Blog maintenance issues

This month the stats for this site showed that there have been over 10,000 views since its inception about 2 years ago. I was bragging about this to my 17 year old son, a computer whisperer, who has very little patience for my relative ignorance of the digital world. He gave me some advice, sort of the "queer eye for the straight guy" variety of advice. ( Reference: "Queer Eye" is a reality TV show where gay men give advice on fashion and lifestyle to clueless straight men.) Apparently it is amazing that anyone visits this site at all, for a number of reasons. The first is "TL;DR"--too long, didn't read. All anyone sees when they visit this site is a wall of words which is probably quite overwhelming unless the visitor is pretty darn determined.

The second is that there is hardly anything to grab the eye. I went with the packaged blogspot formatting and haven't changed it at all the whole time I've been writing. It is really quite attractive, I thought, but maybe the furniture needs rearranging.

And third, there are no photographs. I was thinking that most of what I write is kind of abstract and doesn't lend itself well to photos, and also before this minute I hadn't even checked to see how to put them in.

Thus the beautiful Haitian woman from the island of La Gonave carrying the aluminum bowl of laundry on her head. She has absolutely nothing to do with this post, but she did teach me how to upload photographs. Perhaps with future posts I can experiment with including random photographs of nature or something gorey from work. I could also just leave it like it is.

How to lose weight, lower your blood pressure, have better cholesterol and live longer, all without me nagging about it

There are various things that appear to be good for people. These include maintaining a normal weight, or losing weight if a person is fat, drinking some alcohol, but not too much, quitting smoking and exercising. Doctors as a whole also believe that lowering cholesterol levels is good, and at my recent update in internal medicine course there was some good data that suggested that drinking coffee is a good thing! Controlling blood pressure is also very important.

Being obese is bad in a number on ways, increasing risk of getting cancer, increasing osteoarthritis of the knees, which in turn is responsible for quite a bit of suffering and death, and increasing blood pressure and heart disease. Diet changes can help, but unlike much of what I have believed, there is no particular diet that is better than other diets for everybody. One study looked at people attempting to lose weight using either a low fat or a low carbohydrate diet. The low carb diets are exemplified by the Atkins  and the "zone" diet, which are rich or unlimited in proteins, even fatty meats, but strictly control the amount of carbohydrates a person eats. When a person does not take in carbohydrates, such as breads or rice or pasta, or sugary foods, that person will begin to use proteins as fuel and produce ketones which have the effect of suppressing appetite. The low fat diet, on the other hand, has been ingrained in us for decades, and belief in its healthful properties has resulted in reduced fat everything, from milk to potato chips.  Although many people can lose weight faster with the low carbohydrate diet, after 10 years both types of diet are equally effective.

A study out of the United Kingdom demonstrated an average reduction in lifespan in moderately obese patients of 3 years. This means that a 5 foot 2 inch woman over the weight of 165lbs could expect to live 3 years less than if she were normal weight, up to about 130lbs.  Her life span would be 10 years less than expected were she 220 lbs. A person could expect to lose 1 pound a week of weight by either eating 500 calories less or exercising the amount it would take to use up 500 calories. On a stationary bike a person consumes about 500 calories exercising hard for 45 minutes, and heavy people use more energy to do the same amount of exercise as skinny people. It is more effective to both exercise and reduce calorie intake because the body can reduce its energy expenditures if it thinks it is starving, and conversely inactive people often find it hard to avoid inattentive overeating.

Drinking no alcohol at all appears to be associated with a shorter life, though long term controlled trials of alcohol drinking are totally impractical, so the evidence is not unassailable. There are many bad health outcomes associated with heavier drinking, more than 3 drinks a day for men and over 1 drink a day for women, but even heavy drinking statistically may be better than none at all! (Obviously this is only meaningful for populations, since an individual can drink him or herself to death and individuals do regularly do this.) Women who drink anything at all have a higher risk of breast cancer, but it is heart disease, not breast cancer that is the major killer of women, by a long shot, and drinking definitely appears to lengthen a woman's life.

Cigarette smoking has almost nothing, in fact I can safely say absolutely nothing, to recommend it as far as health goes. OK, I can imagine some scenarios in which cigarette smoking has probably saved someone's life. Perhaps once someone leaned over to pick up a cigarette and just barely missed being hit by a bullet, or avoided being bitten by a malaria carrying mosquito due to being surrounded by cigarette smoke, but in regular life cigarettes do cause heart disease, strokes, vascular disease, lung disease and cancers of many sorts.  The CDC reports that 1 in 5 deaths in the USA is attributable to cigarette smoking. Physicians are not very good at getting people to stop smoking, but there are various medications, including Chantix, budeprion and nicotine products that can significantly reduce cravings for cigarettes with very few side effects.

A gradual decrease in the amount of exercise that Americans regularly engage in is mostly responsible for our devastating epidemic of obesity which will lead to health care costs that we cannot even begin to imagine at this point. As little as 30 minutes of exercise a day for 5 or 6 days of the week can make a significant improvement in many health outcomes, ranging from preventing Alzheimer's disease to preventing heart attacks.

