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Tuesday, December 31, 2013

Healthcare Spending--moderating? David Blumenthal et al explain.

David Blumenthal and others recently published a paper in the New England Journal of Medicine entitled "Health Care Spending--a Giant Slain or Sleeping?" In it they look at the ongoing, and rarely discussed, phenomenon of slowing of healthcare spending, which has persisted over several years. Health care spending grew remarkably after the establishment of Medicare and Medicaid in the 1960's, resulting in the fact that health care costs now equal about 18% of our gross domestic product (GDP) when they were only 5% before these programs were introduced. This was no coincidence. A third party payer, even one we expect to value frugality such as the government, will increase utilization of services because they are already paid for, and will increase prices for the same reason unless the prices are negotiated. In Europe, prices for procedures and medications are frequently  negotiated, but in the US powerful drug companies and device manufacturers successfully resist this, resulting in relatively free floating prices. In the past few years, however, overall health care costs have slowed their growth considerably and now actually lag behind the increase in  GDP. We have had a much slower economy since 2008, which could be expected to slow health care spending, but this effect has been beyond what economists would expect based on this.

The authors discuss the many factors that may be involved in slowing healthcare costs, and also present some strategies that might help encourage this trend. They suggest that some of the provisions of the Affordable Care Act, including establishment of healthcare models that make providers of healthcare more financially responsible for the health of patients rather than profiting from their illness, may already be having a positive impact. Movement towards having patients be more involved in their own health, including making informed choices about treatment and testing may reduce unnecessary costs. The article is definitely worth reading. They conclude that healthcare, despite the encouraging trends, is still overpriced and can can stand to be more frugal without sacrificing patient care. This is true. In my experience, testing and treatments are still ordered without adequate attention to necessity or cost. Preventive strategies to reduce grave illness are still underutilized and drug companies still overcharge for their products and convince us that their value is higher than it really is. We continue to use the very newest and most expensive technologies to delay the moment of death for patients who are genuinely dying and ought to be allowed to do so in comfort and with dignity. All of these things come with huge price tags.

The article ends with a couple of very important points, and then misses a few more because the authors are most likely not practicing physicians. Dr. Blumenthal, the first author, is the president of the Commonwealth Fund, a philanthropic organization which researches social and health policy. He has been a primary care physician, but has been influential in policy and administration for many years, suggesting that he probably no longer takes care of patients in the hospital or clinic.  His coauthors, Kristof Stremikis and David Cutler are in public policy and economics, respectively, and are not MD's. The points that are particularly important  that they did mention in the article are that consumers can be a powerful force for improving both quality and in reducing costs if, and only if, they are given data about quality and costs. Also, that the way we presently pay for medical care, especially the way we bill, is incredibly inefficient (also, in its complexity, so prone to fraud and inaccuracies, though they didn't mention this.) What they did not mention is that physicians can be a powerful force in improving quality and reducing costs if they, also, are given data about these things. Doctors still do not know how much a given test or procedure costs, what portion will be paid by a patient out of pocket, and mostly do not have guidelines that help them not to order excessive testing or treatment. Billing is only a small part of the problem of administrative burden.The increasing demand on nurses' and other caregivers' time by electronic health records which appear to be endlessly hungry for valueless detail that must be entered on a computer not only reduces all of our abilities to do good bedside patient care but clouds our minds with trivia and chases experienced staff, both nurses and doctors, to early retirement because of inadequate (and irrelevant) data entry skills.

I commend the authors of this article for clear writing and excellent synthesis. The fact that healthcare spending is already going in the right direction is fascinating and almost entirely neglected in the press, probably because it doesn't support the more popular story that everything to do with healthcare in America is going rapidly to hell in a handbasket. I expect the ongoing vigorous debate about healthcare reform will keep people discussing costs which will make both physicians and patients more likely to pay attention and reduce frivolous expenditures.

Monday, December 16, 2013

This is what happened when I went to to sign up for health insurance

Today in the mail I received a letter from my private health insurance company informing me that my current policy, which was being cancelled because it didn't meet minimum standards of the new healthcare law, would actually be available to me next year. In other words, I could keep my plan.

There has been a big kerfluffle about a presidential promise to allow people to keep their health insurance plans if they liked them, which turned out not to be true under the health care law. Having read the law I thought that was pretty clear. I figured that my plan wasn't compliant and I would therefore find myself signed up for some more expensive policy by my health insurance company when 2014 rolled in. I am not entirely sure why the president told people they could keep their non-compliant policies, and apparently he has been spanked soundly for saying it. The "Keep your health plan act of 2013" passed the house in November, but I cannot find anywhere that it passed the senate, and now I have received a letter that suggests I can keep my health plan. I find nothing online to explain this confusing set of contradictions.

But all of that aside, I decided today that I would plunge into what is supposed to be a horribly broken system for obtaining health insurance. The process sounded interesting a month or two ago, but I was way too busy to explore it. Today, though, my schedule cleared out a touch and I got the letter from my insurance company, so I decided to give it a whirl. And...

It was fine. There was no problem.

First I went to the website for Idaho's health exchange as the letter from my insurance company instructed. Since Idaho has been grouchy about anything to do with the healthcare law, we are not quite yet functional as a state exchange. The website routed me to the federal health insurance exchange via There I expected horrible bugs and delays. I don't doubt that people have had terrible bugs and delays, but today things went as smoothly as a greased watermelon in a warm lagoon. The website was attractive and uncluttered, the fonts were easy to read and the navigation was fast. I signed up for an account. I entered my name, the names of my children, social security numbers, and attested to our citizenship and the fact that we didn't smoke. I promised that I was telling the truth. I was then routed to a page of options for health plans, categorized by level of coverage. Coverage is either bronze, silver or gold, depending on how much the plan pays and how much I pay to have the plan. I went for bronze level since I expect to die suddenly after experiencing perfect health all of my life, and figure that my children will be well until they are kicked off my plan at age 26. I am willing to bet my $12,500 out of pocket maximum on it, and have a health savings account with something like that amount of money in it, should I lose my bet. I had 6 choices of plans, offered by a variety of different companies and chose the cheapest which was about $25 more expensive than this year's non-compliant health plan that I was invited to keep. My experience with my present insurance company involves a yearly price hike of around 20%, so this increase in cost was in no way disappointing.

Having signed up for insurance in the past, I'd have to say this experience was better. If I had been less financially well off, I would have also had a break on price, which would have been nice.

I don't know what to say about the failed roll out of the Affordable Care Act other than the fact that at this present moment it works fine. Will it destroy American health care as we know it or cause an already overburdened system to implode? That remains to be seen. Will coverage for preventive care dramatically reduce costs by improving the overall health of Americans? Not sure. But on Monday, December 16, 2013 at 5 PM the process of comparing and purchasing a health insurance policy was easy.

Rural Medicine: Idaho and Africa and elsewhere

Rural medicine, I guess, can be defined as health care that happens in places that aren't big cities or referral centers. The vast majority of the populated earth's crust that has any health care at all is served by rural practitioners. I have done a little bit of rural medicine in Haiti, in Mexico and now a bit more in South Sudan. I have also worked in a rural health care system in Idaho for nearly 20 years.  People benefit hugely from health care delivered to them in their less densely populated home turf, despite the fact that health care in such locations lacks technology and specialist services that are often available cities or university medical centers.

In the US, most rural health outposts are within an hour of a major medical center, either by ambulance or helicopter, so transfer to a high tech center is usually possible when there is an indication. In developing countries people are often grateful for any medical care that can be provided and transfer to a higher level of care is much slower or impossible.

When a person in the US discovers that he or she is very sick they usually call an emergency medical service team which sends at least 2 trained medical technicians within a few minutes to evaluate the patient and transport them to a hospital if that is necessary. In some areas like the Alaskan bush and truly isolated parts of the US this is not true, but the vast majority of non-city dwelling Americans have access to emergency medical services. In rural South Sudan a person who is very sick will first receive any folk remedy available and if that is not effective, will begin the long journey, on foot or carried on a litter by relatives, to the nearest health care facility. Such a trip may take days.

