Sunday, August 29, 2010

Hospital Medicine: Out of Order

Physicans in Reverse Gear!

Here is some inside dope on the medical profession for patients to ponder.

We are all reading these days about improving the process of delivering medical care. This effort aims to raise the level of medical quality, and to minimize errors of omission and commission. This is why all surgeries and medical procedures begin with a ‘time out’, when there is a brief huddle confirming the identity of the patient and the intended operation. This is to prevent scenarios, such as:

“Mr. Patella, we replaced the wrong knee, but you would have needed a new one at some point. No need to get out of joint over this – the rehab is on us.”

Numerous medical specialties are now using checklists for medical procedures that include a series of steps. For example, if every heart bypass patient needs to proceed through 24 pre-operative steps, including laboratory studies, diagnostic tests, specialty consultations and an informed consent discussion, then a checklist is an effective tool to ensure compliance. Indeed, without a tracking mechanism, it is easy to understand how important steps can be omitted, with serious consequences. Chec-lists have been standard operating procedure in the airline industry, which have an excellent safety record.

Of course, there is a risk that physicians will become numb to all of these warnings and ‘time outs’. How carefully, for example, do we listen to flight attendants’ warnings and instructions prior to take-off?

This issue is relevant to how we physicians approach hospital patients. Here’s how we were taught to do it by our professors and mentors. See the patient first. Take the medical history personally, before you review the results of the CAT scan and other diagnostic tests. After taking the history directly from the patient, proceed with a methodical physical examination, which may provide important diagnostic clues. A medical condition that was considered probable after the history may be rendered unlikely after the examination. Additionally, an unexpected abnormality found on the physical examination, may lead the physician to pursue a different line of questioning that was not considered initially. After these two fundamental steps, the H & P, have been completed, the physician creates a differential diagnosis, a list of reasonable diagnostic considerations that can explain the patient’s condition. The doctor does not need to consider every diagnostic possibility, only those that are reasonable. For example, if you were to search diagnoses such as abdominal pain or fatigue on the internet, you could create lists that contain over a hundred entries. Sometimes, our patients bring us these lists convinced that their symptoms are explained by an obscure parasite, not present in this country, because the parasitic disease description matches the patient’s symptoms exactly.Obviously, physicians will expand the list of diagnostic possibilities, if the working list proves to be inadequate.

At this point, additional medical data are reviewed or tests are ordered to narrow the list, hopefully down to the correct diagnosis. Sometimes, the H & P is sufficient to make a reasonable diagnosis, and no further tests are required. For example, a patient who sees me with 6 weeks of heartburn that is consistently relieved with antacids doesn’t need to swallow my scope to make the diagnosis. I already know it, or I should.

This is how we were taught to see patients. Here's how it's done in the real world, particularly in the hospital. Every day, we physicians commit medical heresy, by seeing the patient last, after x-ray results, labs and specialist consultations are reviewed. I know this is true because I am one of these medical heretics. It is standard practice today to do what our medical school faculty beseeched us to avoid - seeing the x-rays before seeing the patient. Nowadays, when physicians enter patients’ rooms, we often already know that the CAT scan shows diverticulitis, or that there is a kidney stone, or that a cardiac stress test is abnormal.

What is wrong with this? Don’t physicians still get to the right answer, even if today’s diagnostic path is reversed?

I am hostile to this approach, which I practice, because it devalues the history and physical examination, which is the core of doctoring. When the physician greets a patient, and already believes that he knows the diagnosis, then the H & P became a diagnostic afterthought, a formality that must be performed more for documentation than for diagnosis. This means that the doctor will not take a broad and probing history, as he no longer feels the need to construct the classic differential diagnostic list. If the doctor meets a patient after viewing a CAT scan suspicious of appendicitis, he may take a cursory history and miss the correct diagnosis, which may not require surgery. It is in patients’ interest for physicians to think broadly at the outset, narrowing down the possibilities over time. It is harder to reverse this process. Once a patient is labeled with a diagnosis, it can be difficult to peel it off. This is why diagnostic labels should not be affixed prematurely. Seeing the patient out-of-order risks this outcome.

Internist to gastroenterologist: "Please see my patient, Mr. Calculus, in room 304 with vomiting. This is his 3rd gallbladder (GB) attack in 6 weeks.

