DB’s Medical Rants

A Medical Mind (the link takes you to his entries - I am commenting on his Dec. 25th post).

The point is, I am sure that a barrier must be crossed to ‘know’ about patients and medicine and science, I am just a little unsure about when that will happen. I know that I have never really understood the science behind what my physician was saying to me, so I could never fully understand the complexities of each decision that he makes. However, when will that time come for me? I know everyone else thinks that time has already come – I can explain many things that they ask. However, when will I cross the barrier of knowledge?

As Anthony matures as a physician, he will face a major challenge. How do you as a physician explain diagnostic tests, treatments and diagnoses in terms that patients understand?

As physicians, we have an obligation to “break it down” into understandable terminology. I spend much time on rounds developing analogies of disease so that patients will understand what we mean.

A good exercise for medical students is to explain medical concepts to those who do not really know medicine. Practice on your friends (when they ask questions - nothing duller than a medical student talking about medicine when not asked). If you can explain things to them, then you will have an idea of how to explain things to patients.

Now for a quick practice session. Explain these 3 concepts in “laymen’s” terms.

Coronary artery stenting
Beta blockade
Osteoporosis and its treatments

Medical decision making should never become formulaic. While I use, and have developed, clinical prediction rules, we must always remember that they are merely diagnostic or prognostic tests. Tests provide us some information, but we should always use them in the context of the patient in front of us.

Community acquired pneumonia-Pneumonia severity index falls short

…These AJM authors reviewed 3065 admissions in Edmonton with a diagnosis of CAP over a 2 year period. 586 (19.1%) were classified as “low risk” using the PSI. Was the hospitalization of ” low risk” patients a shameless, thoughtless waste of precious medical resources? Apparently not. Almost half ( 48.4%) were sick enough to be in the hospital for more than five days.19% suffered one or more complications and 31% were still unable to ear or drink to maintain hydration by the fifth hospital day. Clearly the admitting physician’s clinical judgment appropriately overruled the PSI score. Fine’s classification system keys to mortality rate.Those in risk classes I to III have a < 1 % mortality rate.The authors point out that the PSI does not work if the patient has COPD or pulmonary fibrosis or HIV infection or immuno suppression, etc. etc. and there are important prognostic factors not captured by the Fine index including nausea,shortness of breath and diarrhea . Their final sentence is: " It is clear that low-risk patients are a heterogenous group and that a low risk for mortality is not the only factor to be considered in admission decisions".Fortunately for a significant number of patients with CAP, the admitting physicians used what seems to often elude guidelines and algorithms namely clinical judgement...

Retired doc makes a most important point. Physician excellence is manifested by excellent clinical judgement. I know of no quality score which measures clinical judgement.

In taking with some faculty colleagues yesterday, I opined that the biggest difference between 1st and 3rd year residents was in their clinical judgement. That is what we teach during residency. All the faculty agreed enthusiastically.

Clinical judgment cannot be taught quickly. One must see many patients who do well, and many who do less well, to learn the difference. One learns clinical judgement over time.

The wise physician interprets all data in the context of the patient history and examination. This includes lab tests, imaging studies, biopsies and prediction rules.

I will rant more on clinical judgment in the near future. This is the essence of excellence. The mystery is how we might measure it.

Study of Heart Attacks Finds Risk in Use of Blood Thinners

Patients being treated for heart attacks involving narrowed arteries and clots that reduce blood flow to the heart are often given overdoses of powerful blood-thinning drugs in the emergency room, increasing their risk of serious bleeding, a study has found.

Excessive bleeding occurred at catheter sites, from existing stomach ulcers and in the brain, where it was particularly dangerous, said Dr. Karen Alexander, a researcher at Duke University and the lead author of the study, which is to be published Wednesday in The Journal of the American Medical Association.

Of 30,136 heart patients treated last year at 387 hospitals in the United States, 42 percent were given excessive doses of blood thinners. Those given extra amounts of two blood thinners - low molecular weight heparin and glycoprotein IIb/IIIa blockers, which are sometimes called super-aspirin - had about a 30 percent greater chance of major bleeding than those given the recommended dose.

The study suggests that 15 percent of the bleeding episodes were from overdoses and might have been avoidable.

All medications have risks and benefits. We should always strive to pick the right dose for any medication. While the emergency room can become hectic, each ER should have a method for insuring that patients get the right doses of medications.

Obviously anticoagulants epitomize the danger of overdosing. We know that whenever we prescribe an anticoagulant we increase bleeding risk. Physicians always “calculate” the potential benefit from anticoagulation and compare it with the potential risk.

This article should cause ER physicians to reassess their protocols for anticoagulation in heart attack patients. Or, if they have no protocols, then they should develop clear protocols with their cardiology colleagues.

Many physicians immediately recoil when they hear about the retainer model. They attack the physicians and use derogatory code words like boutique, justice, and two-tiered system.

However, one should always look beyond the surface to understand the good and bad in any situation. Perhaps the retainer model provides some solutions.

For those with AMA subscription - West Virginia looks at retainer model

The group is preparing a report for West Virginia Gov. Joe Manchin that offers several recommendations for addressing the health care needs of the uninsured. Among the suggestions is a three-year pilot program that is built on Dr. Wood’s retainer practice-supplemental insurance model.

Many legislators, after hearing Dr. Wood describe the program to them in testimony, compared his model to the way some coal miners received health care years ago. The workers actually would pay a set monthly rate for care from the mining company’s physician.

Dr. Wood’s model, however, was based more on costs than nostalgia. He started by offering the model to his own employees, which he said cut his own practice’s health care costs by more than 50%. He estimated a company could save about 30% in administrative fees by adopting his model.

Dr. Wood said his fees for patients would be $83 per month for an individual or $125 per month for a family. The pilot program, however, could vary depending on the services offered, he said.

