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

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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Thursday, December 8, 2016

The how-to guide for Mycobacterium chimaera

A few cases at a time, the Mycobacterium chimaera outbreak associated with heater cooler units (HCU) continues to grow. For reasons unclear to me, the response from CDC and FDA to this train wreck in slow motion has been underwhelming. We continue to field calls from hospitals struggling to deal with an approach to the outbreak.

On today's IDSA list-serv (IDea Exchange) Dr. Luther Rhodes wrote: ”The silence is deafening. I call on those physicians with hands on experience in evaluating post open heart patients referred to ID for evaluation of concerns, signs or symptoms of possible NTM infection to speak up loudly and clearly. Lessons learned, protocols developed, evaluation and testing tools learned dealing with large scale regional patient notification should in my opinion be shared …”

We have posted several times on this topic, but I thought it might be useful to summarize how a hospital could approach this problem in a single post. To view older posts, type chimaera in the search box in the top right hand corner of your display.

Step 1: Determination of risk

Whether you have seen a case or not, the first question is whether your hospital has used the LivaNova Sorin T3 heater cooler unit (HCU) in the last six years. If the answer is no, there is no immediate action you need to take. If yes, then the investigation begins, as you must assume the units are contaminated, regardless of the manufacturing date.

Step 2: Risk mitigation

If you are currently using the LivaNova (Sorin) T3 unit, the most important risk mitigation strategy is to get the units out of the operating room. The molecular epidemiology clearly points to contamination of the HCUs at the manufacturing facility, which allows the units to produce an infectious bioaerosol that contaminates the operative field. Separation of this bioaerosol from the operative field is the key to eliminating the risk. Why the FDA won't clearly state this is very puzzling.

At the University of Iowa Hospitals and Clinics our engineers were able to quickly (within a few days) devise a solution by creating a 6” x 6” hole through the operating room wall on the semi-restricted side of the room. The area identified for creation of this portal was determined by hose access to the OR table with minimal interference with staff and equipment; access to power; and the ability to leave proper corridor width per life safety code.

Testing demonstrated that positive pressure was able to be maintained in the OR after creation of the portal. The portal itself with a sliding door was constructed of Corian in some cases and stainless steel in others. A hose protection mat was placed in the ORs to protect the HCU hoses and to provide a ramp effect for equipment to be relocated as needed during the cases. One advantage of the T3 HCU is that remotes can be purchased that allow the perfusionist in the OR to control the HCU located outside of the room.

Once the HCUs were moved out of the OR, we demonstrated no difficulty with appropriate heating or cooling. Remember, given the long incubation and detection period of these infections (maximum 6 years to date), if you do not eliminate the risk now, you will likely be chasing cases for many years with no end in sight.

We do not believe that culturing HCUs for M. chimaera is helpful. Most laboratories are not adept at performing environmental cultures for mycobacteria, so the negative predictive value of cultures in this setting is poor. In other words, if cultures are negative, you cannot assume that your machines are not contaminated. Moreover, even when cultures are performed in expert labs, the culture results for any given HCU are not consistent over time; they may be negative at first sampling, then positive on subsequent samples, or vice versa. And it has yet to be demonstrated that once a HCU has tested positive it can be successfully decontaminated, which is an additional reason that we believe that elimination of risk requires removal of the HCUs from the OR.

Follow manufacturer's recommendations for cleaning and disinfection of HCUs.