This patient has now been labeled with GB disease.Will the gastroenterologist be open-minded enough to take a full history? Will he discover, for example that this patient ‘borrowed’ pain pills from a friend to relieve his back discomfor? Perhaps, his symptoms are a side-effect of these medicines. If so, then removing the gallbladder is the wrong move.

The out-of-order approach also has eroded physicians’ physical examination skills. If I already know from viewing a CAT scan that a patient has an enlarged spleen, then I will be biased when I palpate the abdomen at the bedside. Sure, I might feel the spleen, but will I examine the rest of the patient with necessary diligence? What if the spleen is not the critical finding? Physicians who examine hearts, lungs and abdomens – when they already know of abnormalities in advance – cannot be fully objective.

Finally, the out-of-order strategy reinforces to patients and the medical profession that testing and technology are more important than the initial human interaction with hands-on contact. This is not true, and yet this is increasingly the way of the medical world.

I maintain the medical history is the most valuable diagnostic took that exists, and it is at risk of being included on the endangered species list. Beyond its medical value, it is a foundation of the doctor-patient relationship, which is already under threat on so many fronts.
Here’s the checklist I wish I used without exception:

___ History
___ Physical
___ Other Stuff

Why do doctors like me who know that the H & P should come first, use the reverse gear istead?  The response to this question should be of great interest to the public, and I hope that this inside dope will appear below in the comments section.   OK, physicians, come clean.

Sunday, August 22, 2010

Stop Medical Malpractice: The White Coat Wall of Silence

Photo Credit

Leisure Guy, one of my most faithful commenters, opines that I am omitting an important aspect of the tort reform argument. He has implored me repeatedly to read a particular book that I suspect buttresses his views, but this worthy pursuit is simply not near the top of my priority pyramid. Since he’s retired, he enjoys the luxury of burrowing deeply into the base of his priority pyramid. With 4 tuitions to go, retirement is a distant mirage for me. I’m can be a ‘leisure guy’, but only in my dreams.

I have written throughout this blog and elsewhere that there are too many frivolous lawsuits against physicians. I have admitted that caps on non-economic damages are not ideal, because they deny some worthy plaintiffs of complete compensation, but I support them because I believe they serve the greater good. I have ranted that there is no effective filter to screen out physicians who should never be invited to the litigation party in the first place. I believe that the current liability system encourages the practice of defensive medicine, which wastes billions of health care dollars and exposes patients to unnecessary risk and expense. I believe that the system is unfair and needs to be reformed. I stand by these views.

Leisure Guy (LG), in between sipping piƱa coladas on his deck, sent me a personal e-mail. Here’s his correspondence in its entirety.
It does seem that, given the goal of reducing the number of lawsuits for medical malpractice, the simplest, most direct, and most effective action is preventing incompetent MDs from practicing, regardless of the source of the incompetence (alcoholism or other drug dependency, dementia, and so on). In fact, it would seem to me that this is much more obviously a course of action than going after lawyers and tort reform: stop the malpractice, and the lawsuits will stop. (That was the experience of anesthesiologists.) But you continue to focus on lawyers and the courts, and I’ve never read a post in which you go after the MDs for protecting incompetents and keeping them in practice---that seems inexplicable.
MDWhistleblower is not like the Sunday evening CBS news program 60 Minutes, where an unsuspecting guest is accosted by a journalist who intends to humiliate the individual publicly and irrevocably. In contrast, I have come not to bury LG, but to praise him. He has an important point that merits inclusion in the tort reform conversation. Is it fair for physicians like me to rail against the unfair medical liability system, while we remain mute about medical negligence? No, it is not.

Reading plaintiff lawyers’ blogs, one would think that medical incompetence is spreading across the medical landscape like a wildfire. We read the ubiquitous assertion that there are 98,000 preventable deaths every year, a statistic that is trying through repetition to become transformed into a fact. In my 20 year career, I have only occasionally witnessed medical negligence. I certainly see and participate in plenty of adverse outcomes. I see every day colleagues who make medical judgments that differ from my own. I am informed by patients about physicians who lack important communication skills and would benefit from a week’s retreat at Doctor Charm School. I see on occasion physicians who are rude to nurses. I regularly see physicians who, along with patients, over utilize medical testing and treatment. I see too often physicians who order medical tests for the wrong reasons.

In some of the above cases, the physician is me.

None of these examples, however, represent negligence. If there is an epidemic of medical incompetence, it either doesn’t exist in my world in northeast Ohio, or I am too incompetent to recognize it. I am interested in the views of other physician readers on this issue. How much true medical negligence and incompetence do you witness?