Elevated cholesterol levels, especially certain types of cholesterol, such as the LDL (low density lipoprotein) is associated with increased deaths from vascular disease such as heart attack and stroke. In some cases it may be a marker of bad health behaviors and bad heredity, but it also appears to be causative, and lowering cholesterol with lifestyle changes, weight loss or medications of certain types does reduce risk of these diseases. The most effective medications to reduce cholesterol are the statins (at least as far as we know) and every year another study shows that being on statins is good for some new thing. This information should be viewed critically since statins are hugely big business for pharmaceutical companies, but even I, a skeptic, admit that using these drugs (things like atorvastatin (lipitor) and simvastatin) probably saves lives, especially in those at high risk for early or recurrent coronary artery disease. Statins can, and often do, cause muscle pain and cramping, and combined with certain other drugs can lead to muscle breakdown due to interactions. In general, though, they are probably as safe as many over the counter drugs and herbal preparations.

Coffee, in the nurse's health study and in other well regarded studies, decaf or regular, and in large amounts, reduces risk of developing diabetes, improves diabetes control and reduces progression of fatty liver disease or hepatitis C to endstage liver disease. This is big. The effect is not tiny either, and if coffee were a new pharmaceutical it could be marketed for this indication. It would probably cost upwards of $20 a cup, though. Researchers have looked for negative consequences of coffee drinking for years and have failed to find any that are significant, other than that coffee can give one heartburn or a sour stomach.

Blood pressure should generally remain below 130/80, though medication treatment may not be indicated until the numbers go over 140/90 and the very old may do better with slightly higher numbers. There are a myriad of medications that work for this, but chief among them are mild diuretics, especially the generic pill chlorthalidone which has been around for decades. Ace inhibitors such as lisinopril are also very effective, and calcium channel blockers can be powerful. Sometimes combinations of these drugs are necessary. 

Diabetes is very common now and by 2030 is estimated to afflict 1 in 10 Americans. We could turn this around by changing our lifestyles to decrease obesity, but that isn't happening, so in the not too distant future, a sizable proportion of all patient visits will have something to do with diabetes. Good control of blood sugars with pills or insulin can decrease risk of complications such as heart disease, loss of sensation, blindness and kidney failure. Treating a patient with diabetes follows some pretty detailed guidelines laid out by the American Diabetes Association, and involves control of blood pressure, blood sugar, cholesterol and screening for early signs of complications.

Looking at the paragraphs above, it becomes clear to me that it is going to be really hard for primary care doctors to instruct their patients in all of the good things they should be doing to live longer and healthier, and I also note that many of the things that I've mentioned are things that I am not that good at telling patients how to do. I'm not great at getting patients to lose weight or exercise, though I think I do a pretty good talk. I can only get a patient to quit smoking if she already plans to do it. I can do the diabetes stuff pretty well, I think, but it sometimes gets forgotten as I focus on what the patient really wants me to help them with, such as some kind of acute or chronic suffering that they are experiencing. I haven't yet tried to get patients to drink more coffee. That may be easier, though having them drink it without cream and sugar may be tricky. High blood pressure treatment is sort of my bread and butter, but it is a task without much thanks since patients usually do not feel better on medications and don't notice the condition at all until someone measures it.

So what I was thinking is that maybe I shouldn't be doing all of this stuff. Maybe I don't need to be the nag, especially since I am not that good at it. I prefer to be the good cop, which means I desperately need a bad cop, or at least a charismatic motivator. What is so special about me as a doc that I need to do all of this counseling? Other people might be better at it and wouldn't need the broad training that I have to accomplish a good 90% of the stuff I laid out. Posters, TV commercials and education in schools could much more effectively beat into peoples' consciousness the importance of diet and exercise and not smoking or quitting. Exercise and life coaches can be awesome motivators. The alcohol industry could be tapped for the funds to advertise the health effects of moderate alcohol, and I bet they would do a darn good job of making the point that alcohol is good for us. Some level of industry/public health cooperation could make sure that this didn't move into the realm of "a little is good so more is better." Diabetes treatment, at the level of periodic visits and medication adjustments, is much better done by a multidisciplinary team, including nurses and pharmacists, and not heavily dependent on physician input. Much of control of blood pressure could be done after home monitoring by a nurse or a pharmacist with a decision flow chart for which drugs to use, and I honestly think they would probably do a better job than I would. If things got dicey, the patient could come to me and I could sort things out. Cholesterol would be the same issue. The drugs to treat cholesterol are pretty limited, and with a fingerstick test at the pharmacy of at my office, medications could be prescribed per a protocol and the patient could be monitored until the dose was correct. Pharmacists can certainly monitor for drug interactions, at least as well as I can. What about the patients who don't want to do all of these good things? I applaud them--not everyone should be a sheep. As the good cop, I doubt I would be much more effective than my somewhat less extravagantly educated colleagues at convincing them to toe the line. If it was really important, I could of course give it a try.

