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images (1)Last night I was at a local pub listening to a band when suddenly everyone’s eyes were drawn to the television over my head. Straining to look around and see what had happened (another airplane crash, Lance Armstrong caught doping as a spectator in the Tour de France?) I read that a verdict was in regarding the death of Trayvon Martin. As the “Not Guilty” verdict was read, the crowd seemed relieved that the shooter would walk away (though civil proceedings will almost certainly follow). I must admit, I have not been following the trial. To me the entire episode was a tragedy.

As we were walking home, we ran into a neighbor and fell into conversation about the events. My wife, who followed the story, pointed out that the shooter was not participating in a neighborhood watch event but was going to the local “big box” to purchase groceries with HIS GUN IN HIS POCKET when he stopped to follow a “suspicious character.” Made me wonder how many of my neighbors are packing heat and why would they feel compelled to do so.

In my home town of Baton Rouge, Louisiana in 1992, Japanese exchange student Yoshihiro Hattori was going to a party and knocked on the wrong door. Mistaken for a burglar intent on home invasion (he was dressed in a tuxedo recreating John Travolta’s look in Saturday Night Fever) and not understanding the meaning of the word “Freeze” in the context of potential victim-of-gun-violence lingo he was shot and killed by the home owner. The home owner was charged with manslaughter and later acquitted with the court identifying that the shooter had a right to use lethal force to “protect himself.”.  In 2005 there were 30694 people who died of gun violence. When a gun is pointed at a person and the trigger is pulled, about 1 in 3 people with die prior to reaching  the hospital. Since the death of Yoshihiro, laws have been changed. in 35 states anyone requesting a concealed carry permit must be given a permit. In 2 states, no permit is needed. In my home state of Louisiana, where the gun laws were “liberalized” after this shooting, about one in every 10000 people can expect to die from a gun shot. Half of these from their own hand.

So, what should my response as a medical educator be? Gun violence is a serious public health issue. It costs about $2 billion in direct costs, and because it overwhelmingly affects young people, there are about $100 billion in indirect costs (loss of future productivity, health care costs for the rest of their lives, etc.). How should we as physicians and educators be involved in the prevention of this often needless tragedy?

First, as with any complex illness we need to be aware who is really at risk and target those people. The belief in our society is that personal risk of violence at the hands of a stranger is great and mitigated by the presence of a gun. Unfortunately, research on gun violence is sketchy at best. Recently, the Robert Wood Johnson foundation published the findings of Andrew Papachristos on their website. He found that a lot of the potential victims (41%) come from a very small circle of people at risk (about 4% ) in a given community. Many of our Academic Health Centers sit in these at risk neighborhoods (and have benefited from caring for trauma victims). Based on this, those of us interested in teaching prevention should be promoting our Academic Health Center’s involvement in these high risk communities through partnering with community organizations.

Second, we need to teach our learners how to preach gun safety. A gun in the home is associated with violence to the people living in the home. About 25% of households report having a handgun (and there are guns enough for almost every citizen already in circulation in this country). These guns should be locked up, especially when there are children in the house. In one of the few studies done of trauma center workers (in Birmingham in 1994) 33% of those with children (who presumably knew better) did not keep the weapons properly stored.

Third, we need to understand and teach risk assessment. Our well child form has a question regarding guns in the home which we ask all parents. If the answer is “yes, there are guns in the home” there is then a prompt that directs us to ask about storage and safety methods. This is because, though patients perceive the societal risk to be great, we need to understand and preach that societal risk is small and localized. The greater risk when a gun is present is to a family member or a stranger that happens to get in the way. For us to convince our patients of that we need to understand and believe it ourselves.

Fourth, we need to fight against willful ignorance. In Florida, where the Trayvon Martin was shot, a law was passed (later blocked) barring physicians from asking about weapons in the home. It is important for health care professionals to be clear and of one voice, the opportunity for gun violence is lessened greatly when there are NO guns in the home and lessened when the guns that are there are stored safely.

