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

Monday, January 31, 2011

Hospitals seeing more Medicaid patients while states lower reimbursement

State governments continue to balance their budgets by gashing Medicaid.

Arizona, which wants to drop coverage for 280,000 Medicaid recipients, is seeking a waiver from the federal requirement that states not reduce Medicaid eligibility. Spending for the program has nearly doubled in the past three years, from 17% of the general fund to 30%.

Tennessee officials are preparing to cap Medicaid use at eight doctor and hospital visits a year. The state has a $1 billion budget shortfall.

Texas, which is considering eliminating Medicaid altogether, is looking to pass a budget that would cut Medicaid reimbursements to long-term care facilities by 33% and hospital payments by 10%.

It's not until 2014 that Medicaid’s reimbursement rate will rise to match Medicare's, possibly enticing doctors to accept it then. So legislators and governors are looking at what they can cut, including payments to physicians now.

Often, the cuts will cause states to lose out on federal matching funds. Tennessee, for example, wants to reduce state spending by $103 million, meaning they'd miss out on $203 million in federal matching funds. In Texas, one health administrator said the state gets $1.50 for every $1 it spends.

And if states cut their Medicaid budgets, the cost of care gets shuffled, but it doesn't disappear. Private insurance rates rise, for example.

The states' budget crises come at a time when Medicaid hospitalizations are rising. Hospital admissions of Medicaid patients jumped by 30% between 1997 and 2008, compared to a 5% growth in privately insured patients, reports the Agency for Healthcare Research and Quality (AHRQ).

AHRQ found that:
--Over the period, a hospital's average cost for a Medicaid patient stay rose 11%, compared to a 34% cost increase for privately insured stays and the 26% increase for uninsured patients, adjusted for inflation.
--In 2008, the average Medicaid patient stay cost a hospital $6,900 and about the same for an uninsured patient, compared to $8,400 for a patient stay covered by private insurance, adjusted for inflation.
--Altogether, Medicaid patient stays cost hospitals about $51 billion, compared to $117 billion for privately insured patient stays and $16 billion for uninsured stays in 2008, adjusted for inflation.
--Medicaid was the primary payer for more than 18% of the nearly 40 million hospital stays in 2008.

But it's not all bad news. Washington state salvaged two programs through a Medicaid waiver that will let the state and federal government share the cost. The waiver, intended originally as a short-term bridge to national health care reform in 2014, will provide about $7.7 million a month in new federal funds, or roughly 40% of the cost of programs funded primarily by state dollars.

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Monday, January 24, 2011

Beyond a spoonful of sugar

First there was that draconian immigration law. Then came the news about the cash-strapped state cutting Medicaid funding for certain types of transplants.

[And of course now the horrible news about the shooting rampage in Tucson.]

spoonful of sugar by truds09 via FlickrJust when I thought Arizona would legislate itself into least-favored state status, there was this article by Pam Belluck in the New York Times. The quick summary: Beatitudes nursing home in Phoenix is an outlier in the care of patients with Alzheimer's dementia, because the staff there are empowered to give the patients what they want. Really. Any time of day or night.

Chocolate? Check.

A nip of brandy? You betcha!

Grandma (Mom?) wants to play with dolls? God bless her ...

This article, part of an ongoing Times series called "The Vanishing Mind," carries the subtitle "Therapy Based on Comfort."

Therapy based on comfort? I love this idea! Ultimately, what else is there?

I find myself asking this question more and more. Health care and hospital practice is all about sacrificing comfort in the name of answers: diagnosis and treatment answers. [Hey! and let's not forget prognosis answers ...] When did medicine, like life, become "no pain, no gain?"

And this newfangled philosophy by Beatitudes is front page news! Literally.

Belluck's article splashed across the front page the same month that the ever-crusty New England Journal of Medicine carried a piece titled "The Emerging Importance of Amenities in Hospital Care."

What earth-shattering trend will the NEJM reveal to us next? "Shelter keeps people warm and dry?"

What's interesting about the way this nursing home treats its patients is, well, the outcomes:
--The patients eat more.
--They're less agitated. They wander less.
--The nursing home has therefore cut way back on its use of sedative drugs and physical restraints.
--This makes the families of these loved elders much happier.

The staff feel better about the care they're delivering, since they're empowered to try to negotiate their way out of challenging situations by giving the residents of the nursing home what they want, rather than telling the residents what they "must" do to comply with the home's (and presumably state and federal) regulations.

