Following recent blog posts on “UpToDate dependence” by intueri, Kevin M.D., Caseblog and myself considerable discussion ensued on medical library lists and blogs about not only the addiction but also the cost of feeding the doctors’ habits. It’s something medical libraries grapple with every year or two when renewal time rolls around.
Medical information specialist David Rothman predicts:
As time passes, UpToDate will have more and more well-designed, well-maintained, effectively-marketed, affordable competitors. The competition will bring subscription costs down to a more reasonable level.
(Can’t wait for it to happen!).
The Krafty Librarian believes UpToDate’s business tactics are heavy handed and its prices are---well, pricey. I knew individual subscriptions were steep (I’ve got my own) but the institutional subscriptions, it seems, are through the roof:
Apparently there are some institutions starting to consider eliminating institutional access leaving their physicians to pay for the product on their own. UpToDate bases their prices on the institution's total number of outpatient and inpatients. No wonder some very big and successful institutions are rethinking the cost of UpToDate. It is not unheard of for small community hospitals to pay $10,000 -$15,000 for online access. I have heard of larger institutions paying $80,000 - $100,000 for access (which of course can't be used at home).
Emphasis mine on that last phrase! That’s a huge downside, particularly when UpToDate’s competitors provide home access for no additional cost! Why is home access important? Because home is where you do background reading, underappreciated but every bit as important as point of care reading. UpToDate has a wealth of background reading content in the form of pathophysiology, detailed disease descriptions, tutorials and case studies, but I suspect the background content is vastly underutilized since most use of UpToDate is at the point of care (to look up diagnostic algorithms and the latest treatment recommendations) when there’s insufficient time for in depth reading.
Dr. Thomas E. Brittingham, master clinician and director of the third year Medicine clerkship at Vanderbilt knew the importance of background reading and, in his letter to students at the beginning of the rotation, said this:
Dr. Carl Moore, Chairman of the Department of Medicine at Washington University, tells me that he finds it necessary to read medicine for 3-4 hours every day, 365 ¼ days yearly. If he finds it so necessary to read in order to remain competent, we probably need to read too in order to become competent. Half of your evenings are unscheduled so that you may have the opportunity to read about the patients you have seen. Read and think extensively about their disease problems….
Read and think extensively. You don’t have time to do that at “the point of care.” And it’s not just for junior medical students. It’s part of life long learning. Of course, back in the days of my medical clerkship point of care reading like we have now didn’t exist. So what’s the ideal reading routine for doctors today? I think it’s a combination of point of care and background reading. At or shortly before the patient encounter use point of care resources to determine the best and most current evidence for treatment decisions. Then go home and read in more depth about the pathophysiology and clinical features in the patients you encountered that day.
---it gets my attention, especially when the mainstream embraces or teaches it uncritically. My mission: expose it. The latest is the Maine Medical Center Family Practice elective, Integrative Medicine focus:
The integrative medicine portion of the rotation takes place both in the Family Practice Centers and in the offices of complementary and integrative medicine practitioners in the community. This aspect includes opportunities to observe patient care and provider/patient interactions and has the potential for complementary therapy treatments. Learning experiences may include integrative medicine consults, mind/body medicine, homeopathy, manual therapies, acupuncture and nutritional and botanical medicine.
I’ve posted many reviews on the cardiac channelopathies. This one recently published in the Texas Heart Institute Journal is open access full text and nicely summarizes the relevant basic electrophysiology.
Topic review from Seminars in Liver disease.
This study in the Australian and New Zealand Journal of Psychiatry sought to evaluate the incidence and mechanism of venlafaxine induced hyponatremia, which was defined as a plasma Na concentration of less than 130 mmol/L. A 17.2% incidence of hyponatremia was noted. Hyponatremia invariably developed within days of the start of therapy and was associated with failure to suppress vasopressin secretion during conditions of low osmolarity. Fluid restriction during continuation of drug treatment was effective. The authors recommend electrolyte testing in all patients over 65 within 3-5 days of starting venlafaxine.
Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is closely related to the class of selective serotonin reuptake inhibitors (SSRI) which are known to cause hyponatremia. Should we be monitoring electrolytes in patients taking SSRIs?
We’re seeing it all over, and across all disciplines. The result is a double standard. Doctors rally behind the cause of evidence based medicine for prescription drugs, yet fail to object when their patients utilize unproven herbs and vitamins. The American Medical Student Association through its Pharmfree campaign holds the drug companies to the most rigorous of evidentiary standards yet promotes numerous implausible and non-evidence based complementary and alternative modalities.
Now we’re seeing it in the field of psychiatry according to this recent Wall Street Journal report.
Now, spurred by the growing disenchantment with antidepressants, an increasing number of people are seeking treatment for depression, anxiety and eating disorders from naturopaths, acupuncturists and even chiropractors. At the same time, more traditional psychiatrists are incorporating massage and meditation in their practices.
The treatments go beyond needles and spinal manipulation. They include Emotional Freedom Techniques -- tapping on the body's "energy meridians" as the patient thinks about upsetting incidents -- and craniosacral therapy, which involves a gentle rocking of the head, neck, spine and pelvis. In cranial electrotherapy stimulation, a AA-battery-powered device sends mild electrical currents to the brain. (The procedure has its roots in ancient Greek medicine, when electric eels were used.)
Kevin M.D. had an interesting take on national health care plans after reading this report revealing the regulatory nightmares and access restrictions of Britain’s NHS.
It’s ironic that the proponents of a national health care system in the U.S. try to bolster their arguments by citing the evils of managed care, that monster we all love to hate. But national health care, in whatever form it may ultimately arrive here will, likely as not, be a system of heavy managed care under multiple layers of intrusive government bureaucracy---everything we hate about managed care and much more.
Don’t forget that Hillary Care was, in large part, modeled after an elaborate managed care scheme proposed by the Jackson Hole Medical Group. Managed care organizations were influenced in the 1990s by the Jackson Hole model. Although Hillary Care died in 1994, its anticipation in the early 90s may have spurred the subsequent wave of managed care in the U.S.
Given recent enthusiasm for the pleiotrophic effects of statins as well as controversy regarding the appropriate goal for LDL cholesterol reduction, a paper in the American Journal of Cardiology (AJC) entitled Low-Density Lipoprotein Cholesterol Reduction: The End Is More Important Than the Means seems timely. The paper reviews multiple lipid lowering trials which show that the more one lowers LDL cholesterol the greater the cardiovascular risk reduction, regardless of the means used to do it.
Moreover, it cited this meta-regression analysis which raised questions about the pleiotrophic effects of statins, concluding:
The pleiotropic effects of statins do not seem to contribute an additional cardiovascular risk reduction benefit beyond that expected from the degree of LDL-C lowering observed in other trials that primarily lowered LDL-C.
Multiple means of LDLC reduction, whether via statins, ileal bypass surgery, diet or binding resins were associated with similar reductions in risk for a given degree of LDLC reduction.
The AJC paper also synthesized the strong data from multiple trials in support of newer aggressive LDLC targets (70mg/dl) for secondary prevention and confirmed the safety of such reductions. Until very recently, clinical studies suggested that statins failed to address a significant portion of the total cardiovascular disease burden, in as much as their use was associated with a relative risk reduction of only about 30%. This was largely due to the fact that when targeted to the less aggressive LDLC goals of the past statin drugs failed to address the cardiovascular risk associated with the metabolic syndrome. More recent data cited in the AJC review, however, suggest that event rates approach zero for LDLC reductions in primary and secondary prevention populations to levels of 57mg/dl and 30mg/dl, respectively.
All this being said, I do believe statins have beneficial pleiotrophic effects related to anti-inflammatory and other properties. I suspect these effects may be of relatively greater importance in the near term in situations such as acute coronary syndrome. With long term use LDLC reduction assumes greater importance.
