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

Thursday, December 18, 2014

Help me understand how you react to uncertainty

Uncertainty is a common experience in health care. For an upcoming book and ongoing research project, I want to be in contact with patients, families, and caregivers to learn their strategies for approaching, dealing with, and understanding such uncertainty.

For example, Ms. A. has back pain unaccompanied by underlying serious disease. She has no way of knowing whether it will go away in weeks, months, or not at all. She wants an MRI, which accepted evidence indicates will neither aid in treating her pain nor reassure her.

On the one hand, both she and the health care provider would like to do “something” as a sign of care; on the other hand, we want to harm neither Ms. A (with tests/procedures that won't work), nor society (afflicted by a health care system which costs too much, delivers poor care in comparison to other systems, and treats people unequally).

There are many scenarios in which treatment is pursued despite evidence showing it does not work more than placebo. For example, hormone treatment in the patient with local (not metastatic) prostate cancer; repeated CT scans for thyroid nodules without symptoms; treatment of ductal carcinoma in situ (DCIS), mammograms in a patient without significant family history more often than every 2 years.

How do you as a patient, family member, or caregiver seek the best care in such a situation, where things are uncertain and more tests/procedures might not work? What strategies do you use? What should health care providers do? Please be in touch with me to help guide this work. zberger1 at jhmi dot edu

See the presentation below for another depiction of the problem.
How Do You Deal With Uncertainty In Healthcare? from 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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

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Wednesday, December 17, 2014

Patient safety, Swiss cheese and the Secret Service

I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR's reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:

It turns out that the top part of the fence that he climbed over was broken, and it didn't have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn't know the radio couldn't override other normal radio traffic. Other officers said they didn't see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn't have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn't fire because they didn't think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would've alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.

The explanation rang true. Of course it was no “1 thing” that went wrong; it was a series of events, no 1 of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “Swiss cheese” conceptual model of patient safety.

First articulated by Jim Reason, the Swiss cheese model holds that serious adverse events that occur in the context of complex systems are generally the consequence of multiple failures, not the fault of a single individual. In the case of a serious patient harm event (e.g., operating on the wrong body part), thoughtful analysis inevitably finds that many things have to go wrong for the surgery to occur. Indeed, just as the Secret Service has multiple layers of barriers around the White House to prevent an intruder from reaching the President, patient safety experts speak of “layers of defense” within medical systems that are designed to assure that small errors caused by human frailty don't allow harm to “reach” the patient.

The “Swiss cheese” description derives from the visual shorthand of imaging a series of slices of Swiss cheese, each of which represents a system defense. In the case of the White House, the perimeter fence, the guard dog and the building alarm are each like separate pieces of cheese. The holes represent imperfections or failures of each slice. For the intruder to get through them all, the holes in the cheese have to line up in a particular way. If the holes don't line up, the fence fails, but the dogs respond, then the system works.

For a wrong side surgery to occur, it may take a similar string of failures: maybe the surgical drape covered the surgeon's pre-op marking and the patient had bilateral disease, and the surgeon working in an unfamiliar OR, and so on.

Addressing patient (and Presidential) safety is almost never about finding the single person who failed at his or her task, or about an easy fix. It is about understanding how complex systems work and creating a culture of safety to continuously improve them. I hope the Secret Service takes that approach, instead of just fixing the fence and firing the guy who was on his cell phone.

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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Life at Grady: Staying open

I met a man in the hospital the other day and fell in love with him. Well. Not “in love” in the eros sense with, like, flying cupids and romantic butterflies. But love nonetheless. It was immediate, too. Kind of like the way people describe meeting someone and falling in love at first sight.

With him, it wasn't so much me laying eyes on him that made me fall in love. It was his throaty laugh and gentlemanly mannerisms. It was in the conversation I heard him having on the phone with his daughter, massaging down her worry the best he could with brave jokes and soft chuckles. I could tell that allaying his family's fears was more important than tackling his own.

I loved the way he said “Miss Kimberly” before every question and how, no matter what I said, he would nod and thank me. He knew that I was a doctor. Somewhere in our interactions, though, perhaps that felt too formal. Maybe not. But whatever the reason, not only did I not mind him calling me “Miss Kimberly,” I actually welcomed it. I did.

His admission was for the thing you don't want people to come in reporting--unexplained weight loss and loss of appetite. Vague abdominal pain and “maybe some kind of knot” in his abdomen. It was bad from the start. Sunken in temples and skin outlining high cheekbones that jutted out prominently since they didn't have to compete with subcutaneous fat. All it took was one look and I knew. This was bad.

But even worse was the story behind the diagnosis. One of those things that, had he been in a doctor's care, quite possibly could have and would have been caught. Or maybe even prevented altogether. Maybe. Like really and truly maybe.

So loving him made this harder. We made the diagnosis and called the necessary parties in to talk about the treatment. At this point, there wasn't a whole, whole lot in the way of “treatment” although there would be palliative things to offer. And he was stoic, that man. Tough as nails and with the courage of ten lions. He looked me in my eye and said, “Okay. I'm okay and I will handle this fine.” And he wasn't saying it because that was what you're supposed to say either. He said it because his insight was excellent and he'd been around living his life as a patriarch long enough to know that sometimes you just have to take what's been handed to you and, well, handle it. Which was what, I think, he'd made up his mind to do.

