Hospital Medicine 2010 panel on health care reform

Yesterday morning’s plenary sessions included a panel discussion on health care reform featuring Eric Siegal, MD, FHM, Patrick Conway, MD, MSC, Leslie Norwalk and Ronald Greeno, MD, FHM. The tone, though not overtly partisan, was generally favorable to the recently passed bill.

What did I learn? Mainly some specifics in this bill that confirmed many of my fears about unintended consequences. The administrative arms of the new health system will have discretionary power to make all sorts of new changes without legislative approval. Just one example is the new subsidiary of CMS, the Center for Medicare and Medicaid Innovation. The perverse incentives and potential new crimes created by this package are staggering. With the prospect of increased bundling of all sorts of services the new catch phrase is “aligned incentives”, really a euphemism for collusion among providers to limit care.

Address by Paul Levy, Hospital Medicine 2010

Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, spoke yesterday on patient safety. He writes a lot about safety and transparency at BIDMC on his blog Running a Hospital. His approach, though widely applauded, is difficult of me to accept uncritically. A highly celebrated example of transparency at BIDMC a couple of years ago, for example, concerning a case of wrong side surgery, seemed oddly selective to me:

What surgical procedure was actually done? We aren’t told, but given that it was characterized as wrong side we know it involved a structure of bilateral symmetry. And, from White Coat Notes (linked from Levy’s post) we learn that it was not an organ removal and did not result in permanent harm. Was it a biopsy, an arthroscopic procedure or carpal tunnel release?

Whatever it was the hospital is apparently not threatened with huge financial loss. Levy’s candor, laudable as it is, must be viewed in that context. After the OR staff disclosed the error to the patient Levy emailed the entire hospital staff, the Boston Globe and other media about the incident! But what if the patient had renal cell carcinoma and had the wrong kidney removed, sentencing him/her to long term hemodialysis? Would Levy have responded in the same way? I doubt it. If he shared such an incident with the media Beth Israel’s attorneys would have concerns and the malpractice carrier would arguably be within its rights to refuse coverage.

What’s equally disappointing is that Levy seems to buy into the popular but implausible notion of never events. In his talk he acknowledged that the idea isn’t scientific and that motivational thinking, the real mark of a leader, may have to trump scientific objectivity. To me, as regular readers know, it’s a goofy idea and one that has consequences.

So how is Beth Israel doing? Despite rigorous adherence to multiple evidence based measures (their hand hygiene rates are second to none) their central line infection rates, though low, are not trending toward zero. In fact they’ve hardly budged in almost two years.

That criticism aside their safety processes are praiseworthy. They do a root cause analysis on every event in designated categories and are relentless in their efforts to reduce harm. Levy wrote about his visit to Hospital Medicine 2010 here.

Hospital Medicine 2010 April 9 sessions---rheumatology pearls

Brian Mandell, MD, from Cleveland Clinic gave the talk.

When to suspect vasculitis? Know the red flags: mononeuritis multiplex; ischemic disease if unusual distribution or demographic (eg Takayasu’s); others.

A positive ANCA is meaningless if the patient’s illness doesn’t resemble Wegener’s, MPA or RPGN.

If vasculitis appears to relapse before tapering of immunosuppressive therapy take infection for granted. If apparent flare during taper, be wary of infection but it could be recurrent disease.

Septic arthritis---11% mortality.


Underappreciated complications of immunosuppressive therapy:

Corticosteroids associated with the widest variety of infectious complications, as they affect all arms of the immune system.

Anti-TNFs and Rituximab---Heb B flare, acute liver failure.

Azathiaprine---hypersensitivity syndrome.


Weakness and elevated CK---differentiate between true myositis and non-inflammatory myopathy. EMG may help.

Aldolase not specific for muscle. Acts more like LDH.

Hospital Medicine 2010 April 9 sessions---selected nephrology pearls

Derek Fine, MD gave a talk on renal problems in hospitalized patients and noted---

It’s the CYP 34A interactions that often get us into trouble with statin myopathy leading to renal failure. Simvastatin has the worst reputation for this but lovastatin does it too and, to a lesser extent, atorvastatin. Read the labeling!