“There would be no strict guidelines,” he said. “It’s going to be more wide open. Clinics can charge what they feel is appropriate.”

Questions from the panel about Dr. Wood’s model have centered on whether it’s fair to charge patients for services they might never use. Such issues will be considered while the panel comes up with its recommendations.

As I write consistently, our current system does not work well. Patients do not spend enough time with physicians.

We need a better model. The retainer model has some major advantages. Dr. Wood’s fees are much less than we pay for health insurance. It is conceivable that physicians participating in a retainer model could decrease health care costs by the amount they receive (or even more). Spending time with patients can decrease unnecessary testing. Physicians now default to ordering CT scans and MRIs to save time.

I hope that West Virginia tries this model. We need data to see the impact of such a model. Perhaps this model could change our concept of health care.

Frequent readers may remember that I love mysteries. I believe that accounts for my love of morning report and CPCs. Many general internists share this love for a genre which closely parallels our field.

For those with access - White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives

Current trends toward routine mass use of sophisticated diagnostic tools is killing off the science and art of clinical reasoning. An ideal clinician would present a harmonic fusion of almost all the investigative methods of fictional detectives and avoid slavish adherence to protocols and procedures

Our underlying premise is that the current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

Clinical analogies with detective fiction generally revolve around Sherlock Holmes.1 2 However, like medicine, detective fiction has subspecialties and intellectual trends.3 A rapid overview of the analogies between diagnostic reasoning and the investigative strategies found in detective literature may provide us with some clues on how to confront the problems posed by the burgeoning number of available technologies.

I disagree with the initial assessment because the authors leave out an important factor. No diagnostic test helps if we do not know to order the test. The intellectual challenge of internal medicine in 2005 remains active. Patients come in with vague complaints, which we must sort through using history and physical clues. These clues help us develop a differential diagnosis (a list of possibilities) which we can rank as to likelihood. Then, and only then, should we use technology to sort through the possibilities.

We could take everyone who comes in with vague complaints and order a “man scan” (the resident’s slang for total body CT scanning). But this strategy would yield too many red herrings, and still not find the underlying problem very often.

After the somewhat depressing introduction, the authors redeem themselves by discussing in beautiful terms the type of reasoning that various famous detectives use. Their final paragraph is classic!

An ideal clinician could be said to present a harmonic fusion of almost all the investigative models outlined above—a rare event. If one investigative quality marks out the mature clinician it is the ability to spot possible inconsistencies among the clinical, instrumental, and laboratory examinations, considering not only what is present but also what is missing. This requires skills in observation and “deduction,” handling of knowledge, pattern recognition, and the astuteness that comes from years of experience. For well honed clinicians, the clinical part of the diagnostic investigation is not just a question of medical history and physical examination but rather the capacity to establish links among various physical and laboratory or instrumental findings with an eye to both the consistencies and inconsistencies. In this context, simple examinations really do have the same value as the more complex and expensive ones.

Bravo! Bravo!! (here db stands for an ovation)

New Test May Cut Customer Base for Cardiac Implants

Late Wednesday, though, Medicare proposed a plan that could portend new limits on that market. In March, Medicare expects to begin reimbursing doctors for a relatively new type of diagnostic heart test that is currently paid for only in some states in limited situations. Studies show that the test identifies heart patients who are currently eligible for electronic defibrillators made by companies like Guidant but are highly unlikely to ever need them.

Medicare’s plan reflects the desire among many doctors and insurers to narrow the use of the devices to groups that are most likely to benefit from them. As things stand now, most of the heart patients getting such implants go the entire five-to-seven-year life of the device without ever needing to be shocked to restart their hearts.

“I think the payers are going to balk at covering many of the implants,” said Dr. David J. Kessler, an electrophysiologist who implants hundreds of the devices annually at Austin Heart, a cardiology group in Austin, Tex. “It’s not going to be the candy store doctors think it is.”

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Perhaps Medicare’s new plan to support the heart diagnostic test will act as a yellow flag.

The test is a modified version of a standard stress test. It costs $350 to $400 depending on where in the country it is administered, and is performed using a $30,000 machine developed by Cambridge Heart, which is based in Bedford, Mass. Shares of Cambridge, which trade on the over-the-counter bulletin board, jumped 50 percent yesterday, to 48 cents.

The machine’s software analyzes a barely measurable electrical wave in the heart known as the T-wave. Heart patients with normal T-wave cycles - at least 30 percent of the defibrillator-eligible population, according to several studies - rarely suffer sudden cardiac arrests.

Cambridge Heart points out that the test also has a track record of identifying patients with abnormal T-wave readings. As a group, such people run higher risks of sudden cardiac arrest than the general population eligible for defibrillators under current federal guidelines. And so, even as the test could eventually be used to limit the overall population of eligible patients, its initial impact might be to make cardiologists more aggressive about recommending implants for those who are deemed at risk.

Interesting and logical!

Once again I reach to Nietzsche for a quote:

All of life is a dispute over taste and tasting.

and for the first time Thomas Sowell

You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.

Come ye, worship at the shrine of evidence! Evidence will fix medicine.

What do I hear blasphemers? Bah humbug?

Some are challenging the religion of EBM - Evidence Based Medicine proponents need to watch out for their friends and A contrarian view of evidence based medicine

I like some aspects of EBM. We should search for the best possible evidence to support our medical decision making. However, like all religious movements, extremism in support of EBM misses the entire point of EBM. We should not eschew the best evidence, even when that evidence does not meet the “highest” standards. We should not become nihilists when randomized controlled trials do not exist.

We should strive to find the best evidence, but never forget common sense and clinical judgement. EBM works better for groups than it may for an individual patient.

We have been preaching tight control of glucose in patients with diabetes for a number of years. We believed that it made a major difference. We were right!

