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Friday, March 30, 2012

Studying for the American Board of Internal Medicine Maintenance of Certification Exam

In 1989 after finishing my residency in Internal Medicine at the University of Washington, I sat down and took the Internal Medicine Boards. I didn't study, didn't look at any information about the test at all ahead of time and passed in the top 10%. It made perfect sense that it would go that way: I had been eating, drinking and sleeping (sometimes) internal medicine for 3 solid years in an excellent program, studying all the time and practicing under recognized opinion leaders in the field. Prior to that I had eaten, drunk and slept the entire field of medicine for 4 years at Johns Hopkins School of Medicine where my mind was positively marinated in everything that was then thought to be true about physiology, pathophysiology and care of patients.

When I took the test it was the last time I would ever have to take it. I was forever certified with American Board of Internal Medicine, and the next year all of the doctors who passed the test would have to re-take it every 10 years to maintain certification. Lucky me, I thought. Under the wire.

For the last 20 years I have been educating myself by reading journals regularly, attending classes in medical things that interest me, taking online education, maintaining proficiency in things like Advanced Cardiac Life Support, teaching medical students and generally keeping updated on what I do. I have been documenting at least 50 hours a year of education, which is enough to maintain licensure in both of the states in which I practice. The number of hours varies by state, along with details of how the hours must be spent, and many require less than 50, but I figure if I get 50 I don't have to check the requirements and I'll be fine.

Last year after reading this article (http://www.nejm.org/doi/full/10.1056/NEJMclde0911205) I decided to start the process of recertifying for the board of internal medicine. It just seemed like the right thing to do. It has been, so far, a very interesting ride. I take the test on April 25.

The board requires demonstrating proficiency in a number of areas via open book tests plus a module of practice improvement, in which I evaluated my present practice using chart reviews and patient questionnaires, made a change in what I did and then repeated the process. I chose to look at how I presented information about preventive testing. It caused me to deliver this information more comfortably and routinely and to write a handout that was based on current recommendations rather than relying on information that had been in my electronic medical record's handout collection that was inaccurate and outdated. The open book multiple choice tests were in many of the subject areas that comprise internal medicine and were meant to be equivalent to about 80 hours of study, though I did more random tests than that because it was interesting. It's after finishing all of this that the board allows me to sit for the test.

At the end of last year I attended Harvard Medical School's marathon update in internal medicine and found that my knowledge of this humongous field that I practice was no longer at the cutting edge. When presented with cases and questions and given multiple choice questions to answer with a little remote clicker I was no longer always right. Whoa. That was weird. It was clearly time to catch up. But how? First of all, being a hospitalist at a completely different place, seeing lots of patients along with specialists has been great. I can't necessarily trust that they are on the cutting edge, but I can see how their practice seems to work and I can read. In this last month leading up to the test I have begun to immerse myself in two sources that are absolutely wonderful tools for regaining mastery (hah!) of all of this stuff.

The first is the MKSAP, the medical knowledge self assessment program of the American College of Physicians. I took the MKSAP about 10 years ago as an educational tool and back then it was terrible. It was in print, very boring and often just plain wrong. MKSAP now is a different animal. It is still wrong at times, but because of reasonable difference of opinion, not carelessness. It is online and is updated and corrected constantly. I use the very long multiple choice tests as a framework for learning the materials, reading the question, deciding what my answer would be, then checking the syllabus materials with a focused question in mind. Then I go to my new favorite resource to check out what an entirely different set of physicians think about the subject. That resource is Up to Date (www.uptodate.com/). Although it is expensive, a year's subscription is almost $500, when I use it, it monitors my time and documents that as continuing medical education credits. Plus it is absolutely excellent. It presents the data behind different approaches to a problem, recognizes variability in practice, and sometimes disagrees with the MKSAP. It does make me think. This studying is an exciting process and I'm really enjoying it. I know it will impact the way I treat patients in a positive way.

