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Wednesday, December 28, 2016

Suicide, psychiatric care and inadequate resources

An article released today in the JAMA sites evidence that the suicide rate in America has risen by 24% in the last 15 years associated with a significant reduction in the numbers of psychiatric beds available. The US has had a lower capacity for psychiatric patients than comparable countries in Europe for years, but in between 1998 and 2013 that number dropped even further.

Waiting in the ER for days

This trend has resulted in atrocious treatment for people with mental illness. Because it is so difficult to find room in a mental hospital for patients with mental conditions that make it unsafe for them to return home, such as suicidal thoughts or intentions, we sometimes see these people spend days or even weeks in emergency rooms just waiting for something to open up. I never saw this a decade ago, but now it is not uncommon, even in our small critical access hospital, to see a patient in one of the little windowless and noisy cubicles of our ER for days at a time. They can't move upstairs to a more comfortable, if inappropriate, hospital bed because our hospital cannot offer psychiatric hospitalization because we have no psychiatrist on staff. Psychiatrists are rare in small towns.

Many factors led up to this

This situation is a slow motion car wreck, not an all of a sudden sort of thing. Care for people with mental illness has been spotty and often terrible in the US, but has generally had a trajectory that aims toward better care and understanding. Early in the 19th century an approach called “institutionalization” created mental hospitals which were intended to care for people with what was then untreatable mental illness for long periods of time. These institutions fostered dependence, usually did not cure or treat psychiatric disorders, made patients vulnerable to abuse and, to top it all off, were quite expensive. Some of the costs were defrayed by unpaid work required of inmates, but in 1973 a court ruled that they were owed at least minimum wage, making the overcrowded and expensive institutions even less viable. Starting in the 1960's a strong movement, led by mental health pioneers, pushed for deinstitutionalization. It was argued that most mental patients could have their needs met by community mental health centers and could live in sheltered living situations such as halfway houses. Many state mental hospitals were closed in the 1970's and 1980's, with good and bad results. The number of severely mentally ill people who are homeless did increase significantly, putting a higher burden on already stressed acute care hospitals. Drug therapy for depression, bipolar disorder and schizophrenia began to be more effective, though, which meant that some people with these diseases genuinely got better and were able to be successfully independent.

Medical insurance and mental health

There was less capacity for inpatient care of mental patients after deinstitutionalization, but for many of these people any care at all was prohibitively expensive because most insurance plans had little or no coverage for mental health issues. In 1996 the Mental Health Parity Act was passed which required health insurance companies to cover mental health costs up to the same dollar amount as covered for medical or surgical care. Insurance companies quickly circumvented this by restricting numbers of visits and numbers of days in the hospital. In 2008, as the real estate market, banks and stock market were going up in flames, a rider was placed on TARP (Troubled Asset Relief Program--otherwise known as the bank bailout) called the Mental Health Parity and Addiction Equity Act. This was worded in such a way that mental health care is now generally covered by insurance.

It is wonderful that people with depression, schizophrenia, bipolar disorder and other serious mental illness can get help without necessarily bankrupting their families. This can mean that people get treatment for these problems before they get serious enough to require hospitalization. It probably also increases the demand for psychiatrists and psychiatric beds, both of which are in short supply.

The American psychiatrist: an endangered species

Psychiatry is not a very popular specialty. Out of about 30,000 residency positions each year, only 211 were for psychiatry in 2014-15. That would translate to 211 new psychiatrists for the whole US the year they complete training, assuming all of those candidates finish the program and choose to practice in the field. Many psychiatrists are aging and retiring and there is already a critical shortage of psychiatrists to meet our present needs. Psychiatry is one of the lower paid medical specialties and is a difficult row to hoe. Successful treatment of patients is very dependent on variables over which a psychiatrist has no control, such as community support, housing and job programs.

Prisons: our new insane asylums

Prisons now house a tremendous number of people with mental illness. In 2007 the Department of Justice reported that 24% of jail inmates had symptoms of psychosis, about a quarter of people in jails and prisons had a history of mental illness and a higher percentage had symptoms of mania and depression. The total number of patients in state mental hospitals is about 35,000 and the number or mentally ill people in prison is over 10 times that number. It is very difficult for people dealing with mental problems to tolerate the stresses of incarceration, leading to high rates of injury in fights and attempted suicide.

