Five thirty eight has this wonderful provocative article – Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much

The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield “competing guidelines”. We all know the controversies over breast cancer screening and prostate cancer screening. Recently BP targets and lipid management have become controversial. Pharyngitis (a personal research interest) has multiple varied guidelines.

In the movie, Pirates of the Caribbean, this classic exchange makes the point:
Elizabeth: Wait! You have to take me to shore. According to the Code of the Order of the Brethren…
Barbossa: First, your return to shore was not part of our negotiations nor our agreement so I must do nothing. And secondly, you must be a pirate for the pirate’s code to apply and you’re not. And thirdly, the code is more what you’d call “guidelines” than actual rules. Welcome aboard the Black Pearl, Miss Turner .

What is the problem? As one of my heroes said many times, everything in medicine requires context. We have differing opinions on the importance of that context.

Given that I have studied the pharyngitis problem for many years, let me use that as my example.

You are a primary care physician seeing an adolescent with pharyngitis. You have two concerns – helping the patient feel better and decreasing the probability of complications, either suppurative or non-suppurative.

Now imagine you are an infectious disease expert. You rarely see pharyngitis patients, but you are worried constantly about antibiotic resistance. Your concern centers on the “overuse” of antibiotics.

You can imagine how these two incarnations of you would view the problem differently. The first you is patient focused; the second you takes a public health viewpoint. Who is correct?

Actually, neither is correct and neither is wrong. The two versions of you have differing context.

Since both views have validity if one agrees with the context, developing a context free rule based on one of these guidelines would constitute a potential error.

The danger of rules (I hope you are reading performance measurement here) comes when they discount context. Some rules have resulted in patient harm.

When insurance companies judge, and even reward, physicians for meeting rule targets, some physicians will overlook context.

This Medscape article about hypoglycemia in the elderly raises important issues about HgbA1c targets. Hypoglycemia a Greater Threat Than Hyperglycemia in Elderly

Performance measures are rampant, primarily because the “suits” believe that we can use them to measure quality. I am proud that the ACP performance measurement committee carefully evaluates many measures. Often these proposed measures get a thumbs down. ACP Performance Measure Recommendations

We need a more widespread accountability on performance measures. The ACP committee careful evaluates the context of proposed measures. Why do other organizations not adopt this enlightened approach?

Exercise – the most difficult prescription to fill

Perhaps this post represents my current obsessions, but the literature suggests very strongly that exercise has great preventive benefits.  Our challenge as physicians comes in trying to convince patients to exercise.

Our medical students seem to understand.  The great majority of our students exercise.  The same goes for our residents.

Back in the 70s when I was a student, it was rapidly becoming clear that very few students smoked.  I have not known a medical student smoker in the past several years.

Physicians and aspiring physicians generally are early adopters of healthy behaviors.  Our challenge is translating our understanding and positive habits to our patients.

The exercise prescription, quite similar to the smoking cessation prescription, requires hard work from the patient.  How do we help our patients adopt a healthy lifestyle?  What are the magic words?

I would love to read comments from readers who have had success in helping patients enter the world of regular exercise.

Exercise does not have to be strenuous.  Regular walking brings great benefits.

Exercise does so much positive, yet too many Americans eschew movement.  We should continue making exercise the norm rather than special.

On becoming a runner – many lessons learned – Part 2 – clothing

Running works better when you have the proper gear.  Clothes are important.  If you are starting, you will probably put on some shorts, a cotton tee shirt and socks.  If you are going to run regularly, you should look into modern clothing.

Most “serious” runners wear technical shirts.  Technical shirts wick – they do get wet, but not as heavy or as wet as cotton. They also lead to less chafing.  My experience suggests that you do not want the shirt to be too tight.  Technical shirts are more expensive, but most runners will tell you that they are worth it once you are running long enough to have significant sweating.

Each runner will need to find their favorite running shorts.  I have tried several, and particularly like the Nike Dri-fit, but each runner will find their own favorites.

Socks are most important to prevent blisters.  I recommend going to a running store and buying socks that wick.  Socks are very important to protect your feet.  I am wearing Swiftwick socks currently, but there are several excellent brands to choose from.

