a direct quote from the 1995 and the 1997 Medicare coding guidelines:

D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

What this means (Happy Hospitalist explains here) is that if you spend enough time counseling, about end of life or other issues relevant to a person's care (and it doesn't have to take very long) you can code a level 3 visit without even taking a history or laying a stethoscope on the patient. No history, no exam, no complexity required. Any time you counsel a patient in any detail at all it makes coding level 3 a breeze.


From discussions I've had with other docs this seems to be a well kept secret, but in the many coding seminars I've attended, whenever I pin the experts down about this they tell me it's true.


So why, then was the new provision felt to be necessary and what would it have added? We were never told. The policy wonks refuse to talk about it. To me that leaves three possible explanations. 1) It was purely symbolic. 2) There was a hidden agenda. 3) The policy makers and politicians were showing their ignorance of the regs already in place.

Obama pulls the plug

---not on Grandma, but on the end of life counseling provision. This is actually the second time the plug was pulled. First time around it was from the House draft of the health care reform bill. This time it's from the “regs” which Obama added via the regulation writing process.


So let's look at the sequence of events in this marvelous example of Obama administration transparency:


A provision regarding reimbursement for end of life counseling was included in a draft of the health care reform bill.


In the debate that followed it was never explained what the provision added to counseling reimbursement already embedded in the CPT codes.


The provision was dropped from the final version of the bill that passed and signed into law.


Boosters of the provision urge implementation via the regulation writing process.


The provision was included in a list of proposed regs.


But the provision was missing from the list when the proposals were submitted for public feedback.


The reg was implemented anyway, more or less in secret.


One of the provision's chief supporters urged it be kept secret for as long as possible, warning in an email “The longer this goes unnoticed, the better our chances of keeping it.”


But the secret didn't last long; it hit the newspapers and the blogs in no time.


The White House failed to respond to a request for comment about why they yanked the provision.


Clearly they want to hide this from public debate. What is concerning is this arrogance on the part of the administration and the obfuscation in the media. Reimbursement for counseling itself, as I explained here, is a non-issue. We've had reimbursement for counseling for a long time, explicitly written into the regs as far back as 1994.

Blogging: “It doesn't matter if anyone reads it.”

This is according to Seth Godin.



As he said, it's the metacognition that matters. Blogging has forced me to think about what I read and how I think.


Via Clinical Cases and Images.

Intraosseous access: when and how

According to this Medscape presentation:

IO access is one of the quickest ways to establish vascular access for the rapid infusion of fluids, drugs, and blood products in an emergency. In adults and pediatrics after 2 peripheral IV attempts, IO is the next-line modality.

Pneumonia in critically ill patients: age matters

From a study in Critical Care Medicine.

Conclusions: Increasing age was independently associated with risk-adjusted short- and long-term mortality in critically ill patients with pneumonia. These findings may help elderly patients, their families, and physicians better understand what intensive care unit admission can offer and help them to make more informed decisions.

Using the EMR to reduce ventilator associated lung injury

The EMR has not lived up to its promise of improving patient safety and quality. Reasons for this might include the fact that the process “improvements” to this point in our experience with the EMR are weak and loaded with unintended consequences. More sophisticated tools will need to be embedded into EMRs before they deliver robust process improvements.

One such idea was recently reported in Critical Care Medicine. The EMR monitored mechanically ventilated patients. Providers were alerted via text page in real time when potentially injurious ventilator settings or measurements were detected. The results:

Findings: The prevalence of acute lung injury was 42% (n = 490) among 1,159 patients receiving greater than 24 hrs of invasive ventilation. The system sent 111 alerts for 80 patients, with a positive predictive value of 59%. The exposure to potentially injurious ventilation decreased after the intervention from 40.6 ± 74.6 hrs to 26.9 ± 77.3 hrs (p = .004).

Interpretations: Electronic medical record surveillance of mechanically ventilated patients accurately detects potentially injurious ventilator settings and is able to influence bedside practice at moderate costs. Its implementation is associated with decreased patient exposure to potentially injurious mechanical ventilation settings.