On arrival at a rural emergency room in the US, patients will usually immediately see a well trained doctor who will respond appropriately to their life threatening needs with interventions that are similar to what they would get at a hospital in a larger city. Specialists will be called if appropriate and often will be at the bedside in close to no time. Testing, including CT scanning, ultrasound, advanced lab testing and x-rays, is completed quickly and a likely diagnosis and treatment strategy is determined usually within a few hours. An IV line is usually placed and, if in doubt, the patient is put on oxygen by nasal cannula. If appropriate treatment for the patient's condition isn't available, transfer to a larger facility is arranged. If the patient is sick but can safely be managed in the rural hospital, admission is arranged. The patient is then taken to a moderately comfortable electrically controllable bed with clean sheets and a pillow, with a pitcher of water and toiletries on the bedside table. In a very good rural hospital in South Sudan, like the place I worked, testing is limited to a fingerstick test of glucose and creatinine (for kidney function), vital signs such as blood pressure and oxygen saturation, if the machine is working, possibly a bedside ultrasound if the health care provider has been trained and the machine is available. Very sick patients are placed on a mattress on an ancient bed in the ward, if a bed is available, and may be given intravenous fluid or medications if their condition warrants it. There is no oxygen, water pitcher, bedside table, sheets or pillows. The medications available are limited, and if what we have is not what the patient needs, they might get whatever is closest to what they need, or nothing at all. Transfer is sometimes possible, but usually delayed by days and sometimes longer. If the problem is one of several tropical diseases which are common, treatment is rapid and appropriate and miraculously life saving at a tiny overall cost compared to treatment of anything in the US. If the patient's breathing stops or the heart ceases to beat, that is usually the end, without resuscitation unless the cause is clearly quickly reversible, like having choked on a peanut. Blood transfusion is possible and sometimes life-saving, since many of the worst tropical diseases are associated with severe anemia. Although blood typing can be done, a full screen for transmissible organisms and minor blood incompatibility is not possible, so potential donors must be people for whom there are very few risk factors which mostly means medical staff. The blood comes out of the donor and is immediately infused into the recipient, relieving symptoms of weakness and heart failure. There are no facilities for processing the blood so it is fresh whole blood that is transfused, which actually has some theoretical advantages over the stored packed cells most patients receive in the US. Some women with problems of labor and delivery can receive life-saving help, based on the expertise of the attending physician or healthcare worker and people with wounds or injuries can often be patched up or splinted or casted. Abscesses can be drained. Sores, including tropical ulcers can be cleaned and dressed and often healed.

In the US, detailed and scrupulous records are usually kept, often in digital format which can be searched if you know how to do it. Records in the tiny hospital in South Sudan are very brief and often inadequate to communicate the course of events without the additional input of the caregivers who may remember what happened and what everyone was thinking. The lack of complete records of medications given was particularly frustrating for me. There were, however, twice daily vital signs most of the time, which are often not available in less excellent hospitals. In order to make an impact on a person's disease it is necessary to know what is happening with the person, thus vital signs such as blood pressure, temperature and pulse are important, as are changes in a patient's symptoms and signs of disease. If we don't know whether the treatments we order are actually being given, our ability to adjust therapy to achieve a desired result is extremely limited. The excessive and almost obsessive data gathering that we suffer from in the US can overload us, but the ability to have some objective data regarding a patient's physical state is extremely helpful. I longed for more documentation in my visits to Haiti, Mexico and Africa. On the other hand, there was something beautifully basic and adequate in the concise paper records in South Sudan. Patients had a card, half of a standard size piece of printer paper, which documented all of their inpatient and outpatient complaints, diagnoses and treatments. They knew to keep these cards and brought them with them for each visit with a health care worker (or received a scowl if they didn't.) The more extensive records from a hospitalization were just thrown away when the patient left the hospital, but a brief summary stayed on the card. The cards were often dirty and wrinkled, but people kept track of them, which made a huge difference in being able to find a way to cure patients persistent or new ills.

So...rural medicine is such a very different thing in different settings, and so incredibly important. It is fraught with huge challenges, especially in the most remote places. These can look like the hospital I saw in the South Sudan, or even smaller primary care health centers, staffed only by a single community health worker trained to treat only a few specific diseases out of the myriad that people have, with a very small formulary of remedies. It can be so very rewarding to see patients who work hard and never ask for medical resources be cured of diseases that stop them in their tracks and threaten to ruin not only their, but their entire family's livelihood. And this does happen, using very basic tools. A few packets of oral rehydration solution or a course of amoxicillin can be lifesaving. In my rural hospital in Idaho we can't transplant a kidney or bypass the blood vessels whose blockage causes a heart attack, but we can care for nearly all of the sick people who come to us, and we do a really good job.  And the community health workers in Africa also do a really good job, treating malaria in children with fevers who might otherwise die, pneumonia in infants who are desperately ill, identifying and treating malnutrition and referring the worst affected to appropriate nutrition programs. After all of the American volunteers leave the hospital I visited in South Sudan and the rains fall, turning roads to impassible mud, South Sudanese health care workers treat patients who continue to present with life threatening illnesses. There is so much that they can't do, but, much more importantly, so much that they can do.

Tuesday, December 10, 2013

Medical Care in Old Fangak, South Sudan

Two days ago I got back from Old Fangak, a tiny town in Jonglei province on the banks of the Zaraf River, a branch of the Nile. Because I am on a self proclaimed sabbatical, and because I have wanted to visit my friend Jill Seaman who treats tuberculosis and Kala Azar in South Sudan for years, I just took off and went there, and now, many mosquito bites later, I am back.

South Sudan is the newest country in the world, having achieved independence July 9, 2011 after decades of civil war in the Sudan. The politics of independence are complicated, involving routine marginalization of the sub-Saharan population of the south by the Arab north. There are also rich oil reserves in South Sudan which may help fund infrastructure improvements eventually. I visited Juba, the capital city, briefly and spent the vast majority of my time there in the town of Old Fangak where the hospital and medical clinic are located. Two weeks and a bit and basically one small town do not make me a South Sudan expert. Still, it was quite the trip and both interesting and valuable on so many levels.

The Hospital and the Diseases
Jill Seaman has worked as a physician in Sudan for decades, originally for Doctors Without Borders (Medecins sans frontieres--MSF) and then through her own organization, Sudan Medical Relief. She works as an emergency physician and family practitioner in Bethel Alaska to help fund the project and is supported by various governmental and nongovernmental organizations including the Alaska Sudan Medical Project which arose in Bethel in response to her work. I had the opportunity to work alongside the Alaska volunteers, who help out with medical projects as well as construction of buildings and bore-hole water wells.

Jill has become one of the worlds experts on the treatment of Kala Azar, also called Visceral Leishmaniasis, a usually fatal parasitic disease caused by an organism transmitted by the bite of the sandfly. Kala Azar causes an intermittent high fever, an enlarged spleen, weight loss, swollen liver and then death, often due to other diseases such as pneumonia or tuberculosis. Two years ago the hospital was treating close to 300 new cases a week, delivering shots to 1000 people a day of primarily the injectible Sodium Stibogluconate, an antimonial, with another antibiotic called paromomycin. The standard course of treatment lasts about a month and makes the patient feel sick, but usually cures the infection which mostly does not recur. Severe cases and ones coexisting with tuberculosis or HIV are treated with every other day liposomal amphotericin B for 6 doses, which is significantly more expensive and also much easier to tolerate. During the time I was in Old Fangak, there were few new cases of Kala Azar, only about 1 a week. Apparently sandfly numbers and bugs in general are lower this year, but nobody is sure why or if this is a trend that can be expected to continue.

The other diseases that were common were Tuberculosis, Malaria and Brucellosis, with a few cases of HIV as well as infectious complications of starvation, snake bites, spear wounds, tropical ulcers, pregnancy complications and cancers. The hospital complex has several buildings including brick and cement structures that have become more dirty and broken down over the years, a new building that is made out of various prefab building materials and is easier, so far, to keep clean and several mud huts. There is a laboratory, a pharmacy and a dispensary, a construction compound a short distance away and a compound where tuberculosis patients stay for the 8 months they are in directly observed therapy.

Since this clinic is a primary health care delivery site, it has a formulary of drugs that is considered to be basic for treating common illnesses. Depending on what diseases are trending upward, drugs sometimes run out, and patients can't get the optimal treatment for their disease. Chronic diseases such as lung disease, diabetes and congenital heart disease were difficult to treat, since they required ongoing medications or surgery, which is not available anywhere close. We saw cancers too, and these cases were agonizing because there was nothing we could give to treat the disease, and strong pain medication was nonexistent. While I was there we saw a 23 year old woman with advanced ovarian cancer and a belly full of ascites. She had been to a regional hospital where surgery was felt to be impossible and had returned to us, so full of fluid she could barely breathe. She felt better after a few gallons of liquid were drained, and was able to walk around the village a bit, but her disease would eventually progress to the point that nothing could be done and she would die, with very little in the way of pharmacological comfort. There were also two very old people, one with a swollen leg from a blood clot, with multiple masses in her liver on ultrasound suggestive of advanced cancer. Anticoagulation with heparin was not possible since heparin is not considered an essential drug and is not in the formulary. Treating the clot when nothing could be done about the cancer would probably have been silly in any case and she passed away on her way home from the hospital. An old man who knew he was dying, but not why, had a huge tumor mass in his abdomen and chest and was able to return home by boat to die in a familiar place. A little boy who had trouble swallowing had what appeared to be a nasopharyngeal cancer. It may be possible to raise money for him to be transported to a center where radiation can be done, but that is very expensive and it is far from certain that it will happen.

