American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, July 23, 2014

Life at Grady: Insulin showdown

Grady Primary Care Center, Summer 2014

Patient assessment: Poorly controlled diabetes

Plan: Initiate insulin therapy

“I think I can manage this with diet and exercise.”

“I believe that being careful about your diet and getting more exercise will help. But my recommendation is that we start you on insulin. I know you don’t like needles, but--”

“I’m definitely not taking insulin. That’s out of the question.”

“I see. Remember that blood test we checked? The A1C test?”

“The one that says how your sugars have been for a whole month?”

“Sort of. More like three months. But yes, that.”

“I remember.”

“Well. Yours was very high. In the double digits.”

“Where should it be?”

“I’d be ecstatic if it was between 6% and 7%. It was 12.5%. That calls for insulin.”

“I hate needles. You’ll have to try something else.”

“You’ve tried pills already. They aren’t working. You need insulin.”

“Is there an insulin that isn’t given through needles?”

“Not that I have to offer.”

“Oh well.”

“I’m sorry. I wasn’t sure what you meant by ‘oh well.’”

“I meant, ‘Oh well, guess we in a jam, ain’t we?’”

“Aaaah. I see. I guess we are then.”

“Insulin ain’t gonna happen.”

“I hear you. And I’ve already talked to you at length about the things that can happen if you ignore your high blood sugar, right?”

“You have. And I’m not ‘ignoring’ it.”

“Well, I meant not doing whatever it takes to control it. Sorry about that.”

“I’ll do anything. Just no insulin.”

*pause for a moment*

“Okay. Well listen--I’m pretty disappointed that I can’t convince you to go with my recommendations. I have the pharmacists here and everything to teach you about using insulin. But I guess you’ve made up your mind.”

“So what pills are you going to add?”




“What the hell?”

“You need insulin. And that is my recommendation. You’re already on three different pills for diabetes. They aren’t enough. At this point, you need insulin.”

“Well, I am letting you know that I need an alternative.”

“I don’t have one.”

“So that’s just it? Insulin or nothing? That’s crazy.”

“I’m sorry you feel that way.”

“Why can’t you just up my pills some more?”

“Because that isn’t right. And it won’t be enough.”

“Hmmmph. I feel like you’re forcing insulin on me.”

“I’m sorry you see it that way. I just care.”

“You care about making money.”

“Making money? Um. No. Definitely not the case. You just need insulin.”

“I have a question. If I was your own sister what would you do? Your own sister with high blood sugar who really, really, really didn’t want to take insulin.”

“My sister? Oh, that’s easy.”


“I’d pin you to the ground with my knee in your chest and hold you there until you got your insulin. I’d sit right on top of your and draw it up and stick you in the back of the arm. Sure would. And I’d do it every single day until your A1C was under 7.”


“Are you serious? That’s what you’d do to your sister?”

Dead serious.”

“You’d put your knee in her chest?

“You’d better believe it. Or I’d just put her in a headlock.”


“Damn. I’m just not ready for insulin.”

“I hear you, sis. But listen--insulin is ready for you.”

“I hear you, doctor.”

Do you? Like really hear me?”

“Yes. And I can feel your knee on my chest.”

“You can?”

“I can.”


*both smiling*


Happy Wednesday. And yes, she took insulin.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.



Don't use feeding tubes for advanced dementia, geriatrics society says

Feeding tubes are not recommended for older adults with advanced dementia, according to a position statement from the American Geriatrics Society. They don’t prevent complications of hand feeding, led to complications, and take away life’s simples pleasures of eating and interacting with others.

Hand feeding is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort, the statement reads, and tube feeding is associated with agitation, greater use of physical and chemical restraints, tube-related complications, and development of new pressure ulcers.

The position statement appeared online July 17 at the Journal of the American Geriatrics Society.

Among the rationales:
• Survival is not better in those who are tube fed rather than hand fed;
• There’s no evidence that tube feeding prevents aspiration, heals pressure ulcers, improves nutritional status, or decreases mortality;
• Tube feeding is associated with aspirations, malfunctions, oral secretions that are difficult to manage, discomfort, use of physical and chemical restraints, and pressure ulcers;
• Nursing home residents frequently need to be transferred to the emergency department to address tube-related complications such as blockage and dislodgement; and
• Greater levels of discomfort have not been observed, despite eating difficulties.