Okay, you say, but this is an isolated example. A nice example of a defined population (Alzheimer's patients) and a select environment (the nursing home).

But what prevents us, other than the inertia of old habits and institutional culture, from holding to these principles in other realms of health care?

Couldn't we provide patients with comfort in hospital settings? Why does it always seem to be either/or?

We move vigorously to treat diseases, but when they become resistant or the treatments themselves too toxic, why only then do we switch to comfort mode? The article commented on here is only the tip of the iceberg in poking holes in that theory.

Remember that you heard it here first: The massive federal health care overhaul (coming to you full-fledged in 2014) will alter the landscape dramatically. Health care entities that offer value, convenience, service, knowledge, and above all comfort, will sip from the chalice of health care innovation and reward.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Friday, January 21, 2011

What’s new in hypertension with JNC 8 on the horizon?

This is a guest post by Juliet K. Mavromatis, FACP, a primary care physician in Atlanta, Ga.

If David Letterman were to make a Top Ten list called: "Things that Doctors do that Really Matter," treating hypertension would certainly make the cut. Hypertension is highly prevalent within our society, with about one in three U.S. adults affected. The relationship between blood pressure and cardiovascular risk is continuous and independent of other cardiovascular risk factors. Treatment of hypertension has been demonstrated to reduce risk of stroke by 35 to 40% and risk of myocardial infarction by 20 to 25%. If you are reading this thinking, "but I've always had low blood pressure," here's some cheerful news: 90% of adults who have normal blood pressure at age 55 will develop hypertension as they age. Thus, the detection and appropriate management of elevated blood pressure is one of the most important tasks in the practice of providing primary care to adult patients.

Those of us who treat hypertension hopefully have heard of the Joint National Committee (JNC) guidelines on hypertension. The latest set, "JNC 7," came out in 2003. Since 1978, when the National Heart, Lung and Blood Institute (NHLBI) formed its first multidisciplinary panel (JNC 1) to review the evidence and formulate its summary, these guidelines have been the major clinical practice rule set governing appropriate treatment of hypertension. It's been nearly a decade and JNC 8 is expected to be released in the spring of 2011.

Recently I had the pleasure of listening to a talk at the Georgia Chapter meeting of the American College of Cardiology by Dr. Keith Ferdinand, Clinical Professor of Medicine, Division of Cardiology at Emory and Chief Science Officer of the Association of Black Cardiologists. Dr. Ferdinand, who has served on previous NHLBI JNC committees reviewed the last decade of data that is likely to impact the newest set of hypertension guidelines.

Some of my take home points from this talk are listed below:

(Click on the "More" link to continue this post.)
Evidence supports the treatment of hypertension in octogenarians. Patients treated with indapamide (a diuretic) with or without perindopril (an ACE inhibitor) had 30% reduced risk of stroke and a 21% reduced risk of death from any cause.

The blood pressure treatment goal for diabetic patients may be revised, based on the ACCORD intensive blood pressure lowering trial, to less than 140/90 (currently less than 130/80). ACCORD found no cardiovascular benefit for the primary endpoint with more aggressive lowering of blood pressure (to less than 120 systolic versus less than 140 systolic) in high risk hypertensive diabetic patients.

ACCORD did find a small reduction in a secondary endpoint, total stroke and non-fatal stroke, in study participants treated to the more aggressive blood pressure goal. In addition the placebo group in ACCORD was noted to have on average relatively well controlled blood pressure.

The ONTARGET trials found that there is not good evidence to support either renal or cardiovascular benefit from the combined use of ace inhibitors with ARBs for high risk patients. These randomized controlled trials looked at ramipril, telmasartan, and their combined use with respect to renal and cardiovascular outcomes.

In refractory hypertensive patients, spironolactone 25 mg should be considered as an additional agent.

Amongst the class of thiazide diuretics there may be differences amongst agents and their prescribed dosages in terms of efficacy for cardiovascular risk reduction. The longer acting chlorthalidone may be more effective than the shorter acting hydrochlorothiazide. Some of the most widely cited studies providing evidence for the use of thiazides as first line treatment for hypertension are based on study of chlorthalidone or using higher doses of HCTZ (50 mg) than those normally prescribed.

