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

Monday, October 20, 2014

Donning and doffing

Many have spent the last month or so preparing for possible patients with Ebola (PPE). I had the opportunity to review the tremendous amount of work that the UIHC infection preventionists have completed towards our preparation. During this process, I watched these videos prepared by the Biocontainment Unit at the Nebraska Medical Center that demonstrate the proper use of Biological Level C PPE. My thoughts when viewing these are that without significant practice, it would be very difficult to prevent contaminating or breaking protocol when removing this level of PPE and that donning and doffing take almost 14 minutes. That’s a bit more time than hand hygiene, so no more complaints about that! And thanks to Nebraska for sharing these well-prepared videos.


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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Saturday, October 18, 2014

Mayo conference: Killing the buzz some more

So earlier this week the Managing Complex Patients conference taught me that watching the sunset might kill a person. Today a lecture on hepatology by William Sanchez, MD, highlighted how the other popular vacation pastimes of gorging and boozing will kill you, too.

He offered a case study of a woman who had just recently started to feel sick and look jaundiced with a history of one drink each weekday and a couple on weekends. She would probably define herself as a social drinker ("Some of my patients are very, very social," noted Dr. Sanchez, also pointing out that a patient's definition of a drink might be different from medicine's), but any more than a drink a day is enough to put a woman at risk for alcoholic hepatitis. The patient needed a liver transplant, he said.

And not drinking won't save you from cirrhosis, if you're chowing down instead. A "tidal wave" of nonalcoholic steatohepatitis due to obesity is about to hit hepatology, just when the liver problems of the Hepatitis C epidemic are projected to slow down.

So as not to close out conference coverage on a down note, here's a fun fact about overeating. Amindra S. Arora, MB, explained the function and habits of the esophageal sphincter during his talk on esophageal diseases. Ever wonder why restaurants give after-dinner mints? It's because chocolate and peppermint relax the sphincter. "You need to vent so you don't feel so full," said Dr. Arora.

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Friday, October 17, 2014

Mayo conference: It's all about the questions you ask.

Several experts speaking at the Managing Complex Patients conference today offered advice on specific questions to ask to elicit useful information.

In a lecture about dealing with and learning from medical errors, Kim Manning, MD, FACP, and Neil Winawer, MD, offered a checklist for helping yourself, your trainee, or your colleague respond to an error.

Roughly (because I can't get their slides to download right now), the questions to ask are:
What happened? What did I do that was good for this patient? (A question that most don't think to ask, they noted.) What could I have done differently? What did I learn? How can I avoid this happening again? How do I feel about what happened? How can honor my patient now? What advice would I give to another in this situation?

Going through this checklist can help convert errors into constructive changes and reduce burnout, Drs. Manning and Winawer said.

And, then, on a much weirder note, Lyell K. Jones, Jr., MD, offered neurology pearls, including some advice on dealing with idiopathic parkinsonian inpatients. It's common for these patients to have hallucinations, he noted, but they're unlikely to admit it, even when asked directly. The best way he's found to get the truth is a weirdly specific question: "Do you ever see small people or animals in your house in the evening?" And there is your bizarre pearl of the day.

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How can we make hand-offs a good thing?

Health care is actually a 24-hour-a-day, 7-day-a-week job. People get sick even when we physicians are supposed to be sleeping or eating dinner or showering or brushing our teeth. Having care available all the time often saves lives and usually reduces suffering. In the U.S., we have that pretty well worked out. Everyone with a doctor has an after-hours number to call and if that fails or the problem is too big, there is always an emergency room or at least an ambulance or fire truck to whisk one away to where help is waiting.

One of the problems with our after-hours options is that a person is rarely seen by a doctor who knows them and is familiar with their medical history. It would be ideal for all of us to have rapid access to the doctor (or nurse practitioner or physician’s assistant) who has been with us for years and who knows what works, what doesn’t and who we can relate to and trust. Unfortunately that person has to sleep and eat dinner and sometimes even go on vacations. Most people run into the reality of seeing different doctors depending on who is available.

In my present profession, hospital medicine, I work for several days in a row taking care of a collection of patients who are in the hospital at that time. Most of them I don’t know. When I have days off, I tell another hospitalist about the patients I’ve been seeing and write a rather complete note. We discuss how I envisioned managing the patients’ medical problems, as I understand them and then I go, and Doctor Next takes the helm.

I always feel bad, at least a little bit, deserting my patients and leaving my physician partners with a job half finished, even though that is the nature of the job. But when I think about it, sometimes it is a really positive thing, and if I approach it that way it can be even more positive.

Not all hospitalist programs have “face to face sign-outs.” It is ideal to sit with the doctor who is assuming care of my patients and explain what is going on. That becomes impractical if there are too many patients and when I am not physically working at the same time as the physician assuming my patient’s care, like in places where there is a night shift physician. Telephone sign-outs are not bad, but are also impractical in a big hospitalist group where my 18 or 20 patients may go to several different doctors when I leave. A good sign-out, in person, from a good doctor is key to not being completely helpless on the first day of a set of shifts. Nevertheless, much can be gleaned from reading progress notes and reviewing labs and sometimes that’s all there is, since two minutes sign-out times 20 patients on a service equals 40 minutes, which is way too much time and still not enough detail to really be helpful.

