Tuesday, October 30, 2007

The old time "peripheral brain" of house officers is now the external universal mind

Returning home from a vacation in Europe I read a delightful and insightful piece by David Brooks in the International Herald tribune entitled "The External Brain". It can be found here.

I actually still have my little black book which was a lab coat pocket sized binder notebook in which house officers in the day wrote things that they thought they needed to know and no, I don't use it anymore. That and the Washington Therapeutic Manual were our "peripheral brains." I find an 40 year old entry under CHF which talks about how to slowly "digitalize" a patient with congestive heart failure and another on how to do the "Ivy bleeding time, both of which are medical museum pieces.

Brooks, in what I believe to be at least in part a tongue in cheek essay talks about how by becoming progressively reliant and dependent on his GPS system he was discovering the "Sacred order of the External Mind." He could now out-source mental tasks to a satellite brain, an external Mind. He says he may now no longer need a memory because with a few key-board strokes he can get what he needs on Google or Yahoo and the drudgery of having to remember so much stuff is eliminated or for more personal material open up his Blackberry.

He writes that he discovered that the magic of the information age was not we could now know more but that it "allowed us to know less."

The clunky,relative information-poor little black book of yesterday's intern has morphed into the powerful PDA through the mystery and magic of the silicon chip animated by the unforgiving logic of the algorithm.This can not only hold a PDR, one of the available antibiotic guides and five Minute Clinical Consultations,etc,etc but when Internet-enabled the entire universe of the external brain can be accessed.

Brooks continues " I have relinquished control of my decisions to the universal mind...Life is a math problem and I had a calculator"

One possibly disturbing counterpoint is noted in Brooks' reference to a piece by Clive Thompson in Wired which claims that one third of folks under age 30 can't remember their own telephone number.

Of course, physicians cannot really relinquish control to the universal medical mind. However, when you have the background and the context of experience, access to the "outboard brain" is unbelievably empowering and having tasted of it you never want to do without it. But as Clive Thompson said in his closing, I would like to still remember my own phone number.

Thursday, October 18, 2007

There are no average patients

Dr. Robert Centor has an important entry in his blog, DB's Medical Rants, dealing with a issue dear to my heart. He refers to an article in American Scientist by Drs. Rodney Haywood and David Kent. These are the same docs who published a recent article in JAMA that I talked about here.

The basic notion here is that averages hide individual differences and Haywood and Kent emphasize the need for risk stratification to be included in randomized clinical trials.

Earlier on I had been able to access a full text version of a classic article on this same general topic but now my attempts to link to that have been met with the realization that now a subscription is required. This is a real shame as it is an article every med student and physician should read and digest.
The Journal is

Milbank Quarterly ( 82(4),661-687, Dec. 2004 and the article is " Evidence-based Medicine;Heterogeneity of treatment effects and the trouble with averages" by Kravitz,RL,Duan N, and Braslow J.

Here is the abstract ( apparently all you can get without a paid subscription now) with my addition of the highlighting of certain phrases.

"Evidence-based medicine is the application of scientific evidence to clinical practice. This article discusses the difficulties of applying global evidence ("average effects" measured as population means) to local problems (individual patients or groups who might depart from the population average). It argues that the benefit or harm of most treatments in clinical trials can be misleading and fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few. Heterogeneity of treatment effects reflects patient diversity in risk of disease, responsiveness to treatment, vulnerability to adverse effects, and utility for different outcomes. Recognizing these factors, researchers can design studies that better characterize who will benefit from medical treatments, and clinicians and policymakers can make better use of the results."

Guidelines are based-ideally-on evidence.The highest rung on the evidence ladder is generally said to be the randomized clinical trial(RCT).The conclusions of RCTs are expressed in terms of averages and the problem is averages are abstractions of data and there are no average patients.

I am glad that DB is pushing on with this topic. He is widely read and a prominent educator and at least his students will benefit from discussion of averages and the madness of guidelines. Also be sure and read the insightful comments to DB's entry by Dr. Richard Fogoros

More on "Is there no end to the wonders that statins will bring about?"