Tuberculosis in rural South Sudan often presents with disease outside the lungs, and when it is in the spine can cause painful deformities which are often associated with paralysis of the legs. Therapy for tuberculosis can prevent death from overwhelming infection but often the spinal deformities are well established before patients even get to a doctor and they end up unable to walk.  Donors sometimes arrange for wheelchairs which are wooden scooters with hand pedals, well designed for the terrain and the patients' needs. There is plenty of pulmonary TB as well, and patients often expose others by coughing before their disease is confirmed and they can move to quarters with other TB patients. Respiratory isolation is just not practical in this setting. I saw several patients with severe spinal deformities, some of whom were dealing with the complications of paralysis--infected ulcers on weight bearing areas and restrictive lung disease which was complicated by pregnancy. I saw a couple of cases of likely tuberculous pericarditis which bedside ultrasound confirmed to be causing heart failure. In the US, pericardial tamponade (impairment of filling of the heart due to fluid in the bag that holds the heart) usually presents as a life threatening emergency. In the cases I saw, the fluid had been present in a diseased pericardial sac for quite a long while and the patient only presented when their tolerable chronic shortness of breath became intolerable due to some other event. Usually fluid in the pleural (lung) space or pericardial sac will decrease in volume when patients are treated with steroids in addition to their TB drugs, though one of these patients did die within a few days of arrival since she was also stressed by the recent delivery of a child and a 4 day trip in the hot sun to get to the hospital as well as other chronic medical problems. In the US both of these patients would have been in the intensive care unit with cardiologists in attendance, but in Old Fangak there was very little we could do acutely besides provide a comfortable place to sleep and a few cardiac medications that may or may not have been effective.

Brucellosis, which is carried by cows, was very common. It presents with fever and joint pains early in its course, but can have a myriad of presentations as it becomes more chronic, including stiffness and pain in the lower back. When it causes severe arthritis it is rarely completely reversible and the treatment for it is in no way benign. In rural South Sudan cows are currency and they are more often held as wealth rather than used for meat or milk. Piles of cow dung are everywhere and cow dung is mixed with clay to make houses.

The hospital is staffed by Jill Seaman, an American doctor, any volunteers (and there aren't many) from overseas as well as local health workers with varying degrees of experience and skill. The health workers use protocols for testing and for treating common symptoms and diseases and do an admirable job of treating those diseases that are most common, including malaria, tuberculosis and Kala Azar which would require the attendance of multiple specialists in an American hospital and much head scratching to be appropriately managed. Diseases that don't fall into common categories may not be treated well, either because they are difficult to diagnose or because treatment is not available. We saw 3 cases of newly presenting symptomatic congenital heart disease, one atrial septal defect and two ventricular septal defects, which may be eligible for free surgery if the patient can get to Khartoum where there is a heart surgery institute. There were also a reasonable number of worried well patients who had symptoms that bothered them a great deal, usually pain of some kind, but no red flag signs to suggest any more than muscle strains from chronic hard work.

Being a woman--not such a great deal
There is very little industry in rural South Sudan and, beyond building houses, gathering wood, cleaning fish and working on farms. A woman's value lies in her ability to have babies. South Sudan has the highest maternal death rate, with 2 women dying for every hundred babies born. Most of these women die at home, but some of them come to the hospital at Old Fangak with their birthing difficulties. When I arrived at the hospital the very first day, a woman was waiting in the minor surgery room on the floor in a pool of blood. She had come to the hospital with bleeding in her 24th week of pregnancy, stayed as an inpatient at bedrest with a threatened miscarriage, then returned home (walked, of course) to deliver her preterm infant who died, then came back to the hospital with a post partum hemorrhage because of a retained placenta. She was anesthetized and Dr. Jill manually extracted the placenta and the patient, though rather anemic, survived and thrived and returned home. The family buried the baby with the placenta. She was a young mother but this wasn't her first child. I saw several miscarriages and threatened miscarriages while I was there and one complication in which the mother lost her life. Unlike some developing countries where girls are devalued and even selectively aborted or killed at birth, in South Sudan a man wishing to marry must pay the family of the girl he chooses with cows, the most trusted local currency. Raising a girl baby to maturity is thus a money maker for a family. Men may keep several wives and women do not appear to have any rights. Domestic violence and fighting of all types was strictly forbidden on the hospital grounds, but not at all uncommon in the community. It would be better, I think, to be born a cow than to be born a woman in Old Fangak. Still, the women I met were often intelligent, assertive and sometimes clearly treasured by their husbands and families.

Tribes and cultures
There are many tribes with their own distinct languages and cultures in South Sudan, but the main 3 are the Nuer, the Dinka and the Shilluk, all of whom I met in the hospital. Those who have had education may speak Arabic or English, but if they do not, they cannot communicate with each other and exist in Old Fangak in what appears to be a fragile peace. Nuer people were in the majority and I picked up a smidgen of Nuer language. The usual greeting "male" means peace, which is a nice thought. Nuer boys have a distinctive scarification on their foreheads which is part of a coming of age ceremony in which the forehead is inscribed with parallel lines with a sharp object by an elder of the tribe. If the boy squirms or cries, the lines are not straight and he is marked as a coward. I didn't see any complications of the procedure while I was there, though I imagine there must be some. Girls also have decorative scars on their face and chests, more often patterns of dots. Occasionally the scars grow thick on the chest and women would complain of pain and itching when this happened. They often pull their own teeth and train the remaining teeth to splay in the front which is considered to be beautiful.

Critters and the natural world
I arrived at the end of the wet season and if I had stayed longer the weather would have gotten cooler, possibly down into the 60 degree range during the night. As it was, it was mostly in the mid 90s during the day, with very high humidity, and I was sticky sweaty all the time. In the evening before I retired to my tent under the big tamarind tree I would take a bucket bath which was delightful, but which would wash off the mosquito repellent, making lounging with friends around the campfire less attractive. Nights were long, as much as 10 hours in my tent reading and writing and thinking, which was a delightful luxury that I don't allow myself very often at home. Night sounds were frogs on the shore of the river, squeaks of bats, sometimes an owl and packs dogs working out their issues in the distance. I mostly slept through the sounds of cats eating overconfident rats. Early morning roosters would crow starting about 4 AM and then doves would begin to coo in the trees and kites and ibis would call. Honey bees would buzz in the trees. They are said to be aggressive but I never had problems with them. There were monitor lizards in the yard and a python in the latrine, cobras in the pantry trying to help with the rat problems and various poisonous snakes that were unlikely to take me unawares since I wore good solid shoes and carried a headlamp. The insect life was fascinating, with huge beetles and praying mantis and evil biting carnivorous ants who attacked our thanksgiving feast leftovers while we slept. Mosquitoes were plentiful, though not as plentiful as they are some times, I'm told. Some of them carry malaria. There are big flat spiders and spiders with long legs but none that seemed particularly threatening. There was a crocodile, but I never saw him. The diversity of birds was amazing and I can imagine bird watching tours might make the area some money eventually. The water of the river is not bad, though it carries schistosomiasis which, if untreated, can cause various major organs to malfunction. There is a treatment for it, though, a single pill of Praziquantel, so I went swimming and enjoyed it very much. Both men and women bathe in the river often and are good swimmers. It looks like they are having fun.

Food, or lack thereof--
Starvation continues to be a major health issue in the area I visited. As the civil war has ended people are starting to farm and garden which increases the variety and abundance of food. People can grow their own corn and sorghum which are major staples. Cows milk supplements their nutrition. They grow a small amount of tobacco which people smoke in pipes in the evenings. The people stuck in the hospital cook their own food, but many of them depend on bags of sorghum and oil from the world food program, as well as bags of "plumpy nut," which is provided to some categories of malnourished people. Plumpy nut is expensive and is provided by aid organizations for patients with severe malnutrition. It is just peanut butter with sugar and milk powder and vitamins added, but the little serving size bags make it easy to eat and it resists spoilage. Women and girls make sorghum cereal by grinding the sorghum on boards or stones with a rounded piece of wood, then cooking it over tiny cook fires. This is usually breakfast, lunch and dinner for people at the hospital. Very occasionally meat supplements their diet. Nobody was fat.

Safety issues
I'm back now, safe and healthy, and I didn't even lose much weight. Stories of Sudan and South Sudan in the news made me and my family and friends worry that there would be gunboats and AK47's and raids with burnt villages and child soldiers and machete attacks. Although this is not impossible in a country where violence has been common and widespread for decades, there has been peace in Old Fangak for 2 years and there was never any hint of danger to me personally from anyone armed or angry. The generation that is now in its teens and twenties has grown up without much of the values that keep communities strong, but still there are communities and people who value them and wise people who act as role models. There are still cattle raids which lead to conflict with physical violence of various kinds. There are many less guns in circulation, and the area where I stayed is disarmed of its guns, though they are still available at the police station should war break out again. Mostly people injure each other with fists and spears, and there is less danger of bystanders getting unintentionally harmed. The most vulnerable I felt during the whole trip was when I was at the airport in Juba flying in and out of the country. It is crowded and inefficient and contrary and seems designed to make transit as difficult as possible. Still, thousands of people every day make it into and out of the country and in fact I had no trouble.