Step 3: Case identification and notification
1. Develop a line list of potentially exposed patients by determining exposure to HCUs over the past 6 years. At our hospital, we found that the easiest way to do this was to identify whether a perfusionist was assigned to the operative case as identified via billing records. It is important to note that you will need to include off pump cardiac cases, since the HCU is typically on “stand by” status, turned on and running in the OR, even if the patient is not on cardiopulmonary bypass. Also, cardiopulmonary bypass is not restricted to cardiac cases; some lung and liver transplants are performed with cardiopulmonary bypass.
2. Notify potentially exposed patients. We began by sending a letter, explaining the problem and asked patients to call a toll free number to speak with a nurse who did a symptom screen on the phone. Patient who screened positive, were advised to see their local physician or to come to a clinic that we set up for evaluation. A letter to physicians was included with the patient letter and patients were instructed to take the letter to their physician. Patients who did not call in response to the letter were contacted by phone and screened. Our marketing and communications group was very helpful in developing patient materials. They also prepared press releases and established a webpage on the hospital's website with information for patients and healthcare providers. It's important to note that patients who are asymptomatic presently will still be at risk for development of infection for several years, so they need to be instructed to seek medical attention should they develop symptoms in the future. The patients at highest risk are those with implants (e.g., cardiac valves, vascular prostheses, ventricular assist devices), though a few cases have been reported in patients without implants.
3. Notify referring providers and internal physicians who may end up seeing infected patients. We sent letters explaining the infection to all referring providers and broadcast emails to our providers internally. It's important for providers to think about this infection when they evaluate potentially exposed patients with culture-negative endocarditis, fever of unknown origin, unexplained weight loss, or unexplained granulomatous inflammatory processes, including sarcoidosis. Obviously it's important for your infectious diseases physicians to be made aware, but other physicians may be involved with cases as well. One of our cases was simultaneously being evaluated by a hematologist, a hepatologist, and an ophthalmologist for a disseminated granulomatous process. Once you have developed your list of potentially exposed patients, you can run it against a list of patients with the aforementioned diagnoses, and further review any patients who appear on both lists.
4. Ask your lab to produce a list of patients who had MAC isolated from blood, bone marrow or wounds in the last 6 years. Run this list against your list of potentially exposed patients to identify any matches for further review.
5. Any patient with a consistent syndrome should have 2-3 mycobacterial blood cultures obtained. If suspicion is high and mycobacterial blood cultures are negative, consider obtaining bone marrow biopsy for histopathology and culture.
6. If mycobacterial cultures grow MAC, depending on your lab's capabilities, you may need to send the isolates to a reference lab for species identification.
7. Report M. chimaera cases to the FDA via MedWatch.

Given that the implicated heater cooler unit is the predominant brand, many hospitals will be embarking on an investigation, so hopefully they will find this information of value.

Useful publications:
Latest review (Infection Control and Hospital Epidemiology), November 2016
IDWeek Presentation of US Multicenter Investigation, October 29, 2016
MMWR, October 14, 2016
CDC guidance
FDA guidance, October 15, 2016
Emerging Infectious Diseases, June 2016

Clinical Infectious Diseases, July 2015

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Wednesday, December 7, 2016

Deaths from alcohol hand rub fires? 0

I just returned from the Healthcare Epidemiology Training course in Ho Chi Minh City, Vietnam, where I had a wonderful time interacting with the students and other faculty. Thanks to Professor Le Thi Anh Thu, we had the opportunity to tour an 1,800-bed hospital in the city and observed many barriers to infection control, including an average daily census greatly exceeding the bed capacity. Many patients are forced to share beds with other patients. However, in one area Vietnam is far superior to the United States; they allow alcohol hand rub at the bedside! You can see Joost Hopman, Andreas Voss and I touring a medical ICU in Vietnam - notice the green hand rub dispensers at the end of the beds.

In the U.S., fire code prevents alcohol hand rub from being placed at the bedside, rendering the practice of the WHO 5 moments impossible. Health care workers simply don't have the time to leave the room to practice hand hygiene after each contact with the environment or patient.

Here is the WHO's take on the fire risk of alcohol hand rubs: ”The benefits of the alcohol in terms of infection prevention far outweigh the fire risks. A study in Infection Control and Hospital Epidemiology (Kramer et al 2007) found that hand rubs have been used in many hospitals for decades, representing an estimated total of 25,038 hospital years of use. The median consumption was between 31 L/month (smallest hospitals) and 450 L/month (largest hospitals), resulting in an overall consumption of 35 million L for all hospitals. A total of 7 non-severe fire incidents were reported. No reports of fire caused by static electricity or other factors were received, nor were any related to storage areas.”

