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Wednesday, November 30, 2011

Life at Grady: Back to reality

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

Recently I saw a man with one of the residents in the clinic whom I'd seen before. He'd had his fair share of medical problems, most of which were secondary to the bad habits he'd picked up over the years. Habits like crack cocaine, gin and cigarettes. Well, turns out those habits all got kicked when he was incarcerated for getting caught with a crack rock in his pocket.

Now he's out of prison and has a low-paying but "real, honest" job. This job let him take time off for his appointment at Grady. And he appreciated that. I know he did because he told me.

Prison was awful; he described it as being in a "time warp." When he was released, he found that his teenage daughter had become a woman with her own children. His once-scrawny son was "big enough to take me down." Lucky him, those children believed in redemption and welcomed their daddy right back into their lives just like the prodigal son...fatted calf, ring of gold and all that.

And their timing was perfect because he was ready to value his life. Prison was awful, yes, but also a gift, he said. Because it brought him out of the cloud he was in and brought him back to life and back to reality.

So now? He wanted to live. He cared about his health and wanted to preserve what he hadn't destroyed.

On this day, he looked a little distracted.

Oh no. Relapse?

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I hoped not. So I just asked. "Sir, you look a little distracted today. Are you alright?"

He wiped his face with his hand and shook his head. "I'm jest flustered, tha's all. I was late so that got me real flustered."

Justin, the resident with whom I was working, followed up with a little more information. "The clerk up front mentioned that you'd come to check in on time but then you left?"

"Yeah," he answered quickly, almost cutting my resident off. He dragged the heel of his hand across his forehead. "Yeah, it was just some stuff, you know, I had to take care of."

Uh oh.


Justin and I exchanged glances. Both of us were hoping it wasn't some symptom of a slippery slope. I studied him carefully--wanting to be wrong.

His face was covered with a thin film of sweat. His hair was a little unkempt and I wasn't sure if it was because he'd just pulled off the knitted skull cap he was wringing in his hands or simply hadn't combed his hair. The tail of his shirt was out on one side and he kept nervously tapping his right foot. The whole sight of it made me cringe a little. Damn. I'd seen that look before. Five years in prison and now this? Damn.

Just as I was parting my lips to speak, Justin spoke before me. "You just don't seem like yourself. What did you have to take care of?"

I shot him an almost scolding glance. What kind of question was that? Especially when your suspicion isn't exactly one that folks readily admit to? But Justin is kind-hearted and not the least bit passive-aggressive. I think he just sincerely wanted to know.

"I had to pay a bill I wasn't expecting yesterday. The electric had a reconnect charge, and I didn't plan on that. So then I didn't have my co-pay when I got up here." He looked down at his shoes. "But man...I really needed to keep my appointment. I needed to see the doctor."

I wasn't sure what to say to that, so I said nothing. He kept talking. "And they wasn't mean about it, you know, but the thing is I am supposed to pay ten dollars for my visit and that's a discount, you know?"

"So they worked it out for you?" Justin queried, still trying to sort it out in his head. Now that I think of it, there was some redemption in that question, too. He was determined to give our patient the benefit of the doubt.

"Well, you know, they couldn't since this isn't, like, the emergency or nothin'. I called my daughter and she helped me out."

"How?" I blurted out before I could stop myself. Now if anyone should have been getting a scolding glance, it should have been me for that dumb question. What difference did it make how his daughter helped him? He was here so obviously it worked out.

But that question didn't faze him one bit. He answered like it was as relevant as "Did you take your medicine this morning?" or "Have you been experiencing any shortness of breath?"

"She was at work, but she was able to get away for a second to wire it to me, so I had to catch the bus up the street to get the Western Union she sent me." Justin and I locked eyes instinctively. "Yeah, so tha's why I was late. I had to walk up to Boulevard to get the bus."

Hold up. So let me get this straight. This fifty-something-year-old man caught a city train to his appointment at Grady on his day off. Had to get the lights turned back on the day before so he didn't have the co-pay for his visit today? So he subsequently called his daughter to wire him TEN DOLLARS? And then walked a mile and caught a BUS to go get it? To see US??

Wow.

"She wired you ten dollars for your visit?" I asked him, almost a little bit too incredulously, since he'd just told us that.

"Well, really she wired me twenty. She was mad because it had to be in a multiple of twenty. I 'idn't realize that and neither did she 'til she got there." He shrugged. "So yeah. I'm sorry I'm all flustered. I just really needed to see my doctor and make sure my pressure and my lab work is okay." He meant that.

I won't even go into what an ass I felt like for assuming he was sweaty and "flustered" because he'd gone around the corner and gotten a hit. And let me tell you, this man was 100% serious and wasn't lying. This man was clean.

TEN DOLLARS? Really? I can probably locate ten dollars in change inside my couch as we speak. And here I am sitting across from this dude who is at least fifteen years my senior and this is what he has to deal with? Man.

Look. Everyone knows that folks are struggling all over the place. But working at Grady Hospital makes this waaaaay more than a notion. I opened a magazine and read about Kim Kardashian and her fifty trillion dollar wedding extravaganza for her 72- day marriage. I read that and then thought about this man interrupting his daughter at work to wire him a ten dollar bill. And her having a discussion with him about the perils of it being a twenty and not a ten that she had to send. If that doesn't make you feel glad for what you have, I don't know what does.

Some folks wonder how we do it, hearing all this stuff day in and day out. But honestly? I left that man feeling inspired and grateful for what I have. And if that isn't a reason to keep coming back to do what you do every day, I don't know what is.

Turns out that his blood pressure was just fine. And so were his labs.

Back to reality.

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Elderly want longevity over quality, but it's tough to predict

Don't assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.

Researchers looked at patients' willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure.

End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade.

End-of-life preferences were assessed at baseline, and at 12 and 18 months. In addition, CPR order during last hospitalization was assessed in patients who were included presently after discharge. Patients were divided into four groups: not willing to trade any survival time, willing to trade less than 6 months, 6 to 12 months, and 12 months. Results appeared in the European Heart Journal.

In multivariable analysis, willingness to trade survival time increased with age, female sex, a reduced Duke Activity Status Index, Geriatric Depression Score, and history of gout, exercise intolerance, constipation and edema. But, the authors noted, even combining these variables did not result in reliable prediction. Of 603 (97%) patients who had a resuscitation preference, 51% wanted resuscitation, 39% did not, and 10% were undecided, with little change over time. Resuscitation orders were known in 430 patients, but they differed from patients' preferences 32% of the time.

At baseline, 74% of the patients were not willing to trade any survival time for excellent health. Of the remaining patients, approximately equal groups were willing to trade up to 6 months, 6 months to 1 year, or more than 1 year. Patients aged 75 years and older were slightly more likely to be willing to trade any survival time, the proportion of those not willing to trade would still be 72% (at month 18, 75%).

Patients indicating any willingness to trade survival time for symptom-free living differed in many ways from those unwilling to trade, the authors wrote. They were older, more often female, lived more often on their own and/or were not married, had more signs and symptoms of congestive heart failure and poorer quality of life.

The authors wrote, "Openness and communication about prognosis, trajectories, and realistic treatment possibilities engender hope and allow patients to plan for their future. This applies to various decisions that confront (congestive heart failure) CHF patients, but may be particularly important with respect to (implantable cardioverter-defibrillator) ICD implantation, turning off the device, and treatment with purely symptomatic medical therapy that may even reduce survival."

An editorial commented that patients must receive accurate information about life expectancy in order to make better choice about their end-of-life. This requires open and repeated conversations in a patient-centered environment.