If much of this public health and protocol driven medicine were not my job, I would have more time to sit down with a patient with complex medical and psychosocial issues and work with them to come up with solutions to problems. I could diagnose their fascinating and disabling diseases, inject their swollen joints, see them the same day they called in with a cough and a fever or blood in their bowels or vomiting or a suspicious lump. I could be a doctor, not a cross between an accountant and a mother hen. I, and my colleagues, could begin to see clearly towards being able to take care of the genuine needs of the scads of patients already in need of primary care, and those who will, if all goes well, be insured by 2014.

Harvard Medical School Internal Medicine Update--Deepak Chopra and more

Having now attended 4 of the 6.5 days of the Harvard Internal Medicine Update CME I am now more grateful for being here. The first day of talks was disappointing, with some of the presenters actually pretty much reading their notes word for word, which I could have done in the comfort of my own home. But many of the speakers since then have been more confident and have been speaking from their hearts and their experience and there has been more to think about.

Yesterday Deepak Chopra gave a special 2 hour lecture about the meaning of life which was quite moving. He is a physician turned writer, though reading his biography it looks like he was always destined to do things that didn't fit comfortably into the medical profession. He started as a medical student in India, went on to become an endocrinologist, was involved in Transcendental Meditation and was a follower of Maharishi Mahesh Yogi, learned Ayurvedic medicine and now is able to span the gap between alternative medicine, established allopathic medicine (what I do) and leave his toes dipped in the positively way-out-there, publishing books and even the occasional article for the New England Journal of Medicine. As a speaker, he probably makes boatloads of money, and spoke to us because his brother, Sanjiv Chopra, a gastroenterologist at Harvard, is the organizer for this course. The talk reminded us about the incomprehensible vastness of the universe and the math and physics which describes that. He described some advances in mind-body medicine, including some data that the genetic markers of aging can be partially reversed by a lifestyle that includes meditation, enough sleep, and a generous helping of peace and joy. There was a brief guided meditation that was delightful, followed by a description of what actually might have happened in our brains during that process. It was gratifying to see such a variety of physicians, who can sometimes be pretty concrete, especially as a group, listen and participate. My take home message included realizing that I shouldn't take myself too seriously.

Today, the first half of the morning was devoted to leadership, which the medical profession can sorely use more of. Four different speakers talked talked about their favorite leaders and what they felt made them particularly effective. They talked about some very significant changes that Harvard had made, as a health care delivery system, and how they did that. It took humility and a sense of humor for the world's best medical school/hospital to recognize that it had problems and to also recognize that making changes could come some distance towards solving them. Like most hospitals, Harvard has trouble making patients feel supported, communicating with families, coordinating care between different caregivers and deciding what care they, as a community, wanted to be giving. They had trouble making sure that frail elderly people didn't go bonkers in the hospital due to weird sleep cycles and changes in activity and medications and stimuli. The process of improvement involved convening groups of people from all levels of service delivery, from janitors through nurses, social workers and physicians, to come up with plans that then were tweaked relentlessly and evaluated constantly until they started to get them right. One example they gave was the diabetes center associated with the Harvard health system, the Joslin Diabetes Center. It wasn't providing consistent diabetic education and despite helping to develop guidelines for care, wasn't actually achieving those guidelines with their patients. They found that by having a team approach, centered on patients' needs rather than on doctors' preferences, they were able to get patients in to be seen much sooner and make everyone, eventually, happier, though not without significant gnashing of teeth.

One of the things that the Joslin Diabetes Center does is to make sure that the first visit for a diabetic involves teaching and an eye exam. Usually our diabetics wait for an appointment and then have an eye exam with an ophthalmologist who may or may not give appropriate feedback to the primary care doctor about the eye findings. Diabetics can become blind with because of changes in the blood vessels after years of elevated blood sugars, that can burst, destroying the retina of the eye. If the changes are caught early, laser surgery can coagulate the abnormal blood vessels and save vision. There is a machine that can photograph the retina without the patient seeing an ophthalmologist which is right in the diabetes center. It takes a few minutes and does a better job of screening the retina than a real human. So far it can't be billed to any of the public insurance companies. One participant in the class asked how it was paid for, and I could see that was a sore spot with the speaker, because it really wasn't paid for. I suspect that the patients who can afford to pay do, and those who can't don't. It is clear that technology like this is a great idea. It is also clear that the only way technology like this will be adopted and not add to the burden of costs for medicare is for medical care to be paid according to results rather than "fee for service" as it is now. I suspect that if costs for work like this were not directly handed on to a third party payer, machines like the one that images diabetics' retinas would quickly come down in price and complexity.