Here is a link to one more in the ever growing list of the wonderful things that statins can do for us all. We now learn that the rate of loss of lung function is lessened in statin users with COPD.

Earlier I had listed some of the other benefits attributed to statins . These included

decreased risk of death from COPD and heart failure
decreased risk of advanced cancer of the prostate
decreased risk of pneumonia in diabetic patients

I also previously commented a study that seemed to show a decreased risk of sepsis in dialysis patients who took a statin. I cynically wondered aloud if some or all of these observational studies on the benefits of statins were not a big push by the statin manufacturers to generate more evidence that the value of the statins extend far beyond the LDL lowering effects and include the nebulous effects "pleotrophic" effects. Such a effort could well be triggered by the market success of Zetia.

There was also the issue of the dueling case-control studies that dealt with the question "do statins decrease the risk of colon cancer" with various studies reaching opposite conclusions. That saga seemed to prove once again you should not bet the farm based on the results of a case-control study.

I certainly do not rule out that some or all of the statins may bring about some type of benefit apart from the cholesterol lowering but the fact is the studies mentioned above are observational studies and are a hotbed of all the potential biases that we learned about in doctor school and basically cannot prove causation. and we need to particularly be wary of the healthy user effect.

Tuesday, October 16, 2007

changing mind set in medicine

Kevin MD references a posting on what life is like for a hospitalist at Kaiser that tells the readers more than what life is like for a hospitalist at that particular HMO.The blog that Kevin refers to is EM Physician-Back Stage Pass and here is the essay.

I believe it tells a great deal about what may be a major paradigm shift in the self image or mind set of physicians in this new culture of managed care.

Here is a quote:

Medical students and residents are seeking a better lifestyle for themselves. I guess we're finally coming to realization as a group that medicine isn't worth your happiness and sanity. That it's hardly admirable to subject yourself to abuse (by CMS, by DHA, by joint commissions,by society by medicine) and be absent in the lives of your loved one. Maybe when doctors were respected,autonomous and paid well...but now,not as much. when this happens, when docs start seeing themselves as employees with jobs,continuity of care sounds like crazy talk. Think how crazy it would sound if we suggested that nurse (or anyone else on the 'healthcare team' were made to "feel guilty" about going home at night....Everyone has a job these days..which is what government created and physicians (at least the professional societies) have allowed to happen.

The loss of pride that DrRich and I have blogged about seems evident in this doctor's view. It seems the doctor author sees himself as 'only" an employee. I re-read his piece and I go back and re-read the an early entry I submitted for this blog which dealt with the transformation of a lay person to a physician and at first conclude that our views are miles and ages apart.Or maybe my views are what I was taught a physician should be and his/hers are what the reality of the current economic medical landscape are turning physicians into.

Different meta-analytic technique fails to confirm increased risk from rosiglitazone

It was only a matter of time before someone published an article using a different meta-analytic technique from that used in the now famous rosiglitazone study by Nissen that failed to confirm Nissen's findings. George Diamond is the senior author of such an article in the Oct. 16, 2007 issue the Annals of Internal Medicine in which by using different techniques from Nissen neither an increased nor a decreased risk from the use of rosiglitazone in diabetic patients was demonstrated.( a subscription is required for full text )

No one should be surprised. The tools of the meta-analysis trade are arcane and the average or even way above average physician reading a meta-analysis either has to accept the findings at face value or ignore the thing entirely because he basically does not understand what was done and is in no position to meaningfully critique the techniques.If the issue is important and/or major economic forces have an interest there will soon be what we have here namely dueling statisticians.(I am not implying that the authors of the Annals article were motivated by those forces and would be surprised if they were)

Is the technique used by Nissen correct or is the method used by Diamond or is that even a meaningful question? It may be the case that combining disparate, incomplete sets of data, often without patient level data cannot ever answer certain questions such as the one posed by the rosiglitazone data analyses. It may well be a randomized clinical trial is the only way to possibly generate a meaningful answer which is what , at least in regard to the "rosi" question, is what Diamond et al suggested.