Don’t forget acute interstitial nephritis. Non-classic presentations are increasingly recognized. (Although not on the list of usual suspects a quick PubMed search revealed PPIs, vancomycin and Cox 2’s as recently recognized causes [1] [2] [3] [4] [5] [6]). Rx: stop the drug, and sometimes steroids.

Renal failure after cardiac cath? Consider atheroembolic etiology rather than contrast induced if onset over 48hrs post or no evidence of recovery in 5 days, particularly if systemic signs/sx.

Iodinated contrast nephropathy? Nothing new there, really, but here’s a Dr. RW bias: If you need to rule out PE why not V/Q instead of CT? It’s just as good in many cases.

Don’t forget phosphate nephropathy (can cause AKI sometimes followed by CKD).

Normal saline as a cause of resistant HT in hospitalized patients? We’re not used to thinking that way. It takes a boat load of saline to resuscitate. Traditionally we have under-resuscitated patients. Why be concerned about hypertension? Because some hypertensive patients are salt sensitive. Even “keep open” normal saline provides a significant sodium load. Look at the periodic table and do the math: 23mg/meq. This is not to advocate for hypotonic fluids in hospitalized patients, because such fluids fairly predictably lead to hyponatremia. The point is to keep in mind that in salt sensitive patients what may seem to be nominal amounts of saline may contribute to resistant hypertension.

Nephrogenic systemic fibrosis, the latest scleroderma mimic, is on the radar screen. I mentioned contraindications to contrast MRI and the relative safety of Gadolinium preparations the other day. In exceptional cases a patient with contraindications absolutely, positively has to have a contrast MRI. Then what? Use the lowest risk agent at the lowest dose possible followed by intensive hemodialysis using special methods.

Poster presentations at Hospital Medicine 2010

Here are a few I found interesting:

Profiling hospitalists for utilization and outcome metrics
If you group has significant hand offs, such as shift work or several-days-on-several-days-off schedules, you can’t accurately profile individual hospitalists. It doesn’t work because patient care is spread out among multiple providers.

Poster 12 by Ansari, et. al., Loyola.


Another study showing no impact of RRTs
---even when the team rounded proactively on all patients transferred out of the ICU.

Poster 28, Butcher, et al, UCSF.


Press-Ganey surveys meaningless
P-G patient satisfaction surveys are attributed to the discharging physician (regardless of who really took care of the patient) and are mailed to the patient for completion days or weeks after discharge. Forth, et al, at Northwestern University, (poster 54) attempted to validate P-G surveys with an instrument used in real time during hospitalization, confirming that the patient knew the identity of the treating doctor. The result? Not validated. No correlation. R values ~ 0.2.


Patients who leave AMA are at higher risk
---for mortality and just about everything else. This was a huge database and apparently the first study of its kind. Should we target the AMA patients for special post discharge intervention as the authors suggest?

Poster 57, Glasgow, et al, Iowa City.


Poor survey perceptions among hospital workers about the patient safety culture
---were strongly associated with higher readmission rates for CHF and AMI in a survey reported by Hansen, et al, Northwestern University and Harvard School of Public Health. Poster 60.


Non-evidence based use of PPIs
---was rampant in a chart review by Rizvi, et al, UTHSCSA (poster 125). Most were started in the hospital for bundle compliance and for a variety or weak and sloppy indications. Many of the PPI prescriptions were continued following discharge with no reason documented. This is in part an adverse consequence of a performance measure.


Patient falls a never event---NOT
Despite a vigorous initiative using a multidisciplinary team, only a dent was made in the rate of patient falls, from 3.07 to 2.42 falls per 1000 patient-days in a study from Northwestern University by Shah et al (poster 192).

Statins in patients with NASH?