This is a novel idea and attempts to use the EMR for all it’s worth. We need a good deal more experience with ideas such as this before the EMR will become a real quality and safety tool.

Outcomes after convulsive status epilepticus

---were generally poor and related to the duration of status in this study:

The median time from convulsive status epilepticus onset to anticonvulsant drug initiation was 40 mins (interquartile range, 5–80). Total seizure duration was 85 mins (interquartile range, 46.5–180). Convulsive status epilepticus was refractory in 49 (20%) patients. The most common causes of convulsive status epilepticus were anticonvulsive agent withdrawal (36.4%) in patients with previous epilepsy and stroke (27.7%) in inaugural convulsive status epilepticus. Mechanical ventilation was needed in 210 (85%) patients. On day 90, 42 (18.8%) patients were dead, 87 (38.8%) had marked functional impairments (Glasgow Outcome Scale score, 2–4), and 95 (42.4%) had a good recovery (Glasgow Outcome Scale score, 5). Factors showing independent positive associations with poor outcome (Glasgow Outcome Scale score, less than 5) were older age (odds ratio, 1.04/year; 95% confidence interval, 1.02–1.05; p = .0005), cerebral insult (odds ratio, 2.70; 95% confidence interval, 1.37–5.26; p = .007), longer seizure duration (odds ratio, 1.72/120 min; 95% confidence interval, 1.05–2.86; p = .03), on-scene focal neurologic signs (odds ratio, 2.08; 95% confidence interval, 1.03–4.16; p = .04), and refractory convulsive status epilepticus (odds ratio, 2.70; 95% confidence interval, 1.02–7.14; p = .045).

Conclusions: Ninety days after intensive care unit admission for convulsive status epilepticus, half the survivors had severe functional impairments. Longer seizure duration, cerebral insult, and refractory convulsive status epilepticus were strongly associated with poor outcomes, suggesting a role for early neuroprotective strategies.

Blood pressure measurement in hypotensive critically ill patients

How many intensivists do it non-invasively?

From a survey of SCCM members:

Measurements and Main Results: Use of non-invasive and invasive blood pressure devices. Eight hundred eighty individuals received an invitation to complete the survey and 149 responded. We found that 71% (105 of 149) of intensivists estimated the correct cuff size rather than measuring arm circumference directly. In hypotensive patients, 73% of respondents (108 of 149) reported using noninvasive blood pressure measurement measurements for patient management. In patients on a vasopressor medication, 47% (70 of 149) of respondents reported using noninvasive blood pressure measurement for management.

Conclusions: The use of noninvasive blood pressure measurement measurements in critically ill patients is common despite the paucity of evidence validating its accuracy in critically ill patients.

Pulmonary-critical care slide show

Pulmonary (Read)

View more presentations from changezkn.

This slide show has excellent content and numerous pearls warranting posting here. Note, however, the following cautions:

Some of the content is dated, e.g. referencing the 2004 Surviving Sepsis Guidelines instead of 2008.

The answers to some of the multiple choice questions are confusing because they don’t match the corresponding letters.

Some case studies in this board review could resemble exam content. If you plan to sit for boards please carefully review ABIM’s terms and conditions before accessing this resource.

Results of a community wide campaign to improve cardiac resuscitation

The Take Heart America campaign resulted in process improvements and more than double the rate of cardiac arrest survival as reported in Critical Care Medicine. And guess what? The campaign was supported by (gasp) industry.

VRE urinary tract infections: when and how to treat

Review in Pharmacotherapy. Full text via Medscape.

Physiology lecture notes

From Eastern Kentucky University. Lecture notes enhanced by You Tube videos.

Physiology lectures from LA City College

These are word files and a few MP3s.

Partial DNR orders: always patient centered, often irrational, maybe harmful

In the era of patient centered care it's fashionable during DNR discussions to let people pick and choose from a menu of interventions, often resulting in “partial DNR” decisions. In some cases irrational combinations of interventions are chosen despite efforts to educate patients and family members on the rationale and expectations for various treatment modalities.