The position statement recommended involving families about the natural progression of dementia, including eating difficulties, and acting proactively to make decisions through advance directives. It also suggested enhance oral feeding by altering the environment and creating individual-centered approaches.

“Oral feeding may be one of few remaining pleasures and a time for socialization for a person with advanced dementia,” the statement reads. “Mealtime must be regarded as an event of importance, instead of a task that needs to be completed as soon as possible.”

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Tuesday, July 22, 2014

Stewardship effective in C. difficile prevention: a meta-analysis

As Dan Diekema, MD, FACP, mentioned last week, when 15% of asymptomatic hospitalized adults carry toxigenic strains of Clostridium difficile, it should alert us to focus on antimicrobial stewardship as a way to prevent C. difficile infections. But how effective are stewardship programs and does it matter what type of program you implement in your hospital? If only there was some sort of systematic review or meta-analysis to guide or decision making.

As if on cue, Leah Feazel and Marin Schweizer at University of Iowa published such a review and meta-analysis titled “Effect of antibiotic stewardship programmes on Clostridium difficile incidence” in Journal of Antimicrobial Chemotherapy earlier this spring. Typical of projects completed by Marin and her group, they thoroughly combed the literature for papers. Here they identified 891 articles, reviewed 78 full articles and included 16 studies in their final analysis. Over all, stewardship programs were associated with a 52% reduction in C. difficile infections incidence. Importantly, programs appeared effective when implemented in whole hospital or geriatric settings and when utilizing a persuasive approach or a restrictive approach. I’ve provided the forest plot of studies below. An additional note is that the studies utilized various quasi-experimental study designs and based on the funnel plot, there appeared to be little publication bias.

Key points: (1) Stewardship works for C. difficile infections prevention, but it would have been nice if there was at least 1 funded randomize, controlled trial or cluster-randomized, controlled trial. (2) The meta-analytic approach, that Marin has pushed through her reviews of surgical site infection bundles and hand hygiene interventions, is a fantastic way to guide medical decision making and should be considered for inclusion in future hospital acquired infection guidelines. The reality is that infection prevention studies overwhelmingly utilize quasi-experimental designs. Why not identify the highest-quality QE studies and rigorously meta-analyze them as done here?

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Young women with heart attacks face more mortality, longer hospital stays

Young women with heart attacks have more comorbidity, longer hospital stays, and higher in-hospital mortality than young men, although their mortality rates are decreasing, a study found.

To determine sex differences in clinical characteristics, hospitalization rates, length of stay, and in-hospital mortality by age group and race among young patients with acute myocardial infarctions (AMIs), researchers applied data from the National Inpatient Sample for patients with AMI across ages 30 to 54 years, dividing them into 5-year subgroups from 2001 to 2010.

Results appeared in the Journal of the American College of Cardiology.

There were more than 230,000 hospitalizations with a principal discharge diagnoses of AMI in 30- to 54-year-old patients, or nearly 1.13 million hospitalizations. Women were nearly 26% of young patients hospitalized with AMI. There were no statistically significant declines in AMI hospitalization rates age groups younger than 55 years old, or when stratified by sex.

Hospitalization rates for AMI were higher in men compared with women across all age subgroups. The absolute number of discharges for AMI among women increased from 56 per 100,000 in 2001 to 61 per 100,000 in 2010. But, the absolute number of discharges for AMI among men decreased from 174 per 100,000 to 171 per 100,000. Although absolute declines were noted for most subgroups of men, women showed either no change (30 to 34 and 35 to 39 years of age) or a slight absolute increase (40 to 44 and 45 to 49 years of age) in hospitalization rates.

Women had higher in-hospital mortality than men across all subgroups. From 2001 to 2010, overall observed in-hospital mortality for women with AMIs declined from 3.3% to 2.3%, (a 30.6% decrease; P for trend<0.0001). For men, the decrease for men was from 2% to 1.8%, (an 8.5% decrease; P for trend=0.6).

Authors noted that the results suggest a greater need for intensive primary prevention efforts in the high-risk young population, and that young women may gain more benefit from aggressive control of cardiovascular risk factors such as hypertension, hyperlipidemia, obesity, smoking, and diabetes.