Much of what we have been hearing about is state of the art by specialists in the different fields that make up internal medicine, delivered by specialists. This gives us a much more in depth level of understanding, but also presents a standard of evaluation that is way more detailed and time consuming than even the most thorough of general internists could produce. Most of the physicians attending the course are general internists in non-academic settings, and many of us are under horrendous time constraints which are getting more horrendous as the primary care shortage progresses and payments tighten. Even though fee for service is on its way out the vast majority of physicians still practice that way, which means that to make the same amount of money that we used to, we have to see more patients, and with increasing insurance and government oversight to assure quality, we have to do more things with each patient we see. I don't practice that way, but most physicians do and are burning out. One doctor got up and told the presenters that she worked in the Bronx with a patient population that is very poor and high needs and she is expected to see 30 or more patients in a day, with no support from nurse practitioners or physician's assistants, and that even though she wanted to change her systems to make them work better, she just didn't have the time to start the process. If she wasn't so committed to her patients she would quit, but she can't imagine what would happen to the system if she did. It is more than sobering to realize that people like her will likely be expected to bear the brunt of the huge increase in diabetics that are coming out of adolescence, large colas in hand, along with aging baby boomers and the newly insured and also take up the slack as thousands of primary care internists retire with nobody to take their place.

It is clear that a herd of physician leaders are going to have to pull their heads up out of the writhing mass of needy humanity, stop seeing 30+ patients a day, and build systems that reduce waste, not only as far as spending on unnecessary testing and procedures goes, but also allowing physicians to do the things that it takes a physician to do, not be involved in busy work and things that we are not good at doing. It will be necessary to design ways to allow patients to use technology for what it is good for, and the medical profession so definitely can't shy away from social networking and digital communications for those patients who can work that way. And if we don't want to waste still more time and energy and human power trying to bill for each one of these communication steps, the payment scheme will need to change. And all of this has to happen REALLY SOON.

There is one thing about the talks (the ones about the nuts and bolts of medicine, not the leadership ones) that continues to disturb me. It is the "evidence based medicine" piece. There is a tendency by the speakers to stick closely to recommendations for therapy that are based on research trials with large populations of patients, getting away from telling us about what they, as individual skilled physicians have seen and done successfully in their practices. Clearly both the science and the experience deserve airtime. But worse than just presenting the studies is a little pervasive lie, or really more of a misapprehension, that accompanies the presentation of the data. The speaker will say, "in the CHARM trial of heart failure in patients with diastolic dysfunction, Candesartan did not reduce the endpoint of hospital admission or death. So you see candesartan just doesn't work in these patients." Yes, but no. In the study, a population of these patients did not get significantly better, but that doesn't mean that the drug doesn't work on our individual patients. I'm sure that when individual patients were evaluated it worked very well on some and absolutely abysmally on others, in fact it might actually have killed some of them. Which is also true for the drugs that did work in the clinical trials.  Saying that a drug does work or doesn't work based on a clinical trial is incredibly misleading and encourages us not to believe our patients when they say "Doc, that stuff really helped" or "I stopped it after a week because I got much worse." Patients often do know how things affect their health. There are many variables in our patients that govern what works for them, and studies do their very best to reduce these variables, making them more reproducible but less relevant to the treatment of real people.  It is valuable to reduce a problem to measurable parts and then perform an experiment because it makes it possible to interpret the data and then allows us to make an educated first approximation about how best to treat our patients. Until we are able to genetically and environmentally define all of the characteristics that make up a human, however, predictions based on our population based science will be inaccurate.

Ranting about continuing medical education, evidence based medicine and cost ignorance

I am attending Harvard Medical School's yearly internal medicine update this week. In a little over 6 days we experience 62 hours of medical education, sitting for 12 hours each day in the conference room of a shiny glass and steel hotel in downtown Boston. We hear world authorities on diseases of all of the major organ systems tell us what they think we ought to know. I am two days into it and still pretty excited, but losing a bit of my enthusiasm.

Most of the presenters follow a set of power point slides, sometimes word for word, that are reproduced in our course syllabus in a size that is nearly entirely unreadable. The form of the talks is to present the scope of the problem, then the recommended testing and treatment, interspersed with the research that is the basis for the recommendations, with an occasional cartoon or anecdote. There are also brief question and answer sessions and cases presented with recommendations on management. There are audience response handsets so we can participate in multiple choice questions, in order to keep us awake and focused.

Each of the presenters is a specialist, the worlds expert on irritable bowel syndrome or sleep apnea or one aspect of liver disease. They teach us how to treat the problems they see as the final go to doctors for the entire world. Some of the diseases are common, but we are encouraged to entertain a differential diagnosis that includes diseases only seen a few hundred times a year. Most of these I have heard of at some time, but could only really say what organ system they involve, not what they look like or how they are treated. We are taught the treatments that studies show work, at least for a proportion of patients. We are taught the 10 blood tests or imaging studies that we should never forget to order if we don't want to miss something. They mention that they realize that we, as general internists, have limited time with each patient, but rarely do they tailor their information to make it practical for us to achieve in a patient visit. They haven't been doing what I love to see clinical teachers do--telling us what they know to be true from their vast experience. I think that the emphasis on "evidence based medicine" has made them doubt the value of their hard won wisdom.

A few of these excellent clinicians have, however, been starting to talk about limitations of population studies to guide therapeutics. One oncologist said that different types of cancer will eventually be seen as collections of "orphan diseases".  Orphan diseases are usually considered to be rare diseases that are well described, but not prevalent enough to warrant as extensive research and treatment development as diseases that are more common and have more of a social impact. What this oncologist meant is that each cancer may have slightly different genetics in different individuals, leading to very different responses to chemotherapies or other treatments.