"In patients whose prognosis is grim, the real question we should be asking is 'Given limited quantity of life, how can we maximize quality?'" the editorial stated. "As the end of life nears, the goals of care should also change, and the alleviation of adverse symptoms becomes the most important objective."

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Monday, November 28, 2011

Hospitalistin'

Keep the big picture in focus
People should be admitted to the hospital because they are sick enough to have an increased chance of dying relative to those going home. My overall patient-by-patient "mission statement" is: Find the diagnoses and offer treatment options that decrease acute mortality and chronic morbidity through efficient and high quality care. Offer palliative care options when such treatment is medically futile or does not provide significant gains in the quantity to quality of life balance. The patient needs to be looked at as a gestalt of both data and intuition regarding the level of acute injury inflicted on the substrate of a certain level of chronically damaged protoplasm.

I have to explain to my patient and their circle that based on what I think is going on, will the treatment options available improve their lives and do those benefits outweigh the risks of that treatment. If not, pursuing aggressive treatment of the untreatable is a study in futility, and palliative care options should be introduced.

Understanding the worst case scenarios, is in my opinion, more valuable to both provider and patient than painting a rosy picture of the future. It is important to foresee negative outcomes to know what to test for and what you may need to treat, but without either you or the patient losing sight or hope of positive outcomes. Positive outcomes do not necessarily mean a cure, it may mean pain control, dignity, and even a peaceful death.

Sweat the details
A good internist is a scared internist: worried about what has happened, concerned about why the current state of their patient is different from before, wondering how complications can occur in the future. We take a microscope to abnormalities, trying to tease out if this is incidentally benign or malignant, wondering if this is evidence of disease or simply a normal perturbation.

Hospitalists must be the diagnostic laser, making light-speed decisions about what to pursue and what to defer as well as carefully convey to outpatient follow-up. We must carefully dissect subjective complaints and objective data using the scalpel of evidence-based criteria and a wealth of subspecialty guidelines.

We must thin out the electronic medical record of redundant or inaccurate diagnoses while updating it with new history. The patient's medication list is not simply the medications they are prescribed but those they are actually taking and when they are taking them. A hospitalized patient demands an agent, their hospitalist, who manages nutrition, hydration, electrolytes, medications, and ancillary therapist evaluations while requesting appropriate specialist consultation and preventing adverse events such as deep vein thrombosis, falls, and delirium. We must take a collection of prior documentation to weave a history, amalgamate in-patient events, tests, and consults as daily progress notes, and then meticulously sift all of this into a timely, complete discharge summary.

Achieving hemodynamic homeostasis
I consider "vitals" to be an acronym for Verify If They Are Living Still. In general most hemodynamically regular people are euthermic with a heart rate between 60 and 90 beats per minute, breathing 8-16 times per minute, have a systolic blood pressure greater than 100 mm Hg and less than 160 mm Hg, and saturate greater 92% on room air. If they don't they are either (1) acutely sick with a physiological response, (2) chronically sick and at their (albeit abnormal for the majority of the human population) baseline, or (3) weird.

Acutely ill humans should have a positive response to appropriate therapy, that is there vital signs approach normal, and negative one to inappropriate therapy. That being said, people die even despite the most optimal of treatment decisions, and people live despite our best unintentional attempts at killing them. You have to determine whether the population mean abnormal vital sign(s) are an indicator of acute pathology or simply evidence of chronic but stable disease.

Returning the patient to basal levels lab result rubor
People are often admitted because of the density of red (abnormal) test results they have. Although abnormals should be recognized they should also be placed within the context of their chronicity and severity.

Some patients have bloody diagnostic tests at baseline. An elevated white blood cell count can be due to chronic lymphocytic leukemia, dehydration, stress, or infection. No matter what we as physicians do, it is unlikely that no matter what we do acutely we cannot change the leukocytosis of CLL. Antibiotics do not treat dehydration or stress, but not treating a pneumonia with its associated leukocytosis is tantamount to medical crime.

Similarly a volume depleted patient may have a CBC in the black, volume contraction hiding their basal anemia, just because they are less in the red, doesn't mean they are any less sick. An elevated creatine in a patient on dialysis has an impressive crimson hue but generates little therapeutic inertia compared to the same value in someone without previous kidney disease.

No matter what intervention is undertaken, the patient with end-stage renal disease will never be in the black when it comes to creatinine, if we waited for this value to normalize before discharging the patient, they would serve a life sentence. As hospitalists we must find with the intent to treat the scarlet letter of abnormal but accept the chronic unchangeable crimson that will show up on some diagnostic tests. We can only attempt to restore our patient to the baseline they had before and hope to prevent the next decompensation as best we can.

ACP Member Mike Aref, MD, PhD, 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. This post originally appeared at his blog, I'm dok.

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Advocate to preserve residency funding despite 'supercommittee' failure

So, you have probably heard about the supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending. But, do you know that the chief target is residency training? That is right. Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money's worth.

Of course, this comes at a time when there is a shortage of residency spots given the expansion of U.S. medical schools, and a dire need for physicians, especially in primary care, to meet the needs of health care reform.

So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the supercommittee pleading with them not to cut Graduate Medical Education funding. Now the situation is dire enough that the Association of American Medical Colleges advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman. (And yes, if you live in a supercommittee state, it's even more important for you to do this).

So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action. For my fellow medical educators out there, you don't need to be left out. The American College of Physicians has a very broad (don't need to be an internist) easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.

Medical educators have actually started a dialogue about the role of advocacy in medical education. Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training. I can think of no other way than advocating for preserving funding for the system by which we train our nation's future physicians.

Vineet Arora, MD, FACP

(AAMC e-mail encouraging residents to take action)

Dear Resident:

I encourage you to take a few minutes to visit the AAMC Legislative Action Center (http://capwiz.com/aamc/home/), select "Residents", and send an electronic letter opposing cuts in Medicare funds that support residency programs. With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction. PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg, gmail.com), AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.

Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.

It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns. You are represented by members of the "Super Committee" that will finalize the deficit reduction plan.

Thank you for your help.

Atul Grover, M.D.
Chief Advocacy Officer
AAMC

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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Too much vitamin D can trigger afib

Too much vitamin D can lead to 2.5 times the risk of atrial fibrillation, researchers found.

To determine if there is a correlation between too much vitamin D and increased heart risk, researchers examined blood tests from 132,000 patients in the Intermountain Healthcare Center database. Results were presented at the American Heart Association Scientific Sessions in November, and appeared at the Intermountain website.

Patients did not have any known history of atrial fibrillation, and all had previously received a vitamin D assessment as part of their routine care. Patients were then placed into categories to compare levels of vitamin D: low (less than 20 ng/dL), low/normal (21-40 ng/dL), normal (41-80 ng/dL), high/normal (81-100 ng/dL), and excess (more than 100 ng/dL).

Patients with low, low-normal, normal and high-normal levels of vitamin D had no increased risk of atrial fibrillation. However, atrial fibrillation risk was 2.5 times greater in patients with excess levels of vitamin D compared to those with normal levels.

The Institute of Medicine currently advises that healthy adults should be able to take as much as 4,000 IU (international units) of vitamin D daily. But the exact amount of vitamin D to achieve normal levels is unknown and usage varies in different regions and communities, which can cause problems, said the researchers.

They encouraged physicians to ask patients about all vitamins and supplements, and that checking blood levels of vitamin D in patients who develop atrial fibrillation may help uncover the cause of the abnormal heart rhythm.

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Wednesday, November 23, 2011

Life at Grady: I won't complain

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

Working at Grady is like working in another little special country sometimes. There are things that are part of our normal here that in other places would seem odd or unusual. These are the things that make me love working at Grady so much.