An editorial stated that persistent excess mortality among young women emphasizes the ineffectiveness of current practices and the need for sex-specific research and guideline development. “It remains vital that sex-specific differences in guidelines constitute more than 1 page of our large guideline documents.”

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Friday, July 18, 2014

When a well-intentioned, authoritative 'no' is better than an insincere 'yes'

The above title may sound rather controversial at a time when patient satisfaction and improving the health care experience is a hot topic around every hospital administration table. It’s something that I’ve thought and written a lot about and also personally feel very strongly about, because nothing short of total commitment to our patients is required when they are at that low point in their lives. There’s so much room for improvement.

Unfortunately though, as hospitals grapple with the issue of how to make the health care experience a better one, some of the ideas being put forward are rather gimmicky. For instance, I’ve seen name badges saying “Have a nice day” or “What can I do to help you?”, which are probably more appropriate for an auto shop or fast-food restaurant. Physicians and nurses simply shouldn’t be wearing them! An attorney, teacher or even a banker wouldn’t dream of wearing that on their suit, so why should a doctor wear it on their white coat? We must keep our respect as a profession and remember that the main driver of patient satisfaction will be the human interaction between doctor and patient. Everything else is secondary.

There are in fact some very real differences between customer service in hospitals and customer service in other arenas. The mantra in the business world that “the customer is always right” does not hold true for many scenarios in health care, when the patient doesn’t know what’s best for them. This is not meant to sound paternalistic, because patient-centered care is the right way forward, but there are definite limits and boundaries in health care. Making informed choices, yes. Being in charge of their own health care, yes. But the reality is that doctors often do know what’s best based on their professional knowledge. Examples include prescribing the most appropriate medication, recommending a certain type of surgery, and not being over-zealous with pain medications, despite the patient’s wishes. In fact, not doing what they think is right may frequently lead the physician down the path of inferior patient care.

The best, and for that matter most popular, physicians that I’ve observed have actually been far from “customer service” types. Not that they don’t strive to go the extra mile for their patients and provide the best possible care, but they also balance their compassion with a strong personality and strong principles too. They are physicians that know when to say “no” and are not afraid of telling their patients what they need to hear and not what they want to hear. Sometimes what they say to their patients could be construed as bordering on rudeness to an outside listener, but their rapport is good enough to negate any hard feelings. I’ve encountered several dozen physicians like this, most of them the “old-school” types near retirement age, and never fail to hear positive glowing reviews from their patients who truly respect them. These are the role model doctors for me. It’s what we have to remember if we think any patient needs a “yes man” doctor to get good medical care. Patients actually respect a well-intentioned authoritative “no” rather than a smiling insincere “yes” over a long-term relationship. Indeed, in most areas of life, this is the case. It holds true for a family member, friend, or even a politician! A recent article in Forbes magazine discussed this very issue, in a piece titled Dr. House Was Right: Give Patients What They Need, Not What They Want”. The article described how patient satisfaction is tied to higher costs, and more concerning—higher mortality. It posed an interesting question between choosing between a nice doctor or a brilliant doctor. The author chooses the latter. However, the 2 don’t have to be mutually exclusive. They can be perfectly balanced. It would be a big mistake if we train the next generation of doctors to be “yes men/women” types in the fear of being seen as giving poor customer service or worried about poor patient satisfaction scores. In our relatively new internet age, when online ratings are available in a second, it’s understandably a worry for many doctors. This has turned medicine into a completely new ball-game that the older generations didn’t have to concern themselves with. Gone are the days when doctors could be safe in the knowledge that they were good at what they did and had patients flocking to them. Will the patient give me a bad review if I don’t do exactly what they want? Should I try to make my patient happy even though I know it’s not good for them?

Patients should know that it may be a mistake to seek out a doctor who pleases them, or use online recommendations to choose them. If you want to find a good doctor, nothing could be better than a solid word of mouth recommendation from a family member or friend.

New physicians should understand that their best peers aren’t necessarily the ones with the best ratings. They should be guided by their knowledge, principles, and stand firm if they believe something is right. As we endeavor to provide excellent care and a better experience, doctors shouldn’t be striving to make their patients happy at every opportunity. We should be striving to make our patients better. With a dose of compassion, empathy and sincerity—the rest will take care of itself.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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