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w-b-park-sure-we-doctors-make-a-lot-of-money-but-don-t-forget-we-spend-a-heck-new-yorker-cartoonI just finished reading The Celestial Society, a biography of George Burch written by his daughter Vivian. I knew him as an older attending who seemed oddly out of touch with students. I now know that he was a beaten, sick man at the time I had contact with him. I also found out that he never deviated from his core belief that what medical schools needed to do was train good generalist physicians and develop tools to allow these generalists to become better doctors. He was Chairman of Medicine at Tulane for 30 years, forced out in the 1970s when he opposed the creation of a practice plan to capture faculty patient care revenues. The dean and the chancellor both felt that without the ability to harness this revenue source, Tulane would be forced to shut down.

It is amazing how much medicine changed in the 40 years of Dr Burch’s career. Dr Burch’s entire career was at Tulane and spanned from the 1920s to the mid 1980s. When he started the EKG “machine” was a string galvanometer and was only done on selected patients. He was instrumental in describing variants of EKGs, wrote the first book on interpretation which made the technology available to all clinicians and developed the circuitry which allowed all 12 leads to be measured simultaneously. All the while he was on faculty at Tulane, making very little money when compared to his private practice colleagues and caring for poor patients at Charity Hospital. To him the academic “life of the mind” and the noble activity of caring for the poor sick should have been rewarded by society. The building of a University Hospital with the corresponding contractually obligated faculty sounded the death knell for this type of medical practice.

The conflict at Tulane was the result of Dr Burch’s stature in the world of Cardiology and the perception that his belief regarding cardiac surgery were holding up progress. He believed that outcomes were terrible. His perception was that patients were more likely to die from the surgery than the disease, a belief grounded in observation but since surgeons kept no data not measurable. He believed that surgeons were uneven at best (again, unmeasurable) and in reality it was the post-surgical care that mattered the most. He abhorred the “chance to cut is a chance to cure” mentality and in his clinical experience many people would be better served to have nothing done than to subject themselves to angioplasty or surgery. Tulane wanted him to refer his patients exclusively to Tulane surgeons and likely expected a larger number of patients to be referred, conditions to which he was unwilling to agree. Medicine was moving into an entrepreneurial direction and Dr Burch was being left behind.

Dr Burch died in 1986. Tulane continues to thrive (at least according to the alumni magazine) despite not being in Charity Hospital at all. Many of his beliefs regarding invasive cardiology have been affirmed. Meanwhile, the article on colonoscopy in today’s New York Times, illustrates the cost we have paid for dismissing Dr Burch’s warnings regarding our abandonment of the generalist physician model and embrace of the entrepreneurial model of medicine.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees….

When popularized in the 1980s, outpatient surgical centers were hailed as a cost-saving innovation because they cut down on expensive hospital stays for minor operations likeknee arthroscopy. But the cost savings have been offset as procedures once done in a doctor’s office have filled up the centers, and bills have multiplied.

It is a lucrative migration. The Long Island center was set up with the help of a company based in Pennsylvania called Physicians Endoscopy. On its Web site, the business tells prospective physician partners that they can look forward to “distributions averaging over $1.4 million a year to all owners,” “typically 100 percent return on capital investment within 18 months” and “a return on investment of 500 percent to 2,000 percent over the initial seven years.”

To quote Chairman George, “I’m not antisurgery, I’m pro-patient.”

I was sent an e-mail regarding one of my previous posts and included was a copy of an address given by one of my former professors, Dr Charles Dunlap, at Tulane’s Ivy Day in 1975. While the scientific knowledge changes, much remains the same. For example:

Among the standards required of a physician few are more basic than integrity and simple honesty. In ordinary business dealings, each purchaser of goods or services is assumed to have sufficient knowledge of the game to safeguard his own interests. In medicine, the rules are different. Each patient puts himself, naked, alone, and helpless, into the hands of the physician. In this transaction, the sole security the patient has is simple faith in the integrity and competence of the physician.