Jet lag is fading, but every morning I wake up finding myself trying to diagnose mysterious tropical disease syndromes and cure the incurable. I am thankful for cold weather and a warm house and a well fed dog who does not expect me to throw a rock at her. I learned a huge amount in a short period of time and met wonderful wise people, both African and American. It was difficult, time consuming and expensive to get to South Sudan and, despite all that I will probably go back.

Wednesday, November 20, 2013

I'm now a certified ultrasonographer: passing the ARDMS test

I just finished taking an exam for the American Registry of Diagnostic Medical Sonography. Having passed it, I can now put RDMS after my name, standing for Registered Diagnostic Medical Sonographer. The RDMS is a credential that many ultrasound technicians carry, and occasional physicians, especially those who make ultrasound part of their practice. So now, should I ever be at loose ends, I can potentially get a job as an ultrasound tech.

To take the ARDMS qualifying test, one must first satisfy various requirements, which fit into categories meant to include ultrasonographers of great experience, ultrasonographers who have gone through a training program (usually 1-2 years) physicians who studied ultrasonography extensively during their medical school and residency training and physicians whose experience includes extensive review of hundreds of scans by experts. Proving experience requires letters from a supervising teacher. The exam is a proctored 5 hour test, 3 of which is in a specialty area and 2 of which tests knowledge of the physics and technology, with a special focus on safety. Due to the miracle of digital communication, I was able to take the test in my own time frame, in a "Pearson VUE" test site about 90 minutes drive from my home. The test site is in a little office space, but has a silent room with constant monitoring, manual pat downs, and rigorous identity checks. Apparently Pearson VUE is part of a multinational company out of England which owns a large share of the Penguin publishing company and specializes in online learning. It was comfortable and low key. Short of having a cookie break and access to online resources, I can't think of a better set up for success.

The exam is pretty specific. My ultrasound mentor recommended I take a review course which, in combination with quite a few hours of study, would probably result in me passing the test. The review course he recommended was by the company ESP ultrasound, taught by people who specialize in making sure students pass the exam. The course director is Sid Edelman, has been teaching for decades, and covers the ultrasound physics curriculum. When I took the course, I thought that the level of trivia they taught could only have been due to some sort of collusion between the people who write the test and the people who taught the course. After taking the test, I realized that the test questions were not necessarily in the study guides for the exam, but that there was considerable overlap between what the course taught and what we were tested on. Much of the trivia that was taught was referred to in the exam questions, nevertheless, exam questions really required some knowledge of physics beyond what the course tested, and many of the questions were tricky, requiring deduction rather than straight memorization. Preparing students to take standardized tests is a very big business in the US, so even in a narrow field such as ultrasound technology there are many choices, from Pegasus Lectures, providing on-site teaching in Atlanta and Tampa, and Burwin Institute which provides online material. Having a professor to emphasize the important information was really helpful to me. Without it I would have questioned the need to learn such a broad collection of detail, and would have found studying much more frustrating.

The physics part of the exam made me wish I had taken a real, in depth course on how ultrasound works, maybe something on a college level that lasted a semester and made me able to build my own basic ultrasound out of stuff I could buy at the hardware store. Since that was not possible, memory of my distant physics education and frequently consulting multiple sources to explain points that didn’t make sense helped me answer some of the more abstruse questions. Because the real physics of the complex machines we use now is beyond most people, what we learned did not truly represent reality. This was very disappointing to me, since I had hoped I would learn enough to be able to answer some questions about why the technology is so slow to develop. I wonder if the lack of detail also helped protect the companies whose livelihoods depend on producing a competitive product. I’m betting that is part of it, though that’s kind of creepy.

During the part of the course that taught me about  ultrasound of the abdomen, thyroid and testicles, I developed awe for the knowledge most ultrasound technicians eventually have of 3 dimensional anatomy. Even at my very most knowledgeable, just after finishing my first year in medical school complete with cadaver dissection, I had nowhere near the depth of understanding of how the organs are packed into the body and served by so many named blood vessels. Ultrasound has repeatedly sent me back to my anatomy books to try to figure out how things lie in the human body. I will undoubtedly continue to improve, but there are many fresh faced young people with many less years of training, who make only a fraction of my salary, who will always be better at it than I am.

Passing the exam means that I know enough of the anatomy plus technical details and disease processes that I can pass the same exam as my technician colleagues, but our proficiency is in no way identical. I can't compete with the exhaustive knowledge of anatomy a career ultrasonographer has, and he or she can't possibly understand the level of implications of constellations of physical, labratory and ultrasound findings and combine them with patients' stories and priorities. It is good that this test has room for all of us. It could have been written so that either us would routinely fail.

So why take this test? I'm not planning on a career change, after all. Being a doctor is plenty absorbing. I noticed that the ultrasound teachers who I work with usually have RDMS after their names. It is a recognition of competence that need not come with a long explanation. I have always been concerned that some group for whom I work will have extensive requirements for ultrasound credentialing. I envision myself happily examining all of my patients with ultrasound and being told that, no, that was not allowed. So far it hasn't happened, but only because most places I work have no concept of bedside ultrasound, other than perhaps as a method of guiding procedures. It also seems likely that the credential will give both me and any employer some confidence in my ability to actually teach other people. I surely do not believe that an ARDMS test should be mandatory for physicians who employ bedside ultrasound because the requirements are way too cumbersome, but it will, for a few, be useful as a way of communicating competence in a variety of aspects of the practice.

I have been intermittently studying this stuff for about 6 months, including such questions as how fast ultrasound travels in soft tissue and the components of attenuation and how they relate to speed of the ultrasound beam and Snell's law and how it might or might not affect real time ultrasound. I have not yet found a way to make this stuff help me, but I trust at some moment I will look back on my previous grasp of the material and wish I had learned it better.

Thursday, November 14, 2013

Who should take statins? What, exactly, do the new American Heart Association guidelines say, and should we agree with them?

Statins made the news in a big way this week. The American Heart Association, in collaboration with the American College of Cardiology, just released recommendations that should change the way we prescribe medications called statins, including drugs like Lipitor and Crestor and their generics, Atorvastatin and Rosuvastatin. The headlines say stuff like "More Americans may be Eligible to Receive Cholesterol Lowering Drugs!" Boy howdy, aren't we all in for a treat?

Big Money:
I am a bit, or more than a bit, skeptical of news about statin therapy because Lipitor, before it went generic, was responsible for over 6 billion dollars in revenue for Pfizer and since it went generic, Astra Zeneca is raking in more revenue than they did last year for their cholesterol drug, Crestor, at about 1.6 billion dollars. This kind of market influence is associated with significant influence on the attitudes of both physicians and patients through advertising and research support. I think that our love affair with statins cannot be separated from the fact that the sale of these drugs is a significant contribution to our economy.

Nevertheless, I recognize that statin drugs have contributed significantly to heart health since they were first released. Statin drugs were first released in 1987 after some false starts. The earliest statin caused muscle breakdown and killed some of the dog's upon which it was tested. Lovastatin, which was considerably less toxic was the first statin to be released. Statins reduce cholesterol by inhibiting an enzyme, HMG CoA reductase, but also stabilize the walls of blood vessels and reduce inflammation. In so doing, they reduce the risk of heart attacks, which are most commonly caused by obstruction of one of the coronary arteries by atherosclerotic plaques which rupture and form a clot that blocks blood flow to heart muscle. Inflammation is important in this process as well.

It has been known for decades that a high level of cholesterol in the blood is associated with increased heart attacks, as well as other conditions related to blood vessels such as strokes. Therapy to reduce cholesterol sometimes reduces the risk of these conditions, and many studies have been done looking at ways to reduce cholesterol. Not everything that reduces cholesterol reduces heart attack risk, though, and reducing the cholesterol and fat in the diet does not have a very significant effect on either overall cholesterol levels or on heart risk. Statins, though, do reduce the cholesterol level quite significantly and also appear to reduce the risk of various vascular events.

The Controversy:
Heart disease is the leading cause of death in the US, so reducing the risk, even a little bit, has the ability to save many lives. Statins do reduce the risk of heart attacks, but for most people, only a little bit. In the patients most likely to benefit, those who have had heart attacks and so are at risk of further disabling recurrent heart attacks, as many as one in 29 patient who take statins for 4 years will avoid having a recurrent heart attack or death when compared to patients who do not take statins, as reported in a recent meta-analysis. For patients who haven't had heart attack, the chance that taking a statin will prevent having one is lower, for women 1 in 148 over 4 years. Statins do have side effects, from annoying symptoms like gas and muscle pains to more significant ones like memory loss, weakness and diabetes.  In fact, the chance that a person with low to moderate risk of heart disease will get diabetes as a result of statins is quite a bit higher than the chance that he or she will be saved from having a heart attack. Dangerous and sometimes life-threatening muscle destruction with associated kidney failure is a rare but real side effect, which I have seen in practice. Significant side effects plague 18% of patients who take statins. A very good article, looking at controversies related to statin therapy, written by a professors from Harvard Medical School and UC San Francisco who question the mainstream belief in these drugs' effectiveness and safety, can be found in this week's New York Times. The vast amount of scientific data on statins is interpreted differently by different experts, but the way I look at it, in the patients at greatest risk for heart disease, 29 people have to take a statin for 4 years in order to save one of them from a heart attack. For patients at lower risk, the numbers are even less convincing. In the lower risk patients evaluated 148 have to take a statin for four years for one of them to not have a heart attack, which means that 147 patients take the drug, along with its side effects, for 4 years to no good purpose.