The initial enthusiasm for perioperative beta blockers was soon tempered by conflicting studies. In an effort to address the controversy the American College of Cardiology (ACC) issued guidelines last year which were somewhat more conservative than previous recommendations. Their class I recommendation was restricted to those patients who were already taking beta blockers and patients undergoing vascular surgery who had had ischemia demonstrated on preoperative testing. A class IIa recommendation was given for all other patients undergoing vascular surgery in addition to certain other high risk patients.
But now we must ask whether the guidelines are evidence based. The MaVS trial, the largest blinded RCT published at that time, demonstrated no benefit from perioperative metoprolol. The study, published last fall in the American Heart Journal, was composed of patients undergoing vascular surgery, a group that would be expected to uniquely benefit from beta blockers.
According to an editorial in the same issue “Larger and even more convincing trials are in the process of publication, demonstrating no impact of beta-blockade on perioperative events.” One of these, the DIPOM trial, was presented at the 2004 American Heart Association scientific sessions.
The editorial writer believes that poor quality studies combined with initial “belief” in the protective effects of beta blockers led to premature endorsement. An appeal to pathophysiology might help explain a lack of observed effect. Most ischemic cardiac events, particularly in this era of revascularization, are caused by rupture of a vulnerable (and often non hemodynamically significant) plaque, a process not mitigated by beta blockers. The relatively few patients with severe epicardial coronary disease who are susceptible to acute increases in myocardial oxygen demand might benefit.
As discussed in the editorial, these pathophysiologic considerations have fuelled interest in the use of statin drugs for perioperative cardiac protection. Early evidence suggests a strong protective effect. At least one larger trial is in progress. While it may be too early to recommend routine perioperative use of statins it is probably safe to say that patients with coronary disease already taking statins should continue them through the perioperative period.
Are perioperative beta blockers evidence based? It would seem that the answer is a cautious no. Should the ACC guideline be followed? There is strong pathophysiologic rationale for the class I indication. Patients already taking beta blockers should probably have them continued as seamlessly as possible perioperatively. The hemodynamic stress of surgery combined with the hemodynamic stress of beta blocker withdrawal might put patients at risk for ischemic events. Those undergoing vascular surgery who demonstrated ischemia on preoperative stress testing are more likely to have severe epicardial coronary artery disease and be susceptible to hemodynamic stress which would be mitigated by beta blockers.
The editorial’s pessimistic view of perioperative beta blockers is summarized by--
Where did the evidence-based guidelines process go wrong? The most readily apparent answer is in the reliance of small and in some cases unblinded trials, which had sparse absolute differences in event rates. When this is encountered in a systematic review, it should be realized that by random error, if a handful of events occurred in the opposite group by chance alone, then the significant result could not have been found. Thus, based on an intuitive and expected effect with beta-blockers, the ACC/AHA guidelines process has produced recommendations that almost certainly will be reversed.
For now, pending further results from clinical trials, I intend to follow the ACC guidelines for the class I indication, consider statin use in high risk patients, and continue statins perioperatively, when possible, in those patients already on statins. I also look for statins to emerge as the “next beta blockers” for perioperative treatment in the coming years.
A study on heart failure medication compliance published recently in the Annals of Internal Medicine concluded:
A pharmacist intervention for outpatients with heart failure can improve adherence to cardiovascular medications and decrease health care use and costs, but the benefit probably requires constant intervention because the effect dissipates when the intervention ceases.
My Internet research on Yoga and quackery led me to the Yoga Journal. While the journal may not be an authoritative source on Yoga it seems to be a pretty good reflection of its popular promotions and claims. So I decided to run it through the Quackometer, which gave it a rating of 9 canards (out of a possible 10) and this description:
This web site has more quackery than my village pond. It is throwing in some scientific jargon and may be doing this to give an appearance of knowledgablity. It shows no sceptical awareness and so should be treated with a suspicious mind. It also looks like this site is trying to sell stuff. Buyer Beware!