The expense of doing all of this is considerable. The maintenance of certification itself was $1675. The MKSAP was $574. Up to date was $499, but I will use it for other things. The Harvard Medical School course was $1675 plus about $2500 for airfare and hotel. The time I didn't work (in my old practice) would have cost about $5000 in missed revenue plus paying staff while I wasn't around, for just the Harvard course. Now that I am doing hospitalist shifts, the process of studying is roughly equivalent to missing a month's worth of shifts, maybe about $18,000 before taxes and expenses. It's a little like being in school again: expensive, time consuming and eminently worth it.

Monday, March 26, 2012

Do doctors understand statistics? Nope.

That's a bit of an oversimplification, of course, because some physicians really do understand statistics, but an article just published in the Annals of Internal Medicine looked at internal medicine doctors' ability to interpret whether tests to screen for cancer actually helped save lives and found that a majority of us do not understand the numbers that explain why some cancer screening tests may be of no benefit.

Lately scientific organizations have released some pretty controversial recommendations about screening for several common forms of cancer. Initially, in 2009, the US Preventive Services Task Force released a recommendation that mammograms not be performed routinely on women under the age of 50 and that evidence was insufficient to recommend mammograms over the age of 75. This was based on lots of data that showed that in these groups of women, the risks of mammogram screening, including unnecessary treatment, were higher than the benefits, except in specific cases. In October of 2011 that same organization recommended against using PSA (prostate specific antigen blood test) screening to identify men with prostate cancer. An overwhelming amount of data over a long period of time shows that repeated testing of PSA in men without symptoms of prostate cancer does more harm than good. In this month's issue of the Annals of Internal Medicine, the American College of Physicians has released its recommendation that screening for colon cancer with colonoscopy or fecal testing be stopped after the age of 75.

There have been passionate responses to all of these recommendations, protesting that they are short sighted and motivated by the desire to save money at the expense of vulnerable populations. How could a test that is minimally dangerous be bad, if it might detect something really horrible like cancer at a time when it can be cured? There are various ways.

The first is something called lead time bias. If a person has a cancer that will lead to their death in, say, 2018, and they discover it early via screening, say, in 2012, rather than when they develop symptoms in 2017, they will live more years after discovering they have cancer by being screened, even though they don't actually live longer. It will look like treatment and screening made a difference, when what really happened was that they worried about it for longer and spent more time in doctors' offices and with treatments that didn't end up helping before their inevitable death.

Another is overdiagnosis bias. It's likely that all of us at this moment have some cancer cells lurking around in our organs, but our immune systems are killing them off before they can set up shop. If a screening test is so good that it identifies the presence of these cancer cells even in those of us who will never have problems, it will look like more of us survive after diagnosis. What will really happen is that a bunch of people with conditions that are of no consequence go around thinking they have cancer and maybe even pursuing toxic treatments for it.

It is also true that people identified by screening at an early and curable stage with a cancer that would have otherwise killed them are in fact benefited by the screening test, though others are not, and that identifying these people by screening everybody (or a large proportion of everybody) is so astronomically expensive and time consuming that other more important means of prevention such as vaccination, nutrition and other aspects of wellness are neglected, leading to significantly more misery than if the test were not routinely used.

Researchers from the Harding Center for Risk Literacy of the Max Planck Institute for Human Development, supported by a grant from the National Cancer Institute presented over 300 internists involved in primary care with data about cancer screening tests and found that they did not understand that when a screening test identifies more people with a cancer that is at an early stage, and possibly not even likely to cause harm, more of these people will survive solely because they were going to survive anyway. The way the questions were worded didn't make the right answer obvious, but that was the point. Data like this is not obvious to patients, and when their doctors also don't understand it, excess testing and treatment will happen.

Thursday, March 22, 2012

Why are patients becoming so much more complicated?