In another part of the essay he points out that rituals are a large part of what we do. As you participate in the ritual of Thanksgiving, consider this quote Edmund Burke, also found in the essay:

Human beings participate in the accumulated experiences of their innumerable forefathers; very little is totally forgotten. Only a small part is formalized in literature and deliberate instruction; the greater part remains embedded in instinct, common custom, and ancient usage.

Happy Thanksgiving

We have gone from a lecture based format to a team learning format in our medical school. In the previous format, I was assigned the “Don’t be a bad doctor” talk to give to the students. I would point out that of the doctors who lose their license, very few lose it for delivering bad care. More commonly, the physician lose their license as a consequence of illicit drug use, writing prescriptions of controlled substances for folks not their patients, having sexual relations with their patients, or a combination of the above. The students were informed that 3% to 10% of physicians reported having had a sexual relationship with their patient. The students, most of whom are young enough to be my children, could not see themselves in a compromising situation such as this so I was seen (or so it seemed to me) as a prudish nag. OK, maybe not but I was introduced to the parents as “The professor who told us not to have sex with our patients.”

This brings us to another one of our physician congressmen, Dr Scott DesJarlais (R-Tennessee).

Rep. Scott DesJarlais, a physician who opposes abortion rights, said in a letter that he was “deeply sorry” that supporters had to find out about the relationship with a patient that occurred while DesJarlais was separated from his first wife. But he said he used stark language about traveling to Atlanta to get an abortion try to get the woman to acknowledge that she wasn’t pregnant.

A group of Tennesseans are trying to hold him accountable. In their words:

“Tennessee law is crystal clear: Doctors are prohibited from engaging in sexual relationships with patients,” Melanie Sloan, the group’s executive director, said in a release. “The only question remaining is, now that Tennessee authorities are aware of Rep. DesJarlais’ blatantly unethical and scurrilous conduct, what are they going to do about it?”

If only he had taken my class. Or read the words of the Hippocratic Oath he recited:

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

Some people suffer from back pain, others SUFFER from back pain. Almost 1 in every 33 office visits is for back pain meaning that for an average primary care doctor there will be a person complaining about back pain in the office almost every day. When I was in medical school I was taught that 80% of low back pain would resolve no matter what the medical approach so the best approach was “Do nothing, Doctor” followed by “Say… I know your back hurts but…” Since then, health care costs have skyrocketed in part because of back pain and it turns out that, though pain may not be lethal, the treatment of back pain has tragically been lethal recently for seven people.

How has the strategy changed since I was in medical school? This paper does a nice job of outlining the problem. First, folks want to know “Why is my back hurting.” Docs, not wanting to stand in the way of self knowledge, have obliged by ordering imaging studies…lots and lots of them. In the last 12 years, the number of MRIs (a test done using a strong magnet) done for low back pain and paid for by Medicare has quadrupled. Why is this a problem? Turns out that one picture is not only worth a thousand words but often a procedure as well. Why is this?

Positive findings, such as herniated disks, are common in asymptomatic people.20–22 In a randomized trial23 there was a trend toward more surgery and higher costs among patients receiving early spinal MRI than those receiving plain films, but no better clinical outcomes. Six other randomized trials, involving a total of 1804 patients from primary care without features suggesting a serious underlying disease, compared some form of lumbar spine imaging with none.24–29 In these studies, imaging was not associated with an advantage in subsequent pain, function, quality of life, or overall improvement.