Can you make it through hospital rounds or a day in clinic without consulting UpToDate? Do you rely almost entirely on UpToDate to research topics or patient encounters, without going to primary sources? Do you feel you’d be unable to practice competently without it? Do you consider it your “peripheral brain” (translate: substitute for thought)? If you answered yes to any of these questions you may be UpToDate dependent. The habit can be darned expensive as Maria points out in a recent intueri post (h/t to Kevin M.D.).
Surveys and testimonials suggest that UpToDate dependence may be widespread. In one study, abstracted on the UpToDate website, over 90% of users thought UpToDate was “integral” to their decision making. Most usage was in association with patient encounters and 50% of usage was in the presence of the patient. Interestingly, most non-use of UpToDate was associated with lack of familiarity with the resource. Comments submitted to the website include “Can’t be without it”, “In time of need, I turn to UpToDate” and “Essential for my practice.”
Now I’m not here to criticize UpToDate. I love UpToDate and have my own personal subscription. It is a wonderful resource and, other than perhaps the cost, I find no fault with it. The problem is UpToDate dependence, which is symbolic of the larger problem of over reliance on “look up” resources. Although look up resources are essential to the practice of evidence based medicine, over reliance becomes a problem when their use supplants knowledge of basic science, acquisition of medical knowledge, background reading and clinical judgment. These essential skills and attributes help safeguard against an overly formulaic approach to patient care and result in fewer mistakes when patients do not follow the usual scripts.
The problem is symptomatic of growing attitudes which de-emphasize basic science in medical curricula and diminish the importance of medical knowledge as well as an agenda to restrict accredited CME to activities directly related to physician “behavior”.
This topic dovetails with a recent series of Med Rants posts on basic science in the medical curriculum, particularly as it relates to the USMLE Step 1 exam. Medical students sometimes complain about the basic science minutia they are forced to learn. DB, the author of the posts, tends to be in sympathy with their view, pointing out that all too often medical school basic science courses merely “teach for the test”. He suggests that the basic science content should be more focused on clinically relevant material.
I don’t know what the Step 1 exam looks like these days, or what DB has in mind for the curriculum. I suspect I would agree with his vision for medical education although I’m concerned that the de-emphasis on basic knowledge along with uncritical teaching of pseudoscience may reflect a dumbing down of medical education.
Notre Dame head football coach Charlie Weis had a thing or two to say after losing his malpractice suit against doctors at Mass General.
Weis, former Patriots assistant coach, said had he won, he would have donated any damages to a charity for people with special needs. " Our family decided to retry this case based on principle, not money," he said. (TED FITZGERALD/ASSOCIATED PRESS).
Well, if there’s a principle here I wish the coach or his attorneys would tell us what it is.
From the Boston Globe via Kevin M.D.
Hey, it’s only exercise! That’s the usual rejoinder I hear. A commenter, expressing astonishment that I would regard Yoga as woo, goes on to make my point by making a woo based Yoga claim:
And, unlike most gym type workouts, it stimulates the parasympathetic system rather than the sympathetic system, which is useful for the majority of people that are under chronic stress and therefore in sympathetic overload. A gym workout for someone in chronic stress is counterproductive as lifting weights or running on a treadmill further stimulates the sympathetic system, the stress/cortisol response and all that that entails.
It’s woo on two levels. First, there’s no evidence that Yoga somehow uniquely activates the parasympathetic nervous system. Secondly, traditional “gym workouts”, carried out over enough time to condition the cardiovascular system do in fact increase parasympathetic tone, as evidenced by the slower heart rates of conditioned individuals.
I plan to parse the religious and pseudoscientific underpinnings of Yoga in future posts.
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are well recognized complications of transfusion but it has been unclear which particular blood products put patients at risk. This retrospective cohort study in Chest confirmed that ARDS and ALI follow blood product transfusion and identified the highest risk for platelet and plasma transfusions.
Background: FDA advisory on transfusion related acute lung injury (TRALI).
When examining the electrocardiogram, look at how the injury current distorts the second portion of the QRS for an important prognostic sign (American Heart Journal).