Diabetes Study Verifies Lifesaving Tactic

A 17-year federal study has finally answered one of the most pressing questions about diabetes: Can tight control of blood sugar prevent heart attacks and strokes?

The answer, reported today in The New England Journal of Medicine, is yes. Intense control can reduce the risk by nearly half.

And, the study found, the effect occurred even though the patients had only had a relatively brief period of intense blood sugar control when they were young adults. Nonetheless, more than a decade later, when they reached middle age, when heart disease and strokes normally start to appear, they were protected.

The study involved those with Type 1 diabetes, which usually arises in early in life and involves the death of insulin-secreting cells.

“This is truly an important study,” said Dr. Robert Rizza, a professor of medicine at the Mayo Clinic and the president of the American Diabetes Association. “And I usually don’t say that,” he added.

One could argue that we only know that this is true for type I diabetes, and thus we do not have the evidence to push as hard with type II diabetes. That reasoning is (in my opinion) flawed. (see previous rant)

But the result also gives rise to questions: Does the same effect occur in people with Type 2 diabetes, which usually occurs later in life and involves an inability to respond to insulin? And why would tight control of blood sugar for one brief period have such a pronounced effect later?

Dr. Fradkin said she expected that the results would hold for Type 2 diabetes. Another large federal study is addressing that question, she noted, but it is already known that tight control of blood sugar in Type 2 diabetes protects against nerve, kidney and eye damage, just as it does with Type 1 diabetes.

In addition, a study in Britain hinted, though it did not demonstrate, that Type 2 diabetics who kept their blood sugar low had less heart disease and fewer strokes.

As the end of the year approaches, I usually review my ranting from the current year. I have chosen 10 rants which I think epitomize my thoughts this year. Some themes recur through these rants, I consider these essential themes for the future health of our health care system.

Feel free to suggest other rants - I had difficulty paring this list down to 10.

1. Some thoughts on doctoring - understanding the patient
2. On great cases and interesting cases
3. A serious conversation
4. The white coat ceremony
5. On being a general internist - time is of the essence
6. How do we avoid arrogance?
7. Is the Oregon assisted suicide law legal?
8. The danger of public report cards
9. The future of general internal medicine
10. Supply and demand

Thanks for reading my thoughts this year. I hope I occasionally stimulate you to think more deeply about health care issues. If I do, then I have succeeded.

Gastric Acid–Suppressive Agents Linked to Clostridium difficile Diarrhea

Proton-pump inhibitors (PPIs) and H2-receptor agonists (H2RAs) are associated with increased risk for community-acquired Clostridium difficile–associated disease (CDAD), according to the results of 2 population-based, case-control studies reported in the December 21 issue of JAMA.

“Recent reports suggest an increasing occurrence and severity of C. difficile–associated disease,” write Sandra Dial, MD, MSc, from McGill University in Montreal, Quebec, and colleagues. “Gastric acidity constitutes a major defense mechanism against ingested pathogens, and loss of the normal stomach acidity has been associated with colonization of the normally sterile upper gastrointestinal tract.”

Using the U.K. General Practice Research Database (GPRD), the investigators conducted 2 population-based, case-control studies. In the first study, each of 1,672 cases of C. difficile recorded between 1994 and 2004 was matched to 10 controls, based on calendar time and the general practice. In the second study, those cases not hospitalized in the previous year and therefore defined as community acquired were matched on practice and age with controls also not hospitalized in the prior year. Primary endpoints were the incidence of C. difficile and risk associated with use of gastric acid–suppressive agents.

The incidence of C. difficile diagnosed by general practitioners (GPs) increased from less than 1 case per 100,000 in 1994 to 22 per 100,000 in 2004. With current use of PPIs, the adjusted rate ratio (RR) of CDAD was 2.9 (95% confidence interval [CI], 2.4 - 3.4). With H2RAs, the RR was 2.0 (95% CI, 1.6 - 2.7), and with nonsteroidal anti-inflammatory drugs, RR was 1.3 (95% CI, 1.2 - 1.5).

“The use of acid-suppressive therapy, particularly proton pump inhibitors, is associated with an increased risk of community-acquired C. difficile,” the authors write. “The unexpected increase in risk with nonsteroidal anti-inflammatory drug use should be investigated further.”

Study limitations include the possibility of unknown risk factors that may have biased or confounded the analysis and lack of data concerning chemotherapy.

This study should remind us that almost all drugs can cause unintended consequences. We should prescribe any drug cavalierly. I always ask what the benefits are - and what risks the patient will have.

Certain Drugs May Be as Effective as Surgical Management for GERD

A Comparative Effectiveness Review from the Agency for Healthcare Research and Quality (AHRQ) found that medical management with certain drugs is as effective as surgical management for chronic uncomplicated gastroesophageal reflux disease (GERD). The Tufts–New England Medical Center Evidence-based Practice Center prepared this report under contract with AHRQ.

“As the first Comparative Effectiveness Review, this report opens a new and promising chapter for helping patients choose the best evidence-based treatment for their own situation,” AHRQ Director Carolyn M. Clancy, MD, said in a news release. “Today’s report will help patients and health care providers make more informed choices when they consider how to manage the symptoms of chronic GERD, and especially when they consider surgery.”

GERD, defined as weekly heartburn and/or acid regurgitation, is one of the most prevalent health conditions in older Americans, resulting in $10 billion annually in direct healthcare costs in the United States in 2000. For chronic GERD, defined as frequent, severe symptoms requiring long-term, regular use of antireflux medications, treatment goals are improvement in symptoms and quality of life, healing and maintenance of healed erosive esophagitis, and prevention of complications, such as Barrett esophagus, esophageal stricture formation, or esophageal adenocarcinoma.