He gave the example of a new treatment for a cancer that completely melted away bulky metastatic disease in one of his patients, based on a genetic predisposition of the cancer cells in that particular person. I have seen this kind of thing on several occasions. One of my patients is completely free of melanoma nearly 20 years after receiving a cancer vaccine in a trial that failed. The study showed it didn't work. Except that it did, in my patient. She had had a recurrence of her melanoma, in a lymph node, which is nearly universally fatal and pretty much untreatable. It went away and she is alive now with no evidence of disease.

Most of the rest of the researchers have not mentioned, though, the fact that different genetics and maybe environments make this "orphan disease" concept true for other common ailments. We are taught that diabetes is best treated with a certain drug first, then another can be added and so on, but anybody who listens to their patients knows that although it is right to start out with certain guidelines, some patients do terribly with drugs that should work and do great with drugs that are bad. There are drugs that are good for people with heart failure, make them live longer and go to the hospital less, except that in some patients these drugs make them sick or even kill them.  Population studies are just not very good for helping us navigate this kind of water. Anecdotes from colleagues with a wealth of experience are, though.

I am also disappointed, again, as I often am in this sort of situation, but the complete lack of awareness of the cost of the therapies and diagnostics by the clinical teachers. Maybe they are aware, but they don't share that information. In the rare cases where they do share some cost data, the numbers are left in some raw form that doesn't give us useful data as to what cost our patients or their payers will see. A radiologist presented some information on new imaging tests which are stunningly beautiful and potentially very useful. He said that he was aware of how radiological testing was overused, leading to unnecessary and harmful radiation and unsupportable costs, but gave no indication about how that information would be integrated into potential use of his new technologies. An oncologist told us that the cost for a course of chemotherapy for metastatic colon cancer that might give a person 2 more years of life compared to the older chemotherapy cost over $30,000 compared to $60 for the old stuff, but didn't say how many courses a person would get in a year. Letting us know this kind of data should be standard. We want what's best for our patients, but we need this kind of data to help counsel people who shoulder at least part of these costs.

how to become a hospitalist part 1

The field of "hospital medicine" has become increasingly popular in the last 10 years, especially for internal medicine physicians. When a person finishes medical school and enters residency, there are nearly boundless possibilities. Residency choices can include specialties such as radiology, surgery, dermatology, emergency medicine, neurology, psychiatry, family practice, pediatrics, obstetrics and gynecology, pathology and lab medicine and even internal medicine. I'm sure I'm missing something. If a person chooses internal medicine, she can still choose to become a cardiologist, rheumatologist, endocrinologist, oncologist or...again I'm sure I'm missing something. But after 4 years of medical school and then 3 years of internal medicine residency, which is a job, but with almost no time off and very little pay, some people are ready to start doctoring. I wanted to be able to be useful anywhere and be able to use the knowledge I'd spent so much time  picking up in medical school to its fullest, and felt that specializing in one organ of the body would be a waste. That is why I am a general internist rather than a specialist. But internal medicine residency was full of taking care of enormously sick patients in the hospital, with small amounts of supervised clinic time, and when I first finished, I was really good at hospital medicine and pretty clueless about taking care of the many issues that come up in primary care. This is also true of internal medicine residents finishing up today. These doctors now have the choice of continuing to work just in the hospital, a choice that I didn't have. It is attractive. The schedule for a hospital physician is pretty cushy compared to a resident's schedule, and the pay is excellent. A standard hospitalist schedule is 7 days on, 12 hours a day, then 7 days off.  What's not to like?

After quitting my primary care internal medicine practice, I have, by default, become a hospitalist. It is possible to do hospital medicine pretty much anywhere and still have time at home. Committing for the long term is not strictly necessary since most patients come in to the hospital, are discharged, and don't come back for a long time, unlike primary care where the relationship with a single physician is key to good care. I will certainly not do it forever, but I'm doing it now. I am presently helping to cover the shifts at my local hospital which is only 25 beds, so quite small. The standard schedule for tiny hospitals which have hospitalists is 24 hours shifts, but typically seeing no more than 12 patients a day, and sleeping at home most of the time. Our hospital is just now developing this program, which will allow the primary care doctors to not come in to admit patients on their off hours if they don't want to, and will give sick patients without a doctor someone who is pleased to take care of them.

There are many companies that just do the job of providing doctor manpower and organization for a hospital that needs hospitalists. These companies are kind of like temp agencies, making sure that the job is done to certain specifications and taking on the responsibility for coverage. I have recently signed up with one of these companies to provide services in a community about 6 hours drive away from where I live.

The company first has to credential me, and the hospital needs to credential me as well. This means I have to submit all of my vital statistics, including history of malpractice suits, even if frivolous, licensing information, straight from any licensing board that has licensed me, and a complete education and job history with verification from all of those places, plus letters of reference and yet more stuff. After credentialing, I need to complete an online training course in how this company does things. One of the primary focuses of the online training is making sure that I document (write, type, dictate) notes sufficient to avoid losing a malpractice case should I be unlucky enough to be called in one, and be paid at the highest ethical rate for anything I do.

