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

Thursday, July 21, 2016

Freedom versus control in a private vs. public health care system

This is my 12th year as a physician in the United States. I was born in London, grew up in Berkshire, and decided to become a doctor when I was a teenager. I remember being asked what I thought about the National Health Service (or NHS, the UK's government-run health system) during my medical school interview. That question is almost a rite of passage for anyone applying to medical school in the UK. My answer was an idealistic one, probably identical to what most people in England—if not Europe—would say. Health care is a birthright.

The NHS is a wonderful concept and immensely fair and just. Nobody should ever have to pay for medical care in their hour of need, right? I speak too as someone of Indian heritage, who has seen up close and personal how unexpected illnesses in relatives can completely bankrupt families, causing untold anxiety and stress. Surely nothing could be worse than that free-market extreme with no public system backup?

During medical school, I also worked for a couple of months in Adelaide, Australia, primarily in Accident & Emergency/Trauma in a major tertiary care center. I also did a stint with the Royal Flying Doctor Service going on airborne missions to the outback, mainly rescuing very sick indigenous (Aboriginal) people and bringing them back to the city. The system Down Under is an interesting mix of both public and private health care, but still with a solid government-run backbone for people who really can't afford insurance. However, at that time, even the thought of having to pay for health care at all still seemed very foreign to me as I began my career as a physician.

Before I came to the U.S. back in 2005 to start my medical residency, these were my views on the funding of health care. Fast forward to 2016, and my opinions have shifted rather dramatically in terms of what a health care system should look like and whether people should contribute more themselves. Looking back to when I first moved here, one of the things that first struck me about U.S. medical care was the sheer speed and freedom of it all. Patients appeared free to choose their physicians, were in more control over their care, and didn't have to wait so long to get things done. My jaw dropped when one of my first patients was admitted from the ER, and had already had most of their tests and scans done, including an MRI. They would then be seen by all of the doctors they needed to, including any necessary specialists, within a very short period of their hospitalization. These attending physicians would follow-up with them daily (unlike in the UK, where the vast bulk of the work is left to more junior doctors).

We can get into a debate about fee-for-service and incentives, but it's human nature that people and organizations work harder when they are incentivized to do so. Documentation was also much more thorough than the couple of lines that I was used to seeing scribbled in a patient's chart (True, a lot of this was for billing purposes, but it's still always good to be thorough). Since my very first week working as a medical resident, I've said, and continue to say, that a homeless person presenting with an acute illness such as sepsis or a myocardial infarction in America, will get better and more outstanding care than a rich person almost anywhere else in the world. There's a very common misconception overseas that patients in America are left dying on roads outside the hospital if they cannot afford care! This simply isn't true, and I learned it very fast. Clinical care in the United States is top-notch (albeit at a high cost). As are the central issues of patient dignity, patient rights, and accountability of any hospital or clinic to seriously address any complaints.

Physicians too in America, appeared to have a much better deal than in the system I'd just come from. They were more in control of where and how they worked, weren't restricted in terms of their career progression by the government, and were also compensated a great much more for their hard work (granted however, they also had a much higher debt burden). Despite the problems and changes in U.S. health care over the last decade, it remains the case that doctors here have an unprecedented amount of freedom in how and on what terms they work, compared to almost any other country.

Having all these different experiences over the years, if you were to ask me today, I don't believe such a centrally controlled system like the NHS is an ideal system to aspire to. It restricts patients and physicians alike. It is too much at the whim of transient politicians, with no medical knowledge, who can enforce a universal country-wide policy change almost overnight (such as a change in patient rights, physician scheduling, or even banning all doctors from wearing white coats and ties, which is what happened in the UK). Neither does a centralized system foster the best environment for innovation or individualized care. Go to any patient floor in a socialized system, and it often has a Soviet-style aura about it, with rows of patients lined up, little personal space, monolithic designs, and staff wearing the same uniform. The collective American psyche is very different from Europeans, and the consumer-driven mentality here probably wouldn't endear itself to an NHS-type system anyway.

With regards to funding, I don't think it's necessarily a bad thing for patients to contribute themselves for doctor visits and hospital stays, as long it is capped at a very manageable level for the individual, with absolutely no “surprise bills”. There's an argument to be made that if people in England are so willing to spend £30 ($50) for regular restaurant visits, haircuts and other entertainment—why not a small co-pay for a doctor visit? Anything that's completely free can easily foster an increasing culture of entitlement, reduced self-responsibility, and sadly sometimes abuse of the system.

At the other end of the spectrum, is the idea of caring for peoples' health from cradle to grave a noble one? Yes, it is. Should anyone be refused coverage because of a pre-existing condition or go bankrupt and lose sleep because of unforeseen medical bills? No, they shouldn't in any civilized country. Do many of the socialized healthcare systems produce better outcomes than us? Yes, they do. Is the high-cost system we currently have sustainable over the long term? No, it isn't.

Perhaps something in-between the two extremes would be best, like Australia, which gives tax breaks for people who take out private insurance, but still offers a public system as backup to anyone who needs it?

For this debate at least, I'm stuck between a rock and a you-know-what.