So let's review the U.S. situation:

Deaths from resistant bacteria? 23,000
Deaths from alcohol hand rub fires? 0
Changing state fire codes to allow alcohol hand rubs at the patient bedside? Priceless

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, December 1, 2016

5 things physicians realize when they're sick

There are so many insightful stories out there about what happens when physicians experience life as a patient or family member. They always make sobering reading for everyone in health care. Over the years I've heard dozens of these stories from fellow physicians, describing experiences when they've unfortunately been sick themselves. It's an inevitable fact of life for everyone that they will be the patient one day, but it's often an especially life-changing experience for anyone who already works at the frontlines of medicine. Based on these experiences, here are 5 pieces of universal feedback:
1. Listening
It's remarkable how often physicians as patients feel that they are not listened to. Imagine that most of the time as well, everyone knows that they are doctors—and it still comes across like that! This isn't necessarily the fault of the hard-working medical professionals taking care of them, but more a consequence of the typical hectic and busy health care environment. Remembering the basics such as sitting down and talking face-to-face with your patients, not being distracted by the computer, and taking all complaints seriously (as most of them usually always are) goes a long way.
2. Brief time slot
Following on from the above, it's amazing how little time doctors actually spend in direct patient care. A doctor may have dozens of patients to see, and can easily forget during a crazy workday that their patient may have waited several hours just to see them. It's the part of the day that's most important to them and the patient will usually hang onto your every word. Even if a doctor is only in the room for 3 minutes, don't forget how much those few minutes mean to your patient.
3. Ability to get rest
One of the most common complaints doctors hear when they walk into a room first thing in the morning, is that the patient couldn't sleep at night. Often passed over with a shrug of the shoulders—not really too much we can do about the noise at night, either from outside the room or a noisy neighbor! But how it hits home when a doctor is a patient that the thing we need most when we're sick is a decent rest.
4. Care coordination
This is something that all doctors, especially those in the generalist specialties, recognize as a huge problem. There are simply way too many cooks in the health care kitchen, a subject I've written about previously. It sometimes feels like the amount of specialists that see medically complex elderly patients could fill a small phone book. While most of these specialists are absolutely needed, it becomes a problem when neither the patient nor the family knows who the “captain of the ship” is, and they are getting mixed messages from every direction.
5. The bill
Doctors conscientiously go about their day and strive to give their patients the best possible care. We hardly spare a second thought for the cost of everything we're prescribing and ordering. With the simple click of a mouse, a test costing several thousand dollars is ordered. Only when one receives a hospital bill, does one realize how crazy the prices are! Everything itemized down to the smallest Band-Aid. Likewise, the headaches our patients have to go through dealing with insurance companies is another thing that's often hidden from doctors.

There are certainly many more observations that could be listed in addition to the above, but these are 5 of the most common. We all need to do better and improve patient experience in areas where we can. Regular feedback like this should give all health care leaders pause for thought.

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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Thursday, November 17, 2016

Tips for attendings: Learning is more difficult than teaching

As a newly minted journal faculty member rounding on the wards, I had great internal pride in my teaching ability. Like many residents and junior faculty I assumed that my teaching would result in the learners growing dramatically (especially since I had delivered the messages so brilliantly {please read that phrase with true sarcasm}).

During my growth as an educator I learned that teaching can help, but not as dramatically as I would have liked.

Try this yourself. Teach something to your learning group. Wait a week or two and then quiz them. At first you will be despondent, but then take time to reflect. How long did it take you to learn things?

About 15 years ago, the housestaff helped care for an unfortunate young woman with Wilson's disease. One resident presented the story at morning report, and I missed the diagnosis. I had never seen Wilson's disease, and really did not know much about how patients with Wilson's disease presented.

Approximately 2 weeks later, a different resident presented her story at a different morning report. I missed the diagnosis again.

The third time (yes this patient's story was recycled for a variety of presentations), I did remember the story. I now know the big clue is the very low alkaline phosphatase in a young patient with new liver disease.

Learning is complex. We learn better with repetition. We learn better with the use of different sensory inputs.

What should this mean for our teaching?

First, never apologize for repetition. Just yesterday I quizzed my team on something I had taught the previous week. One of four remembered the concept. So we repeated the key teaching points.

Second, encourage your learners to read about what they learn each day. I recommend that learners keep a small notebook (or enter notes into their smart phones). Each day they should pick 2 topics to reinforce. Spend 10 to 15 minutes on the topic. Reading about something that you just heard helps solidify the memory.

Understanding the difficulty of learning medicine should inform educators. Our job is to help our learners grow. This growth requires repetition. We owe our learners a great deal. Understanding and repetition are a good start.

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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