Archive for: June, 2010

Signs of life in medical social media

Jun 30 2010 Published by under Medicine

Many of us who are involved in social media have bemoaned the sluggishness of our own professions in adopting new media. There are two notable developments in my own field that seem to be holding up.
The first is the twitter stream for the American Medical News. This is an online and print newsletter put out by the American Medical Association, but in true social media fashion, the feed is not simply a conduit for their own articles. The feed retweets frequently and tweets stories from other media outlets and blogs.
The second is a blog from my own specialty organization, the American College of Medicine. It has a "QD" (medicalese for "daily") news feature, and also features content from well-known medical bloggers.
This sort of online presence is a great start. I'm not an AMA member, but I occasionally read the American Medical News, and now that they tweet, I'm even more likely to check them out. Their willingness to link outside their own organization is critical.
So, folks, what other examples have you got for me? What am I missing out there?

2 responses so far

"A state of institutional denialism"

Jun 29 2010 Published by under Medical education, Medicine

Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents' work hours. This was driven largely by Zion's father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.

"You don't need kindergarten," he wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call -- forget about life-and-death."

It was largely thanks to Zion's tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.

Medical residents have traditionally worked long hours, especially in their first ("intern") year. In fact, they used to "reside" in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn't changed much, which sort of surprised me).   The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts.  During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night,  which has long been typical for internal medicine residencies.  

In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run.  Hospitals can only support a certain number of residents, and they count on these residents and the care they provide.  Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners).  And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints.  

Many of these changes involved a more toward "shift work" and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift.  This creates its own problems for both patients and residents.  There are concerns that shift work may lead to a disruption in continuity of care, since patients are being "handed off" potentially several times a day.  Also, residents are not supposed to be performing functions that are primarily "service" rather than educational.  During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.

These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies.   While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.

Resident Safety

As medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects.  The 2009 IOM report summarizes some of the evidence for fatigue-related injury.  Much of this evidence is readily available through PubMed.  Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue.  There is also good evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents.  And these data are not new.

Patient Safety

Data on patient safety isn't new either.  A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones.  That's just one good study of many.

Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes.  One of these fixes is the implementation of reasonable resident work hours.

Denialism?

Responses in the literature and in doctors' lounges have been tangential and almost intentionally obtuse. A colleague of mine at another institution has opined that the medical profession is in a state of "institutional denialism" about the effect of long hours on safety and performance.  I don't think that is unfair.  The evidence on this has existed for years, yet we've made only cosmetic adjustments to our training programs.  Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem.  The work hour limitations they mandate will very likely help, but there is a larger systemic problem.  Medical training is lengthy and expensive.  If we're going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs.  If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt.    Quick fixes, even smart ones, aren't going to do the trick.  

The Libby Zion case that eventually led to the new work rules was over a quarter century ago.  How long will it take us to create real, comprehensive solutions?

Continue Reading »

11 responses so far

Science journalism pet peeve

Jun 28 2010 Published by under Journalism, Medicine

I frequently read about the latest medical and scientific "breakthroughs" in the mainstream media, and in modern media such as sciencedaily.com. One commonality is lack of citations. If I'm lucky, they may cite the source journal or meeting. If I'm really, really lucky, they may even give a general date (e.g., "JAMA in June"). But I never see an actual citation. That would be one simple way to improve science journalism. A standard citation would give readers the tools to evaluate the primary source. In science, we consider that pretty important.

36 responses so far

The vaccine problem: are we doing it wrong?

Jun 27 2010 Published by under Medicine

Author Chris Mooney has a provocative piece up at the Washington Post today. He argues that scientists are misunderstanding the dynamics of science-policy debates. Because, he argues, ideology often trumps scientific fact in the minds of the public, we (scientists) need to work harder to engage the public to win their hearts before we win their minds (please forgive me, Chris, if I didn't get this quite spot on).
While I appreciate Chris's general point---that we can't just "fact" people into submission---I think some of his arguments beg for a more critical analysis. Point one, scientists are missing an important piece of data:

One the one hand, the nonscientists appear almost entirely impervious to scientific data that undermine their opinions and prone to arguing back with technical claims that are of dubious merit. In response, the scientists shake their heads and lament that if only the public weren't so ignorant, these kinds of misunderstandings wouldn't occur.