On Monday the clinic was pretty busy. We finally wrapped up the last patient for that session, and at about 12:40, I sprinted down the stairwell and trucked through the hall on my way to get some food. I had only twenty minutes before being expected back so my brisk walk turned into a jog. I waved to passersby and chuckled when a gentleman said in that very Grady way "Don't run nobody over, Doc!"

Purse on my shoulder, white coat on and heels clicking on the linoleum...in quest of the Monday special at Subway and hoping the line wouldn't be horrible when I got there. Just as I reached the E elevator area, which is just before my turn to get out of the door, I heard something that made me slow down.

What is that?

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I furrowed my brow, stood still and listened for a moment. That's when I figured it out. It was the voice of an aged male...singing at the TOP of his lungs. And it wasn't in a mentally ill or obnoxious way, either. It was in this way that seemed reminiscent of what it must have been like for folks picking cotton out in fields or scrubbing their floors on Saturdays. Not a performance type voice either. Just this loud and proud and unashamed voice bellowing out a Negro spiritual.

"I HAD SOME GOOD DAYS
I HAD SOME HILLS TO CLIMB
I HAD SOME WEARY DAYS
AND SOME SLEEPLESS NIGHTS...."

I eased toward where the voice was coming from and laid eyes on the singer--an elderly African-American man who appeared to be nearing his ninth decade. He was holding a cane and coat over his arm, and had simply decided to close his eyes, throw his head back and break out in song while waiting for the Grady elevator.

There were easily twenty people waiting in the vestibule with him. And you know what? None of them seemed the least bit fazed by this occurrence. Not the least bit. In fact, several of them offered shouts of praise--not to him per se, but those shouts that you hear in black churches after the first few stanzas of any gospel song. Meant not for the singer but technically for God.

He kept going in his wobbly voice:

BUT WHEN I LOOK AROUND
A-A-AND I THANK THANGS OVER...
ALL OF MY GOOD DAYS...
OUTWEIGH MY BAD DAYS...
I WON'T COMPLAIN!!!"

I smiled as I watched, taking it all in. Then something even GRADY-er happened. A woman that appeared to be no more than five years older or younger than this man JOINED IN with him. Yes! Joined in singing the same song equally as loud has he! And they didn't even appear to know each other! She just came up beside him, lifting one hand to the heavens and not even really looking at him. But she was on his page most definitely...her gravelly voice belting out through the corridor in that same unabashed tone..still punctuated by shouts of affirmation from others nearby.

And so in unison they continued:

"SOMETIIIIMES THE CLOUDS HANG LOW
I CAN HARDLY SEE THE ROAD
I ASK THE QUESTION LORD,
'LOOOORRRD. . . WHY??? SO MUCH PAIN???'
BUT HE KNOW WHAT'S BEST FOR ME
ALTHOUGH MY WEARY EYES THEY CAN'T SEE
SO I'LL JUST SAY, 'THANK YOU, LORD.'
I WON'T COMPLAIN!!!"

It was absolutely beautiful. Beautiful for me because, yes, I'm a believer, but beautiful beyond that, too. Here were two strangers --both African-American elders-- who had surely lived through being spit at, called "boy" or "gal" or "nigger" or "nigra" and referred to collectively as "coloreds." Who, if they were Georgians, had lived through a gubernatorial campaign with the motto "NO! NOT ONE!" for the leading candidate who promised to never let one--NO!Not one!--black child integrate a school in Georgia. (That candidate won by a landslide.)

They knew of a "White Grady" and a "Colored Grady"...a world with air conditioning on one side and open windows with flies and sweltering temperatures on the other. They were told that one of them equaled 2/3 a man and for this reason they stood in protest with signs pleading with the world what should have been evident: "I AM A MAN." They sat in the backs of buses and entered through back entrances. Withstood teenage boys with pink twisted snarls speaking to them like they were children just because of some false superiority in their skin color. Forced to say yes'm or no'suh to these same KIDS, despite the fact that they were young enough to be put over a knee. Or worse, withstood poisonous words from the mouths of young adults that they themselves had raised.

And yet. Despite all of that, here they stood. Strangers. Singing...still singing from the depths of their guts these simple words:

"I won't complain."

I didn't cry then. At the time it hadn't fully sunk in so I just smiled and then went on my way. But later on as I was driving home I thought about what they were singing and the sincerity in it. I let it sink in, the entire scene...and I did cry. Man, every time I imagined them and what they must have seen in their lifetimes more tears came. I felt so indebted to them.

Then I cried some more, feeling ashamed for the things I'd complained about that very day.
This? This is Grady.

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Tuesday, November 22, 2011

Insurance status affects length of stay for some hospitalized patients

Patients without insurance have shorter lengths of stay when admitted to for-profit hospitals for preventable illnesses, researchers found.

Researchers analyzed length of stay for insured and uninsured patients by for- and non-profit hospital status. The study applied data from the National Hospital Discharge Survey (NHDS) from 2003 to 2007 for patients ages 18 to 64 years. The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), which were considered to be preventable, and non-ACSCs.

Ambulatory care-sensitive conditions were defined as those conditions for which hospitalizations are thought to be avoidable through preventative care and early disease management: seizures; ear, nose and throat infections; chronic obstructive pulmonary disease; bacterial pneumonia; asthma; congestive heart failure; hypertension; angina; cellulitis; diabetes; hypoglycemia; gastroenteritis and dehydration; and kidney and urinary infections. Non-ACSCs were also studied for comparison. Hospitalizations were excluded if patients left against medical advice.

Results appeared in the November/December issue of the Annals of Family Medicine.

After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay across all hospital types (2.77 days) than for those with either private insurance (2.89 days, P=.04) or Medicaid (3.19, P less than .01). In-hospital mortality rates were not significantly different among types of insurance, the researchers noted.

Across all hospital types, the length of stay for those without insurance was shorter in an adjusted analysis of ACSCs. ACSCs treated in government hospitals showed no significant difference in length of stay regardless of whether the patient had insurance, other than Medicaid or was not insured, researchers noted.

The authors wrote, "Because of the nature of ACSCs, we would expect that individuals who lack access to health care as a result of no insurance would arrive at a hospital with a more severe illness. Instead, our study found that length of stay for patients with ACSC diagnoses was shorter for those without insurance, results similar to those for non-ACSC diagnoses."

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Monday, November 21, 2011

The role of touch when talking to patients

My wife has two world-class oncologists who help her manage her Stage 4 lung cancer. Both are excellent clinicians. Yet their skills differ in one very important way. Her radiation oncologist physically touches her a lot (in a good way of course). There are the touches on her arm, a hand on the shoulder, hugs, and of course a thorough hands-on physician exam. Her medical oncologist, not so much.

No Touching by Sterlic via Flickr and a Creative Commons licenseWe all recognize the therapeutic value of touch. Abraham Verghese, MD, a Stanford physician and professor, at the 2011 Med2.0 Conference, described the power of touch associated with the physical exam. In the following scenario he describes an interaction with a chronic fatigue patient who came to him after being seen by many other physicians: "The patient was very voluble and kept talking as I began the physical. I always begin my routine, my ritual with the patient's hands ... it seems natural to hold the hands. I slip my finger to the radial pulse and then examine the fingers looking for cyanosis and clubbing ... As I began my routine, this talkative patient began to quiet down. I had an eerie sense that the patient and I had slipped back into a primitive ritual ... one in which I had a role and the patient had a role.

"When I was done the patient said to me with some awe ... I have never been examined like this before. If this were true that was unfortunate since this patient had been examined by other physicians many times before. Following the exam, I told the patient the same thing he had been told by other physicians, I don't know what the problem is ... but here's what we will do. I had earned the right to tell the patient this because of the examination."