When I was in medical school, lo those many years ago, patients used to come in with diagnoses like pyelonephritis or cellulitis or pneumonia or myocardial infarction or cirrhosis of the liver or heart failure. They were very sick, and I was very inexperienced, so it was always a challenge. I drew blood for various blood tests run by a lab, got a urine sample and looked at it under the microscope, got a chest x-ray and sometimes an EKG. I took a history and did a physical exam and wrote this all up on a piece of paper and made my conclusions and wrote orders and started an intravenous line for medications. A nurse would do vital signs, clean up messes, give medications and call me if something bad happened. Rarely had my patients had anything more complicated medically than a hernia operation and rarely did they take more than 6 medications. It was often perfectly adequate to get the entire medical history from the patient, which was good, because finding medical records was difficult.

After the initial head scratching, a patient would usually have 1 or 2 important things going on and I could focus my attention on curing those things. Abnormal lab tests were usually due to some immediate or far reaching effect of their primary problem.

In the ensuing years since my graduation, the numbers of tests and therapeutic procedures and medications that are commonly used has grown tremendously so that now it is unusual to admit someone to the hospital who has less than 10 distinct problems. Each of these problems has some sort of workup associated with it and often a medication, and has a significant implication for what treatments can be given for the current problem and what new testing needs to be done. There are so many more mistakes to be made than there used to be.

It seems likely that the fact that physicians and other healthcare suppliers are paid "fee for service" is directly responsible for the fact that patients have gotten more complicated. People haven't fundamentally changed, but the numbers of tests we do on them has, and our concept of our patients as collections of measurable variables has lead to an appearance of complexity. But they really are more complicated, even outside of our improved ability to peer into their inner selves. They are more complicated because of what we do to them.

A diabetic patient now may easily be on 4 medications for blood sugar control, 2 for high blood pressure, one for cholesterol and an aspirin. Then, of course, they also take something for depression, pain, a sinus infection, a weak bladder, gout...All of these drugs are incredibly powerful and can lead to death or dire illness alone or much more commonly in combination. Side effects are difficult to identify. In a fee for service world, patients see many specialists and each one has his or her own set of medications to offer, which balloons the numbers of drugs taken and geometrically increases the chance of side effects and drug interactions. Every time we do a procedure to a patient, we beget more diagnoses--at the very least a "status post" diagnosis, but often failure of the procedure results in further disability. Imaging, such as CT scans and MRI scans, has increased steeply in the last 10 years, leading to discovery of mostly irrelevant anatomic anomalies which frighten patients and confuse physicians and require repeated and more focused imaging for clarification.

Long lists of diagnoses clutter the mind with irrelevant data, but are the way we get paid for what we do. A person with a simple pneumonia will warrant a low level service code, but if I mention that they have heart disease (be it distant) and high blood pressure and borderline glucose intolerance and flat feet and piles and wens and and and and... the level of complexity and thus the billable amount goes up. But, having enumerated all of these ills, I now need to think about them and comment upon them and then I am paying less attention to the sick patients' immediate needs, and am much more likely not to notice a wrong drug dose or a lab test that implies a complication.

It's not entirely clear how to get back from here. Having insurance companies (including Medicare) pay for whole person care, by the person and not by the procedure, will begin to lead us back to where we need to be. Providing good competent primary care which can reduce reliance on specialists can help. Deliberately limiting the number of prescriptions taken by patients, realizing that taking a large number of good drugs is a bad thing (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1885000/) should reduce the harm we do with the best of intentions.

Local anesthesia with lidocaine, buffered lidocaine, warmed buffered lidocaine, slow injection of lidocaine: publishing the results of perforating my own arm

I have done procedures using local anesthesia with subcutaneous lidocaine for over 20 years, and by the look on peoples' faces, I know that lidocaine stings. About 10 years ago I heard that adding a small amount of bicarbonate to the lidocaine took the sting away, but I never really had a chance to try it since my clinic never had any bicarbonate around. Just recently I went over the literature about reducing pain with injections and read that slowing the injection and warming the lidocaine is also effective in reducing the sting.

The pharmacy of my home hospital is very understanding and cooperative and they treated me to a vial of lidocaine 2%, a vial of 8.4% bicarb and all the insulin syringes I wanted. The insulin syringes have 28 g needles which are only slightly thicker than an eyelash so hardly hurt at all. I buffered the lidocaine with 1 part bicarb to 9 parts lidocaine. (It turns out that despite concerns that lidocaine would not be stable in a buffered solution, it actually is, if kept refrigerated: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827006/) I injected about 0.1 ml subcutaneously into my left forearm for each variable.