In short, transitions of care are difficult, no matter how you slice it, and the more intensity that is put into the communication, from departing to starting doc, the better it is. But there is a silver lining to this dark cloud. Sometimes when we treat patients we go off down a wrong path. We concentrate on one aspect of a history or a data point and head off enthusiastically, missing what is really going on. If the doctor who takes over when we go is attentive and not excessively busy, the patient gets another chance for us to get the right answer. If done right, every transition can be a second opinion.

In some of the hospitals where I did my residency training, they had these wild and woolly doctor free-for-alls called morbidity and mortality conferences. They were a chance to dissect all of the decisions and actions that contributed to a patient becoming sicker or dying under our care. They were not quite blood baths, but doctors did cry regularly as they were grilled on their reasoning by more senior physicians, resting in the certainty of 20-20 hindsight. Besides being confrontational and unpleasant, these were incredibly informative and it was hard to forget the lessons learned in that context. We rarely see these anymore, but I miss them. Instead, I try to keep track of situations where what my colleagues have done or have thought was going on turned out to be wrong, and to discuss it with them later. This can be tricky and needs to be done in a trusting relationship, with the understanding that they will do the same for me.

We have been discussing lately doing a small morbidity and mortality type meeting with the emergency physicians, who by necessity only see the beginning of a patient’s evaluation and frequently do not have the benefit of all of the data, and the hospitalists, like me, who receive and take care of the patients from the emergency room and eventually hear the end of the story. I suspect this will be really interesting and will not only improve our medical thinking but also help us work together better. It will be a little bit tricky finding a time when even a quorum could be present together because of our very different work schedules, but I’m looking forward giving it a try.

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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The very real-world limits of patient satisfaction

Everyone involved in health care, and particularly hospital care, has witnessed a sea change over the last decade. Things that were never even thought about, let alone formally taught to frontline doctors and nurses, have now come to the forefront. Chief among these is the drive towards improving patient satisfaction and delivering a more optimal hospital experience.

True, a large part of this is due to federal incentives and tying reimbursements to patient satisfaction scores. Whatever the motivation, a lot of this focus was in fact long overdue. As one of my own personal areas of interest, I really believe that health care must always strive to be more customer service oriented with a focus on keeping our patients as comfortable, informed and satisfied as possible. Being sick is horrible enough for anyone without feeling like you’re being treated badly or with disrespect.

I’ve written a lot about the things we can do to improve care, like spending more time with our patients, being clear on wait times, allowing them to get a good night’s sleep, and even giving them more palatable food to eat. Yet sometimes I fear that the patient satisfaction movement is going a bit too far and not realizing where to draw the line. Interestingly studies are now also showing that patient satisfaction isn’t necessarily correlated with good care, including a recent study published in JAMA.

My own experience is that the vast majority of patients are pleasant, motivated, listen to the doctors’ advice, while also asking very reasonable questions or expressing legitimate concerns. But let’s look at a few everyday real-world hospital scenarios where keeping patients happy and granting their wishes definitely isn’t the best thing:
• The patient who has a narcotic dependence who is demanding additional pain medications (often when already over-sedated)
• A patient who is insisting on a treatment or discharge plan that you know goes against your better judgment and is not safe
• A patient who has a misunderstanding of a clinical situation and is drawing the wrong conclusions, or seems unreasonable in their complaints

These are just 3 examples that will be familiar to all those practicing at the frontlines. It’s important that the new generation of doctors and nurses doesn’t have “patient satisfaction at all costs” drummed into them so much that they are reduced to yes-men professionals. As much as we strive to improve communication skills or the comfort of hospitals in a patient-centered environment, it simply isn’t always the case that the doctor and patient are completely equal partners. Just as the job of a teacher isn’t to please their students, the job of a doctor isn’t to always please their patients. Ironically I’ve found that patients tend to appreciate and respect an educated, authoritative well-intentioned “no” over an insincere “yes,” especially over the long-term.

In hospitals we are already in a work environment that is among the most compassionate and understanding. All doctors and nurses will also be familiar with the angry relative who storms into the hospital demanding immediately to speak with the physician. Just think what would happen if someone ever aggressively walked into a bank and demanded immediately to speak with the bank manager in a raised voice? Security would probably promptly escort them out. But health care is an emotional arena, and we make allowances and are always accommodating (as we should be).

In the new patient-centered health care of the future, the worst-case scenario would be for doctors to be fearful of a patient being able to pull up his or her iPhone and threaten them with a bad online review if their wishes are not immediately granted, or scared to tell a patient that they need to lose weight because it might offend them. That shouldn’t be the health care satisfaction of the future. Doctors must never be afraid to stand by their principles and clinical judgment. Patients are ultimately the ones who will lose out if that happens.

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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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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