Nevertheless, my friend LG correctly points out that we physicians are not effective or serious at holding our members accountable. Sure, every state has a medical board, but we all know how egregious an offense must be to result in a serious professional sanction. It is not part of medical culture to identify colleagues who have demonstrated competency lapses, committed a negligent act or may be impaired. Recall the adage, ‘friends don’t let friends drive drunk’. Physicians don’t turn in colleagues who may be in need of remediation and rehabilitation, except in extreme circumstances. What stops us? Are we scared that we will be stigmatized as a squealer and ostracized? Do we rationalize that we might not know all the facts about a practitioner who may appear to be missing the mark? Do we look the other way hoping that some other corrective mechanism will descend from the sky to address the issue? Do we allow our empathy for a fellow colleague to corrupt our judgment? .

I don’t retract a single syllable of my views on the need for tort reform. But, we physicians should also heal ourselves. This is our professional obligation and would also deepen the trust between us and the patients we serve.  Not only is it the right thing to do,but it's a smart move also.  Haven’t we learned over and over again what happens when we don’t act proactively to solve a problem?  The White Coat Wall of Silence will become yet another target for 'reformers' to shoot at.  Let's take this target off the field.

Sunday, August 15, 2010

Plagiarism and Academic Integrity: Annals of Internal Medicine Caves

We have a classroom in our home. It’s called the dinner table. This is the locale where over the years, my wife and I have tried to teach 5 kids right from wrong. As we parents ourselves still struggle with these issues, it is clear that integrity remains an indefinite element of life’s curriculum.

There was a time when this table was an actual classroom, when my wife and I home schooled 2 of our youngsters for about 3 years. I could devote an entire blog to this adventure.

Many of our family dinners were seasoned with discussions about integrity. We have discussed and debated the lapse in integrity that has seeped into our educational culture, as well as into society at large. We have reviewed dozens of news accounts detailing ever more resourceful methods of cheating and stealing ideas without attribution. This phenomenon has no boundary and has permeated the medical profession. Euphemisms like ghostwriting cannot camouflage the practice for what it often is – cheating.

Yes, I know that times have changed, and many of yesterday’s values have been retired. But, I don’t regard personal integrity to be an elastic virtue that is subject to modification based on popular culture and demand. Honesty and personal probity are absolute, not relative values that can be shifted or sanded down.

Indeed, it is my view that diluting the definition of integrity has damaged every level of our society. Once this occurs in one sphere, such as education, it is impossible to contain the practice there. It seeps out and spreads. We must forcefully identify it when we see it and strive to reverse its propagation. This endeavor is often a tough slog upstream, but the objective merits the effort. I think that it is a fight than we can win.

The July 20th issue of the Annals of Internal Medicine reported that 5% of applicants to residency programs plagiarized portions of their personal statements. Presumably, all of these individuals will become physicians, and some will become academic researchers. Isn’t personal integrity an absolute requirement for these professions? One could argue that plagiarism should be a disqualifying offense. An editorial on the journal article in the same issue states that:

If the integrity of the personal statement is increasingly polluted by Internet samples of hired consultants, perhaps the personal statement is ill-suited to this era and best left to history. In 1 stroke, this action would solve the problem of plagiarism on personal statements substantially more effectively that a nationwide campaign.

I vigorously reject the editorialists’ view. The proper response to unethical behavior is to denounce it, not to escape from it. If our profession is stained by plagiarists who are cheating on their applications to medical residency programs, we should hold these individuals accountable and strive to raise the ethical bar of all applicants. To ‘reassess’ the need for the personal statement as a response to plagiarism is itself cheating. Every year, high school kids are caught cheating on standardized tests. Is the cure for this to abandon the test or to work harder to teach our kids about raising their IQs, or integrity quotients? Ethical goalposts should be firmly rooted.

In a prior post, I have lambasted the legal profession for dumbing down academic standards in an effort to burnish the credentials of law students.  Our profession should not emulate this approach.

I am dismayed that one of our most prestigious medical journals has gone soft, when a firm hand is required.  I'd like to invite the editors to my dinner table so my kids can teach them right from wrong.