My conclusions:
1. Lidocaine stings when injected quickly.
2. It pretty much doesn't sting at all if it is injected slowly, but it is very difficult to inject it slowly because a tiny syringe wants to give way quickly when pressure is applied to the plunger. I suspect I could get good at this if I practiced and used two hands.
3. After a little bit of lidocaine goes in, the rest of the injection, if not given too quickly, is painless.
4. Buffered lidocaine is less painful than straight lidocaine if injected quickly, and painless if warmed and injected slowly.
5. Warmed lidocaine (just warmed in the hands for a little while) injected slowly is quite painless. Warming it matters.

Tuesday, March 20, 2012

Simply love them: using lidocaine to anesthetize the skin before arterial punctures or IV insertion

Lately I've been doing hospitalist shifts at a busy medium sized hospital that serves a complicated and pretty sick population. Patients frequently have lots of life threatening medical problems that interact in unpredictable ways, putting them at high risk of dying when they get an acute illness. When they come in they are vulnerable and scared and sometimes angry and difficult. I am sometimes needed in more than one place at a time, which makes it imperative that I figure out some way to make the interaction work so that things will move smoothly in the direction of helping the patient start getting better.

What has been working particularly well has been the approach of deciding ahead of time to love them, and then talking to them and hearing enough of their stories that I can develop a respect for where they are in their lives. When a person is truly vulnerable, there is just nothing like love and respect to buy cooperation. And it is also much more fun for me, because then I look forward to my interactions with them.

Occasionally there is a patient who is really bound and determined to make staff cry or one who lies about everything in order to manipulate caregivers, but they are not very common, and sometimes, if everything goes just right and I've eaten my wheaties and drunk my green tea and worn just the right earrings, love and respect can win those over. I saw one of these folks just tonight and he was incredibly irritating, made me miss dinner, told me almost nothing that seemed like it was probably true, but I kind of like him now and if all goes well we will have a great visit together tomorrow and he won't monopolize all of my time telling me stuff that strains belief.

Some of the things we do to patients in the hospital that make them the most sad and also irritable and uncooperative are related to sticking them with needles. Needle sticks just plain hurt. They don't hurt much for very long, but they keep being repeated at random intervals, and two kinds of needle sticks are particularly painful. When a needle goes into a vein, that hurts but not much, but when a needle goes into an artery it really aches. Arteries are deep and surrounded by nerves. People who are critically ill get many arterial punctures in order to find out if their oxygen and carbon dioxide levels are normal and also to monitor their acid-base balance. They are often delirious when it happens, but it still really hurts, and they remember the hurt when or if they recover. When an intravenous catheter (an IV) is placed, a plastic tube with a needle in it is put in a vein, but often it takes awhile to find the vein, and during that time the needle is digging around in the flesh. Ow. Both of these procedures can be performed after injecting some numbing medicine with a tiny needle that really doesn't hurt much at all. The numbing medications is usually lidocaine, which can burn, but can also be nearly painless if 1 part bicarbonate is added to 9 parts lidocaine, buffering the slightly acidic solution. It hurts even less and works faster if the buffered lidocaine is warmed to body  temperature. If buffering the lidocaine is not possible, a slow injection, over 30 seconds, works almost as well. Patients like being numbed first. I know I would.