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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Tuesday, July 19, 2016

VA funds 2 new antimicrobial resistance and HAI prevention programs

It wasn't long ago, that many of us were concerned about the lack of attention that antimicrobial resistance was receiving, particularly in regard to funding for researchand also infection prevention programs. Yet over the last few years, there has been increased attention throughout the US including the release of the National Action Plan to Combat Antibiotic-Resistant Bacteria and increased funding for CDC, NIH and AHRQ. Besides the lack of novel interventions that extra research funding will help tackle, another huge barrier to preventing MDRO and HAI is lack of information on how to successfully implement the few interventions we have within hospitals and healthcare systems.

It is this gap between efficacy and effectiveness that VA's Quality Enhancement Research Initiative (QUERI) seeks to fill. QUERI's mission is to “improve the health of Veterans by supporting the more rapid implementation of effective clinical practices into routine care.” And it is the goal of QUERI investigators to “ask crucial questions regarding the intended and unintended impacts of implementing new treatments or programs – and the best strategies for speeding their adoption into practice.”

With that background it is incredibly exciting to announce that VA has funded two new QUERI programs that target MDRO and HAI.

The first program titled “Building Implementation Science for VA Healthcare-Associated Infection Prevention” is led by Dr. Nasia Safdar in Madison. Dr. Safdar and her team partnered with VA's National Center for Patient Safety to achieve two broad aims. First, they will implement and evaluate an evidence-based intervention - daily chlorhexidine bathing of hospitalized Veterans for prevention of HAI. Second, they will establish a VHIN (VA Healthcare-Associated Infection Prevention Network) and assess current practices and needs related to HAI prevention. The long-term goal is to utilize the VHIN as a platform for VA facilities seeking to undertake pragmatic implementation science initiatives related to HAI prevention. You can read much more about her program that began in October 2015, here.

The second program titled “Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence” or CARRIAGE is set to begin in October 2016 and aims to address the growing concern of antimicrobial resistance through strategies implemented across VA patient care settings. The three projects will evaluate hand hygiene surveillance methods, enhance the implementation of new CRE prevention guidelines and promote judicious use of antibiotics through a multi-hospital antibiotic timeout program. The program directors are Michael Rubin, MD PhD (Salt Lake City) Charlesnika Evans, PhD, MPH (Hines, IL); and Eli Perencevich, MD MS (COI alert)

The next few years promise to be an exciting time for MDRO and HAI prevention in VA and throughout the U.S. as we develop, test and implement new methods to enhance patient safety.

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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Tuesday, July 12, 2016

Why I love the new NEJM CAUTI study!

Sanjay Saint's group at Michigan published the kingdaddy of CAUTI studies in the New England Journal (free full text here). And yesterday, 1 of the authors guest blogged for us on the study.

Although it's not a randomized controlled trial, it's just about everything else you'd want to see in a CAUTI intervention study:
• large and multicenter (over 900 units in 603 hospitals across 32 states),
• well designed,
• well executed,
• conceptually similar to the CLABSI Keystone study, arguably the most important study in our field since Semmelweiss, which demonstrated a huge (2/3) reduction in CLABSI, and
• bundled interventions, including daily assessment of catheter necessity, catheter avoidance, aseptic insertion, proper catheter maintenance, feedback on CAUTI rates, and multifaceted training via in-person or virtual training, monthly content calls, and monthly coaching calls.

Now, the results:
• Overall, there was a statistically significant reduction in CAUTIs of 14% after the intervention;
• Absolute rate reduction was 0.35 CAUTI/1,000 catheter days; and
• When hospital units were stratified (ICU vs non-ICU), all of the reduction was found to be in non-ICUs. There was no significant change in CAUTI rates in ICUs.

So let's bring this study a little closer to home. We'll assume that a 700-bed hospital has 35,000 catheter days yearly. If they implemented this intervention with the same results, the number of avoided infections would be 12.2 annually. If 1% of CAUTI patients become bacteremic (see here and here), they would avoid 0.12 secondary BSIs per year. And if 11% of bacteremic UTIs result in death, they would avoid 0.01 deaths per year. Expressed another way, this comprehensive, bundled intervention would result in saving 1 life every 100 years. Saving any life is a noble goal. But context is key. CLABSIs have an attributable mortality of 25%. In other words, CLABSIs kill people relatively commonly. CAUTIs rarely do. And there are many other nosocomial events that kill more than 1 person every 100 years.

The take home message is that a superb study designed by the world's CAUTI experts didn't yield much impact. This is no fault of the investigators. It's due to two reasons: (1) the attributable morbidity and mortality of CAUTI are relatively small; and (2) CAUTIs have low preventability (at least in 2016).

Dan Livorsi and Eli Perencevich summed it all up in their ICHE editorial last year when they questioned whether an NHSN-defined CAUTI is an episode of preventable harm. Is the work we do on surveillance and prevention of CAUTI an opportunity or an opportunity cost? I think the answer is clear.