From the Medscape Ask the Experts series:

There are 2 considerations for the use of statins in patients with nonalcoholic steatohepatitis: to control the hyperlipidemia that is frequently associated with NASH, and to use them as therapy for NASH itself. Statins can be used to treat hyperlipidemia in patients with chronic liver disease.[1-3] The risk for statin-induced hepatotoxicity is minimal in patients with chronic liver disease, and serum aminotransferase levels can be monitored. Any statin can be used; both pravastatin and atorvastatin are acceptable for such patients.[4-6]

If you’re attending SHM 2010

---stop and say thanks to a drug rep. Really.



Without their support a meeting of this caliber would not be possible.

I’m a walking advertisement for Big Pharma at SHM 2010

I have no choice. I can’t access the sessions otherwise. But I don’t mind.

Arrived in Washington, DC

---late last night to attend Hospital Medicine 2010, our national meeting. Travel was difficult yesterday thanks to fouled up flight plans. I’m very tired this morning but pumped up about the meeting with its incredible networking opportunities (hope to see some of you here!) and wonderful course content.

You can follow meeting highlights at the official HM 2010 blog. If you want the politically incorrect version just stop by here over the next few days, where I will be posting updates as time and energy permit.

Hospitalized patients often not in the loop about their care

From Mayo Clinic Procedings:

RESULTS: Of 250 eligible patients, 241 (96%) agreed to be interviewed. A total of 233 (97%) of 241 physicians completed the interview, although sample sizes vary because of missing data elements. Of 239 patients, 77 (32%) correctly named at least 1 of their hospital physicians, and 143 patients (60%) correctly named their nurses. For each aspect of care, patients and physicians lacked agreement on the plan of care in a large number of instances. Specifically, there was no agreement between patients and physicians on planned tests or procedures for the day in 87 (38%) of 229 instances and in 22 (10%) of 220 instances. Complete agreement on the anticipated length of stay occurred in only 85 (39%) of 218 instances.

Nursing staffing and mortality after hip fracture hospitalization

Presented at the American Association of Orthopaedic Surgeons 2010 Annual Meeting and reported in Medscape:

In a retrospective cohort study presented here at the American Association of Orthopaedic Surgeons 2010 Annual Meeting, the risk for death among elderly patients in the hospital with hip fractures increased 22% when the nursing staff was reduced by 1 full-time nurse each day, Peter Schilling, MD, from the University of Michigan Medical Center in Ann Arbor, told meeting delegates.

This is not terribly surprising to me. These frail patients are labor intensive and require close monitoring.

Nephrogenic systemic fibrosis

---is the latest scleroderma mimic. It can cause disabling skin contractures, internal organ involvement and sometimes be fatal. A recent review in Journal of Hospital Medicine offers helpful advice.

Here's the skinny:

The risk of NSF varies with the brand of gadolinium based contrast used. Gadoteridol (Prohance) carries the lowest risk. Gadodiamide (Omniscan) is a high risk product. The others are intermediate in risk.

Avoid contrast in patients with GFR below 30 (be careful how you estimate GFR!), those with ESRD and those with AKI.

Mechanical ventilation 101

A review published in SMJ, reproduced as free full text via Medscape.

Concise and practical.

The hospitalist model and the fragmentation of health care

Over at Med Rants DB cited an article in Annals of Internal Medicine lamenting the discontinuity of care associated with the hospitalist movement. Earlier today I pointed out that hospitalists, rather than being the integrators of health care some purport them to be, have in many ways become the enablers of fragmented care.

So now that we have built discontinuity into the system how can we mitigate the effects? This is a good opportunity to point out, again, that there are now guidelines for communication between hospitalists and primary physicians. These guidelines do not put the onus for communication on the hospitalist. It's a two way street, a push-pull function. According to the guidelines emergency room physicians should call the PCP and discuss the case before handing the patient off to the hospitalist for admission. The PCP is expected to contact the hospitalist and provide input, as well as visit the patient in the hospital. These guidelines are not well publicized. They were not promulgated or promoted by the Society of Hospital Medicine. They could go a long way toward closing the communication gap, but I suspect adherence is very low.

Should I cut the ACP some slack?