Many organizations have published in favor of anesthetizing for arterial punctures (http://ajcc.aacnjournals.org/content/15/6/595.full is a review of this literature.) Most places that I have worked do not anesthetize arterial punctures routinely, mostly because it takes longer and partly because the operators (nurses or respiratory therapists) have been taught that a stick for a stick doesn't make sense. Except that it does if it is your wrist or the wrist of someone you love. It is even more rare to anesthetize for the placement of IV's and this is a much more common procedure. (http://ajcc.aacnjournals.org/content/17/3/265.full.pdf goes over this literature.) Arguments are often made that it takes longer to do it this way and that these procedures are often done in a big hurry, but if it were done all the time, the equipment and medication would be easily available and I'm positive it wouldn't add more than a couple of minutes to the procedure. Physicians also routinely cause discomfort with aspects of our physical exams: we make our patients cold, we poke them too hard and we leave their bedclothes messed up. Some discomfort is unavoidable in hospitalizations but being gentle and mindful can go a long way to reducing it.

Monday, March 12, 2012

Yale University Ultrasound Course in Puerto Rico and learning from resource limited settings.

I just got back from Puerto Rico, where I attended Yale University School of Medicine's yearly emergency medicine and critical care ultrasound course. First, Puerto Rico is a tropical island in the Caribbean which has been relatively blessed by the universe, at least as compared to Haiti which is within hailing distance. It uses American currency, has American style roads, mostly deals in English but has rain forests and warm beaches and loud tree frogs and quiet bats that make being outside at night amazing and other worldly. It is not very expensive to fly there, even from the west coast. It is not as cheap as other developing countries, but not as expensive as traveling in the US. It was wonderful to go there in March. I don't usually do this sort of thing, the resort vacation that becomes a tax deduction because of medical education, but this one had fantastic faculty and was everything I could have hoped for.

I have been excited about bedside ultrasound since I took a course at Harvard in November. I have been using ultrasound at the bedside ever since then, and getting better at it all the time. It takes a huge amount of time, though, to get competent at finding the right angle and location to look at the various innards and figuring out what it is that is actually in that image. I am having to really relearn my anatomy. Every time I am taught, hands on, by someone who is really good, I progress by leaps and bounds.

The faculty for this Yale course included Chris Moore MD and Katja Goldflam MD, excellent teachers, both of whom have emergency medicine backgrounds. They really know their stuff, and have designed a curriculum that they use with medical students and residents at Yale. The course consisted of basic concepts, lots of cases with video clips of ultrasounds and many hours of hands-on experience with healthy volunteers. The food was also great.

There are accepted uses for ultrasound, like evaluating kidneys, babies, hearts and gallbladders, bedside uses that not everyone knows about, including guidance for procedures and evaluation for collapsed lungs or fluid where it shouldn't be, and there are ultrasound techniques that are frankly entirely dismissed by most doctors, which include evaluation of the bowel, the lungs for pneumonia or congestive heart failure. At the course I was most impressed by one of the participants who is a pulmonary and critical care physician, trained and working in Puerto Rico. His knowledge of ultrasound was impressive, and he said that he routinely uses ultrasound in his office to diagnose pneumonias, because it is more accurate than chest x-ray.  This sounded intriguing, but I couldn't quite believe it. So I checked it out, and sure enough, a group in Italy has been publishing reports of how much more accurate ultrasound is than chest x-ray, using CT scanning of the chest as the gold standard.
http://www.ncbi.nlm.nih.gov/pubmed/19555605 since at least 2009.

I find it interesting that in resource limited settings, like Puerto Rico and Italy, technology that is better is used more often than it is in the US. Cost incentives clearly have something to do with it, since people make very little if any money by performing bedside ultrasounds, and it takes more training to evaluate the lung with ultrasound than to order a chest x-ray. The ultrasound uses no resources and requires no third party to read it.

I'm thinking that there are probably many other tricks that physicians in resource limited settings use that are more effective, not even just more cost effective, than what we do in the US.

Friday, March 2, 2012

Inappropriate medical care, high costs at the end of life, zombies and more (a rant)

It isn't that it was a bad day, because it wasn't really. There was too much work, yes, and I ended up staying late, but it was mostly made of good interactions and I felt generally competent. So, no, it wasn't just a bad day. Still, this evening I feel like the best possible future would be one in which there was no technological medical care, where we just worked on sanitation, vaccinations, good nutrition, maternal health, mutual respect, stuff like that, maybe even penicillin, and called it good.