The combination of ACE inhibitor (benazepril) and dihydropyridine calcium channel blockers (amlodipine) may be superior to the ace inhibitor and diuretic (hydrochlorothiazide) combination for hypertension treatment (ACCOMPLISH).

Atenolol is falling out of favor, with a relative lack of evidence supporting its use as a first line therapy for hypertension. More attention is likely to be given to beta blocker selection on the basis of demonstrated cardiovascular outcomes (metoprolol, carvedilol) in JNC 8.

As a primary care physician I found it very useful to hear Dr. Ferdinand's opinion about what's to come with respect to JNC 8's hypertension guidelines. I already will be changing some of my practice based on this knowledge. I look forward to reading the guidelines and hearing the reaction of experts in the spring of 2011. It appears as though with hypertension, as with other fields of medicine, there will be a growing emphasis on specific drug and dose selection as opposed to class of drug selection.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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Thursday, January 20, 2011

Point-and-click medicine: The EMR game

Whistleblower readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients' medical data from other physicians' offices, emergency rooms and hospitals.

In addition, data input in the physician's office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40-yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I'm not a businessman, but I have learned that when something owns you, it's generally better for the owner than the owned. This meeting was about the hospital's upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made.

(Click "more" below to continue reading this post.)

In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients' care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

One advantage that computerized ordering aficionados claim is that physicians' orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn't know that I had?

One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order "reform" sound like it originated from folks who understand doctors?

I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.

I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don't practice medicine or understand physicians' needs. What's good for billers and coders may not help physicians in exam rooms with living, breathing patients.

I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that "point-and-click" medicine was more about medicine than about pointing and clicking.

Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point-and-click blogging. Hmm. I can see the goal line. Become a subscriber!

This post by Michael Kirsch, FACP, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, January 12, 2011

Life at Grady: Tick-Tock

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

Same-day sick appointment in the Grady Primary Care Center:

"I can't sleep, doc."


"Yeah. And it ain't like I'm sleepy, either. I just be sitting there. Just up and bored."

"Tell me about your evenings."

"I get in bed at like eleven. I turn on my television and just watch some TV. You know, Leno and the news. My old lady falls asleep and then I just sit there. Wide awake. After while, I shut off my television and just lay there."


"I know . . . . I ain't supposed to watch TV in bed, but I'm telling you, doc, it ain't that."

"That television can be harder on you than you think. Has it always been hard for you to sleep?"

"No, ma'am. I used to sleep fine. And as for that TV? Naw, it ain't that. I been sleeping with my TV for years. See, I know just what the problem is."

"What's that?"

"I'm a light sleeper and the noise-- it keep me awake."

I needed more information. "Noise? Does your ladyfriend. . . uhhh. . . snore?"

"Naw!" He chuckled at the very suggestion which made me imagine his better half as a dainty, princess-like woman who gently sighed all night. "She sleep quiet as a mouse." I smiled at the image.

"So. . . you mean the TV noise? I'm confused."

"Naw. Not the TV. This." He pointed at his chest.

I looked puzzled. Was he some kind of human beatbox that played involuntarily? I didn't get it. He saw the confusion in my face and elaborated.

(Click "more" below to continue reading this post.)

"This, doc." He pulled down his shirt to show me his midline sternotomy scar from what was obviously some kind of open heart surgery. I narrowed my eyes and tried to get his point.

"I got this mechanical valve put in my heart almost a year ago. And doc, I promise to God, when it get real, real quiet in my house, I can hear it. Loud. I'm for real."

Wow. This was a new one for me. Though surely this was not a new problem under the sun, it was definitely my first time sitting across from a patient who had it as their chief complaint. His chart said, "Can't sleep." Now that I could deal with. In fact, I'd grabbed his chart to help move things along in the clinic thinking I could knock this out (and him out) in two seconds flat. In my head, I was already preparing to launch into my spiel on "sleep hygiene." Insomnia is such a common issue, and almost always, the patient is doing something that can be easily modified. Like watching television or sitting on their laptop/Kindle/iPad all night sending light to the brain and telling it that it's time to get up and boogie. I thought this guy had me at "television", but never expected this. Dang.

"So. . .what are you hearing?"

"The click. That thang click nonstop. Same thing you hear when you put your thing on my chest to listen, tha's what I hear up in my ear. Like somebody snapping some metal fingers."

I furrowed my brow and tried to think.

"Messed up, ain't it doc? How anybody 'posed to sleep with that in they ear all night?"