Dr. Verghese believed that, unlike the other physicians seen by the patient, he had earned the right to diagnose the patient and expect the patient to accept and act on his findings. Why? Because of the patient trust he had earned in part through the power of touch.

Turns out that there is scientific research to back up Dr. Verghese's claim. According to researchers, people are able to more accurately discern a wider range of feelings and emotion from touch than from gestures, expressions, and sometimes even words. That's because touch is the first language we learn. Tiffany Field, PhD, of the Touch Research Institute in Miami has found that benefits of touch seem to stem largely from its ability to reduce levels of cortisol, a stress hormone manufactured by the body.

Given the high degree of personal stress associated with a trip to the doctor, a lab test, or hospital visit, I suspect we could use a whole lot more touching, not less as is the trend. Dr. Verghese has a name for this trend. You know, where clinicians gather around the computer and not the patient. He calls it iMedicine, and it's not a good thing.

That's my opinion. What's yours?

Source:
Keltner, D. Born To Be Good: The Science of a Meaningful Life" (Norton, 2009)

This post by Steven Wilkins, MPH, 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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'Thank you for your consult ...'

Until recently, there was a financial difference between performing a "Consultation" and a "New Patient Visit" for office visits (Medicare stopped paying for Consultations at a higher rate than New Patient Visits in 2010). I won't get into the ins-and-outs of what the criteria for a consultation were, why payment for the codes were eliminated for Medicare patients, etc. (If you want to read more about the difference, click here). The long and short is: in specialists' offices, patients often get/got billed for the more expensive "consults" when in fact the visit was not a consultation at all. Let's just use this understanding as the brief background for what I'm about to say.

I work at an academic medical center. My patient base is quite different from that of a typical gastroenterologist in that I often get asked to consult on (i.e. render an opinion about treatment for) patients by other gastroenterologists. Because I see patients from all over the state, patients often come from several hours away and do not expect to get their routine GI care where I work. Patients frequently return to their referring gastroenterologist for their care after I have rendered my opinion or helped them through their situations. This is the way tertiary care medicine is supposed to be. When a patient returns to their gastroenterologist, they are closing the circle of the consultation.

How then should I feel when a referring physician sends me a note on a patient, originally sent to me by him, that says something to the effect of: "John Doe is being seen in consultation at the request of Dr. Ryan Madanick for a history of colon polyps." ?

Here are my issues with this:
I didn't send the patient to him in consultation. I know how to take care of patients with a history of colon polyps. As a matter of fact, I DO perform colonoscopy. The patient returned to his care because he was the patient's referring doctor in the first place, not because I wasn't certain about the best option for this patient's care.
The patient is returning to the original referring physician. The visit shouldn't even be billed as a New Patient Visit. It is an Established Patient Visit (which pays a lot less).
If the patient's insurance covers Consultation codes at a higher billing level, we are all losing (well, except for the payee). The patient probably wouldn't see any difference. However, if this happens time and time again, the payment system would break down (or wait, maybe it already did.)

Let's get this straight. I know the referring doctor well, and I think he practices good medicine. Still, we know why the note was documented this way. And this is exactly the type of fraudulent billing practice that got the Consultation codes removed by Medicare.

I'll end by making a plea: Please don't bill a patient and their insurance for a consultation when it is just a visit.

Ryan Madanick, MD, is an ACP Member, 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. This post originally appeared at his blog, Gut Check.

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Dementia inpatients must be shifted away from hospitals, back to nursing homes

Sending dementia patients to the hospital could overwhelm the health care system and not offer them any better care at the end of life, researchers noted.

The researchers obtained data on all hospitalizations involving a dementia diagnosis for the 85 years and older group between years 2000 and 2008 from the nationally representative Nationwide Inpatient Sample database, a part of the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project.

Annual hospitalization data came from the U.S. Census Bureau. They projected the future volume of hospitalizations involving a dementia diagnosis in the 85 years and older group two ways, with and without allowing for population growth, to compute the absolute minimum potential growth and then to account for population growth and 7 the observed historic increase in the age-adjusted incidence of dementia hospitalizations between years 2000 and 2008.

The research letter appeared in the Nov. 14 issue of Archives of Internal Medicine.

Researchers noted that between 2000 and 2008, patients 85 years and older comprised less than 2% of the total U.S. population, they represented more than 40% of all annual hospitalizations associated with dementia. The actual absolute volume growth from 700,000 to 1.2 million hospitalizations among patients with a dementia diagnosis between 2000 and 2008 equated to population incidence increase from 16,398 to 21,088 cases per 100,000 population.

The estimated 2050 volume of dementia hospitalizations in the 85 years and older group may be between 3 and 7 million, depending upon accounting for population growth, or a potential a 10-fold growth in the volume of these hospitalizations.

Even at its minimum, the absolute growth in hospitalizations involving a dementia diagnosis could overwhelm the health care system, the authors noted.

"In addition, humanistic considerations dictate that this degree of aggressive care may be inappropriate for many patients with dementia," the authors wrote. "For example, it has been reported that patients with advanced-stage disease have a prognosis comparable to metastatic breast cancer or stage IV heart failure. Although our data are unable to convey the severity of the observed dementia diagnoses, a recent study noted that 18.7% of nursing home residents with advanced dementia were hospitalized near the end of life, even though the most frequently stated goal of care was comfort. For such patients, hospitalizations represent more of an intrusive burden than a desirable intervention."

Commenters told Reuters that the burden will have to shift back to nursing homes to care for non-life threatening illnesses such as pneumonia, in order to lower acute-care hospitalization costs and provide more comfortable care.

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Friday, November 18, 2011

Patients need teamwork in medicine

Atul Gawande, MD, says that we're used to doctors working like "cowboys," rugged individualists who are responsible for making sure your care gets done right. We don't need cowboys, he says. We need "pit crews," teams of doctors working together toward a common goal, with each playing their own role.

It's an appealing idea. Pit crew-like teams work, and work well, in trauma units across the country.

But there's a problem: if you haven't just been airlifted to a hospital after a horrible accident, you're not going to be treated by a pit crew. You're going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.

Dr. Gawande knows this, and he picks a heck of an example of the problem:

"But you can't hold all the information in your head any longer, and you can't master all the skills. No one person can work up a patient's back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don't even know what it means to 'protocol' the MRI."

Why is that such a good example? Because it's exactly what happened to my brother at one of the leading medical centers in the country. He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the "unexpected cancer found growing in his spine." It all worked well ... except that he didn't have cancer at all. In fact, had he been treated for cancer, he might not be with us today.

The truth is when you get sick, there is no pit crew rushing out to help you make your way through the system. There are overburdened, time-pressed doctors making decisions based on fragmented and often incomplete information. Scientific studies showing diagnoses are inaccurate more than 20% of the time are a clear warning sign and a symptom of this public health crisis.

If you're sick, you don't have time for the system to change. And so while we may not want our doctors to be cowboys, as a patient, you better learn how to be one. Be self-reliant, demand answers, and, above all, know this: the person with the greatest stake in getting your care right isn't your doctor, it's you.

This post by Liam Yore, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Evan Falchuk, JD. 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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Thursday, November 17, 2011

Medicine's next-generation doctors have different priorities

Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes. You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.

Atari 2600 by moparx via Flickr and a Creative Commons licenseYeah, Atari. Look it up, kids.

Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue, that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life.

These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.

But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on. Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.

For example, a study in American Medical News, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves, stable and predictable practice environments, and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.

This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused: "Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?"