I'm not so sure Chris is right about this. Those of us who fight against the anti-vaccine movement have known for years that it behaves like a cult, making the members nearly impervious to reason. Many of us realize that the core of the anti-vaccine movement are not our primary audience. Our real audience is fellow activists (igniting the core) and those who have not committed themselves (nearly everyone). Chris's argument is most valid when applied to this latter group who may or may not be turned off by the aggressive rhetoric of both sides.
But as Chris argues later, their minds may be more or less made up. They may choose a side based on their basic ideology rather than rational argument. If we can't sway the cultists, and their ideologic fellow travelers are already spoken for, what are we doing?
We are also speaking to policy makers. The public health establishment is science-based but susceptible to politics. We are arguing for them to hold fast, not to bow to the vagaries of politics and ideology. And we are bringing our own inflamed base into the fight.
Chris argues---admirably---for a more democratic approach to swaying the public on scientific issues, giving as an example Canadian nuclear waste disposal. In Canada, the government has worked to involve the public and other interested parties.

In Canada, for instance, the national Nuclear Waste Management Organization spent three years listening to the public's views about how to handle nuclear waste disposal and promised that no dump or repository would be sprung on a community without its consent. Throughout the process, even critics of waste storage efforts remained engaged and supportive of attempts to come up with the best possible solution.

There is a fundamental problem with science policy decisions. As a nation, we are a democracy, yet science is not. Not every community has the appropriate natural resources to serve as a nuclear waste repository. What happens when, as in Nevada, a good scientific choice is a bad political choice? Is the community really open to persuasion? And are anti-nuclear activists (who, as Mooney implies, are moved more by ideology than reason) really going to ever be persuaded that any site is adequate?
Those of us arguing for sound science policy are not ignorant of ideologies and of our own inabilities to sway true believers. We get that. But neither do most of us believe we can simply open up science policy to a vote. When the public "votes" that vaccines cause autism, what are we to do, halt proper vaccination until we can convince everyone, just to go through the same cycle in another few years?
This is a representative democracy. We must convince policy makers to isolate, as much as is possible, science policy decisions from the election cycle. And we must be loud advocates of sound science policy, realizing that we are fighting ideology. The more we isolate the Jenny McCarthy's, the more our own voices will affect policy.

44 responses so far

I miss you!

Jun 24 2010 Published by under Medicine

When you walk into a good coffee shop, you can smell it. It's a smell nothing like the smell of the old, sour coffee sitting in a carafe at the office. It's the smell of dark, dark beans, cracked open, releasing complex odors of fruit and of heat. And as much as I enjoy sitting in a coffee shop reading and writing, I don't get much time for that these days. But I can bring it home.
I love opening a new bag of beans. They have that shine to them, a shine that is lost very quickly. And when you pour those fresh beans with their volatile sheen into the grinder, they jostle and release just a bit of their aroma. That intensifies the moment the grinder blades cuts into the beans. Sometimes I use a drip coffee maker, sometimes a press, and rarely an old copper Turkish coffee pot. I think the press is my favorite. I warm it up first, and then dry it and pour in the course grounds. I pour the hot water over them, give it a stir, put on the press, and set a timer for three-and-a-half minutes. The smell in the kitchen isn't as intense as when using a drip pot, but when you press the coffee and pour it, there is a small crema in the cup, and the coffee has real texture.
I usually wait a few minutes for it to cool comfortably, then sip it, taking in the smell, taste, feel. I love to read and I love to write with a cup next to me. I rarely finish a cup, because it gets cold, so I pour a bit out and freshen it up. And I feel, in the most subtle of ways, the little boost as the caffeine hits.
The weekend is a great time for me to enjoy coffee. I love to sit around and sip it doing something completely relaxing. But when one of my 14 hour days is dragging on, I want to have a cup to get that extra little something. And I love to sip it when I'm bored.
Now that my coffee is nearly devoid of caffeine, I'm developing a new relationship to it. I took a small amount of regular this morning, as medicine really to ward off the withdrawal symptoms that have been pestering me. That sip, and a half a cup of half-caf today was it. I'd love a cup now, but I'm not sure; the caffeine in it apparently meant more to me than I thought.
But I'll be content with good decaf. There's plenty of good decaf beans out there, and once the worst of the withdrawal is done, I'll be happy.
It's a good thing I'm not an addict or something. I can't even imagine what that must be like.

12 responses so far

We need to fix Medicare NOW!

