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Turning Our Residents into Minions

Turning Our Residents into Minions

As doctors, we can all remember the attending doctors who struck fear in our hearts or the senior residents who turned us into their personal scut slaves. Some people consider this a rite of passage: to tolerate abusive behavior by those who outrank us. Doctors train for years, deprive themselves of sleep and personal time. Is this truly an educational experience? Is this truly the way we should be passing on the education? During my training, I learned under many great doctors and educators. But, I have also experienced the nasty grilling that strikes fear in the hearts of medical students the world over. In my experience, these power plays caused more anxiety than any true learning. And I served my tour of duty as a scut monkey under senior residents who liked to put students and interns to servitude, and often ridicule. I doubt any doctor cannot recall any incidents of humiliation during their training and education. Now, as an attending doctor looking back, I see how unnecessary all this hazing really was. I teach many medical students and residents in my practice, some of them doing their core family medicine rotations and some just shadowing. I ask my students questions, but I never grill them or make them feel humiliated. And many of them keep in touch for years and let me know where their careers have traveled. “This leads to a dangerous outcome: doctors who don’t know how to say they don’t know.”   I know that as an attending with over 15 years of clinical experience, I do not know everything. No one does no...
CME: Improving Pediatric Asthma Care

CME: Improving Pediatric Asthma Care

The current rate of childhood asthma in the United States is at a historically high 10%, according to recent research. Clinical practice guidelines recommend that clinicians provide parents and caregivers of children with asthma a regularly updated written asthma management plan. They are also recommended to administer annual influenza immunization for all children with asthma, prescribe daily controller medications in high-risk children, and screen for environmental tobacco exposure. Few studies have assessed compliance with recommendations that have been set forth by national medical societies and associations. It has been speculated that population-level surveys may provide such information and help identify social determinants of health and unique considerations that may benefit from tailored interventions. Learning From California For a study published in Population Health Management, Ulfat Shaikh, MD, MPH, MS, and Robert S. Byrd, MD, MPH, sought to determine the quality of life and healthcare utilization of children with asthma. “We used 2011-2012 data from the California Health Interview Survey because it is well collected and the sampling procedure used is excellent,” explains Dr. Shaikh. “The data are quite likely generalizable to the rest of the country because the population of California does not have significantly different rates of asthma than other states. We also wanted to use these data from 44,000 households to help identify ways in which pediatric asthma care could be improved.” Gaps Observed Dr. Shaikh says she and Dr. Byrd found several gaps between current practice and national recommendations for asthma care. “We found that children with asthma tended to use the emergency room more than they should,” she says. One-third of children in the study...
CME: Symptomatic Knee OA on the Rise

CME: Symptomatic Knee OA on the Rise

Throughout the United States, the rate of knee replacement operations has surged in recent years. Experts have speculated that the increased prevalence of knee pain or of symptomatic knee osteoarthritis (OA) is due to an aging and increasingly obese U.S. population, which in turn may be the cause for the increase in knee surgeries. However, formal assessments of the secular trend of knee pain and symptomatic knee OA have been lacking. In the Annals of Internal Medicine, David T. Felson, MD, MPH, and colleagues addressed this void when they conducted a study examining whether a change in the prevalence of knee pain and symptomatic OA could be attributed to age, BMI, and radiographic knee OA. “It’s largely unknown if the increase in knee replacements was due to patients seeking the procedure more often,” explains Dr. Felson. “We also don’t have a great deal of data on the trends in knee OA.” Key Findings For their study, Dr. Felson and colleagues collected data from six National Health and Nutrition Examination Surveys (NHANES) conducted between 1971 and 2004 and from three examination periods in the Framingham Osteoarthritis (FOA) study between 1983 and 2005. “We wanted to see if the prevalence of knee OA had increased over time,” Dr. Felson says. In all samples studied, the age-adjusted prevalence of knee pain and symptomatic knee OA increased substantially over time. Between 1974 and 1994, the prevalence of knee pain—with adjustment for age and BMI—increased by about 65% among Caucasian and Mexican men and women and among African-American women in NHANES (Figure 1). In FOA, the age and BMI-adjusted prevalence of knee pain and...
Non-Cardiac Surgery Risks After Stenting