The major issue, beyond the economics and financial interests of drug companies, revolves around differing views of our mission as doctors, and also around differing experiences of physicians involved. If a person is a cardiologist, avoiding heart attacks is practically the only thing that matters. Cardiologists rarely see their patients for problems other than those related to their heart problems and don't face the day to day difficulties related to statin side effects. When a patient has muscle pains and cramping or stomach distress, he or she doesn't usually expect the cardiologist to resolve the problem. Cardiologists are great champions of statin therapy. Large organizations, such as the American Heart Association are also great champions of statins. The big picture for them is that a small effect on decreasing heart attacks, multiplied over millions of people who might take statins, means many lives saved. As a physician who treats individual patients, however, and as a person who may someday be a patient, I find it hard to advocate taking a drug with a very complex range of effects for a very small chance that it will make a positive difference. Even if we believe that our responsibility to the population is more important than to the individual, how do we assign value to patients whose lives are potentially saved against the much greater number of patients who feel just a little bit sicker because of a medication we prescribe?

The New Guidelines:
This week, to great fanfare, a new approach to prescribing statins was introduced. Many experts reviewed the extensive research, focusing on randomized controlled trials which are the most rigorous way to evaluate effectiveness. They were interested in finding the most effective and efficient way to reduce heart attack risk by influencing cholesterol. They looked only at statin therapy, since the vast majority of good research was on statins, as opposed to, say, fish oil or niacin or fiber or chelation therapy. They found that the most efficient way to reduce heart disease risk with statins was to check the cholesterol of all patients over the age of 40, and treat those with high risk of heart attack with either moderate or high doses of statins. The patients who should be encouraged to take statins are in one of 4 groups:
  1.  Patients with LDL cholesterol greater than 189, who probably have a genetic condition that puts them at very high risk of heart disease. 
  2. Patients between the age of 40 and 75 with diabetes, whose LDL levels are above 70 (very low.) 
  3. Patients with prior heart attacks.
  4. Patients with a 10 year risk (see this risk calculator) greater than 7.5% of having a heart attack.

They recommended not checking cholesterol levels compulsively in order to reach certain set goals, though they do recommend checking the occasional level to see if the patient is actually taking the drug. It appears that treating to a target is very energy consuming and encourages us to add drugs that don't have evidence of effectiveness. In my experience, it can lead to focusing on numbers rather than on humans, but can also be the basis for conversations that might lead to more exercise and healthier living. Still, not focusing on cholesterol numbers will free us up to pay attention to issues of patient care that are probably more valuable. There were no good studies on treating patients over 75 with cholesterol lowering drugs, other than those with prior heart attacks, but it seemed likely that they would benefit. No recommendations are made for these folks, other than that they should discuss pros and cons with their physician.

Regarding side effects, the general implication of the article was that patients with muscle pains on statins should try to take them anyway, and that doctors should make sure to ask the patient before starting therapy if they had muscle pains so they could counter any complaints with the assertion that they had this before starting the drug. Having treated patient with statin therapy for years, I think that muscle pains are a very common side effect and can be disabling. I think that minimizing the importance of these symptoms by telling a patient that they should continue to take the medication that causes this will potentially reduce patients' quality of life and overall activity level. I am disappointed in the way this issue was handled.

One very interesting implication of this study is that an elevated cholesterol alone does not mean that a patient should be on a statin. Many people who are concerned about their health take a statin for an elevated cholesterol level, but their risk of heart attack is extremely low, so taking a statin will do nothing to improve their health. This is a positive development.

These new recommendations may be somewhat better than the rather random approach to cardiac risk reduction related to cholesterol that existed before, but are likely to overtreat patients without heart disease, resulting in patients whose health will be worse related to side effects, and who will be more dependent on the health care system because they will now be taking a drug. The guidelines will allow some people to stop taking their statins, which is good. I feel suspicious of the huge media coverage of this recommendation (most treatment recommendations get no news exposure) and I do expect that all of the free publicity will substantially increase the revenue of the companies that make statin drugs.

Wednesday, October 30, 2013

Third trip to Haiti: inspiring projects on La Gonave

I just got back from the Haitian island of La Gonave (lagonav in Creole) after 8 days there visiting people who work on projects we help to fund. I'm glad to be home, because this is where I live and I missed toast with jam, my dog, and not being sticky sweaty all the time. Still, it was a wonderful trip and full of things to get excited about.

I first visited Haiti in 2010, about 3 months after the big earthquake hit the main island and killed 250,000 plus people, primarily in Port Au Prince. I went to La Gonave, 35 miles off the coast of Haiti, on a trip that was planned before the earthquake and which had nothing to do with the acute worsening of misery associated with the widespread destruction of the main island's marginal infrastructure. La Gonave was definitely affected by the earthquake, but nobody was killed, mainly due to the fact that there were very few large buildings and very few people inside in the late afternoon in the few places that did collapse. Poorly constructed houses did fall down or become uninhabitable, so some people were homeless or had to live in rickety structures of wood or palm leaves or in cramped quarters of their extended families or in chicken coops. Many were anxious or grieving because of the loss of friends or family members in Port Au Prince. People came to the island from Port Au Prince to get away from the destruction, with injuries, needing food and water and medical care, but by the time we got there most had gone home and life was returning to its baseline.

Baseline for La Gonave is very rural. It is about 8 by 25 miles and is home to about 200,000 people, most of whom live in the main town of Anse a Galet.  There is very little tourism, and almost all of the non-Haitian faces belong to aid workers of some sort or another, and there are very few of those. We visit a community in the mountains above Anse a Galet, 6 miles away, though it takes 1 1/2 hours by truck due to terrible roads. In the mountains there is no running water, no electricity and very little cash economy. The island was once a tropical paradise, I hear, but the French and then the Haitians deforested it and when it was brown and ugly, sent undesirable people there to suffer. There is very little in the way of government programs. Apparently it is possible to get a policeman to come eventually if something happens, but I have never seen a policeman. There is a hospital in the main town which is charitably funded by Episcopals, I think, and is slimly staffed. It is beyond the financial means of most of the people who live there, and so they get very little medical care. Foreign aid groups such as World Vision provide for some services like vaccination, but a minority of people are able to access care.

Human beings are amazing, though. Put them on a brown hot deforested island and they make communities, build schools, grow gardens, they organize for the rights of women and children, they make music. The people who live on La Gonave descended almost entirely from African slaves. Their common language became Haitian Creole, which combines a kind of phonetic French with words from English and other languages. After France recognized Haiti's independence, the country was saddled by crippling debt to both the US and France, hindering its ability to become economically viable. Haiti has also had terrible and cruel leadership for decades, and political unrest and official corruption has resulted in very poor infrastructure, despite huge amounts of aid which pours in on the heels of the various disasters (hurricanes, droughts, earthquakes) which befall them. La Gonave gets only a very tiny amount of that aid, though in the 2 years since I was last there, a UK based charity, Concern Worldwide, has built over 100 deep water pumps which have drastically improved everyday life for people who spent hours a day fetching a few gallons of water from the few springs scattered around the island. Church organizations give some money to support churches and schools that have a religious mission. The most energetic of young people make their way to Port Au Prince for education and then to the US, wiring money home to families which bolsters the tiny cash based economy of the island. There are essentially no exports, except sometimes fruit or fish which go to Port Au Prince. It is a subsistence culture, but it is also green and beautiful, and safe and welcoming to someone like me.

My thoughts in visiting La Gonave have evolved significantly since I first visited. I initially supposed that I should just bring as much medicine and medical testing equipment as was practical because I was sure to see lots of people dying because of lack of medical care. It turns out that there was some ill health, but more just discomforts of being human and working really hard, and there was very little I could treat. The sickly die in childhood, those who are left are pretty tough. Older folks couldn't really get to where I was, and many people who might have been helped by my services, like those with hypertension and diabetes, would have needed those services long term for me to have done any good. I did save a goat who was sick and maybe a baby who had pneumonia survived due to an antibiotic I gave her, but I was unable to do anything for the woman with advanced breast cancer or the one with the non-healing wound or the grandmas whose blood pressures were upwards of 200/140. There are drug dispensaries on the island, with various medications which might be useful, but people can rarely afford even the very reasonable prices for these. What really improves the lives of people in developing countries (the US, around the industrial revolution, was a good example) is clean water. Diarrhea, mostly transmitted by contaminated drinking water, kills more babies than any other disease. In Haiti, AIDS also kills people, and starvation is a significant part of the disease syndromes that shorten peoples' lives. Anything I might do for my Haitian friends would tend to be temporary, but anything they can do for themselves sustainably might make a long term difference. This time I focused on projects that could be made to be sustainable, without unacceptable long term financial support from aid agencies or our Haitian focused nonprofit, Paloma Institute.