Evidence reviewed in the report suggests that for most patients with uncomplicated GERD, proton pump inhibitors (PPIs) can be as effective as surgery in relieving symptoms and improving quality of life.

Although one of the indications for surgery may be to alleviate the need for pharmacotherapy, the evidence does not conclusively show that a significant proportion of patients undergoing surgery can eventually stop their medications. In the studies reviewed in this report, 10% to 65% of patients treated surgically resumed medication use.

“While advocates of surgery continue to suggest that it might be more effective than medical therapy for prevention of Barrett’s esophagus and esophageal cancer, evidence supporting this assertion has been inconclusive,” the authors write. “A challenge in treating GERD is that neither improvement in symptoms nor reduction in the need for antisecretory medications has consistently correlated with objective measures such as normalization of esophageal pH exposure or healing of esophagitis. The endoscopic approaches, in particular, have drawn into focus the disparities that can exist among various objectives in treating GERD.”

In February I linked to a column about a health writer who had had bilateral knee replacement surgery. A health writer gets new knees. This entry has (to date) received 24 comments. Today, in the NY Times, she tells us what happened since then. A Year With My New Knees: Much Pain but Much Gain

It’s been a year since my seriously arthritic knees were replaced by manufactured titanium ones. Many readers who recall the postoperative difficulties I wrote about last February have asked for an update. They want to know how I’m doing, and whether I would do it over again if I had to.

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A word of caution: as with any surgery, knee replacement is not always perfect even in the best hands. I have met several people with lingering problems, including one who experienced permanent nerve damage and another who must use a cane despite a year of physical therapy and reassurance from her surgeon that her new knee is “perfect.”

While they are a remarkably good imitation, titanium knees are not as versatile as natural healthy knees. Kneeling on them is not comfortable, even with a cushion, and they don’t bend as much as natural knees.

While a normal knee can bend to about 145 degrees, I can bend my left knee 120 degrees and my right 115 degrees.

I now have to garden sitting down. I can ride a bike for miles. Though my knees often hurt when I start out, they feel better after riding than before - no more postexercise icing and pain.

As with arthritic knees, my artificial ones get stiff when they remain in one position for long, so I still have to get up and move around often.

I have not tried tennis and, given my back problems, may never return to the court. I can run for a bus without pain and go up and down stairs like a spring chicken (which I’m not!).

In November, I walked through the Los Angeles Zoo and Griffith Park for nearly four hours without pain that day or the next.

Perhaps most exciting of all, after two years off the ice, I am skating again with no knee discomfort during or after.

I expect to be back on cross-country skis and snowshoes this winter.

With metal knees I have to put up with a personal body check before every flight, so I make sure to leave plenty of time at airports.

The bottom line? I’m still glad I chose to have both knees replaced at the same time. I doubt that I would have gone back for the second one after experiencing the first. I am also glad to have knees that permit me to walk for miles and stand on my feet for hours without pain.

As Paul Harvey would say - and now you know the rest of the story!

My analysis:

Knee replacement surgery is not magic. One does not immediately resume an active lifestyle. Patients should make the decision to consider knee replacement surgery only after very careful consideration. The ideal candidate is the patient whose quality of life has been greatly compromised because of their knee pain AND is highly motivated to go through the rehabilitation process. Rehab requires hard work. Thus, the patients who really benefit are those who start out in poor shape and are willing to “pay the price” in the gym to restore function.

As with all surgery, the patient should be willing to accept some risk. Anesthesia has risks. Knee replacement carries the risk of infection. One has a short term risk of blood clots. I am certain that I have left out some important other risks.

Thanks to Jane Brody for sharing her story!

From the Annals of Internal Medicine
Link for subscribers - Comparing Yoga, Exercise, and a Self-Care Book for Chronic Low Back Pain: A Randomized, Controlled Trial

Editors’ Notes

Context

* Yoga combines exercise with achieving a state of mental focus through breathing. In the United States, 1 million people practice yoga for low back pain.

Contribution

* The authors recruited patients who had a recent primary care visit for low back pain and randomly assigned 101 to yoga or conventional exercise or a self-care book. Patients in the yoga and exercise groups reported good adherence at 26 weeks. Compared with self-care, symptoms were milder and function was better with yoga. The exercise group had intermediate outcomes. Symptoms improved between 12 and 26 weeks only with yoga.

Implications

* Yoga was a more effective treatment for low back pain than a self-care book.

—The Editors

I know the senior author very well. He has studied low back pain his entire career, always in a thoughtful manner. Thus, I believe the results - and will recommend this to friends and patients.

A reader sent me this link - You smoke you croak

A SICK dad blasted NHS “bullies” yesterday after a hospital consultant refused to treat him unless he stops smoking.

Ailing Fred Smith, 60, was told he must quit cigs for at least six months before he even gets an appointment.

Fred was referred to the specialist with blocked veins which could have led to him losing a leg.

But he was horrified to be told: “Stop smoking first.”

The snub is thought to be the first time in NHS history a potentially very ill person has been refused an appointment because they smoke.

Fred, who gets through 15 hand-made roll-ups a day, said: “This man has never even seen me yet he has the affront to say he doesn’t want to treat me.

“As a taxpayer I’ve helped pay his wages and train him. Now he’s paying me back by using bullying tactics.”

The painter and decorator, of Lincoln, first reported leg pains last month.

His GP referred him to Lincoln County Hospital and asked for an appointment with surgeon Andrew Lamerton — who wrote straight back to snub him.

Dad-of-two Fred said: “It’s ridiculous.”

Last night the United Lincolnshire Hospitals NHS Trust defended the surgeon, saying: “The most important factor that can help patients with vascular problems is to stop smoking.”

Wow! If I refused to treat all patients who smoked (or drank, or were obese, or engaged in risky sexual behaviors, or injected drugs IV, or had tatoos), then I would treat very few patients.