A recent paper in Critical Care Medicine reviewed the literature on partial DNR orders. Based on the limited published experience the authors suggested that the practice was “clinically and ethically problematic” and concluded:


Discouraging partial do-not-resuscitate(s) order may help promote more accurate and comprehensive advance care planning.

Osteoporosis treatment after hip fracture: how often done and by whom?

Not nearly often enough, and it depends on the specialty service according to this study.

The 2010 dumb awards for public policy speech

Bright people in high places occasionally say dumb things. In such a politically charged time as 2010 it made for great entertainment. Here are a few that made me laugh, mostly about health care reform. In no particular order.




Democratic Congressman Phil Hare on health care reform.


“I don't worry about the Constitution on this.”



And at 1:00 the Congressman confuses the Constitution with the Declaration of Independence.






Peter Orszag's New York Times column on October 3---


in which he implied (in a smooth way, but still strongly implied) that doctors don't work hard enough, doctors aren't used to having their performance measured, and hospitals shut down for the weekend.






A NEJM writer declared that if the Republican agenda on health care moved forward it would be a recipe for a failed republic.

Well, they won big in November. Better stock up on some survival provisions.






Nancy declared that we had to pass health care reform in order to find out what was in the bill.






Paul Krugman dropped the bomb about death panels.



This was such a bunch of double talk, it's hard to know what he really meant, but the plain point seems to be that we need to soothe the death panel alarmists now, then implement the panels later. Whatever he meant, it was dumb.






The interview with Bill Maher in which he said...


Well, he said a lot of dumb things. The whole clip is stupid. You'll just have to watch.

The end of life counseling debate---it's baaack!

Saturday's New York Times reports: Obama Returns to End-of-Life Plan That Caused Stir.


First a disclaimer. I am not against end of life counseling. In fact, as a hospitalist I often find myself wishing PCPs had spent more time discussing end of life issues with their patients.


On the other hand the political maneuvering and obfuscation by participants on both sides of the debate have long perplexed and concerned me. Boosters of the provision never adequately explained in plain language why it was necessary or exactly what it would add to what was already in place. Medicare payment for counseling was already embedded in the system of CPT codes. More than that, Medicare has for years allowed higher coding, exempt from the “key components” criteria for levels of service, if counseling was the principal reason (took more than 50% of the time) for the visit. That fact was never acknowledged in any of the debates or news reports I encountered. It raised the obvious question of why a new provision was necessary, and the question was never answered.


For me that was the key question and it was the one thing that made me just a little uneasy about the provision. Since we already had regulations in the CPT codes making it easy to get higher reimbursement for counseling, just what did the new provision add? Was it even better reimbursement? How much better? Did it elevate the topic of advance directives to some singular status above other types of counseling? After reading the provision in the original bill several times I was left with more questions than answers. No, there was no direct provision for death panels, nor was there any mention of pulling the plug on grandma. What was clear was that the mechanics would have to be worked out by policy makers with considerable discretionary authority.


This was supposed to be the administration of transparency. Transparency would have been helpful here. Unanswered questions, obvious questions, often lead to unhealthy speculation. Though not a death panel alarmist myself it's not hard for me to understand death panel alarmism in the public debate. It might have been averted had the proponents better articulated their position, and done so in plain and specific language.


The provision for end of life counseling was dropped from the original draft before final passage of the health care reform bill. So why is it resurfacing now? The New York Times article explains that the Obama administration has decided to implement the policy through what is known as the the regulation-writing process. It's a way to circumvent Congress---to enact the provision without legislative approval. The process isn't anything new. It's been used by Presidential administrations for decades. What's concerning is the effort to suppress debate. Again, from the Times article, referring to an e-mail from Democratic Representative Earl Blumenauer, one of the lead supporters of the provision (my bold):

Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”

The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”

That's what rubs people the wrong way. It's the transparency thing. This is an issue that needs clarity. Proponents didn't provide it the first time around. They owe that to the American public. An additional round of debate would offer them another chance to demonstrate clearly that this provision is nothing more than what they say it is: a means to facilitate informed treatment choices for patients.