On becoming a runner – many lessons learned – Part 1 – shoes

Last July I started becoming a runner. As part of my weight loss project, I started walking and surprisingly (to me) start jogging and finally became a runner. I know that I am a runner now for several reasons:

1. I have run a race – a 5k.  Moreover, running the race was thrilling and I plan to run another later this summer.

2. As I consider my daily schedule, my first consideration has become figuring out when I can run.  With my current travel schedule running sometimes occurs in the morning and sometimes in the evening.  While the time varies, the day does not seem complete without some time to run.

3. I think about running and read about running regularly.  Gaining knowledge about shoes, training, gear, etc. has become a passion.  I enjoy browsing in running stores, as well as talking to those who work there.

4. Finally, I love to learn from other runners.

My knowledge is incomplete, but I will share these lessons.  These thoughts are not original, but rather gained from much reading.

Shoes

It really is the most important equipment that you need.  The proper shoes make all the difference.  Finding the right shoes resolved my knee pain ( I had pes anseritis for many years.  Wearing the wrong shoes induced 2 black toe nails.

The shoe companies and many running stores incorrectly have advised many customers about what type of shoe runners should wear.  For many years they told me I should wear stability shoes because they thought I was over-pronating.

Even if I was over-pronating, recent data have shown that stability shoes are not necessary.  This article from RunBlogger really opened my eyes – Do You Pronate?: A Shoe Fitting Tale  via @Runblogger.

Recently I went to a wonderful shoe store that had me run on a treadmill to analyze my running style.  In watching the video with the sales person, we could clearly see that I was a neutral runner.

When I switched from stability shoes to neutral shoes, my knee pain resolved.  I had to learn this over time, but many new runners may get frustrated because they are wearing the wrong shoes.

Over the last year I have learned several things that are very important for my running.  Each runner will have to learn about their own key issues.  Toe box room is my first requirement.  When I started, my shoes were not large enough in the toe box.  My first shoes were size 11 1/2, but now I regularly buy size 12.  My toes need room, and increasing the size has decreased toe injuries.

Here are my favorites web sites to read about shoes:

Run Blogger

Runners World

Running Shoes Guru

Running Research Junkie

Thoughts about MOC

As readers might imagine, I spend much time thinking about MOC these days. Over the previous 3 days, I attended the AMA meeting as part of the ACP delegation. MOC occupied much air time during that meeting.

Many physicians will agree that we have a responsibility to keep educated on developments relevant to our patients. This maintenance of knowledge standard is easily justified. MOC has more parts than knowledge acquisition. As I engage in conversations and meetings, physicians ask for the evidence that a secure exam, performance activities and patient surveys will improve patient care.

We live in an era of “evidence based medicine”. Physicians receive significant criticism when we do not follow the evidence. That point has been pounded into our psyche, and thus when anyone sets criteria without providing satisfactory evidence we rebel.

Face validity is wonderful, but face validity does not always translate into measurable validity.

So we must ask, we are morally required to ask, does current MOC meet a standard of improving patient care? It may, and the critics may be wrong, but we need outcome and quality research to determine if each component really matters.

Fair minded physicians certainly disagree about the topic. Having done all the MKSAP 16 questions last year, I found studying and testing myself helped my knowledge and gave me strides towards keeping abreast of new concepts. Of course that exercise is vastly different than the secure examination and the other required parts of MOC. What is right? I only wish we had sufficient data to inform the discussion.

For more on this topic I recommend Do Recertification Demands Waste Doctors’ Time and Money?

Are academic physicians that different from “practicing” physicians?

Regularly someone tells me that practicing physicians believe that ACP is run by academicians, and therefore not responsive to the needs of private practice. As a long-time academic, I find these comments prejudicial and uninformed. Why do I have that reaction? Likely, my reasoning stems from hearing the same complaints about administrative hassles and MOC from both groups.

Many years ago, those in practice had a very different clinical experience from those who spent their careers in “the ivory tower”. But life has changed, and academic medicine has changed.

We who teach students and residents now have accepted major clinical responsibilities. We interact with electronic health records, fill out device requests, stay on the phone for prior authorization and have administrators encourage us to increase our RVUs. While we can find significant differences, the conversations and concerns about practice have great similarities.

During my years on the ACP Board of Regents I have had many colleagues from both private practice and academics. We have mutual respect and similar concerns. The distinction has blurred over the years.

I would encourage academicians to better understand practicing physicians, and similarly practicing physicians to better understand academic clinician-educators. Our concerns are really not that different.