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

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Thursday, September 3, 2015

Hand hygiene interventions: a network meta-analysis

Summer is in full blaze (especially for those in Rome, France and the western U.S.), so we don't have much time for long posts. However, I had to point you to an excellent study in BMJ (open access) by Luangasanatip et al. that utilized a systematic review and network meta-analysis to determine the comparative effectiveness of the WHO 2005 hand hygiene campaign and other interventions. The WHO-5 Campaign (not to be confused with the WHO 5 Moments) recommended a multimodal strategy consisting of 5 components: system change, training and education, observation and feedback, reminders in the hospital and a hospital safety climate.

The authors completed a systematic review of interventions from 2009-2014 and used prior reviews to identify other studies. A strength of the analysis was that they looked beyond randomized trials and included high quality quasi-experimental studies including non-randomized trials, controlled before-after trials, and interrupted time series studies. They then completed a network meta-analysis which suggested that the WHO-2005 campaign was effective and compliance could be improved if other interventions were added including goal setting, reward incentives and accountability.

For those interested in reading more about network meta-analysis, I suggest you read John Cornell's editorial and the PRISMA Extension Statement in this past June's Annals. Briefly, it allows direct and indirect comparisons of interventions. For example, if 2 interventions are not directly compared they can still be compared if they were both directly compared to a third intervention (see Figure 1 above - Treatment D vs Treatment B or C through their direct comparison to Treatment A). Additionally if there is a closed-loop of studied interventions, additional information can be gained from indirect comparisons even if direct comparisons also exist. For example, in Figure 1 above, we can learn about Treatment A vs Treatment B from their direct comparison but also indirectly through Treatment C.

I encourage you to read the full study and the editorial by Matthew Muller. Very nice to see that the BMJ published this important study. And for those in the southern hemisphere, enjoy your cool weather. These summers seem to be getting worse and worse.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Wednesday, September 2, 2015

Better than germ-zapping robots

Joe Schlesinger, an anesthesiologist and critical care medicine colleague from Vanderbilt University, sent me this photo he took a few days ago at a hospital in Kenya. If only U.S. hospitals were so forward thinking.

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, September 1, 2015

Good enough?

There are a few themes that permeate this blog: the impact of new technology on medical practice, evidence-based care, health care financing, and a patient-centered approach to care delivery. The recent dust-up over the release of surgeon-specific outcome data touches almost all of them.

ProPublica, a not-for-profit organization devoted to investigative “journalism in the public interest,” got the ball rolling last week with the publication of their “surgeon scorecard.” They compiled 5 years of Medicare data (2009 to 2013) on 8 generally elective surgical procedures: knee and hip replacement, laparoscopic cholecystectomy, lumbar spinal fusion (broken out by anterior and posterior approach), “complete” prostatectomy, transurethral resection of the prostate, and cervical spinal fusion. For each one, they identified a list of principal diagnosis codes associated with a hospital re-admission within 30 days of the surgery that could reasonably be interpreted as complications of the index surgery.

For example, if a patient had undergone knee replacement and was admitted within 30 days with a principal diagnosis of “infection due to prosthesis” then that counted as a complication of surgery. Details of the methodology were provided online. The complication rates were adjusted by patient age, gender, and a few other variables, and their user-friendly tool allows for easy look-up of complication rates by surgeon or hospital.

The site also contains highly favorable testimonials supporting the public release of these data and the methodology used. Not surprisingly, lots of other online sources bubbled over with objections, some of which were pretty thoughtful and some of which were prettyangry. The major criticisms were mostly about the inadequacy of the risk-adjustment and the potentially misleading conclusions that result from limited sample sizes. This of course, could have serious implications for patients and surgeons. No one wants to mislead patients or mislabel physicians.

After wading through the methodology and a lot of the critiques, I ended up siding with others, like Ashish Jha, who made a pretty compelling case that, from the perspective of a patient, the scorecard is a helpful advance. Not perfect, but better than the “data-free zone” that most patients experience when they are faced with choosing a surgeon. Furthermore, providing better tools for patients will require more investment in the collection of reliable clinical data (not just billing claims), and a commitment to transparency about patient outcomes.

What do you think?

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Tuesday, August 25, 2015

Not letting a computer come between me and my patients

Ask any frontline physician at the moment what one of their biggest daily frustrations is and you will probably hear a very similar thing whether you are talking to a primary care, emergency room, or hospital physician. The thing that most takes them away from patients and makes them forget the reasons why they went to medical school in the first place, is the need to now spend most of their day staring at a screen and performing data gathering and “type and click” tasks.