Let me end with the perspective that, with or without the new provision, end of life counseling can (and always has) cut both ways. Depending on how honestly and skillfully the conversation is carried out (and it does take a great deal of skill) the outcome might be a better educated patient equipped to make an informed and rational choice, or, perhaps all too often, a poorly informed patient who is maneuvered into inappropriate exclusion of potentially effective care. The New York Times piece, quoting an academic palliative care specialist, gives these examples:

For example, Dr. Silveira said, she might ask a person with heart disease, “If you have another heart attack and your heart stops beating, would you want us to try to restart it?” A patient dying of emphysema might be asked, “Do you want to go on a breathing machine for the rest of your life?” And, she said, a patient with incurable cancer might be asked, “When the time comes, do you want us to use technology to try and delay your death?”

I'll give Dr. Silveira the benefit of the doubt and acknowledge that the Times may have misrepresented her statements, but these are examples of misinformation, inappropriately leading the patient away from beneficial care. If this is how an academic palliative care specialist, arguably the best among the experts in such counseling, informs patients about their options, how is it done in the real world? This is where the law of unintended consequences kicks in.


So what about the heart attack followed by heart stoppage (usually VF)? It would be inappropriate to expect most patients to give an informed answer to that question without explaining the very high success rate for defibrillation when VF is witnessed in a hospitalized patient experiencing MI. As for emphysema, mechanical ventilation does not mean going “on a breathing machine for the rest of your life.” A course of mechanical ventilation for COPD and respiratory failure is a valid option for many patients, is often of short duration and carries a reasonable prognosis.

What did we learn about patient safety in 2010?

St. Louis City Hospital

Popular belief holds that due to a “movement” that was launched about a decade ago, patients in hospitals are safer. Although patients are better off year by year due to incremental improvements in medical knowledge and technology there has been little published evidence up to now regarding any impact of the patient safety movement. I blogged last year, following a negative report by the Consumers Union, that the movement was a failure.

Then last month a study was published in NEJM showing no improvements in patient safety over a several year period during the decade of the movement. Following this disappointing report there has been much speculation as to the reasons for the failure. While some ideas, notably central line and perioperative check lists lived up to their promise, others such as CPOE and medication reconciliation, while elegantly simple in concept, failed because they were full of unintended consequences and inscrutably hard to implement in real practice. Other measures such as hand washing, due to their implementation as performance measures, may have had little more than cosmetic impact as I explained here.

I have also maintained for several years that the Institute of Medicine (IOM) report on patient safety, credited by many with launching the movement, actually harmed the cause. Patient safety experts, citing the need for transparency to facilitate discussion and analysis of adverse patient events, were calling for a culture of reduced blame. The IOM report, with its sensationalistic claim that up to 98,000 patients died in the US every year from medical errors, had the opposite effect.

Because the IOM is a subsidiary of the National Academy of Sciences most observers viewed the report uncritically, assuming that it was a scholarly work, despite heavy criticism in the scientific literature and a repudiation of the claim by the lead author of the Harvard Medical Practices study upon which the IOM conclusion was largely derived. In fact, the IOM report was anything but scholarly. It was a massive publicity stunt. Bob Wachter, one of the report's leading enthusiasts, even characterized it as a piece of masterful spin. Its claim of 98,000 deaths by medical error was no more scholarly or fact-based than Sarah Palin's claim about death panels. Despite its flawed nature the popular press gave it a life of its own. Far reaching effects on public perceptions and policy soon followed. I recently examined the public policy consequences of the report and the manner in which it helped produce a culture of provider blame which undermined the cause of patient safety in a guest post at Kevin MD.

Hospitalists at the close of 2010: how are we doing and where are we headed?

