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

Thursday, August 21, 2014

This is what we need more of

There’s a new randomized trial published in the Journal of the American Medical Association that evaluates the efficacy of post-cholecystectomy antibiotics in patients presenting with mild/moderate acute calculous cholecystitis. Upon diagnosis, all patient received amoxicillin+clavulanic acid 3 times a day pre-operatively and once during surgery. This open-label trial compared patients randomized to 5 days of post-operative antibiotics with the same antibiotic regimen vs. no post-operative antibiotics. Patients were followed up to four weeks post-operatively for SSI and other infections.

In the 414 patients, in the intention-to-treat analysis, the infection rate was 15% (31/207) in the post-operative antibiotic group and 17% (35/207) in the no-antibiotic group. The absolute risk difference was small (+/- 2.0%) and the 95% CI for the difference included zero for all key outcomes in the intention-to-treat analysis including superficial, deep and organ space infections.

The study appears to have high internal validity and randomization looks adequate. However, the lack of placebo and a relatively large non-inferiority outcome threshold (11%) are potential limitations. Of course, the study was also limited to amox-clav and perhaps some would favor testing other antibiotic regimens.

However, the lack of true difference will hopefully lead to further validation studies or adoption of a no post-operative antibiotic recommendation for this surgical procedure. This study and hopefully more like it are exactly what we need in order to reduce antibiotic exposure in hospitals and subsequent selection of antimicrobial resistant pathogens, including Clostridium difficile. It’s great to see important antimicrobial stewardship questions asked and answered.

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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Wednesday, August 20, 2014

Administrative burdens to blame for burnout in primary care

I spent this past weekend at a wonderful wedding in Richmond, where I lived for over 20 years. At the reception I had an important conversation with one of my former residents (I was an intern and he was a second year). I knew him before medical school, and have kept in touch for the past 37 years during which he worked in a classical internal medicine practice.

He quit primary care this year.

He loved his patients, and his patients loved him. He has a wonderful bedside manner, and is thoughtful and refuses to rush through his patients. He cannot do it anymore.

If this story was unique, then I would not write this rant. But this story is becoming commonplace.

Physicians want to care for patients. We want to spend sufficient time with the patient so that we can fully understand the patient’s problems. We try our best to aid our patients in the many dimensions of their illnesses.

We despise seemingly stupid documentation rules, which lead to many clicks in the electronic medical record. We hate pre-authorization requirements and device forms. We burnout when we are told that we are spending too much time with each patient. We burnout when the “suits” have no respect for our working conditions.

This physician has a job with the hospital now. His patients have to find another physician, not because he was tired of caring for them, but rather because the administrative complexities of modern practice put a dagger in his spirit. These complexities, all developed to standardize care for the better, are hurting patients. When we drive physicians like my friend out of primary care, we have a broken system.

As we discussed his personal situation, I could only nod and empathize. Unfortunately, this is not a new story; rather, it is an increasingly common one. I am tired of hearing it. But do the perpetrators of this nonsense understand in any meaningful way?

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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Life at Grady: The Interpreter

I saw a man the other day who mostly spoke Spanish, but who also spoke relatively okay English. So I came to see him and, because of his limited vocabulary in English, had a very “business only” encounter with him. Because of his pride, he didn’t want me to go off to get an interpreter. And so. I saw him and evaluated him. And that was that.

Another patient on the same floor spoke pretty much only Spanish. So I called the interpreter line and sat quietly at a computer charting while waiting for the interpreter to come to my rescue. After about ten minutes, up comes my blue-smocked comrade Ana, poised and prepared to bridge the gap between his Espanol solamente and my English only.

Ana was great and things went well so all was fine. We prepared to leave and Ana kindly bid me adieu. But just then, someone spoke words to her in Spanish from across the room. She walked a bit closer and we learned that my first patient, upon seeing me with an interpreter, had a change of heart about not communicating through his native tongue. Ana was super gracious and obliged.