Non-Cardiac Surgery Risks After Stenting

Studies have shown that patients who have recently received a coronary stent and later undergo non-cardiac surgery are at higher risk for adverse cardiac events. “This is partly due to a combination of the patient’s heart disease and the body’s stress response to surgery,” explains Mary T. Hawn, MD, MPH. Research has identified several important cardiac drivers and surgical factors that can increase risks of adverse events, but little is known about the contribution of these factors to overall postoperative risk or if risks change over time following stent procedures. Incremental Effects of Stents on Non-Cardiac Surgery In a study published in the Journal of the American College of Cardiology, Dr. Hawn and colleagues compared adverse event rates in patients who previous received stents and underwent non-cardiac surgery with those not undergoing surgery. “Our purpose was to determine the incremental effect of surgery on perioperative events and estimate the relative contributions of surgical and cardiac factors,” Dr. Hawn says. The analysis matched 20,590 surgical patients to 41,180 non-surgical patients who previously received a stent between 2000 and 2010. Stent recipients who underwent non-cardiac surgery had higher rates of heart attack and/or cardiac revascularization when assessed at 30 days after surgery. However, the incremental risk of non-cardiac surgery ranged from 3.5% immediately following stent implantation to 1.0% at 6 months. “After 6 months, the incremental risk of non-cardiac surgery remained stable out to 24 months except with high-risk operations,” says Dr. Hawn. Assessing Stent Type: DES vs BMS When incremental risk was examined by stent type, the overall adverse event rates were lower in patients with a drug-eluting stent (DES),...

Is Burnout Talk Causing More Burnout?

Almost every day for the last few years, someone is writing about physician burnout or depression. The problems begin in medical school. A recent paper featured drawings that medical students had done depicting faculty as monsters. One student felt so intimidated during a teaching session that she drew a picture of her urinating herself. The paper equated faculty and residents supervising students to “zombies, vampires, ghosts, and other supernatural figures.” In dealing with the state of the world today, the authors cited a comment by the novelist Stephen King saying that to cope with adversity, people make up horror stories. That sounds pretty serious. Could the problem be declining student resilience? An article about college students in Psychology Today pointed out that they are less able to deal with seemingly minor affronts. And teachers are reluctant to “give low grades for poor performance, because of the subsequent emotional crises they would have to deal with in their offices.” “If emotional contagion has such an impact on Facebook users, maybe all these stories about burnout and depression have an impact on students and doctors too.”   This has forced faculty “do more handholding, lower their academic standards, and not challenge students too much.” The article pointed out that college students exhibit more anxiety and depression and take more prescription drugs for these problems than ever before. It’s not just students. A systematic review of 54 studies found that 29% of resident physicians were depressed or had depressive symptoms. The number ranged from 20.9% to 43.2%, depending on the method studies used to assess depression. Investigators from the Mayo Clinic and...
Wanted: Older Adults in Cancer Trials

Wanted: Older Adults in Cancer Trials

Studies have shown that older adults account for most of the cancer diagnoses and deaths that occur in the United States and make up the majority of cancer survivors. More than 50% of cancers in the U.S. occur in people aged 65 and older, a demographic that is expected to grow exponentially in the coming years. However, the evidence base for treating this patient group is lacking. In addition, few policy initiatives have targeted the lack of evidence on older adults with cancer. “Older adults are largely underrepresented in clinical trials, and it’s rare when these trials are designed specifically for older adults,” says Arti Hurria, MD. “This patient population tends to have different experiences and outcomes with cancer treatment than younger counterparts. We’re also expecting a doubling of the U.S. population that is 65 and older, and we project a 67% increase in cancer incidence among this age group. These data emphasize the importance of involving older adults in clinical trials so that we can optimize treatment for these patients.” In response to this issue, the American Society of Clinical Oncology (ASCO) recently released landmark recommendations to improve the evidence base for treating older adults with cancer. The call-to-action statement was developed by ASCO’s Cancer Research Committee and published in the Journal of Clinical Oncology. It made five overarching recommendations to improve the evidence base for treating older adults with cancer (Table). Improving Trial Designs The first recommendation from ASCO is to use clinical trials to improve the evidence base for treating older adults. There is growing recognition that eligibility criteria in clinical trials could be relaxed without...
Updated Guidance for STDs