It’s no secret to regular readers that I’ve been critical of the American College of Physicians. Dr. Robert Centor, a blogging colleague who writes Medical Rants, took me to task about one of my recent posts. In my comment thread I characterized the ACP as elitist because of their hierarchical membership structure, to which he replied:

I must take umbrage in your characterization of ACP as an elitist organization. ACP really has a wonderful mixture of academicians and private practice physicians in its leadership. ACP has changed dramatically over the past decade. No other organization even tries to consider the breadth of internal medicine in its mission.

You really should reconsider ACP as an incredibly important society.

OK, let's be clear that I consider ACP an important professional society. They offer excellent educational resources for internists which I have taken advantage of many times over the years. Maybe elitist is too strong a word, but early on it struck me that in their two-tiered membership the ordinary members were like second class citizens. Advancement to fellowship in the organization was next to impossible unless you were in academic medicine. When they made fellowship attainable to community internists they changed to a three-tiered system with the new and more elite rank of Mastership. I understand the organization wanting to recognize different levels of achievement, but it rubbed me the wrong way.

In that same post I also said the ACP no longer supports general IM as a unique specialty. DB responded to that assertion with an entire post of his own, but he didn't directly address my criticism. I agree with every word of that post. He said that the hospitalist movement has contributed to the decline of general IM (my italics):

What happened? We have two problems: (1) the growth of hospital medicine and (2) the lack of payment growth for outpatient medicine. Hospital medicine has grown because hospitals willingly pay reasonable salaries for hospitalists. Hospitalist programs grow dramatically for several factors that I have previously enumerated. Residents are attracted to these programs because they understand the job very well, they are paid reasonably, and the schedule provides significant non-working days.

The growth of hospital medicine has made the dualists a dying breed.

At SHM 2008 one of the keynote speakers said words to the effect that the hospitalist movement was poised to be the grand integrator of health care. Instead the movement contributed to the disintegration of health care by removing the dualist's niche. We became the grand enablers of a fragmented system.

While DB didn't address my criticism directly he cited factors in the decline of traditional IM that are no fault of the ACP. Don't blame the organization, he said.

Fair enough. I don't blame the ACP for all of Internal Medicine's problems. I am saying that the ACP is powerfully positioned to help general Internal Medicine regain its identity yet chooses to do nothing to further that end. I have cited evidence here, here, here, here and here.

Finally, though a little less relevant since Pharma cut off many of its gifts to physicians, I was disturbed a few years ago by the ACP's hypocritical stance on physician-Pharma relations, which you can read about in this press release.

So: Yes the ACP is an important organization. Yes they have produced some incredibly valuable educational resources for physicians. No they are not to blame for Intermal Medicine's problems. And yes they have irritated me just enough times to dissuade me from joining.

Med school then and now

The latest issue of Vanderbilt Medicine updates the recent evolution of Vanderbilt Medical School's curriculum:

On Bonnie Miller’s to do list: dismantle the 100-year-old medical education system.

“We can’t change the way we provide care without also changing the way we educate providers. It simply won’t work,” said Miller, M.D., senior associate dean for Health Sciences Education. “In the world of personalized medicine, there will be no way that one provider can know everything needed for every patient encounter every time, but medical education is still built on this assumption of the omniscient doctor.”

Vandy curriculum planners know students can't learn it all. It wasn't always so. On my first day of class there in the 1970s the anatomy professor told us in his introductory remarks that while the course content may seem like a lot of minutiae, it was all relevant. Learn it all and learn it well, he said. At the beginning of our third year Medicine clerkship the students met in a conference room with the chief resident. He held up a copy of Cecil's and announced that we were expected to be “thoroughly familiar with the contents of this book.” We knew he was blowing a little hot air but the message was clear. If you didn't know it all you needed to try harder.

In the same issue of Vanderbilt Medicine is an account of Dr. John Shapiro's legendary second year pathology course in the mid 1950s:

Dr. Shapiro’s lectures were peppered with questions. Since pathology involves both gross and microscopic examinations, most lectures were given in a darkened room while slides were projected. There was no doubt that he could see through the back of his head and in the dark because every few minutes he would spin around on his stiff leg, point to one of us, call us by name and fire a question. Any incorrect answer evoked a caustic, demeaning retort...