As I understand my responsibility as a physician, I do my best to help patients. I give very strong advice with regards to all the issues I raise above. I do my best to explain the problems these risk factors pose.

If the surgeon really wrote this letter, then I believe he is guilty of abandonment. He has (in my opinion) an obligation to see the patient, and explain the importance of smoking cessation. After evaluating the patient he might recommend against surgery until smoking cessation is achieved - but he has a responsibility to explain this to the patient.

What do you think?

As we say in Alabama, “you ain’t gonna believe …”.

Journal Faults a Medical Group in a Dispute Over Independence

The Canadian Medical Association Journal gives readers a mixture of scientific research papers and journalism. Now a dispute about the boundary between the two has led to charges of censorship and the creation of a committee to review the journal’s independence.

This month, the journal’s editor in chief, John Hoey, asked two of his reporters to follow up on a recent regulatory decision that made Plan B, a morning-after contraceptive pill, available without a prescription in Canada. They, in turn, sent 13 women to buy the pills at pharmacies in each of Canada’s provinces and territories.

Dr. Hoey said he expected that some of the women would find that purchasing the pill was not easy. But he was surprised to learn that all of them were asked for detailed personal information, in some cases including sexual history, which was entered into computers.

“We thought these privacy issues were important to the story,” Dr. Hoey said.

The reporters found that the information was being collected because the Canadian Pharmacists Association had asked pharmacists to do so.

On Dec. 9, after his reporters interviewed officials at the pharmacists’ association, Dr. Hoey received a telephone call from Graham Morris, the Canadian Medical Association’s executive in charge of publications. While the association had no advance notice of the journal’s contents, Dr. Hoey said it was made clear to him that the pharmacists had complained to the medical association.

“He said, we’re not going to let you publish that story. It’s shoddy journalism and what business is it of ours to be criticizing the pharmacists,” Dr. Hoey recalled, adding that it was the first time in his 10 years as editor that he had been ordered to cancel or change a story.

The pharmacists contended that because the journal was a scientific publication it should have conducted its informal survey of pharmacies accordingly, using both ethical and peer review committees.

“We said this was not appropriate for a research journal,” said Louise Crandall, a spokeswoman for the pharmacists’ group. The medical association said that it was unable to make anyone available for comment.

Dr. Hoey’s position, however, is that the informal survey was journalism, not research, and that the pharmacists’ argument was “just a way to force us to pull the story.”

After initially considering resigning on the grounds of editorial interference, Dr. Hoey said, he took three steps. An article appeared about the information collection but without mentioning the experiences of the 13 women.

Then on its Web site, the journal published an editorial describing the attempt to cancel the story and criticizing the medical association for interfering with its editorial independence.

This story speaks for itself. Bravo to the editor.

General internists often love mystery stories. When I hear about or care for an interesting patient, I look for colleagues to tell. We love trying to solve the puzzle.

Lisa Sanders is a general internist. She regularly tells stories of interesting diagnoses in the New York Times Magazine. Today’s magazine has a real puzzler - Running Complex

Excerpts do not do this story justice. If you are a physician and enjoy a good puzzle - go read the story and try to figure out what is going on.

As we seek to improve quality of care, we should not forget the importance of the diagnosis. One of my colleagues who has studied quality of care for the past 10 years, gives this example:

A 56 yo diabetic man comes to your office. You check his HgbA1c, note that he saw his opthalmologist last week, examine his feet, recheck his lipids (the patient is already on simvastatin), check his renal function and screen for albuminuria. You note that his BP is well controlled on enalapril and hydrochlorothiazide. His vaccinations are current.

As the patient is leaving your 20 minute visit, he causally mentions that he has had some chest pain.

If you disregard the chest pain (you are running behind in your schedule) and omit the complaint from your note, you will still get a great quality score. You have done all the things that the quality measure police say you must do. But medical care is more than complying with a check list.

Say another physician is less compulsive about the checklist, but she spends an extra 5 minutes discussing the chest pain. Characteristics of the chest pain bother her; she orders a stress test which is markedly abnormal.

So which physician has done a better job?

Cases like the one which Dr. Sanders describe are difficult to capture in a quality score. Yet the physician made a great diagnosis. The diagnosis may well have saved the patient’s life.

As I have written this week, I am not disturbed that Dr. Topol lost one of his administrative positions. Administrative positions in academic health centers come with no protection and no guarantees. However, this situation will likely hurt the reputation of the Cleveland Clinic more than it hurts Dr. Topol. Sometimes you do not want investigative journalists investigating your situation.

Ties to Industry Cloud a Clinic’s Mission

Dr. Eric J. Topol, a cardiologist, has been perhaps the most public face of the prestigious Cleveland Clinic Foundation, a prominent medical center regarded as one of the nation’s best.

Not shy in the media spotlight, Dr. Topol has cultivated the persona of a Naderesque crusader against drugs he deems dangerous, as well as their makers. Some of his most impassioned criticism has been aimed at Merck and its drug Vioxx, the painkiller the company withdrew from the market over questions about its safety. But he has also been outspoken recently about other drugs.

Now, Dr. Topol’s bluntness - refreshing to his admirers, startlingly unscientific to his targets and his critics - has drawn a bright spotlight to his own conduct and that of the Cleveland Clinic. In the last month, he has been demoted and the clinic’s image has been tarnished in what has become an unusually public dispute pitting him against the clinic’s chief executive, Dr. Delos Cosgrove.

Dr. Topol, who retains the position of chairman of cardiovascular medicine at the clinic, suggested in a Webcast on Thursday (www.theheart.org) that his unabashed willingness to take on Merck was a principal reason for his removal this month as head of the clinic’s medical college. In what Merck lawyers have suggested is a vendetta, he described the company’s behavior as “appalling” in recent testimony in a Vioxx lawsuit.