Updated Guidance for STDs

The CDC recently published an update to its 2010 sexually transmitted disease (STD) treatment guidelines in order to address key questions regarding the treatment and clinical management of these diseases. Published in the Morbidity and Mortality Weekly Report (MMWR), the guideline addresses several key updates, including: Alternative treatment regimens for Neisseria gonorrhoeae. The use of nucleic acid amplification tests for the diagnosis of trichomoniasis. Alternative treatment options for genital warts. The role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications. Updated HPV vaccine recommendations and counseling messages. The management persons who are transgender. Annual testing for hepatitis C in individuals with HIV infection. Updated recommendations for diagnosing urethritis. Retesting for chlamydia, gonorrhea, and trichomoniasis to detect repeat infections. A Focus on Risk Assessment As the guideline indicates, primary prevention of STDs should include behavioral and biologic risk assessment. As part of the clinical encounter, the CDC recommends that clinicians routinely obtain sexual histories and address risk reduction using the “Five Ps” approach (Table). “Regarding partners, clinicians should ask patients if they have sex with men, women, or both,” explains Kimberly A. Workowski, MD, FACP, FIDSA, lead author of the guideline update. “They should also ask about how many partners they’ve had in the last 2 and 12 months and whether it’s possible that their partners have other partners.” In terms of practices, Dr. Workowski says it is important to know if patients are engaging in vaginal, oral, or anal sex because certain infections can reside in certain anatomic sites of exposure and, in many instances, may infect patients without symptoms. Additional questions pertain to past history of sexually transmitted...

Dr. MedLaw’s Tips for a Great Deposition

A deposition is not to find out the facts.  That is what the medical record is for. A deposition is not a battle.  That is what the trial is for. A deposition is a job interview.  You are being interviewed for the position of “defendant.”  Your own attorney is as much involved in that as the plaintiff’s attorney is because by the time that you are deposed your carrier has already made a preliminary determination, based on its own experts’ analysis of the case, as to whether it will settle, and if so, for how much.  A weak performance at your deposition will make the carrier want to cut its losses as to you. Your deposition is your chance to lose your case before it has started. Here are some simple steps to avoid that: Review the chart thoroughly and create a summary. Do this to refresh your memory as to the medical facts and as to whom you spoke with about the case. Most plaintiffs’ attorneys set up their case analyses in the form of timelines.  The notes that you take during your chart review should be in this form as well. Educate your attorney. Plaintiff’s attorneys will know their cases inside and out but many defense firms will send a lawyer with little familiarity about the case to cover a deposition.  You therefore want to make sure that your lawyer has the facts at his or her fingertips.Put together a short presentation in layman’s language that summarizes the medical facts, including the standard of care, and review it with your attorney.  This will also help you clarify your own thoughts and keep your testimony...
CME: Key Determinants for Diabetes Drug Adherence

CME: Key Determinants for Diabetes Drug Adherence

Multiple medications are often prescribed to help adults with type 2 diabetes manage hyperglycemia, diabetes-associated conditions like hypertension and dyslipidemia, and other comorbidities. “Prior studies have shown that non-adherence to diabetes medications is associated with many adverse outcomes,” says M. Sue Kirkman, MD. Research indicates that better adherence to diabetes medications improves control of intermediate risk factors. It also reduces the likelihood of being hospitalized, can lower healthcare costs, and may decease mortality. Taking a Closer Look Studies aiming to estimate rates of adherence to diabetes medications vary widely depending on the types of patients involved in the analysis and how investigators define adherence. Most analyses tend to look at either individual-level or system-level factors independently, but few have used large generalizable cohorts. To address this research gap, Dr. Kirkman and colleagues had a study published in Diabetes Care that used a large national database to look at adherence to oral diabetes medications in more than 200,000 adults with type 2 diabetes in the United States. For the investigation, the study team used the medication possession ratio, which Dr. Kirkman notes is a fairly standard way to assess adherence. “We pre-specified a number of variables related to patient, provider, and prescription factors, and then looked at their association with adherence,” she says. “A multivariate model was then developed to look at the independent effects of each variable since many of them correlate with one another.” Important Findings Overall, about 70% of patients involved in the study were adherent to their medications. “We identified several factors that were associated with non-adherence, including younger age, being new to diabetes therapy, being...

Do Video Recordings Help or Hurt Doctors?

A recent event at the trauma center where I work raised some serious questions regarding the use of video recording for education and quality improvement. We have done this in the trauma bays for several years with the idea that the recordings were protected under the peer review umbrella. They have been useful in analyzing problems, improving workflow, and investigating medical error in the trauma setting. I have generally been in favor of such recordings as they have helped improve our protocols, identified inefficiencies in our evaluations of trauma patients, and in one or two incidents, identified critical errors that could have led to significant harm. Recently, we treated a patient who has made me rethink the wisdom of such recordings. The man was brought in after an unwitnessed head injury. He had contusions on his face and a scalp laceration. He was uncommunicative with the medics and combative with the staff on arrival. In response to his shouting and flailing about, he was restrained and ultimately sedated. A head CT showed no intracranial trauma, and he was reexamined once he was calmer. At that point, he complained that he had been restrained against his will and made allegations of assault against the trauma team. Due to a previous lawsuit, the hospital has a protocol for patients who allege assault. Under that protocol, the local police are informed and come to talk to the patient. If the patient continues to claim assault, a formal police investigation starts. Such was the case with this patient. The officers opened a criminal assault investigation based on the patient’s claim and proceeded to...
CME: Smoking Cessation After PCI

