Au revoir to the visiting Dr. Wang

For the past few months, our Johns Hopkins Division of General Internal Medicine has hosted an internist from Peking Union Medical College Hospital, Dr. Yu Wang [also on Weibo]. She leaves at the end of May. The aim is to help foster a relationship between our two institutions; UCSF and PUMCH are already working together. While I am no expert about the Chinese health system, I wanted to share some of what I learned from her during her visit.

PUMCH is a tertiary care hospital, similar to Hopkins. But while Hopkins has recently taken the bit of primary care in its teeth, PUMCH, says Dr. Wang, is not about to make that its priority. Rather, the Chinese government has apparently launched an initiative to train tens of thousands of new primary care providers across the country. (Johns Hopkins is newly involved in training some of these at Sun Yat-Sen University.)

When Dr. Wang discharges a patient from PUMCH, she gives them a detailed discharge summary to take to the doctor they next see--not their primary care doctor, because they don't have one. Nor can she expect that they take the medications recommended for them during their stay in the hospital, because most medications, she says, are paid for out of pocket in China.

I am planning a trip to China to visit PUMCH and I hope to have some first-person impressions then. Meanwhile, I hope to find some general sources about the Chinese health care system to enlighten me. A colleague of Dr. Wang's, in the emergency department at PUMCH, is also on Weibo, and once I sign up for the service, I look forward to learning more about health care in China.

Thank you, Dr. Wang, for your visit and for helping connect our two institutions!

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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

Labels: discharge, guest post, Zackary Berger

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posted by Zackary Berger, MD at 9:00 AM   0 Comments

'"Nightmare" on Hospital Street

Not sure how we missed last week's JAMA medical news piece featuring our very own co-blogger Dan Diekema, MD, FACP, but I suspect we might have been distracted by something pretty terrible. The article highlights the rise of carbepenem (CRE) and third-generation cephalosporin-resistant Klebsiella pneumonia strains originally described in ICHE by Braykov et al. The CDC's Arjun Srinivasan emphasized that these strains are almost exclusively hospital-associated and now is the time for hospitals to implement the latest CRE recommendations from the CDC 2012 toolkit.

Dr. Diekema "emphasized the importance of infection control basics such as ensuring a high rate of hand hygiene adherence among staff and making sure that surfaces and equipment are properly disinfected" and said, "If you don't shore up those things, screening [for CRE] isn't going to help."

I'll just paste in my favorite section: "An additional problem is the piecemeal approach to tracking these infections. Only six states require facilities to report CRE cases. "We need a more coordinated response," Dr. Diekema said. He explained that the CDC is doing as much as it can with the resources it has, but underfunding of public health at the national and state levels makes it difficult to mount a more coordinated national effort to contain the spread of these infections. More research is also needed on the best strategies for environmental disinfection, ensuring adherence to hand hygiene and other measures that would prevent the spread of health care–acquired infections."

CRE isn't just a nightmare, it's a recurring nightmare. And just like the nine Nightmare on Elm Street films, it'll get worse over time, especially if we continue with the current "piecemeal approach" prevention plan.

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.

Labels: Controversies in Hospital Infection Prevention, Eli N. Perencevich, guest post, handwashing, infectious diseases, nosocomial infections, public health

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posted by Eli Perencevich at 9:00 AM   0 Comments

Treating the patient, not the disease

The team presented his story during pre-rounds. He had lived his life "cleanly," not smoking or drinking, eating in moderation. Recently he had a malignant disease present, and now had a new metastasis.

As a physician, we want to like all patients, but in fact, we have favorites. This man engendered respect and concern from the first time we entered his room. In trying to reconstruct our response, I feel at a loss. I cannot explain this feeling, one that I suspect all physicians have regularly. We just want to do a bit more for some patients. From the first time we met him, he knew that his prognosis was poor.

We worked on considering a treatment for the metastasis, but then another symptom occurred, and we discovered widespread metastases.

Each day when we visited his room, I girded myself for the conversation. Each day I left the room feeling a bit better. Each conversation could have been much more difficult had he and family not been so understanding and appreciative. We had the conversation about treating the patient and not the disease, because we could not defeat the disease. We made clear that we would not stop treating the patient.

Each day he encouraged me, not explicitly, but implicitly. Each day I sat at his bedside and held his hand. We made certain that all his symptoms were well controlled. We made certain that the family agreed with the patient's plan.

An important lesson occurs to most physicians over time. We can cure some diseases; we can slow the progression of some diseases; we can prevent the complications of some diseases, or at least delay those complications; but we should always remember that we are treating patients, not diseases. When we can no longer impact the disease, our responsibility does not change.

Patients, not diseases, are our responsibility. We must always remember that.

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 Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Labels: cancer, db's Medical Rants, end of life, guest post, patient communication, professionalism, Robert M. Centor

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posted by Robert Centor, MD at 9:00 AM   0 Comments

Medical culture may drive inappropriate testing, not profit or defensive medicine

Medical training and an exaggerated perception of benefit may drive overuse of myocardial perfusion imaging (MPI), a study found.