But his demotion has drawn attention to the mounting tensions between the clinic’s research mission and its deep ties to the businesses that finance that research. Both Dr. Topol and Dr. Cosgrove refused to comment for this article, but associates say Dr. Topol may decide to leave the clinic.

Dr. Topol will land on his feet. Many institutions would gladly hire him to bring repute to their cardiovascular activities.

The Cleveland Clinic may take a major blow here. Reports like the one I cite above will likely damage the Clinics reputation. Reputation does matter for this institution.

I believe the important issue here is not Dr. Topol’s ongoing criticism of Merck. Rather, I would bet that we are witnessing a personality clash between two men. Dr. Topol, despite a previous probable conflict of interest, is currently occupying the moral high ground.

The real tragedy here is not Dr. Topol’s removal. The real tragedy comes when academic physicians and their institutions compromise their ethics for money.

The dispute at the Cleveland Clinic goes far beyond a simple power struggle between strong-willed men who competed for the clinic’s top job. Dr. Topol severed his ties to industry after being embarrassed last December by an article in Fortune magazine. But the continued controversy has focused attention on the many longstanding corporate ties at the clinic. Those business links involve not only staff doctors and researchers, but also Dr. Cosgrove and the clinic’s board.

The Cleveland Clinic is emblematic of the way the drug and medical device industries and the investment community work closely with medical researchers and doctors to develop and promote new medicines and technologies. Almost inevitably, such relationships raise concerns about possible conflicts of interest that could lead doctors to favor some treatments over others or to bias the results of medical research.

“It’s not just the Cleveland Clinic,” said Les Funtleyder, a health care strategist at the investment company Miller Tabak & Company in New York. He says other high-profile academic medical centers also have numerous financial ties that raise the potential for conflicts of interest.

Dr. Jerome P. Kassirer, a former editor in chief for The New England Journal of Medicine, describes the potential conflicts at the clinic “as extremely serious ones” but notes that the Cleveland Clinic is “not unique at all.”

Now I do not believe that money is the root of all evil. Some evil occurs without financial motivation. However, we must always understand that there are no free lunches. We must always remain cognizant of the implications of any financial deal. We must guard against compromising our scientific integrity.

Unfortunately, too many in our society are willing to make compromises in the interest of money. One can deal with industry and maintain ethical standards - but it takes work. Too many get seduced by the money and disregard developing necessary ethical protections.

I hope this story leads all institutions to examine all of their relationships to industry. Journals require disclosure of financial interests. I do not think all academic institutions require such disclosure. We in academic medicine have a moral responsibility to maintain the public trust in this regard. Unfortunately, too many have placed their own success above that moral responsibility. Unfortunately, some institutions are also guilty.

Thus, I find this story more troubling beneath the surface than on the surface. I would not classify the Topol situation as a whistleblower problem. I doubt this story is really about Vioxx. Rather we have a clash of 2 egos complicated by the questionable financial interests of one. I suspect that Dr. Topol’s loss of one of his positions was in the works for a long time. I have seen such conflicts in academic medicine personally. In the long run, the institution will suffer.

The Cleveland Clinc is guilty of faulty leadership. They have had short term financial gains, but will probably lose in the long run. And that is the real story that grabs my attention.

Nurses face sexual harassment from patients

Nurse Sarah Andres is so used to male patients calling her “sweetie” or “cutie” — or even asking her for a kiss — that it rarely upsets her anymore.

“I usually chalk it up to they don’t feel good, a lot of them are confused,” said Andres, who has been a nurse in St. Louis, Missouri, for five years and works in the critical care unit at St. Mary’s Health Center. “I never really thought of it as sexual harassment.”

But nursing organizations say such treatment is common, and it is definitely sexual harassment.

We all have seen this. Female physicians have almost all experienced it. This is not just a nursing issue. Female MDs, physical therapies, dieticians - the list could go on.

Many men in our culture have no clue about appropriate behavior. Most patients who say these things are just clueless - but some live within a subculture where such comments are routine and accepted.

I have no good answer for this problem and hope that some female readers will comment.

I am a sports fan. ESPN is my favorite network. Over the past year I have noticed that more and more athletes are suffering from sports hernias. I did not recall hearing this phrase in the past. I was reading an article about Donovan McNabb this morning. It included a reminder that he is having surgery for a sports hernia. One of the guards on my favorite college basketball team is out recovering from sports hernia surgery. Here I am, a full professor of medicine and I do not know what the heck a sports hernia is. So - the internet comes to the rescue:

The ‘Sports Hernia’: A Common Cause of Groin Pain

Athletes who participate in sports that require repetitive twisting and turning at speed, such as soccer or ice hockey, may be at risk of developing a ’sports hernia’—disruption of the inguinal canal without a clinically detectable hernia. Insidious onset of unilateral groin pain is the most common symptom. Concurrent pathologies, such as osteitis pubis and adductor tenoperiostitis, may complicate diagnosis. Plain radiographs and a bone scan can aid differential diagnosis, but herniography is not recommended. Surgery is the preferred treatment. Structured rehabilitation should enable athletes to return to sports activity 6 to 8 weeks after surgery.

Now you and I know what the sportscasters are talking about!

Patients Trust Physicians, but Are Likely to Go to Internet for Health Information

I have no problem with patient internet usage. I do hope that over time we can have a method for recommending sites with valuable high quality information.

Obviously, I use the internet a great deal, as do you. The problem we have when investigating any subject is to validate the source for quality. If one browses the internet for medical questions, one can find varying quality levels.

With those reservations, I would rather respond to a patient who takes enough interest in their health to spend time on the internet. My only concern is for those patients who find what they want to find, rather than finding the best evidence.

Before the internet, we had patients who would look everything up in the Merck Index. This is not a new phenomenon, just a more accessible one.