Wow. That was messed up. I had no answer for that question. I really didn't. I leaned my chin into my hand and sighed. A concerned, perplexed, mind-searching sigh.

"Have you. . . . tried a noise machine? You know. . .like one of those ones that has all the soothing sounds? Like rain. . and thunder. . .the beach. They have machines that do that. Stuff like that?"

"I think it ain't nothin' I can turn up that will be louder than some metal clicking in my body."

Pretty much, he was right. So I just sat there, staring at him kind of like the way a dog stares at you when you are eating. Alert, but sort of dumb-looking. I realized that it was like someone trying to drown out their own hum--covering the ears only makes it worse. I wanted him to get some rest. I really did. But the truth was that I had no answers. None whatsoever.


Today I'm reflecting on the fact that (more often than folks realize) sometimes doctors just don't have an answer to the problem. Or as I once heard a medical student say, "I got nothin'."

The good news is that, since common things are common, this is usually not the norm. Most of the time, we do have a strong idea of what's going on, and with that we can set out on a clear cut plan toward reaching a solution. But sometimes the problem or complaint or ailment is one that, for the life of you, all you can say (under your breath, of course) is, "I got nothin'."

You can't sleep because you are disturbed by the mechanical click of your life-saving artificial heart valve?

Earplugs? You'll still hear it.
White noise? You'll still hear it.
Sleeping medicine? Ability to sleep isn't the issue and you'd be too groggy to do your job.

Yeah. I got nothin'.

Over the years, I have learned that one of the best things to do in these times is enlist the patient as my consultant and collaborator on the plan. There's something called the "explanatory model" that we teach medical students to use during the history-taking portion of their patient encounters. The explanatory model is this point where you essentially ask the patient what they think is going on. Some wise medical educator finally put two and two together and recognized that patients often are spot on when it comes to pinning the diagnosis.

Case in point:

"I have back pain."

"Did you injure yourself? Pull a muscle? Lose weight? Gain weight? Do something new? Do a new exercise? Sleep somewhere unusual?"

"No. No. No. No. No. No. No."

"What are you thinking this could be?"

"I think it's a urinary tract infection, because it's exactly like the last time I had one."

Urinalysis comes back ten minutes later: > 100 white blood cells per high power field--diagnostic of exactly what the patient said.

So, yeah. We often use the explanatory model to assist us with diagnoses, but I've come to lean on it a lot more for treatment plans--especially the ones that don't involve prescriptions or procedures. This day, more than ever, I needed my patient as a consult.

"Sir. . . . I'm going to be honest with you. I am wracking my brain trying to think of what you can do for this. I'm just not sure how to make it where you can't hear that clicking. How 'bout we put our heads together on this one, okay?"

"That sounds good."

I turned the computer monitor around and started doing a literature search on the noise of mechanical heart valves. "First, I'm looking to see if any experts have any ideas." I punched in a few terms into a search engine. "What kinds of things have you tried?"

"Honest, doc? I tried having on the TV. I tried having a couple drinks, but then I knew that getting myself drunk wasn't gon' be something I could do every night." We both laughed.

"Yeah, you're probably right about that solution," I said with a wink. "Hmmm. Everything I'm seeing here just talks about the fact that some valves are noisier than others."

"Mine is the St. Jude."

"Yeah. . .that's a noisy one according to this. . . . Let's see what the patients are saying, okay?"

"Okay." He closed one eye like he was debating telling me something for a moment. Then he said, "You know what I did try one time that did kinda work, Miss Manning?"

I offered him a quick glance while still skimming a few message boards. "What's that?"

"I slept with a pillow over my chest, and my old lady gave me one of them eyeball masks. Something about that mask make you sleep good."

I stopped what I was doing and looked at him. A mask. Hmmm. I never thought about a mask. Good thought, actually. Closing out light is good for melatonin production which is good for restful sleep. Hmmm.

"I felt so funny with that mask on," he went on with a slightly sheepish grin, "like I was some kind of . . .I don't know. . . what my old lady call it? A diva."

I cocked my head to the side and then giggled. He was anything but. "You are so not a diva, Mr. Jefferson." We shared a smile before I went back to reviewing the comments on one of the patient websites. "I'm seeing here that one person said they learned to love the click since it reminds them that it's working." .

"That's a good way to think about it."

"Have you worn the mask any more than the one time your lady friend gave it to you? I like that option because they really can help you get good sleep even if you can hear the sound."