In front of my team I was regular sad. Like, “Man, I hate this” sad but not really much more. But in the safety of a conversation with my very dear friend and Grady doctor, L.M., I grieved. And no, I'm not being dramatic by saying “grieved” either. I wept into the phone and told her how very, very sad I was about this man that I now loved and how badly I wished she or I had met him ten years ago. Met him and ran his labs and said, “You know? Let me check this” and then discovered all of this earlier. But I've been living and doing this long enough to know that a lot of times the reciprocating circuit of ”if I coulda woulda shoulda” is as futile as a dog chasing his tail.

But still. I loved him. And today I'm sad because this is going to silence his beautiful, smoky laugh and quiet his glistening eyes. Short of a miracle, it will.

I allow myself to love patients--and people--in this way. I do. It leaves me raw and vulnerable, yes, but still. I would much rather feel it than not care. If meeting that man and telling him such bad news ever became “business as usual” for me, that would make me far sadder. Far, far sadder.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.



Monday, December 15, 2014

Lessons learned from 35 years of ward attending

My first time was January 1980. I remember where and remember 1 patient. Like many new attendings I overestimated my skills. Over the years I have learned much about ward attending success. Now I plan a series of posts that share some thoughts.

The overriding principle of ward attending seems obvious, but apparently evades many who become ward attendings. We have several responsibilities. First, we must try to have the team deliver the best possible care for our patients. Second, we must help all of our learners grow into excellent physicians.

These responsibilities have changed from the 70s and early 80s. Then the attending did a bit of teaching, but the resident had the patient care responsibility and ran rounds. My resident rounding experience helped frame my current ward attending style.

When academic practices started billing for attending services, the attending role changed focus. Unfortunately, some attending physicians undervalue the teaching role.

So compared to 1980 when I started, the role has more complexity. We have to balance work hour requirements, billing requirements, learners' needs and patients' needs.

Yet the job is doable, and in many ways more enjoyable now than when I started.

We should prioritize several factors in developing our attending style. First, the interns and residents have work to do each day. We must respect their time constraints. No matter how brilliant we are as attending physicians, rounds that last too long are disrespectful and therefore substandard. Second, the learners should have the opportunity to present their plans and we should evaluate those plans. If we strongly disagree, we must explain why we should go in a different direction. Our disagreement should stimulate a learning situation. We should have good justification for changing the plan, but we do have a responsibility to the patient to develop the best plan. If one can justify more than one way to address a current issue, let the learners proceed with their plan. Finally, we are role models. We must demonstrate excellent bedside manner, respect for patients, and physical exam findings. Our learners need us to show them physician excellence. We must discuss patient interactions and patient education.

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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Friday, December 12, 2014

Health care information technology: new rules

Information technology clearly has a long way to go before it delivers on the immense promise of technology to truly improve health care. Most of the current solutions—quickly rolled out in response to Meaningful Use requirements—are slow, inefficient and cumbersome. Physicians (and nurses) spend far too much time staring at their screen and navigating the system, often to the detriment of patient care time.

A study published last year in the Journal of General Internal Medicine shockingly found that medical interns now spend only 12% of their day in direct patient care and 40% with computers. Statistics like that are a great shame for the practice of medicine. The problem is not so much the idea of increased use of information technology in health care, but that what's available right now is suboptimal and actually takes longer to use than it should. So until those dream systems of the future are released, here are 5 new rules for our interactions with health care IT:

1. Do not let the computer cost you your patient relationship

During any patient encounter, refuse to spend more time looking at a computer screen rather than them. Even if it takes a bit longer and you need to use the computer again later, sit down and spend time engaging in direct conversation. This applies especially to office care, where the worst thing a doctor can do is keep turning their back on the patient every few seconds to start typing away and being a data entry robot

2. Do what's necessary

If free data entry takes too long on your IT system, try to enter the minimum needed in order to be succinct and to the point. Avoid typing long descriptive paragraphs if they are not needed, which can take a lot of time above and beyond what's required

3. Learn the intrinsic quirks of your system

Every IT system has its own quirks and way of getting things done. There will likely be more than one way of placing a certain order or entering data. By getting to know your system well, you can often find a quicker and more efficient way of doing something

4. How you interact with your computer

Many tasks, such as ordering a medication, can be done “on the go”. If you get into the habit of sitting down every time you are in front of the computer, a task that could take 10 seconds can easily turn into 2 or 3 minutes. Whenever you can, stand up and do whatever you need to, and get right back to where you should be—with your patient

5. Give feedback and organize

My experience is that hospital IT departments are usually very responsive to feedback from frontline doctors and do whatever is in their power to make the system work better. It could be changing a menu option, altering a screen appearance or reducing the amount of clicks it takes to perform a given task. If you see something that can be done to improve workflow, pick up the phone or send an email. And on a national level, how about making this problem a bigger issue?

As electronic medical records evolve, the likelihood is that we won't be having this conversation in a few years. The ideal systems of the future will make life better for both doctors and patients—seamless, user-friendly and efficient. They will also be the ones that are “seen and not heard,” allowing direct patient care and maintaining the human relationships in medicine. Until that day comes, let's get to work.

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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