The stuff that is bothering me is use of really high end technological medicine to prolong life at its very bitter, and I do mean bitter, end. The woman found unconscious at home after not breathing for so long that her brain had died, kidneys had quit, but her heart still had the ability to pump, so she is in the intensive care unit receiving constant dialysis, on a ventilator with intravenous nutrition and scads of tests every day, all for the expected outcome of death, soon, or the less likely outcome of being able to breathe on her own so she can live in a nursing home with a feeding tube. Or the woman with cancer who has a huge ulcer on her bum, down to bone, which will take months to heal, leaving her in a nursing home and weaker than when she got it in the first place, all for the privilege of dying in pain of her incurable and progressive cancer. Oh, and did I mention that they will start dialysis for her kidney failure so she can tolerate the surgery for her bedsore so she can heal to go to a nursing home to get a different bedsore so she can start chemo again so she can slightly delay her inevitable death of cancer? And the wraithlike man on dialysis for 11 years, only skin stretched over bone now, in constant discomfort and now failing to be able to even maintain his own blood pressure, who has clotted off all of his dialysis access so they will put a new temporary dialysis catheter in his chest tomorrow so he can live to go to a nursing home where he will lie in bed waiting for visitors or for the nurse to come give him pills and get dialysis 3 times a week until his catheter becomes infected and he is again admitted to the hospital to be saved again.

It feels like we are just playing with these peoples' lives, giving them these ridiculously complex, painful and expensive medical procedures just because we can, not because they have value. And they are expensive, man they are expensive. Each of these will cost hundreds of thousands of dollars, if not in excess of a million dollars in some cases. If the money was nothing, well then it would be fine, or not exactly fine, but not so horrible, but the money isn't nothing. This sort of thing is strangling our economy and having an impact on everyone's life. Much of this expensive and inappropriate medical treatment is going to the very poor and the very uneducated, the smokers, drinkers, abused, neglected, educationally left behind, because these people are the sickest and the least likely to have had discussions with providers about what they want to get out of life and out of medical care. These people are bamboozled into thinking that what we give them, our fancy machines, our pull-you-out-of-the-mess-you've-gotten-yourself-into-one-more-time procedures, actually will give them something good. In fact, mostly, they just cause long term disability and dependence.

At this point the non-ranting part of me, the let's be fair, there sometimes are good outcomes voice in my head is asking to be represented. Sometimes people are saved and they go on to get clean and participate in activities that enrich the lives of themselves and others. Cool. And also sometimes I think that for people with really rotten childhoods, an interaction with a loving and respectful medical staff is good in itself. But most of this good is achieved without our incredibly fancy and tremendously costly toys. And we are making new ones all the time, despite regulatory agencies that make it more difficult. These toys are things like newer ventilators that can force oxygenation out of lungs that are wet and squishy and over stretched, dialysis machines and heart lung bypass that can do the functions of the human body while it can't run itself. Beds filled with air like floating on clouds, that might prevent bedsores. And potions, how we love the potions we use, so everyone gets an antibiotic, or 3, and we can support peoples' blood pressures which means that they stay alive a little bit longer, but actually just die pretty soon anyway.

And the regular drugs we hand out like candy, blood pressure and heart pills that are incredibly powerful, but also deadly in combination with a little kidney dysfunction, a little diarrhea with dehydration and a little ibuprofen. I just today saw someone with that combo, potassium level over twice normal, would have been found dead had he not dragged himself in. Preventable. I'm not entirely sure why he wasn't just found dead on his floor, but we will save him.

It feels like we are creating a race of zombies, walking dead who don't know that they are dead, because we didn't tell them. We never discussed how death is a part of life, and that we don't get to decide whether we die or not, but we can have some input on how it looks and feels when we go. No discussion of the fact that the value of a life is not directly proportional to its length. I think these folks deserve better.

But, big caveat, I am not against all intensive care or resuscitation. But, just like not everybody needs the highest end whatever, intensive care, life sustaining therapies, resuscitation, really isn't appropriate for everybody. Just because we have it doesn't mean we need to use it.