He sat there for a moment and squinted his eyes. "You know, what? I can try that. I only wore that thang once or twice and -- real talk-- it did help even though it don't cover my ears. Why don't I try that."

"You cool with that?"

"Yeah, doc. I'm cool with that. Plus I take enough medicines."

I nodded my head and charted our plan into the computer.

"And you know what else I'm thinkin?" he added as I typed into the electronic medical record. I raised my eyebrows and turned in his direction.

"I'm thankin' that I like that part about seeing my click as my reminder that my heart got fixed." I paused again and gave him my full attention. "I almost died before they changed out my valve, Miss Manning. It was infected and they said I could almost die. I was in the intensive care and everything."


"Yeah. And I got kids, and even a grandbaby now."

"So I guess it's like every click is another second that you get to be here loving your family."

"Kinda like every click got a testimony in it. My testimony."


"That's a beautiful way to look at it, Mr. Jefferson." I thought about his poignant statement and shook my head. "Mmm mmm mmm. Every click is a testimony. I love that."

He looked down at his chest and then up at me. "You know what, doc? I love it, too."

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Tuesday, January 11, 2011

Boomers 2011

In 2011, the first wave of baby boomers will turn 65 years old. Sixty-five still has currency because that's the age at which non-disabled Americans are eligible to be covered under the Medicare program (now itself having reached middle age).

As our economy continues to recover (hopefully) from the Great Recession, the entrance of millions of Americans to the Medicare rolls over the next decade and a half will be a formidable planning challenge. Click on the chart to watch the baby boomers population surge.

So is the promise of Health Care Reform (the "PPACA"), which will enlarge Medicaid by an additional 16 million Americans--about half of the projected growth in coverage for those currently uninsured.

A couple of recent patient encounters got me thinking about these phenomena, and how we are very much in historically uncharted territory:

Never have we had so many living so well for so long. We have an entire generation of people reaching "seniority" who will continue to want the most out of life, without many guideposts on how to achieve it.

As an example, take a patient of mine I'll call Ted. He'll turn 65 in 2011. He's retired, healthy, and financially secure. Every year I see him once or at most twice for a physical and preventive care. He is motivated to exercise and undergo cancer screening, since he wants to enjoy his "dotage," and not succumb to some of the ravages of aging. I say some, since each year in anticipation of his physical, he sends me an update on his health status.

His numbered list this year was about a page and half, with copious detail on various ailment and insults. But it was number six, the last item, that really grabbed my attention. His prose has a poetry all its own: "Finally, I'd like to comment on the aging process again, if I may. I have alluded to 'death by small cuts' in the past as a way of describing what I was experiencing as I think about myself. This past year I've noted several specific things: my drop in motivation to exercise; my arthritis has become more pronounced; a notable decrease in my speed in walking ...; I am slower on steps than before, but still able to do as many as I need to; I find a distinct difference in how my sons and son-in-law always take the heavier boxes, packages, air conditioners, etc. ...; [I see] distinctly more courtesy from those so inclined, in public, as doors are opened, or I'm allowed to leave elevators first, for example; it takes longer to do chores in the yard, and I must pace myself very differently than in the past; I nap for 20-30 minutes in the afternoons, when I've done something physical earlier that day. There's nothing to prescribe, I'm afraid, short of a draught form the Fountain of Youth, but I thought you'd like to know some specifics on what I'm seeing as another year goes by. It does seem to change a bit every year. I'll tell Dr. P. [a geriatrician relative of his], of course, but I really don't think I'm bringing any breakthrough ideas to the field of Geriatrics, as I begin my eligibility for that class."

A man with too much time on his hands? Perhaps. But someone in touch with his body and its rhythms, trying to capture the emotions of aging. I tell him that he's "in the 99th percentile" of my patients, in terms of his health awareness and motivation for healthful longevity, because it's true.

I was ruminating about Ted, and what to advise him, when I had a similar sort of encounter with Sally [not her real name]. Sally is also 64, and stuck in the middle. She cares for an aging mother, and no longer has her children to care for since they've been married off.

Sally's main issue at her visit, other than preventive health (she's also retired and financially independent), was her anxiety about where to focus her energies.

Then, like a lightning bolt, she asked a simple question:

Had I ever heard of a doula?

Yes! What a GREAT idea! She could volunteer her time and serve as a doula.