“The context in which patients consume health information has changed dramatically with diffusion of the Internet, advances in telemedicine, and changes in media health coverage,” lead investigator Dr. Bradford W. Hesse and his associates point out in their report, published in the Archives of Internal Medicine for December 12/26.

To track these changes, Dr. Hesse with the National Cancer Institute in Bethesda, Maryland, and his associates analyzed data procured in the first Health Information National Trends Survey (HINTS), administered by telephone to 6369 adults between October 2002 and April 2003.

Results showed that 63.0% of respondents had ever used the Internet. Of these, 63.7% had looked there for some type of health or medical information. Other health-related Internet activities, such as purchasing medication, communicating with physicians, or participating in an online support group, were taken advantage of by less than 10% of users.

The authors report that 62.4% of respondents said that they trusted physicians “a lot” for cancer information, compared with 23.9% for the Internet.

When asked where they would prefer to go first for information about cancer, 49.5% reported wanting to go to their physicians. In actuality, only 10.9% of those who had sought information about cancer reported having gone to the physician as a source of first resort, whereas 48.6% went to the Internet first.

“Ongoing attention may be needed to adjust reimbursement policies for time spent with patients interpreting printouts, for accommodating shifts toward informed and shared decision making, for steering consumers to credible information sources, and for attending to the needs of those who fall through the cracks of the digital divide,” Dr. Hesse’s group suggests.

I have carefully written my rants in such a way as to only provide plausible alternatives for Topol losing his position. We really do not know whether Topol was effective in his position.

Are all firings in academic medicine justified? Certainly not!

Do those of us in administrative positions have a “right” to our position? Certainly not!

Topol may be the best administrator in the country, or he may be the worst. Likely some like him and some dislike him. Most politics are local, and we do not really know what happened.

My point - which I have meant to make previously - is that his removal really is not important. He will not stop speaking out nor will other academicians.

We need not blame his removal on “whistle blowing” and that is my point. The reasons for his removal are of local importance; his opinions are of national importance. He still has access to the national media, and I expect we have not heard the last of his opinions.

Dr. Eric Topol is a world famous cardiologist. He is a wonderful thinker. He is outspoken. He still retains his chairmanship.

A reader sends in this commentary:

I live in NE Ohiio and I can tell you: The Cleveland Clinic is big business and Dr. Topol was not well liked by many factions. He was very good at rocking the boat as long as he could grand stand and be out front on supposed problems. He got rid of the evil McDonald’s and their bad food. The only problem was the house staff could not afford the nice salads, nor could the food service keep up demand, thus leaving people with no place to eat in their allotted breaks.

Make no mistake, this is about egos, money, and sweetheart deals.

In no way do I believe that his removal will intimidate him. Nor do I believe it will intimidate many academicians. This situation is much more complex than a whistleblower case. This situation is probably a clash of huge egos.

Eric Topol claims that he was fired because he testified against Merck. The Cleveland Clinic argues that this is just coincidence.

At least 2 blogs have weighed in:

“One Horrible Debacle,” Indeed: Topol Fired

Enjoy the Silence

Although the timing certainly seems suspicious, I believe that all we can say for sure is that we have a True-True situation - but we do not really know if they are related.

Some of us look for conspiracies under every corner -

People always search for meaning. But in our confused and ever changing world we feel particularly perplexed when it comes to making sense of the problems that confront us. One of the most important ways in which an absence of meaning is experienced is the feeling that the individual is manipulated and influenced by hidden powerful forces - not just by spin-doctors, subliminal advertising, and the media, but also by powers that have no name. That is why we frequently attribute unexplained physical and psychological symptoms to unspecific forces caused by the food we eat, the water we drink, an extending variety of pollutants and substances transmitted by new technologies and other invisible processes. As a result, global warming is not simply a climatic phenomenon but an all-purpose evil that can account for a bewildering variety of destructive events.

from On the hunt for a conspiracy theory. I could just as easily make the case that Dr. Topol’s personality could have led to his dismissal. I understand his desire to blame this all on the Vioxx incident, but unless we have tapes of conversations we can never know.

I suspect that this incident may have been the straw the broke the camel’s back. But perhaps it really is coincidence.

I disagree with my good friend Roy Poses on this one. This is not a crisis situation. Dr. Topol still has an excellent faculty position and reputation. All executives in academic medicine serve at the whim of their boards. Some get fired for the right reasons, and some for the wrong reasons. Since we know nothing of his executive style, we should refrain from commenting on the firing. Rather we should concentrate on the lessons that the entire Vioxx experience should teach us.

I was talking to a second year law student the other day. He is studying evidence (that is the name of the course). In court, one must carefully follow the rules of evidence, else the evidence is not admissable.

Medicine should be much easier. We should rely (when possible) on objective evidence. We should minimize the impact of poor evidence (like anecdotes). Most physicians find the field of “complementary and alternative” medicine not really a field, but rather a garbage dump. Why? We react strongly, because we want scientific evidence and we decry those who try to sell people snake oil.

Dr RW is on a deserved rampage against the AMSA concerning this issue. Please read these posts:

The American Medical Student Association Promotes Chelation Therapy

The hypocrisy of the American Medical Student Association

So far, so good—-the AMSA says they’re all about science, evidence and ethics. But wait. Dig deeper and you find AMSA actively promoting quackery and pseudoscientific nonsense. Let’s look at a few links. Here we find that they advocate for complementary and alternative medical education. What does that mean? Well, they’ve just formed a naturopathic medicine interest group. (Here’s some reliable information on naturopathic medicine). They have also published a booklet entitled Between Heaven and Earth, a 46 page “Introduction to Integrative Approaches to Health Care.” Far from being a critical or scientific approach, the book actively promotes unscientific methods. Then there’s their Complementary Therapies Primer which teaches and actively promotes all sorts of nonsensical and outlandish claims. Included are promotions of chelation, homeopathy, aromatherapy, therapeutic touch, polarity therapy, rolfing, qigong and ayruvedic medicine.