Sunday, August 8, 2010

Health Care Reform: The Worst is Yet to Come

Do you see or do you observe? Most readers have likely given just a glancing glimpse of the photograph to the left, which I took during recent vacation in Costa Rica. Most, including me, would have recognized that the photograph is a tree, and then moved onto the riveting text. While this identification would be correct, it would not be the whole story. Look more carefully, and see if you overlooked a finding on the photo during your cursory review of it.

The health care reform plan, now law, also has many camouflaged elements that were not visible, even to the informed public. In the coming years, as the layers are peeled back, there will be many surprises for the public and for the medical profession, which I hope and pray will remain a profession.

The Patient Protection and Affordable Care Act was signed into law in March 2010. No, it won’t be repealed, despite some shrill populist campaigning to do so from the political right. I also doubt that the judiciary will turn it back, despite efforts to do so in nearly 2 dozen states. Nevertheless, public support of the bill will steadily wane as its provisions and costs become apparent in the coming years. It remains my view that the plan will cost much more than predicted, and will deliver much less than we have been promised. When this inevitable result occurs, the nation will collectively develop acute carpal tunnel syndrome from the wild finger pointing we will all be engaged in.

Here are some highlights of coming attractions.

No permanent SGR reform. Congress is still kicking the can down the road, year after year. Let me use a fancy gastro term to describe this phenomenon – no guts.

A ‘physician compare’ website will provide the public with results from the government’s Physician Quality Reporting Initiative (PQRI) ‘quality’ measurement program, which we practicing physicians deride as a sham that wastes time and money and fails to assess true medical quality. I’d like to think that I practice high quality medicine. Unfortunately for me, none of the things that I hopefully do well can be measured. What is easy to measure, however, doesn’t really matter.

Mandatory deductions in Medicare reimbursements will begin in 2015 to physicians who do not submit acceptable PQRI data to the government. Physicians must participate in this bogus program, or we will be docked. Another fine example of your overtaxed dollars hard at work.

Requires that an imaging service (e.g. CAT scans or MRIs) with physician ownership advise patients that the imaging services can be obtained elsewhere and provide them with a written list of other available imaging centers. This latter provision is bizarre. Would we expect any business to provide the customer or client with a written reference list of competitors? When I stop by Starbucks for some overpriced and bitter coffee, I don’t expect them to hand me a list of other coffee bars down the street. Perhaps, my own gastroenterology (GI) practice should prominently list all other GI practices within 5 miles of our office in our waiting room.

Seniors currently enrolled in Medicare Advantage programs (25% of all Medicare participants) are about to be cut loose when the government cuts payments to these private programs. Of course, benefits to these seniors will be cut accordingly. Many will be forced over to traditional Medicare at higher costs because of high Medigap policy costs.

Allots relative pocket change to examine alternatives to current medical malpractice litigation. In other words, we are going to study the problem. While we’re at it, let’s commission another study to confirm that the earth is a sphere and not a flat plain.

Independent Payment Advisory Board is a 15 member cabal that will wield great power to control Medicare costs. They are prohibited from reducing member benefits, rationing care, increasing premiums or raising taxes. So docs, what is the one remaining pool of cash that these guys have access to? See photo below.

Of course, I could write, “Wait, there’s more!”, but you get the idea. Thirty-two million citizens are to be given medical coverage, half of of these under the strained and sagging Medicaid program, when we don't have sufficient primary care power to meet current needs.  Who will see these patients?  Can physicians afford to incorporate large volumes of Medicaid patients into our practices?

I acknowledge that many supporters of the health care reform legislation truly believe that it will serve the public good, or at least initiate a process that will ultimately deliver true reform.  I don't agree with them.  While there will be fewer uninsured Americans - a most worthy outcome - it is not clear that they will have ready access to quality medical care. Is it worth lowering the quality of our medical care system in order to cover more individuals?  Many would privately agree with this compromise, but would never say so in front of a microphone.
While it is politically palatable to confiscate and redistribute physicians' incomes, imagine the tsunami that will develop when the patients are fleeced and controlled.  The truth is, similar to the taxes paid by the wealthy, that even if all physicians' incomes were appropriated, it would do nothing to address the cost escalation spiral.  Who will tell patients the truth that the era of endless medical care and treatment will be euthanized?  Look what happened when the apolitical USPSTF issued some modifications on mammography guidelines.  Does the public really believe that they will be left whole afterwards?  Once the medical profession, Pharma, insurance companies, et al are dumped into the wood chipper, then the public will be targeted.  Physicians are the low hanging fruit, but be assured that your government will reach the top of the tree.