And so. I will keep this simple. Here are 10 things I learned about my patient today after I’d already evaluated him but then returning to him with an interpreter. Some of the details are changed, of course, to protect anonymity.
1. He has been married for 38 years.
2. The part of Mexico that he is from is right in the center of the country which helps him to not mind about how landlocked Atlanta is.
3. The key to staying married for 38 years is to talk things out and share your feelings. Even if you get into a big argument, listen to each other and don’t just walk away. And always stick together.
4. Sons can be trouble. Girls are easier.
5. He has 9 children, 5 of them sons. But fortunately only one is really big trouble. The girls are all angels.
6. He has 29 grandchildren and more on the way. As in literally more on the way.
7. Atlanta has been his home for the last 25 years but since his whole community is Spanish speaking, he hasn’t fully mastered English. But he has come a really long way.
8. Even though his daughters are easier, the child that takes care of him the most and is the most helpful is one of his sons. (Who has 3 kids of his own and one on the way.)
9. Dialysis is frustrating.
10. Family gatherings at his house never have any less than 100 people.

And for the record? Not a single thing changed about my assessment and plan. But I know for certain that coming back to him and truly humanizing him was therapeutic for us both.

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.



Wednesday, August 13, 2014

Life at Grady: Nothing to lose

You were shivering and covered with goose flesh. A slick film of sweat enveloped your skin and stayed that way no matter how many times you tried to wipe it away. Food particles floated on top of the murky liquid in your emesis basin, sloshing back and forth on your lap with every tremble of your rebellious body. You looked up at me with eyelids at half mast; you tried to speak but could only moan. With your torso still quaking you finally got a few words out: “I-I-I-I fee-fee-feel like I’m gonna d-d-die.” And the look on your face when you said it made me believe you.

Damn. This wasn’t what was intended. You were supposed to make it over to your friend who said he had some money. Once you got the money, things would be fine. You’d get what you needed before feeling like this set in. But you stepped off of that bus and walked those four blocks just as you said you would. Problem is, when you knocked on that flimsy screen door, the person who came to greet you wasn’t your friend.

“He ain’t here,” the other person said. You could feel the urgency welling up inside of you. Your head cocked sideways as you studied the person on the other side of that screen. He had you by at least 50 pounds but that didn’t stop you from making a quick assessment about whether or not you could take him down.

“He's supposed to have some money for me. Did he leave it?”

The other person just laughed out loud when you said that. Then, intuitively he stopped and said, “Don’t even think about getting froggy and trying to leap on nobody neither ‘cause it won’t end pretty for you.” That urgency turned to desperation when he slammed the wooden door shut in front of that screen. You started to knock, begging for something, anything he might have in there but the minute you heard that loud click you stepped away. Was it a deadbolt or a Glock? You weren’t sticking around to find out.

Light became dusk. And dusk became dark. That urgency and desperation evolved into physical sickness. Innards threatening to hurl and bones feeling like each one was being broken from the inside out. And this? This wasn’t what was intended.

Calmly, I took your medical history. I asked you about your story and listened as you told me what happened through your chattering teeth and glistening face. But honestly? The explosion of red confetti dots covering your left hand and forearm explained it all. Well, not all of it. But at least it explained your immediate clinical picture.

“How did this happen?” I asked.

Somehow you got what I meant by that question. You knew that I wanted to know how this happened. All of this. You spending your days roaming around and hoping to get what you need to not feel like you feel now. At what point you even stepped into the threshold of this shitty existence. And I am thinking of that adjective to describe it because this just could not have been what was intended for you life.

“I got in an accident. A bad one. They gave me some pain pills and they gave me a couple of refills. Next thing I knew, I was hooked.”

“Dang.” You offered me up this lopsided shrug when I said that and something about that gesture made me sad. I squinted my eyes as I tried to sift my brain to get the course of events. Then it clicked and I nodded slowly. “First the pills . . .then. . I guess you turned to heroin because it was easier to get?”

“That and way, way cheaper. It hits you harder, too.” You winced between sentences and then went on. “Nobody get on this stuff like they did in the old days. Just about everybody I know that shoot up or snort heroin started off on pills. First they was prescribed by a doctor and then all hell broke loose. Like I don’t know nobody that just chose heroin to get blowed right off the rip. No way. It’s just the way to keep from getting sick.”