Jun 24 2010 Published by under Medicine

Medicare is the government health care program for the elderly. For internists such as me, Medicare patients make up around half our practice. Because of historical budget tools, every year Congress goes through the motion of watching our reimbursement cut, and quickly fixing it. It's a terrible system. As a small business, my costs are pretty much fixed: rent, employee pay, health insurance, supplies, etc. Every year, a Medicare pay cut goes into effect, and then our checks are held while Congress puts together a temporary fix.
This year, the pay cut is 21%. That means that I will have to try to pay my rent, my employees and my suppliers and myself on somewhere around 10-12% less pay. We work on very narrow margins to begin with, so this means that we may not be able to pay our bills. This week, the Senate managed to pass a fix that would have stopped the pay cut. They did this by stripping away other legislation it was attached to. When it went to the House, Speaker Pelosi added back a bunch of unrelated legislation, which essentially insures that the fix won't pass, or if it does, it won't be for a long time. We've been informed that our checks, which were being held by Medicare until the fix, are now being mailed out with the 21% pay cut.
This may seem boring, this may seem like whining from someone in a higher income bracket, but providing medical care to our seniors is expensive. When these checks hit our accounts, we're going to have to make big cuts just to pay the rent. These cuts may mean we have to try to run the office with fewer employees, we may need to cut our health insurance for our employees, and we will definitely need to stop taking Medicare patients.
This is not something that can wait. There are fewer and fewer primary care doctors taking Medicare patients every day. With more Americans reaching Medicare age, it will rapidly become nearly impossible for them to find doctors.
This cannot wait. Please call or write your representative now. Currently the House is the body holding up the "doc fix". Doctors and their elderly patients need your help immediately.
Here's how you can find your Representative's contact info.
I've also started a twitter hastag #FixMedicare to help brainstorm ideas and connect people who care about this issue.

15 responses so far

ACGME moves to limit resident work hours

Jun 23 2010 Published by under Medical education, Medicine

When it comes to medical blogging, no one has been as consistently good, fresh, and snarky as Orac. Respectful Insolence sets the standard for all other medical blogs, and though Orac may not be a media star like some other med bloggers, his writing has had a significant impact on some important medical issues such as vaccination. The fact that he is often the target of vicious attacks by anti-vaccination activists and other quacks and wackos shows just how good a job he is doing.
Though he has been criticized for being a bit loquacious, his thoroughness is one of the traits that makes him so effective. So I was very happy to see his post on the so-called "July Effect", the idea that hospitals are more dangerous in July when the new interns start. I love July, as difficult as it sometimes is. I always call the new interns "Doctor" and it always makes them do a double-take. Orac's takes a very detailed look at a new study of the July Effect, and the data still aren't clear as to whether and how July may be more dangerous to patients.
Another question regarding resident training and safety is resident duty hours. The data are not at all clear as to the effect of these hours on residents and patients, but despite a paucity of data there are reasons to believe that some parts of medical training may not be great for young doctors or their patients. In their continuing effort to address these concerns, the Accreditation Council on Graduate Medical Education (ACGME) today released a new set of standards for medical resident supervision and duty hours.
Before I explain these changes, which residencies will be expected to adopt, let me explain the traditional schedule. It's no secret that residents work some crazy hours, although over the last ten years there have been some efforts to control this. Residents have been known to have fatigue-related auto accidents, and as stated above there may be patient safety issues related to fatigue. Different specialties have different schedules, with internal medicine (my specialty) being neither the worst nor the best (surgery and OB/GYN tend to be the worst). Classically, internal medicine interns take call "q4", meaning that every fourth night they stay in the hospital. This means that on Monday, for example, they may come in at 0530 to pre-round, stay all night, finish all their work by Tuesday evening and go home to roll out of bed early again the next morning. It's usually pretty easy to identify the "post-call" residents: they are wearing scrubs, unshaven (if relevant), rumple-haired, and they look tired.
The ACGME has decided to focus on first year residents (interns) in their new standards, as these are the residents who have the least experience, and the data indicate they may---maybe---be at higher risk for committing preventable errors.
The new standards set a limit of 80 hours of work per week. They also limit interns to no more than 16 hours of work at a stretch, with at least 8 hours between shifts. This is going to have a significant impact on the design of medical residencies. One of the advantages to the more torturous schedule was continuity-of-care. When I admitted a patient on Monday afternoon, I would be with them during the critical first day of their admission, seeing the patient through the whole initial work up. The new standard will essentially mandate a shift-work model, in which an intern will admit the patient, then hand her off to another intern to go get the mandated rest break. The ACGME recognizes the potential problems of "hand-offs" and allows some time "off the clock" for them.
One of the shifts likely to be implemented is "night float", where a few residents will take admissions and keep an eye on the house. Many programs already have night floats, but the new system will make them nearly unavoidable. When I was a resident, we generally did 14 nights in a row (if I recall correctly) from 11 pm to 7 am. The new standards will limit these shifts to six in a row.
Residency spots are limited in number. Institutions can only afford so many residents per year, and with further work limits, hospitals that depend on these doctors are going to have to rely increasingly on other clinicians to care for patients. Physicians assistants and nurse practitioners are already being used extensively to care for patients in hospitals, and this role will probably increase as a direct result of these changes.
As valuable as my "in the old days" training was, these changes are probably positive in the long run. It's not good to over-fatigue our young doctors, who may be risking their lives driving home after 30 hours at work, and if it has a positive effect on patient care, great.* But we still must remind our young doctors that when they get out into the real world, there is no ACGME, no limit on work hours.
______________________________
*DrugMonkey pointed out the implication of this statement. Upon self-examination, a few things underly this. First, I have a responsibility to both my patients and my trainees. The evidence of benefit to patients of these changes is not strong, but I do anticipate benefits to trainees. I am also biased by my own post-call traffic accident.