Voila: an idea. Let's have Boomers fortunate enough to afford retirement give back to their communities. Volunteering. Teaching. Attending.

This recent New York Times column raises the whole question of adult education as a "new frontier."

What would you suggest for our Boomer friends?

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Thursday, January 6, 2011

More on when hospitals are like hotels

[Editor's Note: This post originally appeared at Medical Lessons]

A recent NEJM perspective considers the Emerging Importance of Patient Amenities in Patient Care. The trend is that more hospitals lure patients with hotel-like amenities: room service, magnificent views, massage therapy, family rooms and more. These services sound great, and by some measures can serve an institution's bottom line more effectively than spending funds on top-notch specialists or state-of-the-art equipment.

Thinking back on the last time I visited someone at Sloan Kettering's inpatient unit, and I meandered into the bright lounge on the 15th floor, stocked with books, games, videos and other signs of life, I thought how good it is for patients and their families to have a non-clinical area like this. The "extra" facility is privately-funded, although it does take up a relatively small bit of valuable New York City hospital space (what might otherwise be a research lab or a group of nice offices for physicians or, dare I say, social workers) seems wonderful.

If real health care isn't an even-sum expense problem, I see no issue with this kind of hospital accoutrement. As for room service and ordering oatmeal for breakfast instead of institutional pancakes with a side of thawing orange "juice," chicken salad sandwiches, fresh salads or broiled salmon instead of receiving glop on a tray, that's potentially less wasteful and, depending on what you choose, healthier. As for yoga and meditation sessions, there's rarely harm and, maybe occasionally, good (i.e. value).

But what if those resources draw funds away from necessary medicines, better software for safer CT scans and pharmacies, and hiring more doctors, nurses or aides? (I've never been in a hospital where the nurses weren't short-staffed.) As for employees who clean hospital floors, nursing stations, patients' TV remotes, IV poles, computer station keyboards and everything else that's imperfect and unsterile, they should get more funding, everywhere. Clerks and transport workers are frequent targets in hospital layoffs, but they're needed just the same.

Two years ago when a family member was hospitalized, his doctor, a senior cardiologist, personally wheeled him in the stretcher from the X-ray area back to the emergency room bay where he waited for a room, so that he wouldn't spend more than the half hour or so he'd already been in the hallway, after the film was taken, waiting for the escort service.

What's wrong is not so much that the physician helped with a menial task that isn't his job. He's a really nice and caring sort, and I believe he didn't mind, really, except that he does have a wife and family at home who surely were waiting on that day. The cardiologist might have used that time, instead, to examine more closely someone's neck veins or heart sounds, or spent a few more minutes reading a journal article, which would make it more likely he'll make the right recommendation to his patients about, say, a drug for congestive heart failure or a new blood thinner.

We can't short-change hospital workers in such a way that physicians fill in on ordinary tasks because there's no one else to perform those, while patients get first-class meals and art classes to make them happier.

I'm reminded of boarding airplanes. I fly coach, and as I pass through the first class section I often think how nice it would be to sit in front and have pleasant flight personnel attend my every need to maximize my comfort during what's typically a miserable trip. But then, I'd be paying perhaps $3,000 instead of $680 for the same flight.

As passengers, maybe we're not so discerning about our pilots or the model of airbus as we should. A pleasant, cheery place isn't always the safest.

In the NEJM piece, Goldman and colleagues write: "Why do amenities matter so much? Perhaps patients simply don’t understand clinical quality. Data on clinical quality are complex, multidimensional, and noisy, and they have only recently become systematically available to consumers. Consumers may be making choices on the basis of amenities because they are easier to understand."

The authors note the potential value of amenities in patients' experiences and outcomes: "One could argue that they’re an important element of patient-centered care. If amenities create environments that patients, providers, and staff members prefer, then providers and staff members may give better care and service in those environments and patients may have better health outcomes."

Amenities are costly, but they attract patients: "[T]he value of amenities is important because our health care system currently pays for them. Under its prospective payment system ... Each hospital receives the same amount of reimbursement for each patient with a given diagnosis and is free to decide what mix of resources to devote to clinical quality and what to spend on amenities. In our research, we found that improvements in amenities cost hospitals more than improvements in the quality of care, but improved amenities have a greater effect on hospital volume."

I'll remind my readers that health care costs in the U.S. total over $2.3 trillion per year, and that number is growing.