In anterior infarction does the S wave in V2 and V3 fail to dip below the isoelectric line? In inferior infarction is the ST takeoff (J point) greater than half way up the height of the R wave? These electrocardiographic findings indicate a worse outcome, in particular poor results from reperfusion efforts via systemic thrombolysis or catheter intervention.
A while back I noted that an up and coming generation of kids will be better prepared for the mandatory woo they’ll encounter in med school because it’s now being taught in undergrad. Today I found something even more astounding. Woo, namely Yoga, is being “integrated” into the curriculum of public schools, starting in kindergarten! The integration encompasses multiple content areas of the curriculum as stated in Yoga for Kids Tools for Schools:
Curriculum Integration: All basic curriculum areas are addressed, as well as classroom management, test preparation, fitness, and environmental and multicultural education.
But it’s more than just physical education and relaxation. In this report from WTVJ channel 6, Miami, kids are being taught some fascinating immune system woo:
Some of the yoga poses have actual health benefits, according to DeWitt. "The Tarzan thymus tap in particular, where they're tapping their chest and tapping the glands in their bodies, that helps stimulate and helps the immune system function better," she said.
Although yoga has been catching on in many school systems it is not without controversy. According to an MSNBC report, some parents are concerned that teaching it in the public schools violates the establishment clause:
Tara Guber and her staff demonstrate a typical session where she teaches the teachers in her home in Los Angeles. When Guber created a yoga program five years ago for a public elementary school in Colorado, she never fathomed her proposal would provoke a crusade by some who argued that yoga's Hindu roots possibly violated the separation of church and state.
But proponents of Yoga in the public schools argue that it is merely a form of exercise, or that it is scientific. Well, that's not only woo but another example of a common guise under which Eastern religions are repackaged for the West. We’ve seen this sort of repackaging not only of Yoga but also of other traditions such as Zen Buddhism (as illustrated by the writings of Alan Watts).
Perhaps the best example, and one which provides precedent for an establishment clause challenge, is Transcendental Meditation, a tradition based on Maharishi Mahesh Yogi’s brand of Hindu faith. For a time TM was promoted in the West as the “Science of Creative Intelligence” (SCI) and introduced into the New Jersey public schools. With support from the Spiritual Counterfeits Project, teaching of “The Science of Creative Intelligence” was challenged in court. On December 12, 1977 the U.S. District Court of New Jersey ruled that due to the religious underpinnings of SCI its teaching was in violation of the establishment clause of the First Amendment. The New Jersey public schools were thereby enjoined from teaching TM.
I wonder if the case might provide precedent for an establishment clause challenge against the teaching of Yoga in public schools. For that matter, given the religious origins of many forms of woo taught in medical schools, at least those that receive government funding, there may be basis for legal challenges at that level as well.
But this time the blogging was done by an outsider, not the defendant. A malpractice action brought by Notre Dame head football coach Charlie Weis over complications following gastric bypass surgery was decided in favor of the defendants. Attorney blogger Eric Turkewitz reports on the verdict and provides links, including one to the sports blog which provided real time coverage.This, by the way, was the retrial of that case which was declared a mistrial after defendant doctors rushed to the aid of an ill juror.Turkewitz’s take on the verdict?
Nationwide, approximately 2/3 of all malpractice verdicts favor the defendants. This occurs because, generally speaking, it is usually the most difficult of cases that go to verdict, and due to juries favoring physicians over patients according to a recent Michigan Law Review study.
Despite recent enthusiasm for intensive glycemic control for septic patients and the provision for intensive glucose control in the Surviving Sepsis Guidelines and the IHI sepsis bundle, patient selection and target glucose range are unclear. Better answers await the results of two currently ongoing large trials. This topic was recently updated in Advances in Sepsis.
The study was just reported in Critical Care. It’s always been intuitive to doctors and nurses that staffing ratios affect patient outcomes. Now with this study, alongside another one showing a mortality hazard associated with low nurse to patient ratios, evidence is being marshaled to back up our intuition. This evidence also favors the judicious use of ambulance diversion despite the Institute of Medicine’s silly mandate from last year.