But people with mental disorders who are at risk for injuring others or breaking the law are more likely to get a bed in a psychiatric facility than people who are simply miserable or increasingly psychotic and have not broken the law, who could really benefit from a stay in a psychiatric hospital to stabilize their medication and give them intensive treatment. It is those miserable, suicidal and psychotic to the point of inability to care for themselves people who end up in emergency rooms for days awaiting a bed.

What would it be like...

I can only imagine how it feels to be seriously mentally ill in some of these situations. Picture being seriously depressed or anxious and being in prison, where kind words are mostly non-existent and there is nowhere to take comfort. Or schizophrenic, hearing voices that break you down, surrounded by nobody who cares. I can hardly allow myself to conceive of depression, anxiety or psychosis while homeless, exposed to the rain and the cold and vulnerable to assault. Closer to home are the patients who wait in the emergency rooms, with nothing to do, no chance to go outside, take a walk, lying on a 30 inch wide gurney covered with rumpled sheets, contemplating suicide while having no idea what is happening and when.

If we were to fix this, what steps would we need to take?

Clearly we need more psychiatrists. We also need more psychologists and they need more authority to treat, including with medications. This is a different conversation, with intrigue that I don't really understand. But we do need psychiatrists, MD trained, motivated, excellent at what they do, and we need to pay them in accordance with how vital their work is. There are already incentive programs to train as a psychiatrist and work in underserved areas, but we need more incentives.

We need more capacity to take care of patients in hospitals, for those times when things get too intense for them to survive independently.

We need systems to help take care of people with mental illness who need jobs and housing and treatment for substance abuse. We need to strengthen social networks in neighborhoods and communities. This is vitally important for keeping patients out of psychiatric hospitals and out of prison.

We need to shift people with mental illness out of the prisons, which are overcrowded, overused and dysfunctional. This will involve better and more capable staffing and better oversight along with more capacity to take care of them in psychiatric hospitals and community mental health facilities.

We need to support the families of these patients because they are often the only stable thing in their lives. Patients with mental illnesses often burn out their families which is a tragedy in so many ways. Programs to support families, including caregivers and assistants to help support patients' independence should be strengthened.

All of this will cost money, but I suspect not more money than we are presently spending on our dysfunctional systems. Shifting money towards appropriate care for people with mental health problems will not only reduce costs that go to warehousing many of them in the prison system and the cost of acute medical care for the homeless and those plagued with addiction, it might also decrease the overall national burden of misery, hopelessness and isolation.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Friday, December 23, 2016

Sepsis bundles and why sensitivity and specificity matter

Graham Walker(@grahamwalker) tweeted this in response to a blog post:

“Agree w @medrants on Abx usage. Sepsis guidelines mandating Abx for anything that COULD be sepsis is the problem”

I responded that his example is brilliant. Let's dissect the problem.

Sepsis is a severe problem that responds better to early aggressive treatment.

Those invested in diagnosing sepsis desire bundles that have a high sensitivity. In case you forgot the definition of sensitivity, it is the true positive rate. Sensitivity here represents the percentage of sepsis patients that you treat promptly. Sounds good; we do not want to miss any patients with sepsis.

But wait! All tests or bundles have both false negatives and false positives. We want to minimize our false negatives, but we cannot do that without increasing the false positives. Since specificity equals 1, the false positive rate, we have a tautology. Increasing sensitivity means decreasing specificity.

Anyone who spends some time considering this problem will understand that a sepsis bundle that errs on the side of diagnosing sepsis will have the expected consequence of giving antibiotics to a significant number of patients who do not have sepsis, but rather other reasons for matching the criteria in the sepsis bundle.

We love antibiotics when appropriately used, but antibiotics are not benign. Patients who received broad spectrum antibiotics suffer the risk of antibiotic associated diarrhea, allergic reactions and other side effects. Broad spectrum antibiotics increase the emergence of antibiotic resistance.

The problem that Dr. Walker describes (and again I quote one of his tweets):

“Lact 2-3.9 and admitting them for their GI bleed? You'd better give them abx, and quickly!”

As he implies, we need physicians to understand the patient's context. Simple guidelines that include a check box will treat many patients appropriately, but still too many patients inappropriately.