We provide some financial support and ongoing intellectual collaboration with a group of master gardeners and community leaders called JLLP (jaden legim selavi paysen--vegetable gardens are the life of the people.) They, in turn, support gardeners, a school, education and sanitation projects and do some micro-lending for various other community projects. During this visit we walked through several gardens which were much larger and more lush and productive than they were the last time we visited, and brought some gardening equipment which is not available there. Transporting seeds to Haiti is theoretically strictly regulated, but vegetable seeds are what they need most, so I may or may not have brought various organic and non GMO seeds of the type that grow well in a hot humid environment. One of the master gardeners, Eligene Deravil, is particularly knowledgeable and devoted to garden experimentation and educating other people who want to have successful gardens. He has a huge garden with beautiful compost piles, grows 3 crops per year and has 3 people who work for him. He was a very poor child, a restavek (domestic slave) when he was small, but is self motivated, unselfish and tireless in all the projects I've seen him take on. It is inspiring to watch him work.

We also try to mentor people in art and craft projects, because most people have very little ability to make money, are very motivated to create things, and La Gonave could sure use an export. We worked with women who were making beaded jewelry and purses out of recycled waste to find items that would potentially sell to US consumers. There is clay, and we worked to find a good source and have, in past trips, explored sustainable pit firing, but have been hindered by lack of good quality material in the area we visit. One man, though, took the clay idea and created a form out of the rather crumbly clay that is easy to find and began to make vessels out of concrete. He was excited about creating large sturdy buckets to be used as composting toilets. He was able to make a very solid and culturally acceptable container during this visit which can be used by families who can't afford a pit toilet, and which can be covered while composting begins, then used as humanure compost for gardens. This will require ongoing experimentation, but in any case is an improvement on what those families do now, which is to poop on the ground, without regard to groundwater contamination or hygiene. He could make one of these for $5 US dollars, which is affordable to people there, and we gave him some startup money to make some to give away to families with no money. He will eventually paint them, and perhaps have deluxe models that will sell for more money to families that are more financially comfortable.

My traveling companion does wild animal rehabilitation at home and we both keenly feel the tragedy of the domestic creatures who get even less TLC than their poorly fed owners. It is fine to be a chicken in La Gonave, since there are plenty of bugs and nobody cares where you wander. Eventually you become food, but it is in everybody's best interested that you be treated well and kept comfortable before that happens. It is not so good to be a dog. Dogs are dependent on humans for food, and there are very few scraps, and nobody has ever heard of dog food. Puppies routinely starve after they are weaned and this is part of the ecology of the place since there is no doggy birth control. Goats do pretty well, much like the chickens, though they are tied up to keep them from raiding peoples' gardens. Donkeys have the worst lives. They exist only to carry heavy loads so it is not necessary that they be treated with any kind of consideration beyond that which keeps them on their overburdened feet. There are people trained in animal medicine, not real vets, but people with training. One of our friends had attended a 2 year animal medicine course given by the aid organization World Vision, but had had little opportunity to use his skills. We came upon a donkey with a saddle sore that was so severe that it was liable to have ended in the animal's painful death before too long. We were able to give him $20 to buy some standard veterinary pharmaceuticals and then give the donkey a little love and debridement, some penicillin and worm medicine and a chance to live a few more years. The owner got a chance to have a functional donkey again and some education in animal care, the under-employed animal medicine technician got practice and publicity, and stories like this travel. We had another such patient in a couple of days, with more people wanting to see how to care for it, and maybe some good will come of all of this.

Birth control and safe sex are vitally important in the developing world and are very tricky due to cultural norms and deeply believed misinformation. I had a terrific translator, a man who had worked in the US for 9 years before being deported due to a visa violation. His understanding of the language and culture made it possible for him to translate not only what I said, but what I meant, and his winning personality made people hear a message that they might have tended to reject. I gave a talk to about 30 people, many of them community leaders, about how wonderful condoms are, and gave out about 1000 very attractive but quite inexpensive (for me--I bought them in bulk online) condoms for distribution. We talked about AIDS, unwanted pregnancy, the way they work and that they don't break and go to your heart and kill you. I talked about personal experiences and people laughed and had a good time. Condoms are not hard to get, and many organizations are set up to provide these free of charge if there is demand. In my tiny way, I hope to create demand, which will mean that use of condoms will be potentially sustainable without me. At the very least, we talked about sex in a way that was open and honest and the 1000 condoms represent 1000 opportunities to not get pregnant or contract a sexually transmitted disease.

The visit also offered an opportunity to learn about schools in rural Haiti. There are many. They are usually not free. The cost per year is $25-$30 USD, and most parents pay this. There are no standards for teaching, and beating and yelling at students is common. Sexual contact between male teachers and female students is frowned upon but not unusual. There is a standardized test at the sixth grade level, which has some influence on the content of what is taught. Haitian Creole is the language used in most schools up until third grade, French thereafter. Some schools are religious and are supported by churches outside of the country. Schools sometimes pay teachers a little bit, but teachers often work for nothing but the promise of someday being paid and the opportunity to have a job in their community. Schools really want money from outside because it is very difficult to make a school self sustaining. Students learn better if they are fed, and making beans and rice for everybody in a small school costs a lot of money. School supplies are less expensive in Haiti than in the US, but in La Gonave they are in short supply, as are books. It is hard to know, as an outsider, which schools deserve supporting. We talked to the leaders of several schools in our area about forming a school district to share resources and ideas, and our translator expressed his desire to start a program to teach adults skills such as teaching and translating so that the quality of education could improve. In our area many of the schools incorporate teaching gardening and crafts so that students might develop practical skills. Education is key to allowing these rural poor children to have real choices in their lives and so we will try to support their efforts.

I saw very few actual patients, since I didn't advertise my visit that way, but did see some. An old woman with a stroke provided an opportunity to talk about high blood pressure prevention and treatment. Hypertension is common in older Haitians and results in the usual complications that we see in the US. Regular treatment with medications is usually not affordable, but high salt diet and late life obesity are modifiable risk factors. Painful knees and backs from hard work on steep terrain with heavy loads were common, and people were grateful for a few aspirins, since over the counter medications are hard to find and expensive. I saw a couple of people who truly needed acute medical care, a baby with probable malaria and a young woman with a severe leg infection, and recommended immediate transfer to the hospital in Anse a Galet, but I have no idea what happened. Both patients would have been hospitalized immediately in the US. I was able to do a few ultrasounds with my handheld machine, and everyone loved looking at babies, who were appropriately positioned and appeared to be healthy. These procedures were primarily to open up conversation about healthy pregnancy, and ultrasound always seems to have the ability to make people appreciate their bodies. I would love to do a more widespread screening for hypertension and cardiac disease, but would prefer to do this as part of a larger effort that might potentially include treatment. I would also need easy access to an electrical outlet, which I did not have.

I'm home now, glad to eat toast with jam and wear thick wool socks and sweaters. E-mail will allow me to see some of the projects that happen in La Gonave, and the miracle of wire transfers will make contributions from me and other people who find this stuff inspiring possible.

Monday, October 14, 2013

The Green Journal speaks out on Bedside Ultrasound

I frequently throw away the American Journal of Medicine (the "Green Journal") without reading it because it is not one that I actually ask for and it doesn't address questions that I find interesting. Lately, though, the quality of the material is better and I am more likely to pick it up and page through the articles.

Today I found that there were two editorials on the use of handheld ultrasounds, specifically the Vscan, the little pocket model that I have used for the last nearly 2 years as a diagnostic tool at the bedside. One article, by Julie Kim MD and colleagues from Northwestern University in Chicago, IL presented the opinion that these devices should only be used as part of clinical trials or for evidence based indications. They based this view on a review of the literature which showed few prospective trials showing improved patient outcomes.

The following article, by Roy Ziegelstein, MD and David B. Hellmann, MD points out that "wise use of hand-carried ultasound may provide valuable information more quickly and less expensively, and thereby benefit both clinicians and patients." Furthermore, they point out that this "may enable clinicians to have a more active role in patient care, may facilitate patient education at the bedside, and may well restore joy and greater satisfaction to the life of health professionals." They do, however, agree with the first authors that before these devices are used by non-specialists in a widespread manner, there must be well conducted trials that demonstrate clinical benefits to patients.

