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Category: Medical Practice

Doctors Urge Caution in Interpretation of Research in Times of COVID-19

September 9, 2020

To:      

American College of Cardiology

American College of Chest Physicians

American College of Physicians

American College of Radiology

American Heart Association

American Society of Echocardiography

American Thoracic Society

European Association of Cardiovascular Imaging

European Society of Cardiology

European Society of Radiology

Heart Rhythm Society

Infectious Disease Society of America

North American Society of Cardiovascular Imaging

Radiologic Society of North America

Society of Cardiovascular Magnetic Resonance

Society of Critical Care Medicine

Society of General Internal Medicine

Society of Hospital Medicine


Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

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Why Primary Care Should Run the Healthcare System

By KEN TERRY

(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.

The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.

Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.

One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.

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Meaningful U’s

By HANS DUVEFELT

Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.

When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.

The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.

The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.

For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.

I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:

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I Cured My Patient, But What Was His Diagnosis?

By HANS DUVEFELT

He cancelled his followup appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do.

Less than two weeks before that he was sitting on the exam table in my office, again and again nodding off, waking up surprised every time his wife prodded him. The stack of printouts from the emergency room illustrated all the normal testing they had done.

He had experienced a brief episode of numbness in the left side of his face and felt tired with just a slight headache. When I saw him the headache was a bit more severe in the back of his head and down the right side of his neck. But his neck wasn’t stiff.

His blood sugar was 87, normal for most people, but this man had a history of diabetes although his blood sugars had steadily improved over the past year. I told him to stop all his diabetic medications although I don’t think he took notice. His wife said she would make sure he stopped them.

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Why is a 1980 Drill in my 2020 Brain?

By SHVETALI THATTE

Late one evening, a trauma patient, a mother of three, comes through on an ambulance. She’s having trouble breathing, despite the breathing tube lodged in her throat. Dr. Nikhil K. Murthy, the neurosurgeon on the case, assesses the situation and orders a CT, which reveals a ruptured aneurysm, or a burst blood vessel. Excess fluid in the brain is fatal, as the increased pressure deprives the brain of vital oxygen. A sense of immediacy surges through Dr. Murthy as he calls for the necessary supplies to perform a ventriculostomy to drain the blood. He rushes to connect the drill bit, brace the manual drill against his body, and drill a hole in the right place, at the precise angle and depth. With the urgency of the situation blaring in his mind, Dr. Murthy has only his experience, training, and intuition to ensure that he does not drill past the skull and into the brain. The stakes are high, and a woman’s life is on the table. 

Bedside ventriculostomies, like the one described above, are common in the emergency department, as the surgery is often performed in life-or-death situations to immediately relieve fluid build-up in the brain. Dr. Murthy’s experience does not stand alone: countless neurosurgeons have stood in his exact shoes. While Dr. Murthy successfully performed the ventriculostomy, saving the woman’s life, not everyone is as lucky: the complication rate for bedside ventriculostomies in the U.S. stands at an egregious 50 percent

“When that woman was lying on the table, a drill braced against her skull, what she and I both needed was a safer, more reliable tool to perform the surgery.” – Dr. Nikhil K. Murthy 

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Post Covid Healthcare is Becoming Like Buying from Amazon Instead of Going to the Mall or Reading an eBook Instead of a Paperback

By HANS DUVEFELT, MD

Now that we are seeing patients via telemedicine or even getting reimbursed for handling their issues over the phone, our existing healthcare institutions are more and more starting to look like shopping malls. 

They were once traffic magnets, so large that they created new developments far away from where people lived or worked and big and complex enough that going there became an all day affair for many people. 

What this pandemic has brought us is a shift in our view of where you have to be in order to get things done. If you can earn your wage remotely and still buy things online when offices and physical stores are shut down, it seemed logical to try to offer healthcare the same way. And most of us have found that it works surprisingly well. 

The analogy with Amazon runs deeper than that. Amazon isn’t just one megaprovider, but also a funnel for many small merchants who sell their products through Amazon. Consumers take advantage of the convenience of this centralized ordering or point of contact with a vast supply network of almost any product that money can buy. But they only give their credit card number to one central contact. 

I don’t follow business literature enough to know if Jeff Bezos chose the name Amazon partly (yes, I know he went through the dictionary) because of a vision of many small contributories coming together into the second largest river in the world. But that is certainly a visual representation of what his business looks like. And “Amazon” ranks higher in the alphabet and sounds a lot catchier than “The Nile”. 

Enter healthcare: Imagine the trusted brand names of our “industry” but without their traditional complete reliance on bricks and mortar places that patients have to visit. 

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Medical Education Must Adapt to Support the Broadening Role of Physicians

By SYLVIE STACY, MD, MPH

As a physician and writer on the topic of medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.

The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.

Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.

Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.   

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Everyone has a role to play: Reducing your child’s risk of developing food allergies

By RUCHI GUPTA, MD, MPH

The average American elementary school class includes two students living with one or multiple food allergies. That’s nearly six million children in the United States alone. And these numbers are climbing. There was a staggering 377 percent increase in medical claims with diagnoses of anaphylactic food reactions between 2007 and 2016, two-thirds of these were children.