St. Louis City Hospital

Hospitalists and outcomes

Boosters of the hospitalist movement have been saying for years that the hospitalist model of care resulted in cost savings. Until this year that claim was not evidence based. Although several studies and systematic reviews had suggested improved efficiency attributable to hospitalist care one of the largest and methodologically best studies on the model showed no difference in efficiency attributable to hospitalist care. But after making a brief splash in the blogs in 2005 it was conveniently tossed into the memory hole. A large new study out this year appears to have tipped the balance of evidence in favor of the hospitalist model by showing reduced length of stay, with an increase in the magnitude of the effect over time through the study period.

There were two items of interest in this year's literature in the related field of comanagement. When hospitalists served as attending physicians for patients admitted with GI bleeds (and thus comanaged the patients alongside the gastroenterologists) costs were higher and there was a borderline statistically significantly higher rate of readmissions in a study I discussed here. Another study just out this month looked at the experience with comanagement of neurosurgical patients at UCSF, which I noted here. According to the results of that study, although the perceived value of comanagement was high, objectively the service appeared to be value neutral.

Current recession and health care reform

Hospitalist salaries have continued to climb, with no sign of moderation, right through the recession. Hospitalists are being paid what the market demands and this is driven by a shortage in the work force. This was documented in the first ever combined MGMA-SHM survey, the results of which I referenced here. The trend will eventually moderate, but no one knows when or at what level. It will likely continue as long as hospitalists remain in short supply. An early influx of hospitalists seeking jobs came from traditional general internists making a career move. That pipeline is likely to run dry soon. Among IM trainees leaving residency, although many take temporary hospitalist positions before landing a subspecialty fellowship or making other definitive plans, the percentage of graduates seeking a hospitalist career is relatively small. Meanwhile, according to 2010 American Hospital Association survey data, 43% of hospitals were making efforts to increase the number of employed hospitalists.

It's anybody's guess what the impact of health care reform will be. It is in a shambles now and we don't know what it will look like in its final form. However, if currently developing economic pressures continue hospitals will need hospitalist programs in order to survive. Although the number is likely much smaller now, according to survey data from almost two years ago nearly half of hospitals did not have hospitalists. So until this growing niche is saturated hospitalist salaries are likely to continue to climb. On the other hand hospitalist jobs could be negatively impacted if large numbers of hospitals are shuttered by health care reform. While that's an outcome that may seem desirable to some policy makers it's not a likely scenario in the near term.

The evolving (or devolving) hospitalist job description

As I said in a post earlier this year, My how we've changed. Cultural and economic shifts have altered the hospitalist's job description over the past decade, and it's not for the better:

Hospitalist skill set, year 2000

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


Hospitalist skill set, year 2010

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

What's new in CPR and emergency cardiac care in 2010 and what does it mean for hospital systems of care?

St. Louis City Hospital

New ACLS guidelines came out last fall. I posted a brief discussion with links to the original document here. For the management of cardiac arrest the guideline changes fell short and remain years behind the best resuscitation science. Welcome changes, though, came in the recommendations for post resuscitation care and stroke care.

In the past, new ACLS guidelines merely meant more material for providers to learn. Not so in 2010. Now, for the first time, ACLS guidelines mean major system changes for hospitals.

A post resuscitation bundle to include applied hypothermia and urgent PCI in many patients is now a class I recommendation:

A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (Class I, LOE B). Programs should include as part of structured interventions therapeutic hypothermia; optimization of hemodynamics and gas exchange; immediate coronary reperfusion when indicated for restoration of coronary blood flow with percutaneous coronary intervention (PCI); glycemic control; and neurological diagnosis, management, and prognostication.