Lastly, 1 point made in the guest post yesterday really bothers me: ”How a hospital addresses CAUTI likely says much about how such a facility attacks other endemic and mundane harms such as falls, delirium and pressure sores.” This is a specious argument. As the Chief Quality Officer of an academic medical center, I spend a great deal of time deciding where to best utilize our resources to prevent both infectious and non-infectious adverse outcomes. In fact, the hospital's leadership team actively engages in setting our quality and safety targets. As a utilitarian, I'm duty bound to attempt to have the greatest impact for our patients. And the reason why I love this study so much is that it makes the decision to focus on issues other than CAUTI even easier.

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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Tuesday, July 5, 2016

Even with the Hawthorne Effect, hand hygiene compliance still hideous

A recurring theme has emerged in hand hygiene science: When you really look, compliance is very, very low. A study 5 years ago reported that compliance was below 10% when hidden video monitoring was utilized. Our group has quantified the impact of the Hawthorne Effect, improved behavior when subjects know they're being observed, on hand hygiene compliance. In a multicenter study, we found that both measured exit and entry compliance increased the longer direct observers remained on the unit.

There is a report of a new APIC abstract in ABC-News that further quantifies that impact of the Hawthorne Effect and highlights the lack of investment in hand hygiene programs. Investigators from Santa Clara, California compared compliance measured by well-recognized Infection Prevention nurses, to observations collected by unknown high-school and college-aged volunteers who were trained to use the same surveillance methods. Here are their findings:

The investigators found that hand hygiene compliance rate observed by IP nurses was about 57%, while hospital volunteers, who tended to blend in and not be recognized as hygiene auditors, recorded rates of about 22%. While this phenomenon has been noted before, the team at SCVMC was surprised by the stark gap, and they have launched a series of interventions to try and drive their compliance rates higher and higher.

So, what do I make of these findings? First, even 57% is too low. Second, hospitals and health care systems continue to throw hand hygiene programs under the rug. We are much happier to report compliance rates of 100% collected by nurse managers on the floor (or compliance of 57% by recognized IPs) and ignore the problem than spend time and money detecting compliance rates of 22%, which would then require additional investments in proven hand hygiene interventions.

Any administrator who thinks compliance in their hospital is higher than 70% or 90% won't invest in hand hygiene programs. Since hospitals are happier to report compliance of 90% to the Joint Commission, we also won't invest in technological and socio-adaptive interventions that will finally improve the safety of our hospitals. We must work to create a safety culture where it is better to report hand hygiene compliance of 20% than falsely high compliance rates of 90%.

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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Monday, June 27, 2016

The 28-year-old MBA telling an experienced physician where to round first

The last couple of decades have seen a dramatic shift of power and clout away from individual physicians and towards administrators and the business side of health care. In many ways, physicians have nobody but themselves to blame collectively—because for any large and respected group of people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

So many different reasons for this sea change can be discussed, but the consequences are very palpable. To name but a few, we've seen the relentless push towards consolidation and mass employment of physicians, a rise in mandates and bureaucratic requirements, and a general explosion in the number of administrative folk while the number of physicians appears to be shrinking! Then there's the more subtle changes that the medical profession has also allowed to happen right under their noses, such as the refusal of many in the hierarchy to even call doctors by their true job title any more—instead labeling them only as “providers” (a subject I've written about including in this article and an open letter to the AMA and all State Medical Boards).

Speaking as someone who maintains a large network of physician friends and colleagues across the country, some of the stories I've heard about what happens nowadays are astonishing. Fortunately, after a few bad experiences, I'm now part of an organization where the relationship between physicians and administrators is probably as good as it can be. But from what I see, this is a rarity.

I relate 1 recent story in particular. I have a very close friend in the Midwest who is quite a brilliant doctor. He went to a top U.S. medical school and got stellar USMLE scores. I've known him for years and am proud to have trained with him. He is sub-specialty board certified, but decided to practice hospital medicine. He told me that his group, which is essentially run by non-clinicians, is completely (and unsurprisingly) focused on the bottom line only. Administrators aggressively monitor their physicians' whereabouts and try to review all of their patient interactions (mostly how it pertains to billing).

Anyway, to cut a long story short, he told me that the administration for some reason or another wanted him to round first on a particular floor. He didn't think it was the right thing to do for patient care (apparently another floor frequently had patients who required closer and more immediate attention), and it culminated in him basically being scolded by a 28-year-old MBA who informed him that he had to round on that particular floor first—like it or not. Needless to say, he didn't take too kindly to this interaction and that particular experience persuaded him that the time was right to move on.

This story bothered me on multiple different levels, as I'm sure it would any self-respecting physician. First and foremost, how did the medical profession surrender so much to the business of medicine that a situation like this could happen? I wonder what our more esteemed colleagues in perhaps their 50s and 60s would have done twenty years ago if a 28-year-old MBA had dared tell them where to round first? Secondly, how did that young man feel so empowered to scold a highly qualified physician and feel so convinced that “he was the boss”? And thirdly, perhaps most worryingly, is this the future of medicine in the United States? If so, is there any way that physicians can wrestle back a bit of control over their own profession to avoid situations like this becoming the norm? Because if we can't, and the practice of medicine is no longer led by doctors, it's not only the doctors who lose. Patients will too.

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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