When I first read the editorials I was frankly very irritated. Both the for and the against positions came out against actually doing routine bedside ultrasound as part of the physical exam. The specific argument was that bedside ultrasound would identify internal abnormalities which were not clinically significant, leading to overdiagnosis and over-testing and probably over-treatment. Dr. Kim et al pointed out that we know that screening for pancreatic cancer and ovarian cancer in patients without symptoms does not change the outcomes of these diseases, and that people with a little ultrasound in their pocket would not be able to resist finding these things. My experience with the Vscan is that it is a fine machine for looking for fluid in the wrong place and for examining the basic functions of the heart, and occasionally for examining abnormalities like tumors that more detailed imaging procedures or blatant symptoms had already pointed out, but that it is not at all easy to find an ovarian cancer or a pancreatic cancer with any degree of certainty, even if I look really hard, which I don't. The point that these authors completely miss is that we physicians are all using our physical exam skills to identify the diagnoses I look for with my little ultrasound, and we know that our physical exam skills have terrible sensitivity and specificity. We really can't tell if a person has heart failure or fluid overload or ascites (fluid in the belly) or pleural effusions (fluid around the lungs) which are vital to giving appropriate treatments.  We are taught how to detect these things with our hands and ears and stethoscopes, but good studies show that, even if we are skillful and attentive, we are not much better than chance at identifying these things with any degree of certainty. Nevertheless we continue to use our physical exam skills to make these diagnoses and treat or test the patient based on educated guesses. Ultrasound, even performed inexpertly, is better than this.

I stepped back a bit from my desire to scream and thought about the issues these authors brought up. Yes, there is a potential for overdiagnosing various conditions of little or no clinical significance or finding diseases that no amount of early treatment can cure. We are going to need to figure out what to do with our new level of confidence in our diagnostic abilities. We will need to figure out how to define competence in this new technology so we don't find ourselves becoming convinced by blurry images of findings that aren't real. But there are many physicians who employ bedside ultrasound successfully and already use their pocket ultrasounds to "have a more active role in patient care and facilitate patient education at the bedside" and are even now restoring joy and satisfaction to their calling. These doctors are not involved in clinical trials, at least not most of them, but are on the forefront of discovering what this technology is really good for. Many medical schools consider performing and interpreting ultrasound at the bedside to be a core competency, and medical students are trained to make it part of their practice. Dr. David Tierney directs IMBUS (Internal Medicine Bedside Ultrasound program) at Abbott Northwest Hospital, the largest hospital in Minnesota's twin cities, which teaches all of the medical residents to be competent to use bedside ultrasound. This program combines extensive practice with wireless communication and frequent conferences to share expertise and produces internists who will most likely seamlessly incorporate ultrasound into whatever patient care field they eventually pursue. Like the stethoscope or the computer, bedside ultrasound, and pocket devices that make it more convenient, have already transformed medical practice, and now the most interesting question is not "should we?" but "how do we?"

It was gratifying that a journal that is one of the standards of Internal Medicine is addressing the issue of handheld ultrasound. It is a little disappointing that the doctors giving their opinions don't seem to actually do bedside ultrasound, which would make their opinions a bit more significant.

Tuesday, October 8, 2013

Medical Errors: Do 400,000 people really die from these every year in America? What does it look like from the inside of a hospital?

I just read an article in the Journal of Patient Safety by a NASA toxicologist and patient safety advocate, John T. James PhD, which addressed the question of medical errors in hospital settings. Dr. James evaluated the results of 4 studies of patient adverse events (PAE's) and extrapolated the results to estimate that 400,000 deaths yearly are associated with preventable patient harms. The Harvard Medical Practice study which reviewed records from several New York hospitals in 1984 estimated that deaths due to medical error numbered about 98,000 per year, and that number has been quoted widely and embraced as the truth by the Institute of Medicine, a nonprofit organization which seeks to advise patients and decision makers about important issues in medicine. This current article uses different methods and suggests that the number may be much higher.

After reading the article about the article on a public interest site on the internet, I perused the comments, which were primarily outrage, interspersed with a doctor or two who seemed pretty defensive and said unpopular things that were on the order of, "What do you expect? We're doing the best we can!" My first reaction was to wonder what exactly the study meant, how was it done and what were the definitions. I found the article and read it and came to some conclusions that probably ought to be part of the discussion.

How did they reach their conclusions?

The 4 studies that were evaluated were in hospitals in various areas of the country in which a "Global Trigger Tool" was used to identify patients who might have had an adverse event, something bad that happened in the hospital. This could have been a missed lab test, a procedure complication, a drug reaction, a hospital acquired infection. The charts of the patients who were identified this way were then reviewed by doctors and the doctors determined if it looked like the adverse event contributed to that patient's death. Each of the studies was performed a little differently, but they shared this general method. They found that about 0.65-1.4% of patients who were hospitalized had an adverse event that contributed to their death. Overall, in the 4 studies, 4252 randomly selected patients' charts were reviewed, and of that number, adverse events contributed to the deaths of 38 people. Based on other studies, 69% of these adverse events were felt to be preventable, and multiplied over the 34.4 million patients hospitalized yearly, they came up with 210,000 people yearly for whom preventable adverse events contributed to their deaths. Since their methods did not include errors of diagnosis or errors of omission, that is not figuring out what was wrong or not treating it according to accepted guidelines, and medical errors are not always well documented in the medical records, the author rounds this 210,000 up to about 400,000 patients who died partly because of medical error.

Why this is somewhat misleading

This is a big and very important issue. I see medical errors and, more often, adverse events from decisions that, in retrospect, were wrong, on a daily basis when I work in hospitals. But there is something very wrong in the way that this article is being reported. The author himself labels adverse events that contribute to death as "lethal errors." Some of them are, but some of them just contribute to the lethal cascade of events, from life choices to decisions to pursue aggressive treatments, which end in death. The overdose of insulin that kills a patient is a rare event. The blood clot in the leg because of failure to order prophylactic heparin that leads to full anticoagulation that leads to gastrointestinal bleeding which leads to intensive care unit stay which leads to ventilator associated pneumonia and death due to drug resistant organisms because the patient was a diabetic who also dabbled in intravenous drugs, or some version of this narrative, is common. The failure to prescribe heparin in the first place should hardly be called a lethal error. In fact, the prescription of heparin in the first place, itself, might have lead to a life threatening complication.

The outrage which is beginning to erupt is taking the form of "doctors kill 400,000 people a year in hospitals due to negligence." That is not what this paper says. It says that 400,000 people who die each year in hospitals are made sicker by the things we do to them. Another issue brought up in this article is that 10 to 20 times this number of patients are significantly impacted by medical error in hospitals. These events might be a hospital acquired infection or a surgical wound complication or a drug error from which a patient recovered, though not without suffering. If the estimate is correct, we are making 4-8 million people sicker in hospitals yearly in our attempts to heal them. We need to pay good attention to all of these things and identify the processes that make them happen and look for practical solutions. This falls under the heading of patient safety. Much is actively being done in hospitals to improve patient safety, but the complexity of what we do limits our ability to protect those in our care from harm.

Swing shift in the hospital yesterday: a day in the life...

I admitted 4 patients to the hospital yesterday and so had ample opportunity to make life altering mistakes in the lives of 4 individuals. The first was a morbidly obese woman with new diabetes who had developed a severe leg infection related to the fact that her legs were always swollen. The infecting organism was probably a staph or strep, and given the community in which I am working, it might be MRSA, the methicillin resistant staph. I started her on two antibiotics, both of which might cause a life threatening allergic rash, and one of which might cause kidney failure. Both might also lead to a life threatening Clostridium Difficile infection of the colon. Starting insulin might lead to a hypoglycemic reaction that could result in death or disability. Simply putting the patient to bed might lead to bedsores, especially if I treat her pain with intravenous opiate medications which could lead to respiratory depression and death or disability.

I then moved on to the man who had been monthly to this hospital due to complications of ongoing methamphetamine abuse with diabetes for which he usually failed to take his medications and endstage liver failure from hepatitis C. This time he wasn't very sick, just had a very high blood sugar level and a very low potassium level. I gave him potassium first, because giving insulin would lower his potassium further and might cause a fatal heart arrhythmia. I gave lots of potassium, because the level was very low, and I risked raising the potassium level to a point where it might cause a fatal arrhythmia. The pharmacy called to see if I really wanted to give all of that potassium and I said yes, and thanks for checking on me. Pharmacy monitoring of physicians' orders is standard, and they catch errors all the time and I really appreciate it. I had to decide whether to give intravenous fluid, and decided not to, despite some kidney failure, because of a long history of going into heart failure with just a little fluid overload.

I then headed to my third patient, a woman with chronic pain and ongoing alcohol abuse, a quart of whiskey a day, who was feeling like she was going into alcohol withdrawal again and also was short of breath because of her chronic lung disease and new pneumonia. She had just quit smoking but was using some kind of nicotine nebulizer she got in a tobacco shop. She was on warfarin, a "blood thinner", which she said had been perfectly stable for months. I ordered the antibiotic for her pneumonia which could cause tendon rupture and antibiotic associated diarrhea, the asthma meds which could make her heart beat erratically and make her delirious, decided against the sequential compression devices for her legs since she had known arterial occlusive disease with recent arterial clot which nearly resulted in amputation, even though I did risk her developing a clot in a vein. I ordered her regular warfarin dose and checked her protime. The pharmacy called a couple of hours later to tell me the protime (monitoring of the effectiveness of the warfarin) was dangerously high, so I thanked them and discontinued the warfarin, asking the pharmacy to monitor it and restart when appropriate. I ordered high dose lorazepam, an antidote to the effects of alcohol withdrawal, which might lead to breathing problems with resultant need for a ventilator which could lead to pneumonia and intensive care unit related dementia.