Neurological prognostication following return of spontaneous circulation (ROSC) has been turned upside down in the hypothermia era. Traditional clinical rules apply for patients not treated with hypothermia. For those patients treated with hypothermia all bets are off, and here's the new class I recommendation:

There is a paucity of data about the utility of physical examination, EEG, and evoked potentials in patients who have been treated with induced hypothermia. Physical examination (motor response, pupillary light and corneal reflexes), EEG, SSEP, and imaging studies are less reliable for predicting poor outcome in patients treated with hypothermia. Durations of observation greater than 72 hours after ROSC should be considered before predicting poor outcome in patients treated with hypothermia (Class I, Level C).

Part 9 of the new guidelines is a useful reference on many aspects of post resuscitation management.

The section on stroke care (part 11 of the guidelines) also calls for system changes. Transport of stroke patients to a designated center and admission to a stroke unit are class I recommendations.

Respiratory failure and mechanical ventilation---anything new and important in 2010?

St. Louis City Hospital

Although there were no landmark trials reported in 2010 several important trends emerged in the literature.

Severity assessment in ARDS

Like several other conditions in hospital medicine (e.g. C diff disease and pancreatitis) severity assessment has treatment implications in ARDS and was a recurring theme in 2010. The major tool for severity assessment is the lung injury score (calculator here) although other methods exist. This year there were three papers dealing with special therapeutic modalities to be considered in patients with ARDS who meet severity criteria. One looked at an old modality considered, in recent years, to be outmoded: the use of paralytic agents added to sedation for severe ARDS. This could represent a swinging back of the pendulum and is likely to remain controversial for some time, at least until further systematic study is done. I discussed the NEJM paper here.

Another paper this year, discussed here, mentioned a meta-analysis suggesting that high levels of PEEP (above those recommended in the ARDSnet PEEP scale) may be beneficial in patients classified as having severe disease.

High PEEP can be considered a rescue therapy. Rescue therapies have not been validated across the board for most patients with ARDS. A recent paper (discussed here) looked at several rescue therapies including high PEEP, prone positioning, high frequency oscillation and extracorporeal life support. These are therapies to be considered in severe disease. Although considered last resort measures which may offer the patient's only chance at survival they may warrant consideration and preparation early in the course of some patients whose presentations meet severity criteria.

Low tidal volume ventilation---not just for ARDS anymore?

There is accumulating evidence that, other things being equal, concerning delivered tidal volumes in mechanical ventilation, the lower the better. Early this year I reviewed the literature on this subject and noted the first RTC to suggest that low tidal volume ventilation was beneficial in patients who did not have ARDS/ALI at presentation, because it reduced the incidence of ARDS/ALI developing during MV.

Special problems in mechanical ventilation of patients with heart disease

Known or occult heart disease presents unique problems during mechanical ventilation and can be a cause of “failure to wean” (FTW). Although this has been known for some time it is underappreciated in day to day critical care practice and seemed to get special attention this year. Awareness of the problem is being raised. Briefly, the pathophysiology of cardiac disease as a cause of FTW relates to the multiple hemodynamic benefits of mechanical ventilation which, when withdrawn, may result in acute myocardial ischemia and cardiac decompensation. Due to the special circumstances of mechanical ventilation cardiac ischemia and decompensation may not be easily recognized. Judicious use of cardiac markers and even serial echocardiograms during spontaneous breathing trials may aid the clinical assessment. I discussed papers dealing with this problem here, here and here.

How can we leverage adherence to best practice in the hospital? New findings in 2010

St. Louis City Hospital

Poor uptake of evidence in clinical practice has been a stubborn problem. Many solutions have been offered, with disappointing results. Up until this year the impact has been confined mainly to process measures and has been modest at best. But a paper published early this year reported on a process improvement initiative which more than doubled the rate of adherence over two years. More than that, it resulted in an improvement in mortality and it came from, of all places, industry. It was, of course, the Surviving Sepsis Campaign.

I've hammered at this issue before and pointed out that the Surviving Sepsis Campaign, described by NEJM Perspective piece writers as little more than marketing disguised as evidence based medicine, is one of the most maligned promotional campaigns in all of industry. The lesson here is that industry collaboration, though not a politically correct option these days, may provide opportunities to leverage better adherence to evidence.