One commenter was rather more direct: "Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out."

Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated, and thus, subject to change.

Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is it worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.

Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.

So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.

John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.

To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.

The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.

However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.

The greater question of whether this is good for patients relates to the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.

I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.

And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.

This post by Liam Yore, MD, 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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The last six months of life are the last place to look for savings

This discussion was inspired by the two women I owe my life to: my mother and my wife.

I cannot identify the citation for this factoid, but the assertion has become engrained in the lore of medical urban myth: 50% of health care costs are incurred in the last six months of life (or some similar figure).

There are other less arresting but more concrete statistics to be found. For example, according to Health Affairs, July 2001, vol. 20, no. 4, 188-195, one quarter of Medicare outlays are for the last year of life. Another more recent discussion concerned the various factors that influence that spending in the last six months. An article in the Annals of Internal Medicine for Feb. 15, 2011, vol. 154, no. 4, 235-242, describes determinants of health care spending and points out that regional variation in medical care does not account for as much variation as is sometimes pretended.

A concise summary of that article by one consulting firm states, "Individual characteristics such as black or Hispanic race, severe functional impairment, having Medicare Supplement coverage, suffering from certain chronic diseases or from four or more, were associated with higher spending. Others, such as having a relative live nearby or having dementia, are associated with lower spending. And some, such as having an advance directive, sex, marital status, education, net worth, or religiosity, appeared to have no relationship. Altogether, patient characteristics account for 10% of the variation in spending in the last 6 months of life." (Quoted from Kevin Roche at vitaadvisors.com) Yet even with all this taken into account, patient and regional factors accounted for only 15% of the variation.

There seems to be a major subtext to all of this discussion about the last six months of life, whether the topic is cost, ethical issues, quality of life, or whatever. The unstated message is that we are wasting money on futile care. The implication seems to be, "Couldn't we devote these scarce medical resources to more beneficial use?" and "Why are we prolonging suffering and poor quality of life at such great expense to so little gain?"

I ask myself these same questions whenever I walk down the corridor of the ICU to see a consult, past room after room of people on ventilators, bloated, mittened and tubed beyond our ability to recognize them as the same individuals seen in the photos I sometimes see pasted to the wall opposite the bed. "Don't we know," I ask, "when to cease and desist?"

But how do we know when it is time to cease and desist? My wife recently posed the question another way. She pointed to a commonly ridiculed question: "Why do you always find things in the very last place you look?" "Well, stupid," is the rejoinder, "because you stop looking after that!" But, she observed, the question really contains an ellipsis: You find things in the last place you think to look. And viewed that way, it is an entirely sensible question. Retrospective data from Medicare rolls are all well and good, but it is entirely different matter forecasting when to start that six-month countdown clock ticking!

The question was brought home to me when last spring my widowed mother at age 85 went into acute congestive heart failure after rupturing a mitral valve. At first it seemed a simple matter: a minimally invasive repair by a trusted cardiac surgeon at a nearby hospital known for cardiac care.

But a pre-operative angiogram revealed a 95% narrowing of her left main coronary artery. Minimally invasive was no longer an option. She needed valve surgery and a bypass graft. My mother was not medically sophisticated enough to weigh risks of surgery versus anticipated length and quality of life, even without the further impairments of disorientation during a 48-hour sojourn in the ER holding unit awaiting a bed. So the call was essentially mine.

I am not a surgeon, but I am a great believer in seizing the opportunity that surgery affords us to cure what can only be palliated by medications. I knew the quality of life and the prognosis with a flail mitral leaflet was not a good one. I told my mother and her surgeon, "Go for it!" Mom was really too confused to argue or question.

The surgery was more complicated than anticipated; she needed a reconstruction of a myxomatous degeneration of one leaflet (i.e. there was nothing even left to sew back together) using Gor-tex. The surgeon assured me she would be off the ventilator in a few days. Instead, she spent three weeks in the surgical ICU relying on what lay people refer to as life support. There was nosocomial pneumonia and central venous catheters. She was delirious and fighting the vent and the nurses for much of that time. When she was coherent again but still not able to be taken off the breathing machine, she wrote on the pad I held for her "What am I doing here? Why are these nurses torturing me? These tubes are killing me! Why did you do this to me? I can't take more of this!"

More than once during those three weeks, my wife asked me, "David, are you sure you did the right thing?" Even her brother, a research cardiologist with advanced angiographic skills, asked me if I had not been overly aggressive in pushing her into surgery. My confidence did not waver. I told them I have seen many patients sicker than her spend twice as much time in ICUs on ventilators and return to my exam room after their ordeal, their health restored and their loved ones grateful.

My mother did recover, albeit very slowly. Six months later she is now living in a one-bedroom apartment at a wonderful assisted-living community nearby. She is happier and leading a fuller life than she was before the surgery. We received the Explanation of Benefits from Medicare a month after her hospital discharge. The bill was $300,000. (Of course, that was retail. Medicare pays the hospital a substantially lower fraction of the list price.) Last time I went to visit her, I couldn't find my mother anywhere in the facility; she blithely told me later she had gone for a walk. Perhaps my mother will enjoy another five or 10 years.

Was it worth the cost? If you ask me, emphatically, yes! But what would we all have said if one complication had followed another and her course had been inexorable deterioration and ultimately a decision to halt aggressive care. It could have easily turned out that way. We would all bemoan the futile waste and unnecessary suffering for a patient in the last six months of her life.

My point is not that we should always be aggressive in caring for the elderly and the chronically ill. The point of the story is that we have such inadequate means of predicting who shall live and who shall die. Some patients like to say it is all in the hands of God and we have no way to do so. ("who by fire and who by water, who by war and who by famine ...")

But my tradition urges us to pray as if all depends on God but act as if all depends on us. My argument is that we can and we must devise better prognostic measures, to guide us in our advice to patients and their families and to inform their decisions along the course of an acute illness.

Which brings me back to the question with which I began this essay: Can we save money and precious resources with such tools? Suppose we could predict the likelihood of survival within 5 percentage points of confidence? Suppose we could tell the family, "Grandma has a 20% chance of surviving this hip fracture, pneumonia and sepsis and a 7% chance of returning to a normal existence." Would there be less futile care? I'm not so sure. There are so many ethical, cultural and economic factors involved.

At my hospital, I am accustomed to seeing rooms occupied by an extended family keeping vigil over a clearly moribund loved one and upon leaving the room I am assailed by the relatives: "Doctor, isn't there anything more you can do?" Families cling to hope and reject any suggestion of "comfort measures only." They even have paralyzing disputes over these issues.

So unless we are prepared to exert some control, i.e. dare I say it, "rationing," it will take more than good prognostication to provide rational, efficient, safe, sane and humane allocation of scarce human and monetary resources. The furor over the imaginary "death panels" concocted by reactionary Republicans illustrates the political problems inherent in such efforts.

Maybe it's time we change the terms of discourse and start talking about "life panels." My wife says wants to know how she can join one; she has a few acquaintances she might want to weigh in on the deliberations. I never cease to marvel at her resourceful talent for devising ways to save money!

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Penrose box

Once we think outside the box, aren't we just inside a larger box? Once the ideas of one box leap outside, might we not be in another box?

I've been a professional student for (too) many years, but the education that I took for granted ended the day I started as attending. The dreaded morning report hosted by harried if dedicated clinicians, the complex grand rounds elucidated by leaders in medicine, noontime and core conferences in a multitude of subjects that were a constant time pressure in residency were rudely stolen the day I graduated. Within months of being a junior attending I was academically starved. Thus I started looking for other opportunities, seeking out the rounds I used to loath, traveling to conferences in far cities, and looking up events that just sounded interesting.