CME: Smoking Cessation After PCI

It has been well-documented in clinical studies that smoking cessation after patients undergo PCI can improve outcomes. Some research has identified certain predictors of smoking cessation after PCI, including beginning vaporizer, previous cigarette consumption and the number of coexisting coronary artery disease risk factors. Few studies, however, have assessed current trends in smoking cessation after PCI and looked at the potential impact of smoke-free policies that are being enacted throughout many parts of the United States. “Historically, patients who undergo PCI are a group that has more difficulty quitting smoking than others,” says Randal J. Thomas, MD, MS. The Effect of Smoke-Free Policies In a study published in the February 15, 2015 issue of the American Journal of Cardiology, Dr. Thomas and colleagues assessed trends and predictors of smoking cessation after PCI in Olmsted County, Minnesota. The investigators conducted the research at a time when local and statewide smoke-free public policies were enacted in Olmsted County. The study followed 2,306 patients who underwent their first PCI from 1999 to 2009 for 12 months. The researchers conducted structured telephone surveys at 6 and 12 months after PCI to assess smoking status and quit rates during the 10-year period. The authors paid particular attention to quite rates around two dates when three smoke-free ordinances were implemented to reduce secondhand tobacco exposure in Olmsted County. The first date was January 1, 2002, when an ordinance was passed requiring restaurants to be smoke-free. The second was October 1, 2007, when ordinances required both workplaces and the entire state of Minnesota to be smoke-free. The data were then analyzed according to three time periods: 1991 to...
Surgeon Convicted of Manslaughter Wins Right to Appeal

Surgeon Convicted of Manslaughter Wins Right to Appeal

Last month, a three-judge panel granted English surgeon David Sellu the right to appeal his conviction. He has already served 15 months in prison. In this space 2 years ago, I blogged about Sellu, who was charged with manslaughter in the death of a patient at a private hospital in London. If you do not want to read that entire post, here’s a brief summary: While recovering from a total knee replacement, a man died from sepsis secondary to an intestinal perforation. Sellu had been asked to consult on the patient. Although I pointed out that many other caregivers must have contributed to this tragic outcome, no one else was blamed. According to the judge’s sentencing remarks, Sellu did not aggressively investigate and treat the cause of the patient’s abdominal pain and his accounts of the events surrounding the patient’s death were inconsistent. Accounts of the case were not detailed, but I assumed Sellu was at fault. “…even if Sellu wins the appeal, his reputation has been ruined, and he will probably never practice again.” – Skeptical Scalpel   Some commenters from the UK pointed out that not all of the facts were known. A website in support of the doctor, whose career had previously been exemplary, was created. Many friends and colleagues said that he had been railroaded and called for the case to be reopened. Last summer, the Daily Mail [a newspaper and website which has been scorned by journalists and readers alike, but shined this time] ran a story revealing the results of a root cause analysis done by hospital staff that found multiple system failures...
Examining Information Sharing Preferences

Examining Information Sharing Preferences

Research has shown that older patients often share control over decision-making and personal health information with family members or friends in order to manage medical care issues. However, it can be challenging for clinicians to balance helping patients and their caregivers work collaboratively to manage health information and decision-making while simultaneously respecting the preferences, privacy, and priorities of patients. To help patients manage their healthcare, patient portals have been developed that connect patients with their healthcare records and oftentimes directly with their clinicians through secure messaging. While portals can be helpful, they may not account for all privacy preferences and offer little guidance on when patients would like to bring their families or caregivers into the fold. Examining Attitudes & Needs In previous research, studies have shown that older patients often want control over the privacy of their health information in electronic medical records, but little is known about how this control relates to family dynamics and the use of patient portals. As reported in  JAMA Internal Medicine, Bradley H. Crotty, MD, MPH, and colleagues sought to identify how elderly patients (older than 75) and their family caregivers approached sharing of health information. “This is an issue that many physicians will encounter, but there has not been much research on the topic,” says Dr. Crotty. For the study, investigators recruited participants from the Information Sharing Across Generations (InfoSAGE) Living Laboratory. InfoSAGE is an ongoing study of the information needs of elderly patients and families within a network of senior housing in the Massachusetts area. Participants joined one of 10 discussion groups to explore the issues. Group discussions were then...
Opioid Misuse, Abuse, & Addiction