I just stared at you when you told me that part. My body filled up with these complex emotions that were hard to get my mind around. Pissed that the medical profession was now a new part of an old problem. Intrigued by this suggestion that shooting up heroin just for the sake of getting high was as played out as Tab soda. Pills had become the Coke Zero, and for many it was on accident. In other words, it wasn’t what was intended. By the patients or by their doctors when they acquiesced and gave “just a little” of “something strong.”

“So you don’t know folks who just decide to give it a shot? I mean, no pun intended.”

“Naaah. Not really. Not no more. Maybe some really stupid rich kids. But most folks I know start with pills. For real. The needles don’t come until they go broke from buying pills. Then, as for the other drugs, once you all caught up in the life, you just in it. So you’ll try whatever, you know? Meth, heroin, speedballs, all that.”

Again, I said nothing. I mean, what could I say? Instead I just sat there pondering this quote from James Baldwin because that’s what that last sentence made me think about.

“The most dangerous creation of any society is the man who has nothing to lose.”

~ James Baldwin

Let me tell you. Some of the deepest truths I’ve learned about addiction have come from simply listening to the voices of my patients. Patients who have lived it or who are living through it. People like my Uncle Woody or like my patient who explained to me the real truth about how a crack addiction develops. And every time it is nothing like what I’d seen on television or heard through urban lore; the common thread being that this--the wretched monkey now perched upon their backs--was never, ever what was intended.

No it was not.

The sad truth is that there was little we could do for you without resources. I couldn’t carefully place you into the open arms of an inpatient rehab facility nor could I hospitalize you until I could. Instead, the ball was placed into your court forcing you in your broken state to dribble down a full court and shoot.

You left before I could wish you luck. That ball before you turned out to be an airball. Your sheets were empty before I could even get back down to you.

I guess in my Pollyanna-ness I imagined this brief encounter as something more pivotal than it was. I pictured us plotting your comeback and me running into you somewhere looking robust and strong someday. And I swear to you, I believed that this could be your story. I did.

But as of today? This wasn’t what was intended. The magnetic pull of your own back alley hospitals was greater than me and my scattered words of encouragement. In your mind, you had nothing to lose at this point--and maybe you were right.

I guess I just wish I could have convinced you of all you had to gain.

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.


Tuesday, August 12, 2014

What the HAC?!

The University of Wisconsin (UW) Hospital is an excellent institution with a stellar infection prevention program. In fact, last year they won the prestigious U.S. Department of Health and Human Services (HHS) Partnership in Prevention Award, which recognizes “prevention leaders in the U.S … who have achieved wide-scale reduction and progress toward elimination of targeted health care associated infections.” Sadly, this achievement may not be enough to keep HHS from levying financial penalties against UW for high infection rates.

Yes, the Hospital Acquired Condition (HAC) scores have come out, and have been generating a fair bit of media coverage, focused on those hospitals most likely to face financial penalties. Funny thing, though—the hospitals most likely to lose money under this program share a lot of characteristics:

“Who is getting penalized? Large, urban, public, teaching hospitals in the Northeast with lots of poor patients. Who is not getting penalized? Small, rural, for-profit hospitals in the South. Here are the data from the multivariable model: The chances that a large, urban, public, major teaching hospital that has lots of poor patients (i.e. top quartile of DSH Index) will get the HAC penalty? 62%. The chances that a small, rural, for-profit, non-teaching hospital in the south with very few poor patients will get the penalty? 9%.”

Interesting. Explanations for these findings include: (1) small size, rural location, southern region and for-profit status magically translate to higher-quality, safer care, or (2) this HAC metric is bullshit, as it obviously doesn’t adequately control for myriad variables that are associated with the score but that are not indicators of quality and safety. What variables? Intensity and accuracy of surveillance, and variation in infection risk of the different patient populations, for starters.

I can overlook bullshit when it brings more attention (and resources) to the critical task of infection prevention. Unfortunately, this particular form of bullshit does the opposite (unfairly punishing already cash-strapped hospitals with financial penalties). As others have pointed out, the current HAC metric is well-intentioned but obviously flawed, and in desperate need of fixing.

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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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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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