I have been dutifully watching the required videos, and have been feeling like maybe this is the wrong job for me. Perhaps I should go to cooking school or start selling real estate or better yet go overseas to treat the really truly sick in a situation in which what I do has more to do with helping people and less to do with satisfying payers and covering my vulnerable rump. I love taking care of people, learning what their issues are, using my experience to help them navigate their way toward better health. In order to document as this company requires, I actually need to change what I do to fit a framework that revolves around billing.

Each encounter I have with a patient in the hospital must be billed in order for the hospital to be paid for what I do. In the notes for these encounters I need to document various elements of the history of present illness, the family, past medical, personal and social histories, specific elements of a physical exam, even if I don't consider them relevant, a systems review, make notes of all of the data that I review and in some situations document start and stop times. After awhile this will become natural to me, and take up less of my brain, but when it becomes natural, the patient encounter will be a different thing than it should be. It will have elements of a checklist and will not truly be about hearing my patients' stories and collaborating on a solution to their problems.

I do think this whole bizarrely complex routine will someday be obsolete, since it seems clear that medical care will move in the direction of being paid for results, that is making people well, rather than by the individual nit that is picked. Still, in the meantime I am feeling like my brain is being filled with drivel.

It appears that all of the good hospitalist companies do training similar to the one that has signed me on.  Even though I don't like learning the intricacies of evaluation and management coding, it is the system we are presently using, and standardizing the way we interact with that system is not entirely a bad thing. It would be disappointing to learn that when I worked very hard taking care of a patient my hospital was paid as if I had done very little, simply because I had failed to mention that I had asked about new rashes or ear discharge or that I had personally looked at the chest x-ray.

The primary inventor of the complex billing schemes is Medicare, though many other insurance agencies follow the same guidelines. If I had my way, physicians and payers would sit down to produce a payment system that wasted minimal amounts of doctor and biller time on producing and reviewing documentation, focusing on making it serve the purpose of communicating important information among caregivers. Payment would be based on achieving goals derived through communication between the patient and or family and the care providers.

Bedside ultrasound--what a great way to improve medical care and potentially reduce costs

I just completed a 2 day course in "point of care ultrasound" at Harvard Medical School.  It was great. I am completely sold, a convert, a true believer.

Ultrasound is by no means a new technology. Bats use it. Bugs use it. Whales use it. A very high frequency sound wave is produced and when it hits an object it bounces back and is sensed by the creature that produced it. Submarines have used it since the first world war to locate objects, since other detection methods based on light were not useful. Doctors have used rudimentary forms of ultrasound since the 1940s to detect abnormalities in the body. In the last 30 years the machines used in ultrasound imaging have become smaller and more accurate, and the number of conditions that can be detected by ultrasound has increased vastly.  

Medical imaging studies of all kinds have become better since I emerged from medical school, and the pictures of the body that they produce are beautiful.  We have x-rays, an old technology, which look at the body by projecting radiation produced by electrons through flesh and detecting the emerging rays on the other side, initially being recorded on a kind of photographic film, and now more often by a silicon detection screen which converts the image into a digital file. X-rays impart ionizing energy to tissue and can cause healthy cells to develop DNA abnormalities which can turn them into cancer cells. CT scans use x-rays in larger numbers to produce more accurate images which a computer can use to create images that look like slices through the body. CT scans impart even more radiation to tissue than standard x-rays. They are also very expensive (at our hospital a CT scan can be billed at two to three thousand dollars.) In order to get more accurate pictures, a contrast material is often injected into a vein, which can cause fatal allergies and kidney failure.  MRI scanning produces even prettier pictures, using the fact that powerful magnets can tweak protons (present in water) in such a way that they produce a signal which can be recorded digitally. MRI scans are not particularly dangerous, except that contrast material used for MRI can cause a horrible scarring condition of the skin in patients with kidney problems, and they are even more expensive than CT scans.  All of these imaging procedures have probably saved countless lives while contributing to the development of iatrogenic disease and billions of dollars of health care related economic mischief.

Ultrasound imaging is very different than x-ray, CT or MRI scans. Safety is one of the greatest differences. Sound waves impart very little energy to tissue at the wavelengths and amplitudes used in medical machines.  Although ultrasound can be used to clean your jewelry or your teeth, imaging ultrasound is much more gentle and does no appreciable harm.

Cost is another issue: ultrasound machines, unless treated roughly, are durable and can take many pictures without using resources beyond the initial cost of the machine.