I feel like we are all stumbling through the rain forest, during a downpour with crackling lightning overhead. We can’t see where we are going, and we can no longer find our way back to where we began the journey. The ground is slippery and we reach for a branch to steady ourselves. Of course, we didn’t see the viper wrapped around the branch, although he found us. The most dangerous predators are those we cannot see, the lurking in the shadows, ready to strike even though our government guide has assured us that it is safe to pass.

Sunday, August 1, 2010

Evidence-based Medicine in Disguise: Beware the Surrogate!

In this post, I will give ordinary folks a ‘peek behind the academic curtain’. I am not an academic physician, but a mere practicing gastroenterologist who spends my days ‘enlightening’ Cleveland colons. Why do some medical studies, which achieve breaking news status, often fall so short of our expectations? Physicians are cynical about these medical milestones, since they are often short-lived. Today’s cure may become tomorrow’s disease.

A common practice and serious flaw in medical research is to rely upon a surrogate marker when studying a disease. Let me explain. If you endure the following few paragraphs of literary driftwood, you will understand press reporting of medical studies on a deeper level.  This could directly affect your medical care and generate some interesting conversations during your next doctor visit.

A surrogate marker is an event or a laboratory value that researchers hope can serve as a reliable substitute for an actual disease. A common example of this is blood cholesterol levels. These levels are surrogates, or substitutes, for heart disease. If a medical study demonstrates that a medication can lower cholesterol level 10%, then we assume that this will also lower the risk of cardiovascular disease. Why doesn’t this same study determine if an anti-cholesterol drug decreases heart attack rates directly? After all, most folks would rather be spared a heart attack than have a silent decrease in their blood cholesterol levels.

Why are Surrogates Used?

It is much easier and cheaper for researchers to measure surrogates than actual disease events. What could be simpler than measuring blood cholesterol levels? In contrast, it would be a very tough slog to show that a cholesterol-lowering drug reduced heart failure or mortality rates. With a surrogate, medical studies can be completed much more rapidly, in contrast to studying actual diseases, which can take a decade or more to complete. By then, the findings may no longer be relevant. Surrogate research is also much less expensive to perform.

Surrogate results have flashy marketing appeal because their findings can be expressed in catchy headlines that extrapolate the actual conclusions. Haven’t we all read headlines like this?

Research shows that new blood test can prevent cancer

Surrogate research is valid if the surrogate truly represents the disease. Often, this assumption is questionable or outright false. Not long ago, cardiologists were going gaga over the CRP (C-reactive protein) blood test as a surrogate marker for cardiac disease. This was great news for the ‘statin’ drug manufacturers who claimed victory when their medications reduced CRP levels, but did this really prevent heart disease? I wonder. Surrogates often take on a life of their own, far removed from the actual disease they represent. Patients shouldn’t care if their ‘surrogates’ are improving; their objective should be to prevent disease, feel better and live longer. Yet, we physicians have often convinced our patients that surrogate improvement means better health. Monitoring cancer blood tests called tumor markers illustrates this point well.

“Great news Mrs. Bedridden. Your cancer blood test improved 10 points!”

“Thank you doctor, but I still can’t walk.”

In my own field, gastroenterologists remove colon polyps with enthusiasm and zeal. Polyps are not diseases. They are surrogates for colon cancer. We hope and believe that when we remove pre-cancerous polyps that we are reducing your risk of colon cancer. Interestingly, there is no double-blind placebo controlled trial (the gold standard of medical research) that establishes that colonoscopy reduces colon cancer. Just because it sounds logical, doesn’t mean that it’s true. There have been medical studies, for example, that have described treatments that reduce arterial plaque, which is a surrogate marker and not a symptomatic disease. Most of us would welcome a treatment that reduces plaque, because we would assume that this would benefit us by preventing heart attacks and strokes. Assumption, however, is not science.

Those of us who have been reading journals for some time are skeptical before we celebrate the medical breakthrough of the day or week. What is sound medical dogma today may fade over time and become junk science. This is particularly true of surrogate studies, which are indirect by definition.

Those who earn their living and their reputations from medical research may have a different view on surrogacy than I do. Indeed, surrogate research is an important research tool, that can open important therapeutic avenues and stimulate additional research. We must be mindful, however, how easy it is to exaggerate their conclusions beyond the data. The public needs understand this issue. Think about this the next time you read a news flash that promises a medical miracle. Chances are that the miracle is a mirage.