Hospital amenities are really nice, and I believe they can help patients heal. But I don't know if it's right to spend limited health care dollars on more than essentials.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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Wednesday, January 5, 2011

Life at Grady: Death with dignity

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

This is ridiculous.

That's what I said to myself while reviewing the chart of one of my recent inpatients. I let out a sigh so exaggerated that three nurses looked in my direction.

This critically ill gentleman with a ruthlessly aggressive and irreversible malignancy that was clearly declaring itself victorious over his young body wasn't tolerating yet another chemo regimen. I shook my head as I scrolled through his labs. Evidence that every one of his organs was failing was even more apparent.

Despite a prolonged hospitalization, multiple chemo regimens with abysmal complications and terrible relapses, a stubborn elephant was standing squarely in the doorway leading to his room. This man was dying.

But like many elephants in rooms, not many people wanted to acknowledge it. Especially since it involved the "d" word.

(Click "more" below to continue reading this post.)

"They cannot be serious, " I mumbled under my breath at the computer screen.

I was referring to the two-guns-blazing, horribly noxious chemo medication he'd just been started on that morning by the specialists. It was sure to make him feel like crap. It would likely make his failing kidneys fail more (which would make his failing lungs fill with more fluid and fail more.) Furthermore, it was also likely to cause some of his final days to be inhabited by nausea so intense that one might liken it to having their insides turned inside out. I hated to see him tortured when the prognosis was so poor.

The other thing was that, despite his critical state and the unlikeliness of a meaningful recovery, his chart still indicated that all heroic measures be performed in the event of a cardiopulmonary arrest. Patients in this stage of disease often sign a "do not resuscitate" order--or as one of the Grady elders once put it to me, a "let me go in peace" order. But not this patient. I was determined to give him the courage to change his mind.

We talked for several minutes about all that had transpired over the last several weeks. I talked to him about the disabling side effects of the chemo regimens only to be followed by gripping setbacks. Over. And over. And over again. I wondered if he knew that it was okay to say, "No more."

"What do you want?" I asked my patient in a quiet voice.

"What do I want." He said it as a statement and not a question. Like he needed to let it marinate.

I cast my eyes downward toward his left hand that rested in my own. I couldn't help but notice his identification band; reminding me of what was so unfortunate about this situation. A man with a date of birth that was well after my own had to decide what he wanted. Or rather, how he wanted to die.

"I know what I really want," he murmured with a sideways smile. I widened my eyes and encircled my fingers around his puffy hand. His rich chocolate skin was smattered with bruises from blood draws and capillary blood leaks. "I want. . .I mean. . . I don't want to die. That's . . . that's what I want. I want to live."

Those words were like a dagger piercing me straight down to the white meat. This young father with a life full of unfinished items to cross off of his bucket list simply wanted what we all want. To live.

I didn't know what to say.

I watched his laborious breathing and tried not to notice his distorted body; all a result of the massive fluid that his failing body was accumulating. Beeping machines surrounded him and we did our best to ignore them.

Just then, a phlebotomist came in in and wrapped a tourniquet around his arm.

"Hey friend," she greeted him in that familiar tone only achieved through repetitive encounters.

"Hey, Vampire Lady," he responded with a weak chuckle.

She quickly plunged the needle-tipped vacutainer into the crook of his right arm. Methodically, she gently attached one glass tube after the next. She met my eyes for a fleeting moment; we both recognized how awful this was. The blood rolling against the sides of the container hypnotized me for a moment. Finally, I shook my head and came to.

What are we doing? I asked myself.

Chiming alarms. Tangled tubing. And someone jostling him from a quiet slumber to draw his blood every eight hours. All for what? I closed my eyes and swallowed hard. This sucked. Why were we doing all this to him? This gentleman was dying.

"Okay, friend, that should do it." Vampire Lady carefully removed the rubber tubing from around his upper arm and placed a bandaid on the oozing site. It would surely bleed out and around that bandage considering his failing bone marrow had robbed him of platelets and his failing liver wasn't making clotting factors.

"One of these days, you gon' stick me and nothin' is gon' come out." He laughed, not really realizing the irony of his joke. She also laughed, but it was that pained, gallows kind--that nervous laughter when someone is on their way to the electric chair.

He looked like he was falling asleep. But his breaths were so fast and taxing that I knew it wouldn't last. He startled me when he returned to our initial conversation.

"I want to live. That's what I want. So whatever they have to give me, I'm gonna take it."