One of my classmates was so terrorized by Dr. Shapiro that he could not walk past the entrance to the wing housing the Department of Pathology. When approaching the third-floor wing, he would descend to the second floor, walk past the frightening area and then climb back to the third floor again...

If the never-ending volume of facts to memorize, the constant stress in class, the military-like requirements of dress and behavior and the ever-present atmosphere of fear were difficult to endure, they paled compared to “Organ Recitals”. An Organ Recital bore no relation to music. “Organ” referred to hearts, livers, spleens, etc.

Our class was divided into groups of four to attend autopsies in rotation. There, we observed the resident’s examination and performed minor tasks. However, the next day was a different story. The class assembled in the autopsy room and stood on movable stands close to the autopsy table. The unlucky four stood beside the autopsy table while the resident presented the patient’s internal organs to Dr. Shapiro. After several cogent comments on the pathologic findings, he began to question one of the four students standing across the table. His questioning was brutal and, with almost savage glee, he exploited any weakness in a student’s knowledge. Occasionally, with fierce expletives, he expelled a particularly unprepared student from the room.

The experience of a sage clinician and pathophysiologic rationale trump EBM, save life and limb

At least this story is pretty convincing that it did for a patient with Group A streptococcal TSS and necrotizing fasciitis.

The treatment under consideration: corticosteroids as an adjunct to debridement and antibiotics.

The clinical experience: several cases decades earlier exhibiting dramatic improvement with steroids.

The pathophysiologic rationale: Group A streptococci are exquisitely sensitive to antibiotics and an exuberant immune response is not needed. This same immune response is injurious to tissues and needs to be moderated.

Caveat: This may not apply to other forms of necrotizing fasciitis, such as those due to MRSA and mixed infections.

More on this general topic later as time permits.

Via Vanderbilt House Organ.

Whither didactic CME?

Our latest Medscape Roundtable Discussion is again about CME. Recall that last year we debated the funding. This time the discussion centered around format. The general sentiment was that the traditional lecture based format be abandoned. Dr. Centor and I wrote the "minority opinion" that traditional didactic CME should be preserved.

Though there’s little evidence regarding whether any CME format is more effective than others there was no shortage of strong opinions in this Roundtable. I did make one strong evidential point:

High-quality evidence concerning the effects of CME is almost nonexistent. The notable exception is worth looking at in some detail. It is a grand experiment involving an educational program that contains all the elements that my Roundtable colleagues find desirable: interactive format; performance measurement; immediate feedback; and rigorous adherence to "best practices." I'm referring to advanced cardiac life support. Quality evidence exists for both performance and patient outcomes. According to both levels of evidence, the program has failed. Studies have indicated that learner retention deteriorates rapidly over time.[1] Real-world adherence to the guidelines is as low as 40%.[2] Survival in cardiac arrest has been dismal, with negligible improvement over decades despite multiple evidence-based updates in course content and certification requirement for virtually all providers.[3] Exceptional improvements have been realized by only a handful of communities, which have departed from the performance measures to employ methods of resuscitation developed by researchers at the University of Arizona.[4] Although considered new, these methods have been used in select communities for several years, regardless of that fact their penetration into CME has been limited to the very activities that many would abandon: the traditional lecture.

Democratic congressman on health care reform “I don't worry about the constitution on this.”

Before the Internet was ready for prime time

---doctors were limited in terms of educational resources. Today webcasts are available on demand for the topic of your choosing. Back then docs relied on broadcast media like Physicians Radio Network (PRN) and Lifetime Medical Television. LMT ran all day every Sunday. I spent many a Sunday afternoon in the 80s and early 90s watching their programming, made possible by support from evil pharma. Here's another montage of promos and ads. LMT had a parade of stars as hosts and contributers and in this clip you'll see Bernard Lown, Bob Rakel and Roger Bone.