Immediacy is the difference that has impressed me most. If I have a patient in my office who I suspect has something wrong inside their body, somewhere I can't see or feel adequately (and the body has lots of those places) I often recommend that they have some sort of imaging test. If it is an x-ray or a CT or an MRI, I order that test, send the patient to the radiology suite where the technician takes the pictures after administering the contrast material if that is required. Those pictures go to the radiologist, a physician who I know but usually don't actually see very often, who interprets what I think is wrong with the patient from a brief sentence I write on my order, looks at the picture, dictates an interpretation (or sometimes calls me, but not often) and I later read that interpretation. Sometimes I look at the picture too, but I am not as good at looking at those pictures as the radiologist, so often I don't. Traditionally, I only order an ultrasound to look for specific things that ultrasounds are very good at seeing: gallstones, blood clots in the legs, function of the heart or blockage of the kidneys. If I do, the technician performs the ultrasound and the radiologist then reads the moving picture of the ultrasound images after they are performed, because ultrasound is a very dynamic procedure, looking at the body's inner workings in real time and from many different angles, since every body is a little different. Still shots from an ultrasound are blurry and hard to read like a glimpse out of the window of a fast moving car. I rarely look at ultrasound images, because only the still shots are available to me and they are of limited use.

Enter "point of care" ultrasound, that is to say ultrasound performed by the examining physician when the patient is seen. When a person gets an ultrasound, a smooth plastic transducer, shaped a bit like the handle of a paintbrush, liberally coated with ultrasound gel is applied to the skin and images appear on a screen. If I am doing the ultrasound, I slide the transducer around, looking at the structures underneath the skin and adjusting my angles and the pictures on the screen until I have seen all that I need to see. If I see something interesting, I can look at it from another angle, can look at structures near it and generally investigate until I am satisfied. There is no sending the patient to a technician, no radiologist being unsure of exactly what I am interested in, no delay. The examination is simply an extension of my history and physical exam. Nice for the patient, because I can tell them more, nice for me because looking inside the human body is unimaginably cool. In the setting of an emergency room, where belly pain could be gas or something life threatening, ultrasound can make a huge difference in survival. Right now, many people with problems that are  trivial get CT scans of everything, just to make sure. Costs are huge and radiation exposure considerable. Routine use of ultrasound by the physician at the bedside could be game changing.

There are drawbacks. Ultrasound can't see everything. There are lung conditions that can be identified, but many that can't be. Certain tumors are too small to be seen, certain other conditions just don't register on ultrasound. MDs who aren't radiologists may miss subtle abnormalities, and if they don't recognize their limits, could reassure a patient in error. Patients may assume that when a doctor has a look with an ultrasound, they will find everything that is wrong inside. Much like the standard history and physical, bedside ultrasound is limited. Doctors worry that if they are not great at ultrasound, they will be sued by patients who discover that something was missed. Still, after the experience that I have had (combined with medical knowledge and 25 years of looking at images) I think that I could help people considerably more with an exam that included ultrasound. And it doesn't really take that long, which is pretty amazing.

Here is an example of how bedside ultrasound might change my practice:

Scenario 1--appointment without ultrasound. A 35 year old woman comes in and tells me that she has been really fatigued lately and has had some belly pain. I ask her the usual questions, do a physical exam which is normal and decide that I need some blood tests and see her back in a week to discuss them. We talk about stress and irritable bowel syndrome and getting more fiber and more exercise.

Scenario 2--appointment with ultrasound. Same patient, same issues. I do a quick ultrasound. I am able to look at her liver, spleen, kidneys, and see nothing of concern. I quickly check her heart, and it is pumping normally, with no obvious problems of the valves or muscle. I then take a quick peak at her uterus and find out that she is pregnant. We can still discuss exercise, stress and fiber, but she and I have learned a great deal more with just a touch of technology thrown in. Blood tests? maybe not necessary. Followup? If needed, and more likely with an obstetrician.

There are certifications for certain physicians who do point of care ultrasound, which involve taking courses and doing a certain number of procedures which are corroborated by radiologists. Really only emergency medicine has standardized requirements like that, and the rest of us docs are left to invent the standards ourselves. These standards should allow us to use this technology and keep us from doing stupid things like saying or implying that we know things we don't know. Most physicians don't know how to do ultrasound, but many medical residents are now learning it as a matter of course during their training. It seems likely that it will become part of what we do, and that when it does, many of our routines will be streamlined.

The course that I took was excellent, but there are many other ultrasound courses throughout the US which are also excellent, at least that's what some of the other participants told me. The American Institute of Ultrasound in Medicine publishes a list of some of the practical ultrasound courses that are available at this website: http://www.aium.org/cme/events.aspx

Advanced Trauma Life Support

My 2 year "sabbatical" started a week ago. It has not, so far, involved much sleeping late or eating bon bons, which is fine, I guess. I am working several 24 hour shifts this month for our local hospital, covering the "hospitalist" service. This involves care of hospitalized patients who have no primary doctor or whose primary doctor is unable to take care of them in the hospital. Some of these patients are critically ill, some have fallen through the cracks of our health care system and others have doctors who choose to do only outpatient or specialty practices.  In some communities, especially in big cities, doctors who have office practices are just too busy to be available to their patients at the odd times that hospital medicine requires and so nearly all of the patients in the hospital belong to designated hospitalists. In our community, most of the doctors do at least some hospital medicine, which is good for continuity of care.

