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

Friday, July 3, 2015

C. difficile and hospital process measures

One of the more difficult things to cover is a study that you've already written about in an accompanying editorial. It's quite hard to come up with anything “new” to write that you haven't already written. Such is the case with a very nice study examining hospital process measures and Clostridium. difficile infections (CDI) just published in BMJ Quality and Safety by Nick Daneman and colleagues from Sunnybrook Health Sciences Centre in Toronto.

Using results of a mandatory CDI prevention practices survey they compared facility-level processes measures and patient level (via ICD-10 codes) CDI rates in 159 Ontario hospitals. Specifically, they looked at implementation of 6 hospital-level measures: (1) isolation at diarrhea onset, (2) audit of antibiotic use, (3) audit of environmental cleaning, (4) vancomycin as first line therapy and (5) on-site diagnostic testing and (6) reporting of rates to senior leadership. Somewhat surprisingly, none of the process measures were associated with lower risk of CDI.

In the editorial, Nasia Safdar and I wrote:

“First, the authors identified low self-reported implementation of most CDI prevention practices, with only 27% of facilities reporting isolation of all patients at onset of diarrhoea, and 16% reporting auditing of antibiotic stewardship practices. Low adherence rates for these two practices in particular are concerning because prompt institution of contact precautions is necessary to reduce nosocomial transmission of C. difficile. And antimicrobial stewardship is at least as important as infection prevention practices, if not more so, for reducing CDI.”

“This study also highlights the importance of implementation science research to tackle the vexing yet pervasive problem of low and variable adherence to evidence-based interventions for reducing HAI, including CDI. The scope of this study did not extend to exploring barriers to implementation or an in-depth assessment of the self-reported practices that may help inform implementation strategies to increase uptake of proven practices.”

and of course my favorite part:

“Last, increasing the evidence base for preventing CDI by undertaking pragmatic randomised controlled trials of novel interventions incorporating efficacy and effectiveness is essential to successfully bridge the quality chasm that currently exists in CDI prevention.”

Reference: Daneman N. et al. BMJ Qual Saf. 2015 Apr 24 (open access)

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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Thursday, July 2, 2015

We got this

July 1 equals new interns. Fresh young faces straight out of medical school stampeding teaching hospitals all over the land. Sounds scary, right? But honestly, it isn't like you think.


Their faces may look nervous but I've been doing this long enough to know that these young doctors are ready. Ready to step in and save your life. And if it makes you feel better to know that we are standing right beside them with our arms out now that the training wheels are off, know that we are. Our eyes ever watchful and encouraging, our examples offered with even more intention. Which creates this reciprocating engine of growth for us, the teachers, too. Year after year after year.

How cool is that?

Under the weather? Have no fear. We got this. All of us.


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.

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Friday, June 26, 2015

Final thoughts on my India tour

I spent 9 days in India, giving 13 talks in 6 days in 3 cities, Chandigarh, Hyderabad and Cochin. India is a country of contrasts and extremes. When it is modern, the modernity equals anywhere in the world. When it is not, the poverty is striking.

I spent much time with physicians, especially internists. Internists are the same wherever I travel. We have the same concerns about patients and interference from the government or insurers.

Internists find the diagnostic process interesting and most important. Indian physicians as well as American physicians understand this. Patients understand that diagnosis is the sine qua non of internal medicine.

We all cannot understand trying to assess value when we cannot easily assess diagnostic accuracy. We cannot understand giving a physician a good “report card” for treating the wrong diagnosis perfectly.

We all understand that medicine evolves and thus we must work to stay current. We all understand that discussing patient presentations leads to the best education.

Patients remain our best teachers. We must all learn to listen to our patients and think carefully about the lessons their presentation teach us. We can use patient stories to emphasize the importance of the natural history of disease or the appropriate pathophysiology or the side effects of treatment.

During my India trip, one physician told me this story. I will try to get the gist of the story correct. He told the story in response to my lecture on the dangers of guidelines and performance measures.

He was practicing in England at the time this incident occurred. England had just started their pay for performance project. An older woman was going to see her physician. She was having symptoms of uterine prolapse. Her daughter accompanied her, but she did not let the daughter come into the examination room because of embarrassment.

The physician comes into the room and starts reviewing each of her known medical problems with a focus on those issues that would impact his performance measures. He never asks for her agenda, and abruptly finishes the meeting.

The woman goes back to the waiting room, and has to tell the daughter that she never had a chance to seek help for her concern.