Of course.

That's what I want, too. I want you to live, too. But the fact is that your body is dying. God is trying to take you home. And short of Him changing His mind, He'll get His wish regardless of what you're offered. And since I had no panacea, I was looking for the next best thing--a peaceful journey to the other side.

So far, it was anything but.

The zealous therapy being offered to him by the specialists hurt me to watch. To me, every toxic bag of experimental, last-ditch medication hung on his IV pole translated to time away from his son and his wife. In my heart, I felt he wanted permission to let go. But since I was on a totally different page than my colleagues, there was very little I could do.

"You got a cure for me in your pocket?" He bravely smiled. I wished that I did.

At that moment, a nurse walked in and pricked his finger for a blood sugar measurement. I cringed, recognizing that even this--a simple piercing with a lancet to his middle finger--was more than I wanted him to endure. The nurse seemed to intuitively know to respect our "moment."

I squeezed the brown pillow that had once been his hand, and put my other on his bony shoulder. His eyes closed in what seemed to be unison with my own. Before I could talk myself out of it, I uttered an internal prayer.

It was all I had left. It may not have been completely appropriate but this was out of our hands. I opened my eyes just in time to see him mouth the words "thank you" while tightening his grip on my hand. I nodded slowly.

The alarm bells went off on his monitor signifying that his respiratory rate was high. I pressed the "silence" button. A minute later it sounded again.

"What do you want?" he finally asked me.

"Excuse me?" I answered, surprised by him turning the question on me. I pushed the yellow silence button once more, hoping to get out of it.

He repeated. "What do you want." Again in that same statement-like way. I decided to let it marinate, too.

My eyes threatened tears as his bloodshot eyes pierced me with a tenacious gaze. What did I want? Was he serious? My heart was screaming:

I want you to live!
I want you to be cured!
I want you to put a boutonniere on your son's lapel on his wedding day!
I want you to argue with your wife over names for your next baby!
I want what you want!

I softened my brow and pressed my lips together to fight the mounting emotion. Finally, I offered him a childlike shrug and said, "I don't know. . .I just want. . . .I just want you to have. . .a death with dignity. That's what I want at this point."

"I'm dying for real, ain't I?"

I pressed my lips even harder and nodded. My eyes stung with tears. "Yes. . . " I paused to keep from crying. "I'm so. . . sorry."

"Me, too." We stared at each other for a moment. This young man--nearly ten years my junior--with the perfect smile and twinkle in his eye, was dying. This husband, this father, this brother, this friend with skin of the same striking dark brownish-reddish hue as my Isaiah's was being called home. And there was no denying it.

"I know I'm sick. . .but. . .do it make sense that I just can't. . . you know. . .put it in writing for y'all to not do anything for me? Like not revive me? I'm just. . .I just can't. I gotta keep fighting."

"Even if it means. . .dying in. . .dying in the hospital?" There. I'd said it out loud. The 'd' word.

"I don't want to die in the hospital."

"But you could. Attached to all this." I reached over and silenced the alarm again.

"I know." He sighed hard. "But I just can't. See, tha's what's hard. I just can't say 'no more.' I gotta go down kicking and screaming. For my wife. For my son. It probably don't make no sense to, but I just can't make myself do nothing else. I just can't let go."

And the truth is, it did make sense for a young father of a son that looked just like him and husband of a doting wife to want to "go down kicking and screaming." To have trouble with letting go. That's when it dawned on me.

Even though my agenda that morning was to get him to "have the courage" to halt all aggressive measures and get home to his family for his final days, I had to acknowledge what was true all along: He was courageous. Who did I think I was--marching in there with my agenda to "give him courage?" Me give him courage?

Love had already done that.

This was his decision, not mine. And just maybe, a death that takes place in a hospital bed surrounded by beeping devices while fighting tooth and nail to the bitter end--for him--was a dignified death. I let go of my agenda and decided to respect his.

The alarm relentlessly sounded again, and again I pressed that yellow square. 60 more seconds of peace and quiet. It was the least I could do. I watched him as his eyelids floated downward and decided to ease toward the door.

"You know what I really want?" he broke the silence, startling me again.

I paused with my hand on the door. "Sir?"

"I think. . . .I think right now I just want something to help me get a little sleep and to help me move these bowels." We shared a quiet chuckle.

"Alright then, friend," I responded before leaving his room.

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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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