24 responses so far

Summer reading list

Jun 21 2010 Published by under Narcissistic self-involvement

I'm looking forward to having some time to read this summer. I've planned a total of two weeks away from work, and if all goes well, I'll get some time to plow through a few good reads. My first trip away will be my usual gig as a camp doctor in Ontario. Last year I brought up The Great Influenza by John Barry, which was ironic, given I landed at flu central. My second week off will be up in northern Michigan. Here's my list, which is heavily biased in subject matter (I'm far too lazy to give a three-source bookstore link, so you'll have to google them):

  1. Breakthrough: Elizabeth Hughes, the Discovery of Insulin, and the Making of a Medical Miracle, by Thea Cooper and Arthur Ainsberg.  Actually, I just finished this one, and I'll have a review up by the end of the summer.  It's a great read about the discovery of insulin, but not available until the fall.
  2. Newton and the Counterfeiter: The Unknown Detective Career of the World's Greatest Scientist, by Thomas Levenson.  I've been dying to read this one.
  3. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, by Tracy Kidder.  A friend sent me this one a while back, and I finally started it.  The first sentence contains the word "beheading".  It's about a doctor, and I love it.
  4. The Poisoner's Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York, by scibling Deborah Blum.  I've been dying to read this (heh...)
  5.  Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, by Mark Pendergrast.  Hopefully it will be as good as The Medical Detectives, one of the first medical books I read, a couple of decades ago.
  6. & 7. Superbug, by Maryn McKenna, another scibling.  It's about bacteria, resistance, and all sorts of geeky things that affect what I do on a daily basis, and that may affect you, especially if you are ever in a hospital or nursing home.  Oops, and one more from Maryn, Beating Back the Devil.

I really wish people would stop writing such interesting books---I don't know when I'll read everything I want to.   Now if award-winning science writer Ed Yong would just crank out a new one, I'll never get anything done.

11 responses so far

Another Fathers' Day---so soon...