This week I attended the Illinois Transdisciplinary Obesity Prevention Program's (I-TOPP) Inaugural Biennial Symposium, which covered factors from the microscopic to the transnational of how obesity can be prevented in children. I'm an adult nocturnist. The youngest patients I see are 19, and the only preventative medicine I do is of a more acute nature, as in preventing my patients from stopping oxygenating or perfusing. What's the point of going to something that I would be unlikely to have any "need" of. Knowledge isn't like that, it is insidious, flashes of brilliance (or snippets of insanity, depending on your point of view) occur while learning the most unlikely and seemingly unrelated things.

The symposium was opened by an epidemiologist at the Centers for Disease Control, Dr. Cynthia Ogden, who went through the data of childhood obesity and problems with the precision and accuracy of that data. Obesity in children is a huge problem, but may fortunately have plateaued. However those children are an added source of patients to an already growing cohort of obese older adults.

Obesity is often simplified as energy in (EIN) greater than energy out (EOUT), which to most clinicians, including myself, means eat fewer calories and expend more. However as I learned, this is a gross oversimplification, not of the equation, necessarily, but of the complex and multitudinous variables that contribute to both energy in and out, including (but certainly not limited to) calorie source, quantity, timing of consumption, genes, gut microbiota, being breastfed, psychosocial factors, location, economics, and many more. These variables are further defined by confusingly dependent and independent equations that have yet to be defined.

Genes! Impossible! Not according to Dr. Molly Bray, who examines genes in obesity. She told us about her and others research into genes that not only affect metabolism but behavior driving the obese to not only have decreased satiety but to shy away from exercise. Phenotypically these genes are environmentally dependent. In times of food scarcity they are genotypically pervasive but phenotypically absent, however when an "obesiogenic" environment presents itself, so too does the obesity phenotype.

One of the genes that has been discussed extensively is fat mass and obesity-associated protein (FTO). FTO encodes for proteins which can demethylate DNA, or promote gene products. This is an amazing concept, since dietary choices, if they are indeed choices and not mandated by genetic and environmental factors, produce concentration gradients of carbohydrates, lipids, and proteins which can interact directly with DNA, and therefore for may affect FTO and therefore drive demethylation.

My conjecture is that this then in turn could produced a cascade effect on other genes involved in metabolism, cellular protein production, and behavior that would drive an organism toward obesity with different velocities. You are not only what you eat but you are regulated by it as well. It is as if the lumber and mortar have to be the building supervisor as well.

The next invited speaker, Dr. Madeleine Sigman-Grant, discussed the development of the All 4 Kids Program, a community-based intervention in pre-schoolers to prevent obesity designed using a Logic Evaluation Model. I don't deal with preschoolers in a professional capacity nor am I planning any community interventions anytime soon. But it was a rewarding and interesting experience to see how someone worked through a Logic Evaluation Model to develop a preventative health intervention.

Dr. Stephen Matthews spoke on spatial polygamy, which is less risque than it sounds. The concept of spatial polygamy refers to individuals having multiple spatial interactions depending on the map technique used. Thus we are defined by ZIP codes, voting districts, census demographics, street addresses, telephone numbers, and e-mail addresses that redefine associations between individuals and their spatial or temporal dependence. Thus it is important to understand the source of our mapping data and the limits thereof.

This creates an interesting parallel in hospitalized patients. Their physical location in the hospital has little to do with their "therapeutic distance" from their physician. Therapeutic distance would be defined as the time between a patient having a need and it being taken care of. Two patients in the same room may have vastly different care demographics and therefore therapeutic distance, even if they are physically adjacent.

The patient with the in-house hospitalist versus the traditional internist on-call from home may have significantly different response times to pages. The comanaged patient may or may not be more therapeutically isolated depending on how clear the nursing staff is on the division of duties between the physicians caring for the patient, i.e. if they don't know who to call, they will take longer to get the right physician to solve the problem.

Despite not being "my area" I certainly took a step outside my box, which would have expanded to include this new information, thus creating a new and larger box. Sometimes the box doesn't change but leaping outside the box in one area just places us within familiar and useful territory in another. Each day of our lives should be a leap outside of our old box, but within a new and larger box. The only way to achieve that is through the core competency of lifelong learning that is no longer quite such a continuous feed after entering the post-postgraduate world.

ACP Member Mike Aref, MD, PhD, 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. This post originally appeared at his blog, I'm dok.

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Wednesday, November 16, 2011

Life at Grady: The extras

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

There is this car wash here in Atlanta that always tries to add on a bunch of other services every time you go there. Like, if all you want is a simple car wash, you know, with bubbles first and water second, they start blasting you with this laundry list of other choices such as tire shine or Armor All on the dash. I don't get my car washed too often but when I do, you can pretty much guarantee that I'm not looking for it to cost the same as a car payment.

The last time I went, I had plans for a preemptive strike.

"I'll have the regular wash--and nothing else unless it's included in the price of the regular wash."

"So, just want to be sure," the car wash dude replied, "You don't want any tire shine or to have the alloy wheels scrubbed, correct?"

"Is that included in the regular wash?"

"It's included in the supreme wash, ma'am. That's only five extra dollars."

"No thanks."

"You can also get tire shine or alloy wheel cleaning a la carte if you wish."

"Is it free?"

"It's only three additional dollars."

"Per wheel?" I muttered that under my breath but he heard me.

"No. Per service."

I sat up in my car and beamed with my brightest, fakest smile. "I'll have the regular wash, then. And nothing else unless it's included in the price of the regular wash."

Car wash dude finally conceded.

So. On Monday I was seeing a woman in the residents' clinic who was in her mid-sixties. She had high blood pressure, diabetes and high cholesterol. She also smoked a pack of cigarettes daily and was fairly overweight. But her approach to this clinic visit was quite similar to my preemptive strike at the car wash.

(Click "more" to continue reading.)

"I just need to get my medications refilled--and nothing else," she stated matter-of-factly.

I looked at her electronic chart and what the resident physician had documented. Her blood pressure was well controlled as was her cholesterol. Her insulin regimen could use a teeny-tiny tweak here and there, but on the grand scheme of blood sugar control, hers wasn't too bad. She really needed to strongly consider quitting smoking, and getting on some sort of exercise and dietary program would also be indicated. Oh yeah, and seeing as she was sixty-something she also needed some screening and health maintenance things. According to her chart, she wasn't up to date on her mammography, colonoscopy, bone density screening, pneumonia vaccine or flu vaccine.

In other words, she needed the supreme wash, not the regular one.

"Okay," I answered carefully, "We can refill your medicines. Your doctor is going to make a small increase to your insulin, but otherwise you've been managing your blood pressure and cholesterol just great."

"Alright then," she said, with her eyebrows raised. She totally had my number.

"I see from your chart that you keep your appointments. I also see your key chain with the photographs. Are those your grandbabies?" I continued.

She looked at me suspiciously. "Yes. I gots twelve grands but this is the little ones. I got some that's older."

I smiled and said, "It looks like you have a lot to live for. I'd like to talk about ways to keep you at your best beyond your medication refills. Would that be okay?"

"Honestly, doctor? No, not really. I don't take no flu shots, mammograms hurt like hell and the last time I got one they said I had to do it again and nothin' was even wrong. Tha's when I said to hell with that test."

"I see. You know, the idea is to catch things before they become an issue. I agree--I've had a mammogram and it's certainly no fun. But you obviously care a lot about your health because you keep all of the appointments. Would you consider--"

"I'll consider getting my pressure pills, my cholesterol and my insulin. Y'all need to be glad I even let y'all give me them insulin shots. My grandmama lived to make ninety and she ain't never had none of that stuff. Including that camera up her rectum." She shuddered and shook her head. "I really ain't getting that one."