Then up the stairs to the transfer patient, a 39 year old man who used IV and subcutaneous methamphetamine and had developed abscesses all over his skin and a heart valve infection. He had been in hospital improving from this for 3 weeks, and now was in my care with a central line (intravenous catheter in his internal jugular vein) and open wounds on both hands and both legs after surgical treatments of his abscesses. He was on high dose pain meds and still complained of pain. He had a fever. His fever might have been from his known severe heart valve infection, from an internal abscess as yet undiagnosed or from the central line. I ordered blood cultures which could only be obtained from the central line because he had no accessible peripheral veins and considered the option of replacing the central line with a new one which would not be a nidus of infection but the insertion of which could cause injury to an artery or puncture the lung, which might kill him. Another option would be a peripherally inserted central catheter (a PICC line) which would have a pretty high risk of resulting in a blood clot in the arm which could migrate to the lung and cause his death. I ordered most of the medications which had been working at the previous hospital. They included drugs that could cause kidney failure, respiratory failure and allergic reactions of all kinds. He was also on an antipsychotic medication that could cause a permanent neurological impairment called tardive dyskinesia in which the tongue involuntarily keeps sticking out of the mouth. When he didn't take that, he had apparently been extremely anxious and agitated.

Keeping patients safer

And that wasn't even a big day. Clearly protecting patients from harms in the hospital is a priority. The most important way to protect patients is to keep them out of the hospital and keep their treatments as streamlined as is possible without risking errors of omission. Keeping patients out of the hospital means assigning priority to resources that keep people healthy. It also means having important conversations with patients about what they really want done and what being in a hospital means. Presenting every patient with the list of the all of terrible things our treatments can do to them is impractical, but we need to bring them in to the conversation. We need to have the time to do this, which means backing off on something else which fills our time. Deliberately simplifying care would help, and we could make this an item for action. If there were fewer medications prescribed, fewer specialists consulted, fewer intravenous lines inserted, fewer surgical procedures offered and performed, there would be fewer medical errors. We can make this happen, but it will involve a concerted decision by patients, families, doctors and hospitals that it is something we all value. Doing less will redirect the revenue stream which will be uncomfortable and disruptive, but so very worthwhile.

Sunday, October 6, 2013

What to do with ancient people

A 100 year old woman is brought to the emergency room by a concerned friend because she can no longer get out of bed to get food or go to the bathroom. Other than being unwashed and a little confused, she is fine. Her electrolytes are pristine, her electrocardiogram the definition of normal, her blood count and chest x-ray perfectly mirror the expected physiology for her age. Even her urinalysis is normal. She takes no medications and hasn't been to the doctor for a decade. She has no living family and her friends have their own lives and problems. She can't go home because she has just gotten too old. What shall we do with her?

When the law establishing Medicare was enacted in 1966 as title XIII of the Social Security Act during the presidency of Lyndon Johnson only half of seniors had health insurance and many had no access to healthcare because they couldn't afford it. Now nearly all seniors in the US have insurance coverage for both ambulatory and hospital care. Medicare also covers a limited amount of time in nursing homes as a bridge between hospital and home. This is truly intended to finish the work of an acute hospitalization and get a patient back home, when an acute illness has made them weak enough that going straight back would risk failure and return to the hospital. Medicare was never intended to pay for long term care, but then how is a person expected to afford care in a nursing home?

Nursing home costs are now around $220 per day or over $80,000 per year. It is pretty rare to find a person who has savings and pensions adequate to cover this much money. The way it usually goes is that a person spends their income and their assets, not including their house, if there is a spouse in it or an intention to return to it, a car and a few other odds and ends such as a wedding ring and a burial plot, down to a certain small amount after which time he or she applies for Medicaid, a state run medical funding agency. Some nursing homes don't accept patients with Medicaid funding because they are either not certified by Medicaid or don't want to accept the smaller amount of money that Medicaid spends for care compared to what a private patient pays. In Idaho, Medicaid pays nursing home expenses for 60% of the patients in these facilities. After a patient spends down their assets and ends up on Medicaid they usually remain in a nursing home for the rest of their lives, and Medicaid picks up the tab. After becoming destitute it would be impractical to return to independent living, even if one were to be miraculously made well again.

So back to our centenarian. She has been brought into the emergency room and, lacking a traditional multigenerational family living together to take on her care, she clearly needs a nursing home. The wheels of nursing homes work slowly, though, as do the gears and engines of the Medicaid program. She needs somewhere to sleep TONIGHT. She is in a hospital, and in that hospital she will remain until a safe place can be found for her to stay. Unfortunately there is nothing really wrong with her except that she has had an excess of birthdays. Medicare, which she probably has, will only pay for her hospital stay if she is acutely ill or we are suspicious that she might be acutely ill for some documentable reason. If she really is ill in such a way that she would need hospital care, not like a cold or a sore back or a urinary tract infection, we can make her an inpatient. As an inpatient, most of her costs will be paid by Medicare. If we think she might be ill, for instance if she has chest pain that might indicate a heart attack, we can admit her under observation for a day or at most 2 days while we make absolutely sure she is fine. If she is an inpatient for 3 days, Medicare will pay for skilled (usually nursing home) care, that is care to rehabilitate her to go home, for a maximum of 20 days. If rehabilitative care is necessary for longer, Medicare will pay a portion of nursing home costs up to a lifetime maximum of 100 days. If it becomes clear that she will never be able to return home, Medicare will no longer pay, and if she can't pay the nursing home costs, she will need to apply for Medicaid which will then pay for her. Once she is at the nursing home, usually they won't just kick her out, even if her Medicaid application is slow to be accepted.

Our patient in question is not sick and can't be badgered into complaining of anything life threatening. She is admitted to the hospital because we can't put her out on the streets and it is not safe for her to be at her home anymore. Since doctors are trained to look for disease, we look really hard and think that maybe her confusion is actually delirium and that perhaps she looks just a touch out of breath so we document anything that goes along with that and then the billing staff attempts to bill Medicare for her stay. If Medicare pays for this hospitalization and later audits the account and finds that she was actually fine, we have committed fraud and the penalties are steep. Deep in our hearts we have intended no fraud, but feel that this hospital stay is unavoidable and that Medicare should pay for it, but they see it quite differently. Our billing specialists have become much more vigilant in avoiding false claims since enforcement agencies have been coming down hard on cases of fraud. Still, they spin their wheels and struggle with verbiage and try to get us to document what seems like exaggeration or hyperbole in order to minimize the amount of uncompensated care that the hospital provides.

This grand old woman who has finally reached our emergency room deserves a gold medal for being not only healthy but for costing the healthcare system close to nothing for decades. If she had seen physicians for every wart and ingrown toenail she might have been gradually transitioning to a higher level of care as she aged, and some of her financial issues would be well in hand. We see few healthy 100 year olds, but stories similar to this are not uncommon and the problem of what to do with the not quite sick and yet not well enough to go home plagues hospitals, in particular emergency room doctors and hospitalists. Emergency room staff spend scads of time trying to arrange dispositions for these patients that don't involve an admission, and then have to explain to the admitting physician why admission is the only option. The hospitalist needs to care for the patient, often while trying to also care for the truly sick. We must also respond to the concerns of the billing specialist who wishes that any money at all would come in to defray the hospital costs that will come of this stay which might be prolonged depending on the willingness of a nursing home to accept the patient.

This is all so very complicated. Humongous amounts of energy are wasted. Social workers battle processes that are designed to make things more difficult and physicians lament that there aren't systems in place to deal with the very real needs of people who age and need help. Hospitals try to bill for the hours of care and problem solving that they do, requesting money from Medicare which was never intended to fund this sort of thing.

I think that this hasn't been solved because it is too painful to look at and the people who suffer the most, the very old and very disabled, don't have an effective voice. The chunk of money that would need to be set aside to do this right would be significant, in a political environment that is already making loud squeaking noises (justifiable) about what medical care costs. What is being ignored is the fact that we are paying for this, and probably paying more because the routines are so horribly inefficient. Hospitals are paying physicians and billers and social workers and those costs are defrayed by higher charges for everything else that the hospitals do. Communities are paying law enforcement officers who are the first responders for folks who fail at home.

I would like to be able to present this ancient patient who presented to the emergency room with her medal of honor for an excellent and healthy life and seamlessly tuck her into a bed with clean sheets and regular meals, if that is what she wants. I would like her never to have to spend 12 hours in an emergency department getting tests she doesn't need with physicians who will someday, if they are lucky, be in her shoes, arguing about who has to take care of her. There are many organizations and individuals thinking about the nuts and bolts of solving this problem, including ways to keep folks in their own home with the help they need and alternatives to governmental funding of nursing care and other great ideas. It is so vitally important to get important stakeholders from hospitals, in conjunction with Medicare and Medicaid, to look honestly at the problem and commit to coming up with some solutions.