I personally am yet to hear of any doctor who is happy with their electronic medical record, and I've worked in many different hospitals up and down the East Coast (that use a number of different vendors). Hate may be too strong a word, but then again maybe it isn't according to some things I've heard physicians say about the computer systems that have been foisted upon them! If we take a step back to when this process all got accelerated, it's largely been a result of the federal government's Meaningful Use program. And while I don't doubt that the program had some very noble intentions, and neither would I ever say that information technology in healthcare is all bad (far from it, a lot of it is quite brilliant in terms of being able to quickly search records), the problem has been in the implementation and the IT solutions that are available currently not being properly reconciled with frontline clinical workflow.

A study in the Journal of General Internal Medicine not so long ago showed that medical interns now spend only 12% of their whole day in direct patient care. That's a shocking statistic if it's the future of medicine.

The fact that doctors are having to spend so much of their time in front of computers, does an absolute disservice to the patients we serve. I've lost count of the complaints I've heard from patients regarding this. “My doctor never even looks at me.” “My doctor just keeps turning around to tick boxes on a computer when I'm with him.”

Because of this, and my absolute resolve to not become like that, I've developed some rules for how I interact with patients in the hospital. This includes never taking a portable computer or attempting to document anything electronically when I'm in a patient room. I always sit down and make eye contact with my patients and if I need to take notes, I do it the good old-fashioned way of writing things down. There's something about entering information on a computer as people talk to you that makes you seem less engaged. We've all experienced this before whether we are at a hotel, airline counter, car dealership, or just about any service situation. When you are being asked for information, it just seems a lot more attentive when someone is sitting right in front of you writing things down as you speak and maintaining eye contact. Computers just don't make the cut. I'm happy to do all the required electronic documentation after I see the patient, but won't let it distract me when I'm with them.

Secondly, I keep close watch on how much time I'm spending with patients during the day. I do everything possible to tip the balance towards direct patient care, including keeping electronic documentation to the minimum required for a good comprehensive patient note and avoiding sitting down at a computer if I'm performing an “on-the-go task” such as placing an order.

Thirdly, every computer system has its own unique quirks and characteristics. As anyone gets used to the system, there are often shortcuts and quicker ways of doing things that become apparent with time. Use these to your advantage. The people who design these systems are not clinically minded (and indeed, many of them are fortunately too young to have barely set foot in a hospital). Neither do they fully understand the world of medicine. It's our fault too perhaps for not insisting on intense clinical feedback when systems are designed, but any feedback you can give or ways of improving the system—be sure to spread the word.

As great as computers and information technology are, medicine is about people, and always will be. It is a uniquely personal and emotional arena. There are certain universal truths when it comes to humanity, and Hippocrates had it right over 2 millennia ago when he offered a pearl of wisdom for everyone in health care: “Cure sometimes, treat often, comfort always.” That's the human side of medicine that no computer can ever touch. For me that face-to-face time with my patients is part of the sacred doctor-patient interaction, and I will not allow any computer to come between us.

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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Friday, August 21, 2015

On feedback and deliberate practice

Medical learners often complain that they receive inadequate feedback. Most programs develop solutions of “formal feedback” sessions. To that I say, “Bah, humbug”.

As a devotee of deliberate practice, I understand that formal feedback does not do the intended job. Rather we need to provide immediate feedback and then repeat the practice session with another immediate evaluation.

This quotation from a blog post (Deliberate Practice: What It Is and Why You Need It) should help:

The 4 Essential Components of Deliberate Practice

Research into the history of education (dating back several thousand years), combined with more recent scientific experiments have uncovered a number of conditions for optimal learning and improvement. Again, from K. Anders Ericsson, here are the 4 essential components of deliberate practice.

When these conditions are met, practice improves accuracy and speed of performance on cognitive, perceptual, and motor tasks:

1. You must be motivated to attend to the task and exert effort to improve your performance.

2. The design of the task should take into account your pre-existing knowledge so that the task can be correctly understood after a brief period of instruction.

3. You should receive immediate informative feedback and knowledge of results of your performance.

4. You should repeatedly perform the same or similar tasks.

It's important to note that without adequate feedback about your performance during practice, efficient learning is impossible and improvement is minimal.

Simple practice isn't enough to rapidly gain skills.

Telling a student after 2 weeks that their presentations are confusing will not help the student. Interrupting and giving immediate feedback on the deficiencies (as they occur) will make the points much more clear. Providing immediate positive feedback will reinforce their improvements.

We have a responsibility to give specific feedback throughout our rounds (whether in the inpatient or outpatient arena). We must tell our learners that we are giving feedback. We must celebrate good work and suggest how learners can improve in a balanced fashion.

We should not be so obsessed with “formal feedback.” It does not lead us to expertise.

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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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