Performance measures can change the physician patient interaction. We are told that medical care should become more patient centered, while focusing on performance measures changes the physicians priorities. We do not have a good measure this concept.

Since quality has many dimensions, we must worry that focusing on some dimensions will decrease our attention to other important dimensions. This story describes a bad medical visit. But the physician likely scored perfectly on his measures.

Talking with Indian physicians has helped me understand the philosophical underpinnings of excellent internal medicine. Their insights in response to my talks opened my mind to important underlying concepts.

And I really did enjoy the sights and the food.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Tuesday, June 23, 2015

Let's consign shared hospital rooms to the dustbin of healthcare history

The medical world has made terrific scientific and technological progress over the last century. Previously incurable diseases can now be treated as day cases and patients no longer have to accept a paternalistic, 1-sided relationship with their doctors. Hospitals too, have a come a long way if you look at pictures of what they used to look like in those old black and white photographs. Whatever the current challenges of health care, nobody can doubt that patients now receive first class care each and every day across the nation's hospitals.

I remember when I first came to the United States a decade ago to start my medical residency in Baltimore, one of the things that impressed me most was the fact that no hospital room ever seemed to contain more than 2 patients together. Having just come from the United Kingdom's National Health Service, which on many levels I still admire, I would regularly round in rooms which would have up to 8 patients in a single large room—sometimes even more in the older hospitals. In this respect, the United States has been well ahead of almost every country in the world for a long time (some of which shockingly still have males and females together in mixed rooms). Nevertheless, as we propel ourselves further into the healthcare future, we can do even better and strive for that ultimate goal: single-bed rooms for all hospitalized patients.

Last year I wrote an article titled “Single bed rooms are a must for future hospitals” in which I listed a number of reasons why we need to move towards this goal. Chief among these are infection risk, patient satisfaction and privacy. These reasons cannot be overstated. I've seen concerns arise on an all-too-frequent basis in hospitals I've worked in. For example, the number of complaints I hear from patients who are disturbed by their neighbor and have found it difficult to rest are too numerous for me to count. I've also been asked many questions by anxious patients and families about whether their neighbor could pass on any infection to them. These are difficult questions for any physician to answer, because we know that for many conditions, it's theoretically possible.

As new hospitals are being built, it is heartening that lots of them are advertising the fact that they will only have single, private rooms. This should become the gold-standard. Think it's expensive? Imagine all the positives in terms of reduced infection risk, happier patients and a generally better reputation compared to nearby hospitals that don't have single rooms. I hope that in the not too distant future, certainly within my career, sharing a hospital room will become just as unacceptable as checking in at a hotel and being told that you have to share your room with a complete stranger! This is, after all, about so much more than convenience and personal preference. For our patients it's about dignity and respect at a low point in their lives.

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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Friday, June 19, 2015

Medical talks in India part 3, dangers of guidelines and the pirate's code

Visiting India, I have given several talks. Three times the hospitals asked for my “Dangers of Guidelines” talk. The talk starts with a famous quote from the “Pirates of the Caribbean” that goes, The Code is more what you call guidelines, than actual rules. This talk resonates with all physicians.

In it I talk about the guideline movement, why it started, and what has gone wrong. And much has gone wrong. We have too many guidelines, conflicting guidelines and “guidelines” without adequate evidence.

The worst part of guidelines is their transformation into rules, i.e., performance measures. Some guidelines transform positively into measures, e.g. patients with systolic dysfunction and no contraindications should receive a prescription for an angiotensin-converting enzyme inhibitor, chronic obstructive pulmonary disease patients with a resting oxygen saturation less than 88% should have home oxygen, and we should follow a checklist for central line placement (with a measure of the rate of central line infections).

At each site, the physicians express the same frustrations with “algorithmic medicine.” They smile when I saw that I can prove guidelines are flawed in 2015. The case of conflicting guidelines proves the point clearly. Guideline development succumbs to biases easily. Logic tells us that if guidelines were not subjective that differing organizations would develop the same guidelines. Conflicting guidelines (pharyngitis, screening for prostate cancer, screening for chronic kidney disease as examples) prove that the committees must inject a subjective assessment. Once we have such proof, then we must question the rest of the guideline movement.

We could develop “universal” guidelines, but only on selected problems. We would have far fewer guidelines and thus far fewer performance measures.

The Indian physicians understand this clearly. They see performance measurement coming on their horizon and they are concerned. We in the U.S. must address this incorrect approach to clinical judgment. We should urge everyone to adhere to the Pirate's Code. Allow guidelines to guide us, but not rule us.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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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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