My resident chimed in. "Did your grandmama smoke?"

Fail. What did he say that for?

"Naw. My grandmama did not smoke." She looked like she really wanted to add on "smart ass" but chose not to. Thank goodness he had the sense to stop that line of questioning.

"Can we strike a deal?" I quickly added. "Like, maybe we could look at them and decide what could be the most important to you."

"I told you what was important to me."

"Can I at least tell you the reasoning behind offering these things so that you can think about it?"

She nodded and at least gave us that, so I took what I could get. My resident and I explained what could be prevented or caught early by getting a flu shot, a pneumo-vax, a bone density scan, a mammogram, and a colonoscopy. We talked about which things disproportionately affect African-Americans--which she happened to be--and described how missing an opportunity to make an early diagnosis could make a difference. And she listened. She at least listened.

At the end of that visit, she got exactly what she came for--her medication refills, and that's it.

I saw her in the hallway when she was leaving and she asked, "Miss Manning, have you had the colon test?"

"No, I haven't," I answered. "But my sister and my parents have. I hear it's not exactly fun, but I know from my patients that colon cancer is a lot worse."

She looked at me intently and nodded. "Hmmm. I might thank about that one," she finally said while folding her coat over her arm.

"Good," I replied with a genuine smile because I could respect that. I offered her a quick hand squeeze and wished her a great rest of the week.

That afternoon as I left Grady I stood looking at my car in the parking garage. I noticed the black smudge all over the fancy alloy wheels that I'd paid extra for back in 2004 when I got my car. I imagined them gleaming like the way they looked back then and paused for a moment. Next I glanced at the dusty tires and narrowed my eyes.

Hmmm. Maybe the tire shine and alloy wheel cleaner wouldn't be such a bad idea after all. I just might think about that one next time.


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Alarm fatigue tops list of 10 most dangerous hospital hazards

Alarm fatigue is the most dangerous of health care technology hazards, topping even radiation exposure and medication errors from infusion pumps, according to the updated Top 10 list offered by ECRI Institute.

It's not surprising that alarm fatigue rang in at #1. There can be as many as 40 alarms an hour in some units. Staff modify alarm setting outside of safe parameters, can't tell the alarm's importance (or even which device is issuing it) or the alarm isn't relayed to the paging system, according to ECRI Institute, a nonprofit organization focusing on patient-safety and cost-effectiveness in health care. Its report (registration required) is online. The report includes recommendations and resources for each of the 10 top hazards.

Staff may turn alarms off or down to reduce alarm fatigue, as well as reduce stress on the patient and family, the report notes. And properly setting alarms is complex to begin with, so ECRI offers best practices to reduce alarm fatigue while maintaining patient safety:
--Examine the entire environment, not only how the alarms are configured but also staffing and even the physical layout of the care unit,
--Establish protocols for alarm-system settings, including default alarm settings specific to each care unit, as well as limits specific to each patient so the proper staff are notified during an alarm,
--Clearly assign responsibilities to staff, including who is responsible for recognizing the alarm, who is responsible for delivering the information to the responsible caregiver, who is directly responsible for addressing the alarm, and who is the proper back-up provider, and
--Establish policies to control alarm silencing, modification and disabling.

Hospitalist Lisa Kirkland, MD, FACP, offers eight more best practices in her column at ACP Hospitalist.

ECRI's extensive report continues to offer best practices and resources for the entire list of top 10 hospital hazards. Beyond alarm fatigue, hazards include:
2. exposure hazards from radiation therapy and CT,
3. medication administration errors using infusion pumps,
4. cross-contamination from flexible endoscopes,
5. inattention to change management for medical device connectivity,
6. enteral feeding misconnections,
7. surgical fires,
8. needlesticks and other sharps injuries,
9. anesthesia hazards due to incomplete pre-use inspection,
10. poor usability of home-use medical devices.

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Friday, November 11, 2011

The health care rush during the holiday season

Like Christmas season advertising, the holiday crunch for procedural medicine is coming earlier every year.

Perhaps that's why the posting on this blog as suffered: we're busier than ever.

Why is this?

I suspect it's because of a variety of forces that are coming together to create the great procedural "perfect storm" this time of year.

Perhaps the most important contributor to the holiday rush is the patients themselves. Patients are feeling the effects of their higher health insurance costs like never before. Higher co-pays and annual deductible amounts are making them frantic to get their high-ticket procedures performed before year's end to avoid paying an even higher deductible amount next year.

Additionally, staff want to take vacation this time of year. This puts constraints on specialist's lab time availability. It's a supply-side bottleneck. To relieve the crunch, the same staff are finding themselves working longer and longer days already.

No doubt the government regulators and hospital administrators are enjoying the fruits of their regulatory victory. Seriously, how could it get better? More cases, same staff, lots of new "efficiencies."

Bada bing, bada boom!

But there's a catch. Maybe not now, but sometime soon. We've seen inklings of it. Nothing big in the grand scheme of things, mind you, but inklings nonetheless: workers are getting frayed. Since hospitals work to keep overhead costs low in anticipation of still more cuts to government payments, hiring has slowed. Burnout of existing staff is a real concern. Not just with doctors, but ancillary staff, too.

So far, our new health care system has been engineered to take care of lots and lots of patients. To this end, they are succeeding. But as this holiday crunch continues this year and beyond, the pop-off valve to our new health care delivery system pressure-cooker remains the doctors, nurses, and other ancillary personnel workers who work tirelessly to feed the beast.

Add to this the fact that our providers are increasingly regulated into forced behaviors without concern to the additional time that these regulations require. There seems to be more time spent on regulation requirements ("performance measures" and the like) in exchange for less time for patients and less time for home. As a result, all our direct providers of health care (nurses, doctors and ancillary staff) remain our new health care system's weakest and most vulnerable link.

And what happens when these worn out, burnt out, overbooked workers make an error as overstressed structures do?

We get more regulations.

This post by Westby Fisher, MD, 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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Thursday, November 10, 2011

EHRs are making all patients look alike?

I saw it begin to happen in the '90s. Residents came to rounds with their daily notes produced on a word processor. The notes were impressive. Legible, lengthy and meticulously detailed at first glance.

Then I started to notice a pattern. The impressive notes began to look very much alike. The thorough exam varied little from patient to patient. And problems that occurred on previous days seemed to persist in the medical record, even when it had resolved. In some cases the previous day's note was printed only to have one or two additional elements added by hand. It was never really clear what was worse: the lack of effort or the illegible writing.

Our electronic health records (EHR) offer similar options. We can smart-text our way to clinical efficiency. Some doctors have entire impressions and elements of the history pre-generated for common conditions. These are advertised features of the most common EHRs. Technology can make us look more thorough than we really are.

The adoption of automated documentation carries the risk that we make all patients look alike. The drive for thorough documentation comes with the failure to convey what's happening with a patient. In some cases this is a consequence of laziness. Other times it's a technique for survival in a regulated world that asks more and more of a doctor's bandwidth.

Medical documentation should reflect the unique characteristics of every patient's story. As physicians it's important to avoid the empty clinical narrative that technology makes easy. As educators it's our responsibility to medical students and residents to see to it that this transition to EHR brings with it the clear thinking and individualized documentation that was necessary with pen and ink.

This post by Bryan Vartabedian, MD, 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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Differences between real and fake patients create multiple choices for care

Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients. Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of "fake patients."