Any premortem examination of these bundles would quickly identify this problem, yet most hospitalists have had these bundles enacted without considering the patient's context.

Now the good news:

The Centers for Medicare & Medicaid Services (CMS) updated the Severe Sepsis and Septic Shock: Management Bundle (SEP-1) measure specifications several times in response to newly published evidence. As a result, CMS will not score the SEP-1 measure validation for Hospital Inpatient Quality Reporting (IQR) Fiscal Year (FY) 2018. CMS is also postponing the public reporting of the SEP-1 measure on Hospital Compare until it is confident that it has valid data that reflects hospitals' performance.

But I doubt that hospitals will reconsider these bundles. CMS discontinued the 4 and then 6 hour pneumonia rule, but still too many patients get antibiotics and are labeled community acquired pneumonia in most emergency departments. While CMS will not be reporting, the sepsis boulder will keep rolling downhill and gaining speed.

And then we will wonder about overuse of antibiotics and emerging antibiotic resistance.

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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Monday, December 19, 2016

Recovering--a sacred time

One day a few weeks ago, after returning from a set of seven 12-hour shifts in a hospital away from home, my husband convinced me to go to a concert. The group performing was the Deviant Septet, based out of Brooklyn, N.Y. They were an odd combination of instruments and they played mostly newly composed music.

The second piece in their program was by Chris Cerrone and was called “Recovering.” I expected nothing, perhaps a nap even, but was completely absorbed by the music which wordlessly represented a magical period that I get to observe regularly but rarely remark upon.

Patients come in to the hospital when they are sick, and often getting sicker. They are vulnerable and place themselves in the hands of strangers. Usually they feel terrible. We do things to them to try to make them better. Often we are successful. And then something magical happens. Their faces look brighter. Their vital signs stabilize. Their eyes focus. They make jokes. It's still not over, though. There are setbacks. There is pain. They are weak and their appetites are not vigorous. But a gate has been passed through.

I don't often take the time to appreciate this transition. For me it is often filled with new concerns. What next? How can we all avoid this kind of event in the future? How much more time before this person can leave the hospital?

This piece of music took me back to the times when I was sick and finally getting better, when the world around me began to be relevant again, and sometimes beautiful. It reminded me that there is a thing that happens, this “recovering”, and spending a little time noticing it will be a good practice.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Monday, December 12, 2016

We used to sell cigarettes in hospitals

Nice article in STAT, a relatively new Boston Globe-affiliated publication devoted entirely to health care. Melissa Bailey reminds us that Candy Stripers used to sell cigarettes to patients to comfort them while hospitalized.

How quaint.

She goes on to point out 5 practices that will seem just as antiquated. Soon, we hope.
1. Advising doctors not to say, “I'm sorry.” Hospitals still do this. It can be seen as an admission of guilt, the thinking goes.
2. Have prescription labels that don't indicate what the medicine is for. How smart. And not even close to standard at present.
3. Not washing our hands in front of you every time. ‘Nuff said.
4. Spending more time typing than talking and listening to you. We can hope, can't we?
5. Easily getting your medical records, without your having to pay, wait, fill out forms, or just be hassled like you're asking for state secrets.

I think this is an excellent list. There are no doubt dozens more. (Why do we awaken people in the hospital so often?) What are your ideas for health care pet peeves you'd like to see abolished?

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Friday, December 9, 2016

Did you get your money's worth today?

It started as a joke, but it has become a mantra. I discuss this phrase on the Curbsider's podcast.

Our medical students pay (in my opinion) an obscene tuition. They are buying a medical education. Therefore we should remember that they are customers who have paid for our service.

As a clinician educator, I try to remember every day that I owe the learners my best effort. I have a wonderful career caring for patients and teaching those learners. The learners make my patient care responsibilities much simpler. But my job involves helping all the learners grow each day.

Learning internal medicine requires persistence and hard work. Our field is vast and complex. We start with naive third year students, have fun with acting interns (fourth year students), help interns through that difficult year and have the pleasure of fine tuning our excellent residents.

Inpatient rounding and clinic attending require us to strive that our patients receive high quality care. During patient care delivery we provide role models and work daily to stretch our learners. We owe them our best effort at helping them grow.

Each day I ask myself, did I give them adequate value. Ask yourself and your learners. Did you give them their money's worth?

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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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