As parents, we want the absolute best for our children. For many years, guidance around food introduction was unclear. Parents were told that babies, and especially those considered at risk for food allergies, should avoid some allergy-causing foods such as peanuts until they were three years old.

But thanks to ongoing research from our nation’s top allergists and immunologists, we are beginning to learn more and more about food allergies, including what new and expecting parents can do to reduce the risk of their children developing food allergies. In fact, studies now show that introducing a variety of foods early is the best course of action and has been shown to reduce the occurrence of certain food allergies like peanuts for many children.

For instance, the partially FARE-funded Learning Early About Peanut Allergy (LEAP) study showed a remarkable 80 percent reduction in peanut food allergies in high-risk infants who were exposed to peanut foods at a young age. Shortly after LEAP, there was the Enquiring About Tolerance, or EAT, study. This project, led by top medical researchers at Kings College London, found significant reductions in allergies to both peanut and egg after introducing small amounts of the foods into infants’ diets. The LEAP-on study soon followed, and had the same children from the original LEAP study remove peanut from their diets for 12-months. The results showed that they maintained their tolerance to peanut, indicating early introduction to babies can result in long-lasting protection from peanut allergy.

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Equipoise and Its Problems

By MICHEL ACCAD, MD

I recently participated in a debate opposing me to Professor Adam Cifu on the topic of “Evidence-based medicine in the age of COVID.” The debate took place on an episode of Dr. Chadi Nabhan’s Outspoken Oncology podcast. Dr. Saurabh Jha was the moderator and he did a great job keeping us on point and asking for important clarifications when needed. It was a fun and cordial moment and I found it intellectually fruitful. You can listen to it here or on any podcast platform. The discussion strengthened my conviction that the central issue about EBM is the conflation of the role of the physician with that of the clinical scientist.

That conflation was quite apparent in a recent online editorial published by Robert Yeh and colleagues on the topic of equipoise during the COVID-19 pandemic. Yeh at al. are accomplished academic cardiologists and outcomes researchers (Yeh was a guest on The Accad and Koka Report a couple of years ago).

I’ll get to their editorial in a moment, but equipoise is a term that I became aware of only in the last few years, mainly from mentions on MedTwitter. From those mentions I developed an intuitive sense of what equipoise must mean: a mental state of uncertainty about a treatment that prompts the medical community to seek a more definitive answer by way of a randomized controlled trial. For example, one might say “I’m not sure if hydroxychloroquine works to prevent or treat COVID-19.  Based on the existing collective experience, there is equipoise about it.  We need a clinical trial.”

That seems reasonably straightforward, but the editorial by Yeh et al. piqued my curiosity so I decided to look into the origin of the term and its introduction in the medical literature.

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“When Blood Breaks Down”: It Can Break Your Heart

By CHADI NABHAN, MD, MBA, FACP

The goal for me and for my clinical and research colleagues is to put ourselves out of a job as quickly as possible”. This is how Mikkael Sekeres ends his book “When Blood Breaks Down” based on true stories of patients with leukemia. I share Mikkael’s sentiments and have always stated that I’d be happy if I am out of a job caring for patients with cancer. To his and my disappointment, this wish is unlikely to ever come true, especially when dealing with leukemia.

With almost 15 years of experience, Sekeres possesses a wealth of knowledge and patient stories making him the ultimate storyteller taking us along an emotional journey that spanned hospital rooms, outpatient clinics, and even his car. We get to know Mikkael the person and the doctor and immediately recognize how difficult it is to separate these two from each other. With hundreds of patients he has cared for, Mikkael could choose which stories to share. He decides on 3 patients, each with a unique type of leukemia and a set of circumstances that makes their story distinct. While I don’t know for certain, his selection likely reflected his ultimate goal of writing this book. It was about sharing life lessons he had learned from his patients–lessons that we could similarly learn—but it was also about giving us a glimpse of history in medicine and the progress that has been made in treating leukemia.

We get to know the three main characters of the book very well. David is an older man with acute myeloid leukemia (AML), Joan is surgical nurse who suddenly finds herself diagnosed with acute promyelocytic leukemia (APL), and Mrs Badway is a pregnant woman who was in her 2nd trimester when she was diagnosed with chronic myeloid leukemia (CML). While learning about their illnesses and family dynamics, Sekeres educates us about the various types of leukemia and enlightens his readers about so much history that I found fascinating. I did not know that the Jamshidi needle that I have used on so many patients to aspirate their bone marrows was invented by an Iranian scientist. Maybe I should have known, but I didn’t, that FISH was developed at Yale in 1980 and the first description of leukemia has been attributed to a French surgical anatomist, Dr. Alfred Velpeau in 1827. Somehow, I always thought that Janet Rowley discovered the Philadelphia chromosome, but Sekeres corrects me when he pictured Peter Nowell and David Hungerford who discovered that chromosome in 1961. As a reader, you might be more drawn to the actual patient stories, but the geek in me enjoyed the history lessons, especially the ones I was unaware of. Sekeres inserts these pearls effortlessly and with perfect timing. He does that so seamlessly and naturally that you learn without realizing you are being taught.

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