Exam by Albertogp123 via Flickr and a Creative Commons licenseWhile there are a variety of things I could say about the process, one thing is clear, the real patients don't ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions! Perhaps the most distinct differences are that real patients suffer from real problems that plague real people, and that is of course why one of the most important lessons for our medical students: Being a good doctor is more than just how well you do on a standardized exam. It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient.

Here are just a few ways in which the real patients we see differ from testable "patients."

Social problems trump medical problems. Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to health care outside of the hospital that prevents optimal care and treatment of their medical conditions. Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.

Caregiver support. Many older patients who are chronically ill are cared for by family members who suffer a lot of stress. This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member. Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.

Insurance compatibility. Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover. In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult. Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act: Let's at least hope so. But for now, it's sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.

Medical necessity. These days, patients can't stay in the hospital to "recover" unless it meets strict criteria for inpatient admission. This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare. The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay. Given that rock and a hard place, it's a difficult position for any doctor to be in.

Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through "caring" for fake patients on a written exam. But, a written exam can only go so far. Given the sea changes occurring on a daily basis in our health care delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients. After all, both are necessary for good doctoring.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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Wednesday, November 9, 2011

Life at Grady: Does it hurt?

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

I was making rounds the other day after lunch and was checking in on a patient who'd been awaiting a procedure. The procedure was fairly straightforward and one that I've sent countless patients down to the interventional suites to have done. More than anything, I just wanted to confirm that he'd left the floor and that he wasn't sitting there seething from the hunger of "nothing by mouth after midnight." Simple enough, right? I'd pop in, see the ruffled sheets and empty bed and then check the box on my little list.

As I approached the door, I saw my patient being backed out of his room on a stretcher. "Hello there, sir," I said. "I was just coming to make sure that nobody left you up here hungry and waiting!"

He chuckled a bit and rubbed his stomach playfully. This patient had some difficulty with communicating, so I took this gesture for the words that would have been harder for him to say.

"So you didn't eat anything, correct?" I needed to still confirm this. He shook his head emphatically. "Okay, good!"

(Click "more" to continue reading.)

My resident and intern had already explained the procedure to him at length. His nurse made certain that his oxygen was connected to the portable tank. The transporter had completed a three-point turn and had the wheels unlocked and ready to go. Everything was set.

I smiled at my patient and patted his hand. "I will see you when you get back upstairs. It shouldn't take very long, okay?"

He nodded. Then he mouthed a question to me.

"IS IT *SOMETHING-SOMETHING*?"

I wasn't sure what he was trying to say. "I'm sorry, sir. Repeat that a little bit slower?"

This time I made it out.

"IS IT GOING TO HURT?"

I was just about to fix my mouth to say no when I instead paused to think about his question. The truth is that I had no idea. I mean, my understanding of it was that he'd be numbed up and subsequently pain-free under such local anesthesia. But the truth is that I didn't exactly know the answer to that. I really didn't.

"Sir? I know they numb you up beforehand so that should make it not as uncomfortable. I have had the numbing medicine before and personally think it kind of stings going in, but once you get numb it works pretty good."

There. I'd told him the truth about the part that I knew. He seemed to find that acceptable.

Today I'm reflecting on the simplest questions in the hospital to which we, okay I, don't know the answers. We can drop all sorts of science on the mechanisms of diseases and the side effect profiles of medications. We can spit the latest literature on the drop of a dime, including the number needed to treat or harm, for countless medical studies. But funny that something so seemingly simple yet important as whether or not something hurts, we scratch our heads on--mostly because we've never thought about it. Which brings me to a story.

When I was a senior resident, I had this really eager medical student on my team. He wanted to go into internal medicine and was as bright-eyed and bushy-tailed as any learner I've ever seen. He was down for trying everything and was glued directly to my side throughout every last call that month.

Several times that month, we had patients with respiratory problems who needed arterial blood samples taken. After multiple episodes of watching me do this emergently, the student was ready to move to the next step in the old "see one-do one-teach one" adage. I promised that he could.

Then the next few times we needed an arterial blood gas, it was always an emergency so I was forced to bypass his wobbly novice hands and use the quasi-predictable pair connected to my own arms. I'd look over at him and feel bad each time, but knew that in these instances, it simply wasn't the time. Poor kid. I really wanted him to have the experience, but not at the expense of derailing emergent care. Toward the end of the month, I had an idea.Why not let him do his first arterial blood stick in the most controlled environment imaginable? Why not let him do one...on me? Of course!

Now. If you are shaking your head at the sheer stupidity of this idea, then you have either a.) had your radial artery on your wrist poked with a sharp needle, b.) allowed a medical student to poke your radial artery with a sharp needle, c.) been in or around the block enough to know how assinine this is, or d.) all of the above. Turns out that your radial artery is protected by a whoooole bunch of nerve endings for a reason.

Sigh.

So in a quiet treatment room, I sat in front of my student, smugly talking him through his first art stick on me, his willing and fully cooperative patient. I had him place a rolled towel below the dorsal side of my wrist and even had him tape my finger tips down. In all my infinite wisdom, I repeatedly told him that it was "all about positioning" and that "when done correctly" it really shouldn't be that uncomfortable a procedure.

Now here's a question: How in the hell did I know that? Answer: I didn't. The truth is that it was all my assumption (and everyone knows what happens when you assume.) I neglected to factor in that nearly all of the ABGs I'd done up until then were either on patients so acutely ill that a 22-gauge needle in the wrist was the least of their worries or who'd had such longstanding illness that they'd become a bit immune to procedures lower on the food chain.

So there we sat. Me with my dorsiflexed wrist and taped down finger tips and him earnestly readying his hand with the needle-tipped syringe. I smiled at him all confident-like and even added that the key is to be deliberate with procedures. Careful and deliberate.

"Okay. Here we go," he nervously said with beads of sweat forming on his brow. "Ready, set, go."

He followed my directions perfectly, deliberately inserting that needle--bevel up, of course--into my bounding and previously marked radial pulse. His hand was steady and he clasped the syringe like some precious inkpen--just like he'd been instructed. He'd checked first to see if his patient was rotated and made certain that the position was perfect.

But none of that mattered. In went that needle...carefully...deliberately...and--

"AAAAHHHH!!! LORD HAVE MERCY! STOP! STOP! STOP! OO-OO-OOOOOO!!! OH LOOOOORD!!!! GET-IT-OUT! GET-IT-OUT! GET-IT-OUT!!! STOP-STOP-STOP!!!!"

Yes. That is what I said through a blood-curdling scream coupled with a few choice expletives. Because seriously? It hurt EXACTLY like hell. Wait, I take that back--I don't know about that either. But damn, it hurt. I'm not sure that I have ever experienced a more painful thing in my life next to having a nine-pound-two-ounce baby. And to this day, I maintain that getting an arterial blood sampling is right up there with child labor with a nine-pound-two-ounce baby--which is something I DO know something about.

Just thinking about it brings tears to my eyes and makes me shiver. I have never seen the arterial blood draw the same, and never, ever order one unless it is absolutely, positively, irrevocably necessary to patient management.

******
Later that afternoon, I stopped back by my patient's room to check on him. He was happily eating a reheated tray of food and seemed glad to see me.

"Well? Did it hurt?" I asked him.

He held up his finger and his thumb and mouthed "JUST A LITTLE BIT."

I put that on a Post-it note in my head and paused for a moment, remembering his respiratory problems. Pointing at my wrist, I queried, "Sir? Did it hurt as much as getting an artery blood sample?"

He waved his hands and shook his head fast and furious. He squeezed his eyes shut, winced and mouthed in words unmistakable:

"OH HELL NO!"

We both laughed because, for once, I knew exactly what the patient meant. Firsthand.

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Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

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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