First author David E. Winchester, MD, FACP, and co-authors wanted to assess whether the single-payer Veterans Affairs (VA) health system would result in less inappropriate use of MPI. They conducted a retrospective cross-sectional investigation of 322 tests ordered in a single VA from December 2010 through April 2011.

Results appeared in a research letter published online June 10 in JAMA Internal Medicine.

Indications for the test were appropriate 78% of the time, inappropriate in 13% and uncertain in 8%. The most common inappropriate indications (16.7%) included testing of patients with low pretest probability who could have undergone treadmill electrocardiogram testing and asymptomatic patients with low coronary heart disease risk (16.7%). Of 9 preoperative MPI tests reviewed, 6 were inappropriate and 3 were appropriate.

Patient characteristics associated with inappropriate MPI tests included absence of symptoms (odds ratio [OR], 4.80; 95% confidence interval, 2.39 to 9.66; P less than .001). There was a lower likelihood of inappropriate testing with symptoms of chest pain (OR, 0.07; 95% CI, 0.02 to 0.20; P less than .001) and diabetes (OR, 0.37; 95% CI, 0.17 to 0.80; =.01).

Researchers noted that profit motives or defensive medicine didn't seem to apply, since the VA is a single-payer system and malpractice claims are mostly handled administratively.

Researchers wrote, "Conceivably, commonalities in medical training, independent of postgraduate practice environment, could contribute to an exaggerated perception of benefit of MPI in asymptomatic patients and those at low risk of coronary heart disease. This exaggerated perception of the benefit would also seem to hold true for preoperative risk assessment, with the majority of preoperative MPI in our study having been inappropriately ordered."

Labels: cardiology, costs, defensive medicine, less is more, malpractice, tort reform

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posted by Ryan DuBosar at 7:00 AM   0 Comments

Life at Grady: Beyond pleasantries

He spoke in those ways that doctors like; those ways that make our job easier. Sitting all the way upright in bed, wide and relaxed smile on his face and eyes on our team and not Judge Judy blaring over his head. And I could tell that, because of this, he stole the hearts of my students and residents. That part I knew for sure because he'd stolen mine, too.

With every word, a sure nod of his head accompanied. Unsolicited compliments came from him about the bedside manner of his student doctor. She blushed quickly; it was endearing.

We were there to see him about his hospitalization for something serious. The diagnosis was one of those ones you don't wish on even an enemy and, as of this encounter in the hospital, the list of options for medical interventions had officially run out. So this, his pleasant demeanor and dancing eyes, we welcomed. We weren't contending with fear or anger or any of those other sticky things that often set up road blocks to patient care.

At least it didn't seem that way.
"What is your understanding of why you're here?" I asked. We were in a semicircle around his bed on rounds. The student caring for him on his left and me, on his right. He swung his head from side to side when speaking. Ever-inclusive of that student. Ever-pleasant which we all appreciated.

"Well," he said, "my student doctor here said it's swelling in my brain. I also saw another doctor
--and he was REAL, REAL GOOD--and he say he don't think I need no more chemos or radiation. And I said, okay! Just do what you gotta do! Whatever y'all think!"
"I see."
"Yep. So now I'm getting some medicine for the swelling."
"That's right, sir. Can you tell me why you have the swelling?"
"Because of some cells, they tell me. Cells all together making some tumors. But the cells got some swelling on 'em."
"Gotcha."
And after he said that, he smiled even bigger. He turned his head to face his student doctor and nodded again. He wanted her approval.

This mostly seemed fine. But, see, I'd been doing this long enough to notice how vanilla these answers were. And I know how easy it is to get lost in pleasantries, especially during difficult discussions.

I asked a few more questions but in different words. I needed to know whether or not he realized what was going on. What it meant for someone to say "no more chemos or radiation" and exactly what that meant from a big picture perspective. So through my questions I tried my best to excavate the truth.

Was he afraid but aware?
Did he lack insight?
Was the pleasantry a mask that hid some early dementia?
Or was he simply a nice guy with a bad, bad disease?
Or worse, was it all of these?

Turns out it was. It was all of those things.
A little afraid. And seemingly aware that anything causing someone to be called to come get admitted is serious. He was right about that. His insight was poor about just how serious, though. He didn't seem to recognize that these were usually talks that open the door to ones about hospice and end-of-life care. Even though, according to the hospital chart, that REAL, REAL GOOD doctor he'd seen earlier had tried to explain this.

We proved that some of this he couldn't grab because of cognitive dysfunction. I asked his student doctor to come back and perform a mental status examination on him. The intern caring for him with that student seemed surprised by that request, but they obliged. He, too, got lost in the pleasantry and didn't see the need to question his cognitive ability. That test confirmed what had perhaps been missed before--a dementia component. Or maybe not missed but, from what I could see, not discussed. And that part would muddy up the full explanation part and likely had for some time.

So, in the end, all of this made it harder. That and the fact that there was no denying that, indeed, he was simply a nice guy with a bad, bad disease. A bad disease that he didn't understand.

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posted by Kimberly Manning, MD, FACP at 9:45 AM   0 Comments