I share his dismay.

Via “This makes me sick” - apparently there is a caption contest at the New Yorker involving this cartoon (although I could not find the contest when searching).

My thoughts:

“Anything you say may be held against you.”

“I could tell you, but we would have to kill you.”

This cartoon caught my eye after last week’s rants and commentary.

In much of my academic life, I strive to minimize bureaucracy. Bureaucracy rarely enables progress. My experience with bureaucrats generally frustrates me. Bureaucracy eschews common sense in favor of rules.

For those with registration - IOM: New agency needed to simplify pay-for-performance measures

The physicians and researchers tasked by lawmakers to help get pay-for-performance off the ground worry that it’s already carrying too much weight for liftoff.

The Institute of Medicine released a report earlier this month detailing a plan to adopt and develop performance measures, the building blocks for any program that bases payments for services on quality of care. While researchers concluded that several good sets of measures already exist, they noted that they are too numerous and spread out to be effective.

“Currently, it’s a little bit like the Tower of Babel. There’s a set of uncoordinated requests to measure and capture different things in different formats,” said Steven Schroeder, MD, a health professor at the University of California in San Francisco and chair of the IOM committee that produced the report. “If they were streamlined and coordinated, it actually might ease the regulatory burden on overworked physicians.”

The group’s proposed solution to this roadblock is to establish a new federal office within the Dept. of Health and Human Services that would coordinate and fund the development of quality measures needed for pay-for-performance, public reporting, accreditation or any other quality improvement effort.

The National Quality Coordination Board would set the benchmarks that government initiatives — and potentially private-sector ones as well — would utilize.

With all due respect to Steve Schroeder (who I know and respect), this is a bad idea. Pay for performance is already fraught with hazard. I worry about the underlying ethics of P4P. I worry about how P4P will impact access to care. I do not want to also worry about a government bureaucracy controlling P4P.

We need a comprehensive look at P4P. While the idea has great initial appeal, I wonder how many advocates have thought through the externalities* of P4P. Certainly, I doubt that politicians understand.

Maybe I should not fear this process. However, I worry that putting the responsibility within HHS will allow politicians too much power.

*In economics, the effects that the acts of consumers or producers have on each other. Externalities range from pollution and technological (see technology) inventions to the change in the range of options available to consumers and are differentiated from internalities because current knowledge prevents the former from being included into the formal equations of an analysis. Externalities may also be regarded as the unanticipated side effects of calculated courses of action.

False Positives From H.I.V. Test

Diagnostic tests have several characteristics. Some tests give a spread of results, but others give a simple dichotomous results - positive or negative. When faced with a dichotomous test, we have 4 possibilities: true positive, true negative, false positive and false negative. While we often worry about false negative tests, false positives can lead to major problems.

Health officials in New York and San Francisco said yesterday that a widely used rapid test for the virus that causes AIDS had been producing too many false-positive results, frightening healthy people into thinking they might be infected.

The test, called the OraQuick Advance H.I.V. test, is the same one the Food and Drug Administration has said it will consider approving for sale to the public for home use without a prescription.

But officials in the two cities and at the drug agency also emphasized that the test, which requires a mouth swab instead of a blood sample, should not be abandoned, because its convenience made it a valuable tool in fighting AIDS.

Rather, they said, the problem needs to be investigated, and clinics and patients need to be aware that a positive result must be confirmed by another type of test.

Difficulties with the test were first reported yesterday in The San Francisco Chronicle.

In New York, Dr. Susan Blank, an assistant health commissioner, said that city clinics performed 3,600 to 3,700 tests for the virus, H.I.V., each month, largely using OraQuick, and until recently they had about five false positives a month, a rate well within the maker’s prediction.

But in November, Dr. Blank said, the number shot up to 30, which was cause for concern.

“We have made several lot switches to make sure we have the most recent specimen kits,” Dr. Blank said, adding that the city laboratories had also reviewed their own procedures to make sure they were using the test kits correctly.

She added, “We have spoken with the company several times and written to the company to try to resolve the problem, and have taken steps to inform the F.D.A.”

The city also informed the Centers for Disease Control and Prevention, Dr. Blank said. Rapid testing “remains an important tool in stopping the spread of H.I.V.,” she said, adding, “I think we need to be careful that we don’t throw out the baby with the bath water.”

What rate of false positives would you consider acceptable? Having to tell someone that they have a positive HIV test is difficult enough without having confirmatory testing. With this rapid test, one would have to put the person with a positive test into testing purgatory. As a result of the test, some without HIV must go through the angst of considering that they may have the infection.

So the trade off here is explicit. What percentage of false positive tests should we accept in the name of rapidity? This question has no easy answer. What will happen to false positive rates if people use the test at home? Who will be available to counsel the person with the positive result?

I am not posing philosophical arguments here, rather I am asking that we think carefully through the advantages and disadvantages of rapid tesing. Some would argue the advantages of speed outweigh the angst of those with false positive tests. I do not see this problem through large numbers. I must think about how those with false positive tests feel. What are those costs?

Some of the posts below express frustration. However, I personally love medicine.

When face to face with a patient, I love being a physician. The opportunity to help patients through a combination of knowledge, experience and bedside manner makes our profession the best. I love the problem solving and the complexity of medicine. I love sitting down with a patient and understanding what makes him/her tick. I even find the difficult conversations rewarding.

I still walk in the room and see the patient smile. I hear their thanks. I help them at the worst moments and they are grateful.

So I will put up with the hassles for the joy and challenge. I am a lucky man to have found the best profession in the world.