In addition, people want to have no pain. Prescriptions of narcotics have doubled for back pain in the last 12 years, with unclear benefit to the patient (but a clear increase in narcotic availability in the community). If the medicine is seen as ineffective, they think maybe surgery will fix it. The number of surgeries have  tripled, with the following result:

Higher spine surgery rates are sometimes associated with worse outcomes. In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest

In an effort to stave off surgery in these patients who want their pain to go away, many patients have turned to injections done by pain specialists directly into the spinal canal to try and eliminate the pain. Medicare payment for this procedure, too, has tripled in the last 12 years (although the Medicare population has only gone up by 10%) with the following result:

Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.57,58 This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates.59–62 Facet joint injections with corticosteroids seem no more effective than saline injections.

Which brings us to the deaths (covered here). They occurred during the application of steroids in the spinal canal for this purpose. The steroid used for these injections can be bought from standard supply houses. The folks who are dead (or are at risk of dying as they might be growing a fungus that will kill them and there is nothing that anyone can do) had steroids injected in them that were made under less than optimal conditions by a “compounding pharmacy.” Even though this pharmacy shipped 18,000 vials of this steroid, it is considered a “mom and pop” operation thus is not under the control of the FDA. No one is sure if this particular steroid was used because it was considered to be better or if it was cheaper for the physicians office (thus maximizing the doctor’s profit). What is certain is that without an injection, there would be no risk at all.

I have been installed as President of the Alabama Academy of Family Physicians. The work should not be too hard and on occasion should be rewarding (or at least ego-boosting). Such was the case the other day when the Executive Director asked me to recall a patient from “my early days” that had made an impact so he could publish my thoughts, thus officially making me an old geezer. I thought back, thinking of the the heavy snow drifts I walked through to get to the hospital (unusual weather in Portsmouth but it was before “climate change”), recalling the large hill that I had to walk up to get both there and back, and this was the patient’s story I chose:
In April of 1987 when I was an intern at Portsmouth Naval Hospital I saw a 54 year old male patient for fatigue and discovered a previous diagnosis of iron deficiency anemia. He was again anemic. He was subsequently found to have Stage 4 colorectal cancer for which he received treatment. About 6 months later I admitted him from the emergency department (where I was working after finishing internship while waiting for training in Undersea Medicine) with jaundice. The ward team provided aggressive care but he died anyway.
The sad part of the story is that this patient had been seen by one of my intern colleagues in July of 1986 (the first month of our internship) for a complaint of fatigue. An iron deficiency anemia was initially found at that time. He was placed on iron, felt better, came back for follow-up, and was discharged from care. No follow-up to identify the cause of the anemia was done at that time.
Though the snow is less in Mobile and the hills less steep, the lessons I took away from that patient are still indirectly shared with every resident and student I teach:
1) It is my belief that quality care should not be dependent on specialty or level of training. My colleague should have consulted with the attending physician who was sitting in an office on the unit (and may have). My colleague could have read about the work-up of anemia after the visit and called the patient back. Being young and inexperienced, he appropriately treated the symptom but did not look for the disease. Avoidable mistakes such as this are not acceptable. We try very hard to put systems in place in our practice so that when the patient receives care, regardless if delivered by a faculty member or from a trainee, it will be predictable and of high quality.
2) Colon cancer is not a pleasant way to die. This patient was diagnosed with a rigid sigmoidoscope (a firm, hollow, silver tube about 2 feet long). Though we knew that early detection of cervical cancer saved lives, we knew little about early detection of breast and colon cancer. We now know that through use of colonoscopy and home stool testing, lives can be spared. I would like to believe that this patient, who was of an age that screening is now indicated, would have potentially been spared this death as the result of a caring family physician facilitating this screening. In our practice we have made early detection of eminently treatable cancers such as this a priority. We all work to assure that our patients have access to these screening tests.
3) We are all going to die. Having a terminal illness makes this likely to happen sooner. There comes a time to move to comfort measures. I want my faculty, residents, and students to be advocates for our patients in disease prevention and treatment. We also need to be advocates for moving from cure to comfort when it is appropriate. In my patient’s case, the Naval Hospital was his “provider.” We did not make that transition easy for him. I am afraid to say we have not gotten much better at this in the last 25 years.
From an article sent to me written by Sanjay Gupta in the New Yorker:
Why have [mistakes by the health care system] been so hard to prevent?Here’s one theory. It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs’ being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.”
“What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better. In 1979, Stephen Bergman, under the pen name Dr. Samuel Shem, published rules for hospitals in his caustically humorous novel, “The House of God.” Rule No. 13 reads: “The delivery of medical care is to do as much nothing as possible.” First, do no harm.”
I got a patient mad at me yesterday when I questioned her judgement. Our team and the specialists in the hospital spent hours going over a patients records, analyzing and reanalyzing existing tests this women had for her complaints and determined that no further testing was necessary, that the complaint was with certainty not caused by organic disease. She then left immediately after discharge (probably with her bracelet still on) and went to the next nearest hospital where she was admitted for the same symptoms and, rather than making a phone call to me or the doctors on call for me, her “admitting physician” proceeded to to the expensive and invasive test we chose to avoid and send her back to me for follow-up. She saw going to the other hospital as being “extra careful.” Had she died as a consequence of the procedure (which revealed no disease per her report as we knew it would), I’m sure we would have taken the blame somehow. Instead, she was befuddled at why I would accuse her of not having trust in me by not following my care plan. “I like you Dr Perkins, I just wanted to get my pains checked out.”
The hospital, which made a lot more on the expensive test than we did by doing the right thing, has yet to send me records.
We have gone from Munchhausen the disease to a Munchhausen the business model.