Jun 20 2010 Published by under Narcissistic self-involvement

I visited a physician this week as a patient. The details of the meeting are in the TMI category, but the long a short of it was he gave me advice that the altmed folks wouldn't believe. Surrounded by the most advanced diagnostic technology, armed with a nearly infinite pharmacopoeia, he made a single recommendation: stop caffeine.
Stop caffeine. Ugh. He said, "Stopping caffeine often solves the problem you're having. You know, it's a drug. You don't need it. It's like speed. Stop it, and I'll see you in a month."
Caffeine is my friend. In college I always wrote my papers in one, long sitting, drinking tea the whole time. I started drinking coffee just after college. My life doesn't always include enough sleep, and my good friend caffeine lets me pretend I living a normal, healthy life.
Except when it doesn't.
Recent literature suggests that much like other addictive drugs, once one is tolerant of caffeine, the boost one feels is really just the mitigation of the withdrawal syndrome. Caffeine, taken occasionally, increases alertness. Taken chronically, it simply helps prevent withdrawal.
And withdrawal sucks. I had some decaf today---my plan is to have a bit of caffeine for the next few days and then just enjoy decaf coffee, which is not completely devoid of caffeine, but the amount is pretty minimal. I love my coffee rituals---buying beans, grinding them, stirring them to evenly extract them. And I hate the lethargy and headache.
But I do enjoy even decaf, and I know the withdrawal syndrome will be over in a couple of days. Despite the fact that coffee does not appear to have serious risk in most people, it is definitely causing me some trouble, and I look forward to mitigating that.
And while I wait for the positive effects of quitting caffeine, I'm enjoying some of the benefits of being a dad on Fathers' Day. This morning, in addition to my decaf, we had fresh bagels (because any other kind are useless), hand-sliced Nova lox, and the usual additions such as Muenster cheese, sliced onion, and of course hand-packed cream cheese. And I stayed up late last night making lockshen kugel and despite not having a recipe, it didn't come out too bad. I'm stuffed. Another advantage to decaf: my dad usually drinks it, and there are few things I enjoy more than coffee with my dad.
And I'm with my kiddo. We're being decadent. We're hanging out in the guest room watching Disney while she snacks on edamame and I eat some leftover kugel. She has a room full of toys, and yet has entertained herself for the last hour-and-a-half playing with a pile of balloons and a couple pieces of styrofoam packing.
PalKid finished kindergarten last week, and we had to cut off four inches of her hair (which doesn't really look any shorter). Tomorrow she starts day camp, which means our morning routine together is over for now. But I have time planned for us this summer, if all works out. I'm taking her up to Canada for my usual gig as a camp doctor, and we've talked my folks into going up north with us for a week. By the end, she'll be good and tired of her daddy. And she'll be a first-grader. Everyone says kids grow up fast, but you never believe it changing a diaper in the middle of the night.
But one of the advantages of decaf is that tonight, after I tuck her in, I can pour myself a cup of coffee, look at pictures of my family, and think about what is past, or passing, or to come.

36 responses so far

Why are you wasting my time?

Jun 16 2010 Published by under Medicine

I've been teaching internal medicine for a number of years now. The practice of internal medicine falls into two broad categories; inpatient medicine, and outpatient medicine. Because of certain historical imperatives, internal medicine training is heavily biased toward inpatient education, and these days, inpatients are sick. To qualify for hospital care a patient must be receiving care that cannot be given outside the hospital; they must meet criteria for intensity of service and severity of illness. Ask any old-timer doc and they will tell you that hospitalized patients are much sicker than they used to be.

This makes hospital-based medicine very interesting. The acuity, the excitement, and the challenge are much different than primary care medicine. There is a real thrill in becoming competent at running a code or putting in a central line. In some ways, inpatient medicine is easier than outpatient medicine. Primary care requires a high tolerance for uncertainty---you can't run stat labs in the office, you can't monitor vital signs every six hours. The hospital feels safe to medical residents, while the office can seem simultaneously boring and confusing.

With that knowledge we can better understand a common complaint of patients, what we can call the "Why are you bothering me" problem.  When residents rotate through the outpatient clinic with me, they often wonder aloud to me why people bother to come in with "silly" problems, like the common cold.  That's when it's time to put the pen and stethoscope down and have a chat.

People come to the doctor because they want to feel better.  Most doctors want to help them achieve that goal, but healing isn't all about ripping out an appendix or performing CPR.  Leaving aside the fact that a lay person cannot always distinguish a bad cold from strep throat---an important distinction---people want a little healing, even the intangible kind.  People come to my office and pay me in order to hear my opinion, to get advice about feeling better, and to be reassured.  The fact that they are not always happy with my advice is a natural and important part of this interaction.  

It is important for all of us who are physicians to remember that there is no such thing as a stupid appointment.  If nothing else, the time can be spent getting to know someone new----misanthropy is not a good trait for a clinician.  And building that rapport can lead to more gravid revelations in the future.  Once you get a complete stranger to trust you, you start to experience "door-knobbing", where a patient, holding the doorknob on the way out says, "By the way doc...". That "by the way" is often the most significant part of the visit.  The cold they came in for becomes the mole on their leg that is getting bigger, or the heart burn that only bugs them when they climb the stairs.  

Once you have decided that a visit is a waste of time, the patient will share that conclusion, and will have no reason to tell you anything of consequence.  And that's not good medicine.

38 responses so far

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