After quitting my primary care practice the first item on my agenda has been to take some continuing medical education classes that I have been too busy to take in the past, and ones which significantly broaden my scope of practice. The first one that I have done is Advanced Trauma Life Support, a course sponsored by the American College of Surgeons to help bring physicians who treat injured patients up to a basic level of competence in the process and procedures involved in good care.

There are various courses that physicians take that are represented by initials. I have recently updated my skills in ACLS (advanced cardiac life support) and PALS (pediatric advanced life support.) The ACLS course involves memorizing several algorithms for treating patients who present with life threatening heart events. These patients are familiar to me, because internal medicine, my specialty, involves lots of work with cardiac issues. Since my patients very rarely die or threaten to in my presence, it is good to review the steps involved in resuscitating them so that when fast action is required, I don't have to delay while trying to remember what to do. I have taken the course many times, and it is now familiar and easy despite the fact that recommendations change a little bit each time. PALS involved lots of studying and working through scenarios online and then a practical test. It was fine, but not remarkable. I now feel entirely capable of saving digital and rubber babies from various near death events.

I chose to take ATLS because feeling confident in taking care of victims of assaults or motor vehicle accidents is basic to being able to provide emergency care, and I may end up doing some of that. When I decided to take the class I had to find a location that offered it at a time that was convenient. I asked friends who had taken it what their experiences were and I searched online and eventually decided to take the course at Harborview Medical Center in Seattle.  I had done several months of residency training at Harborview and found it to be staffed with skilled and committed doctors and nurses who saw lots of very sick and injured people and who were at the front line of innovations to make care better. I wasn't sure that a structured course like ATLS would be different when taught at a major trauma center like Harborview.

The ATLS curriculum started after a doctor crashed his small plane in Nebraska and observed from the inside just how fragmented and inadequate trauma care was.  His wife died instantly and three of his children were critically injured. In the year that followed he and others in the medical community began to design a course that would standardize trauma care in a way that would dramatically improve its quality. What is taught now has been changed and honed and continues to change based on research and experience. The class involves lectures and practical sessions, scenarios and written and oral testing. Harborview did a terrific job. The course director, Dr. Sam Arbabi, is a trauma surgeon who is actively involved in caring for injured patients as well as doing research in public health and teaching students and residents. The different systems were covered by a diverse array of surgeons from all over the country, all of whom had different practices and experiences which they incorporated into  their course material.  The students were also extremely diverse, from small town emergency physicians to surgical residents to primary care physicians who needed trauma background to meet the needs of their injured patients when specialty care was not always available. In some continuing medical education courses, students, despite the fact that they are MDs, are assumed to be stupid. ATLS at Harborview was very collegial. We, the students, were recognized as the front line in trauma care. Patients with multiple severe injuries often end up at Harborview when the small hospitals that initially see them are unable to provide the kind of care that they need. If we, at these small hospitals, take good care of them, Harborview will be much more likely to save them.

We learned a method of thinking about injured patients that allows us to make good decisions when our brains might be overloaded with emotionally relevant pieces of data that can lead to being unable to do the right thing first.  The process involves the familiar ABC mnemonic, standing for Airway, Breathing and Circulation. No matter how bad a person looks after being hit by a car or beaten up by a gang or trampled by elephants, if air moves in and out of their lungs and their heart continues to beat, they are alive and their other injuries can be treated in good time. The details of how to do all of this are made up of thousands of hours of training throughout medical school and residency and beyond, but remembering that it is necessary to support movement of breath in and out of the lungs and to staunch bleeding is basic to trauma care and can provide an anchor for the rest of what we do.  Beyond this, each professor taught us about a specific area of care, including broken bones, injured brains and spinal cords, lungs which may be popped, contused or bleeding, hearts with similar issues, and the whole collection of innards which work so beautifully when unmolested, but so very poorly when squashed, skewered, perforated or macerated.

The final exam, which leads to certification, involved a practical demonstration of my ability to verbally and physically walk through treatment of a volunteer paramedic or nursing student with gorey makeup and rubber wounds associated with a realistic scenario, such as having been run over by a truck after falling off of a motorcycle or running into a bridge abutment. There was also a wickedly tricky multiple choice exam, with which I didn't entirely agree given the fact that much of what is right to do in any given situation depends on things which aren't possible to clarify in one paragraph. The very last activity of the very last day of the class was a small group discussion of triage of patients in disaster or multiple victim events. Who among the hurt and dying can best benefit from the limited resources available? These discussions allowed us to get to know each other and the course directors better and work through our conflicting values to come up with a consensus that will probably be helpful in future apocalypses.

So the class was excellent. I heartily recommend ATLS at Harborview in Seattle.

As I drove back home, the 5 1/2 hours from Seattle to Idaho, I thought about the fact that the vast majority of traumatic injury that leads to death, disability and dismemberment is directly due to our unconditional love for the internal combustion engine, particularly the automobile. Without motor vehicle crashes, trauma medicine would be a significantly smaller specialty. I clung somewhat more tightly to my steering wheel and drove more slowly and wished I could be footloose without driving my car.