Opioid Misuse, Abuse, & Addiction

In recent years, clinicians have changed their attitudes regarding the use of opioids in light of the growing public health issue surrounding the potential of these drugs to be misused and abused. Risks associated with opioid use include overdose, drug dependence and subsequent withdrawal, addiction, and a negative impact on physical functioning. “For many years, the United States went through a stretch when opioids were prescribed increasingly for pain relief,” explains Kevin E. Vowles, PhD. “Recent research, however, has indicated some potential problems associated with increases in opioid prescription rates. As a result, the prescribing of opioids is leveling off, but there is still a segment of the population that stands to benefit from using these medications.” Experts have endorsed the notion that there is a need to differentiate and identify types of problems that may occur when using prescription opioids among patients with chronic pain. Some studies have attempted to calculate rates of problematic opioid use behavior, but these trials often suffer from imprecise and poorly defined terminology. “We’re lacking high-quality evidence on the identification of patients who are at risk for misusing and abusing opioids,” Dr. Vowles says. An Updated Review For a study published in Pain, Dr. Vowles and colleagues performed an updated review of problematic opioid use among patients with chronic pain. “Because previous reviews have indicated substantial variability in this literature,” says Dr. Vowles, “we took several steps to enhance precision and utility.” The authors gathered data from 38 studies and explicitly coded the terms for rates of problematic opioid use in the available literature. They referred to different patterns of use, such as...
Analyzing Inappropriate Antibiotic Use

Analyzing Inappropriate Antibiotic Use

In recent years, there has been increased attention on the overprescribing of antimicrobials due to a surge in drug-resistant bacteria and superbugs. Current estimates show that about 2 million Americans are sickened and another 23,000 die from drug-resistant infections each year. These issues persist despite quality improvement efforts and the launching of campaigns to fight the problem. According to published research, antibiotics are used in approximately 56% of inpatients who are cared for in hospitals in the United States. However, antibiotic use is deemed inappropriate in nearly half of these cases. The inappropriate use of antibiotics can contribute to significant health issues, including antibiotic resistance, clinical failure, adverse drug events, and excessive costs. In a retrospective study published in Infection Control & Hospital Epidemiology, Gregory A. Filice, MD, and colleagues sought to detail the relationship between diagnostic errors and inappropriate antimicrobial treatment courses. The authors analyzed 500 randomly selected inpatient cases at the Minneapolis VA Medical Center in which an antimicrobial course was prescribed between October 2007 and September 2008. Four reviewers who were board-certified in internal medicine and infectious diseases then assessed the accuracy of the initial provider diagnosis for the condition that led to the antimicrobial course and whether or not the course was appropriate.   Misdiagnoses Common Study results showed that initial provider diagnoses were correct in more than half of cases the cases assessed, but many were incorrect or had diagnostic accuracy that was undeterminable. In 6% of cases, the initial provider’s diagnosis was a sign or symptom rather than a syndrome or disease. “Overall, only 58% of patients received a correct diagnosis,” says Dr....
CME: Examining Patient Desires for ED Function

CME: Examining Patient Desires for ED Function

Average ED wait times in the United States vary considerably, but some locations have particularly long wait times. This time spent in the waiting room often frustrates patients and their families as other ED visitors receive care while those who are waiting are given few, if any, updates. Some research has explored educating patients while they wait to be seen by ED personnel, and this appears to be a potentially valuable tool. “Some studies suggest that providing education in the ED waiting room is of interest to patients,” says Jeffrey Druck, MD. In a study published in the Western Journal of Emergency Medicine, Dr. Druck, Paul Leccese, and colleagues aimed to determine baseline knowledge of ED and hospital processes among ED patients. “One of our goals was to establish types of information that waiting room patients wanted, including expected wait times, causes of delays, and the triage process,” explains Leccese. “We also wanted to see how they would like this information to be delivered.” In addition, the study asked participants what they expected regarding wait times for labs, imaging studies, and admission. The authors also assessed links between racial groups and their desire for information as well as whether or not patients wanted educational health materials. New Data For the study, a 32-question survey was administered to patients and showed that 55% of the 544 respondents indicated that they had a primary care physician (PCP). Of these patients, about 53% reported calling a PCP before they came to the ED. About 72% of participants wanted to know about delays, but just 25% wanted to know others’ wait times. “While...
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