I had to go into the hospital and round this weekend. I also had to go in and round two weekends ago (we treat holiday weekends separate from the regular rotation so it just fell that way) and was feeling particularly sorry for myself. Fortunately it has been a light weekend so far (wait…there is a saying in clinical medicine… “they can always hurt you more” … with doctors being a very superstitious lot and me still having 12 hours to go,  I retract that last statement). It has been an OK weekend.  I did have several observations worth commenting on occur in the course of the weekend:

1) Personal connections are powerful – I have a long-term patient, Mr A.,  who has multiple problems and was admitted on Thursday to the ICU. He was transferred to our service on Saturday and I rounded on him. The residents told me that he was not doing well, being a bit confused. When I walked into his room and when I walk up to his bed and inquired about his health he looked up, smiled, and said “Doc, I’m doing well. How are YOU?” I responded that I was doing well also and he then asked “And the wife? Your two children? LSU gonna win that baseball game?” Confusion resolved. To be honest, I have tried working with this patient for a long time to get the diabetes, hypertension, and other chronic problems under control. In my mind I have not given Mr A his money’s worth. It may be that as a result of our personal connection, he has done better than he would have done without me.

2) Wound care trumps antibiotic choice, every time – Ms B was admitted with a badly infected laceration following a fall. She had been in the hospital for several days and there was a flurry of antibiotic changes prior to the weekend. My philosophy is typically when covering for the weekend to follow the plan of the weekday team. In this case, it was clear that the weekday team was hoping that changing antibiotics would make up for a lack of attention to the wound. The weekend resident worked to optimize healing of the wound and it looked much better after 24 hours. The lesson there is while we have a lot of antibiotics in our armamentarium, often we need to find an old fashion barber surgeon.

3) Dementia is a terminal illness – We are all going to die. I hope to die at the age of 85 immediately after finishing the Boston Marathon (not only making for a great story but leaving my children with a messy transportation problem to deal with). It is my experience that very few of us will be so lucky. Most of us will drift away with multiple chronic illnesses, hopefully receiving less and less marginally useful care as we get closer and  closer to death. We now have the ability to replace kidney function, provide artificial nutrition, and provide respiratory support. We do not have brain replacement therapy. Let’s acknowledge the finality of dementia and forbid the replacement of feeding tubes rather than repeatedly trying to make families  say “Yes, I want my loved one to die” when the patient keeps pulling it out. Clearly, death is not a choice.

4) Patient care at its best is fun – Medicine at its best is a collegial activity. Multiple smart people get together and problem solve on behalf of a patient who has a complaint or condition that is either bothersome to them or that we’ve decided will become bothersome soon. In an article from the New England Journal of Medicine about money and the changing culture of medicine, the authors identified that “money” put barriers in the way of collegial patient care. As they say “Once money enters the conversation, selfishness comes along with it.” The fun thing about rounding on the weekends is that my thoughts and those of my colleagues are often not on the bottom line. We talk informally about patients, share ideas, and all in all try to “do the right thing” for the patient. I will say that being rainy outside helps to keep us focused on the patient and not on the beach, too.

As a southerner, I really like colorful expressions. “That dog won’t hunt” is one that I use when I am hanging with my Yankee friends and I want them to give me a “what is he talking about” look. “I wouldn’t know him from Adam’s off ox” is one that I love but I find I have to explain it way too often as I am not usually hanging with people familiar with oxen team terminology. One that I find more useful as I get older is “lipstick on a pig” as in “That’s just putting lipstick on a pig.” The expression, per Wikipedia, describes “making superficial or cosmetic changes in a futile attempt to disguise the true nature of a product.”

The medical education process seems to have taken a “lipstick on a pig” approach to reform. I have written about what people want in a doctor before (found here) and here is WebMD’s list from an article in the Mayo Clinic Proceedings:

Traits listed by the patients, along with the patients’ definitions of those traits:

  • Confident: “The doctor’s confidence gives me confidence.”
  • Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
  • Humane: “The doctor is caring, compassionate, and kind.”
  • Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
  • Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
  • Respectful: “The doctor takes my input seriously and works with me.”
  • Thorough: “The doctor is conscientious and persistent.”

Contrast that with the criteria for selection for medical school (grades and scores on a single standardized test) and the criteria for selection for residency training (grades and scores on a series of 2 standardized tests). It is my experience that test scores often don’t correlate with the things patients want in a doctor.

Recently, post-medical school training has attempted to emphasize qualities other than test-taking skills. The ACGME Outcomes Project, for example, has been in effect for 14 years and requires residencies providing post-medical school training to measure growth in characteristics such as those listed above. Efforts to change the medical student curriculum, though emphasizing the behavioral buzzwords found in the WebMD article, continue to have an assessment component focused using multiple choice type questions. Growth as a person is subordinated to acquiring knowledge for assessment via multiple choice testing, rendering the curriculum change efforts “lipstick on a pig.”

I have focused most of my career attempting to mold learners in their post-medical school years and have found that attitudes are set. Where residents come into the program from medical school regarding their attitudes towards patients is where they tend to stay. I was excited to recently come across this article, implying that it may be our educational efforts in the early training years that are lacking, not the learners’ ability to change. The authors suggest that the learners’ ability to store and regurgitate knowledge (IQ) was fixed, but their ability to incorporate professional values such as compassion and integrity (EQ) is fluid. To accomplish changes in behaviors and attitudes is going to mean not applying more lipstick but getting rid of a lot of the pig. Picking “listen to the patient” from a multiple choice answer list will no longer be a sufficient assessment. Assessing the learner at baseline (even prior to admission), establishing a set of non-negotiable standards, measuring behaviors using Standardized Patients as well as real patient encounters on multiple levels, using peer evaluations to capture attitudes not observed in formal settings, and forcing reflection on the part of the learner with the learner at risk of failure for not performing up to par will be necessary to effect these changes. It will mean changes in the training milieu as well. No more “Butt Boxes,” lists of words mispronounced by illiterate patients, comments about patients’ lack of “personal responsibility” to justify providing substandard care, or other activities that belittle or dehumanize patients in public or (more insidiously) private.

The authors suggest that establishing a strict standard and enforcing a “zero tolerance” for learners and faculty are necessary to drive this type of reform. I can only wonder if we can meet this standard or if we will quickly run out of faculty and students while trying to do so.

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