I have ranted on and on about meta-analyses (MAs) before and have borrowed heavily from the powerfully instructive writings of Dr. Steve Goodman. Medical students should have the following sentence grafted into their frontal lobes. The outcome of a meta-analysis is a function of the studies that one decides to include and the summary statistic used and various experts differ in regard to what statistic to use and the method of inclusion of studies.

They are basically observational studies in which the "subjects" are studies or trials and the "truth obtaining" value of observational studies is well recognized to be several notches lower that the randomized trial. Statistically combining two or three randomized trials does not always magically generate a higher degree of truth ( ie. correspondence to reality) than does the individual trials although sometimes it might. The trick is how to figure how when it does and it is a trick I have not learned.When are we dealing with apples and oranges and when are we merely seeing apples with minor and insignificant variations in color and consistency?

There is an editorial in the same issue of the Annals by Mulrow et al that says in part:

The analyses by GlaxoSmithKline,Nissen and Wolski and Diamond and colleagues and the FDA teach us that summarizing data about scarce adverse events is difficult. Summary estimates, confidence bounds and statistical significance can vary depending on analysis techniques.

This means that well meaning, honest investigators can reach completely opposite conclusions based on how they decide to analyze the data and there can be honest disagreements about how to decide on which technique to use.

But in regard to rosi I believe we cannot get the cats back in the bag. With what has been published and magnified in the news and on the web to prescribe rosi to a new type 2 diabetic would be to pin a large target on your back with a sign that says sue me please even if we really are not sure if rosi increases risk of cardiovascular events or not and we may never "really know". Sometimes issues are just dropped and we move on to something else.

Thursday, October 11, 2007

Even PAs are moving away from primary care?

An article that can be found here suggests that my prediction that not too far down the road primary care will be delivered mainly by "mid level" practitioners may not be on target. It seems that fewer PAs are opting for primary care mirroring a trend in med students to shun primary care. Low pay, shrinking prestige ,cost of education and low level of job satisfaction are factors said to push docs away from primary care and the same factors may have a similar effect on PAs .

Thanks to KevinMD for calling attention to the article referenced above.

Maybe "mid levels" will be replaced by something like PA assistants (PAAs) or NPAs ( nurse practitioner assistants). The third party payer spin doctors will need a better name than "lower levels" to refer to them, however.

Wednesday, October 10, 2007

The 2007 Chicago marathon-a hot weather wipeout

The weather is not supposed to be hot for the Chicago marathon which is held in October. This year it was hot and so hot that things seemed to get out of hand. One news report described what took place as "havoc".

The race directors at some point canceled the race in mid course due to the excessive heat which should not have been a surprise as the preceding week had been unusually hot. Many runners continued ,however, ignoring barriers and the shut down of the watering stations. One runner died but the official report is that he did not die from heat related cause but from a pre-existing cardiac condition. Some runners blamed the race directors for poor planning and at least one person connected with the race blamed the runners for pouring water over their head instead of drinking the water. He was quoted as saying he had never seen runners pour water over their heads. He should watch runners in the summer and fall in Houston.Apparently some runners left the course to get drinks at local stores. Things did not go smoothly.

Many runners were treated by the medical teams set up for the race. This brings to mind the issue of medical management of the collapsed runner, an issue of personal and professional interest to me. Professional because internists are supposed to know all about electrolytes and the like and personal because I continue to participate in marathons and if I ever collapse I hope someone knows what to do.

I have posted before on this subject quoting the work of Dr. Noakes from South Africa who is a well known authority in this area who has emphasized the importance of hyponatremia and the critical necessity to know the serum sodium level in a collapsed runner and has urged race directors to arrange for access to point-of-care serum sodium determinations. The point has been made that determining the sodium level should precede the reflex starting of normal saline as that is not the appropriate treatment for severe hyponatremia.

This sodium issue has to be raised in regard to the death of the young runner concerning whom news reports indicate he died from mitral value prolapse (MVP).

I was puzzled as to how MVP would be the mechanism of death and my doubt was reinforced by a very recent posting by a cardiologist, Dr. Wes. He knows much more cardiology than I and he expressed his doubt about the putative cause of death.You have to wonder about electrolyte problems and arrhythmias.There are well documented deaths in marathoners due to severe hyponatremia . After the 2000 Houston marathon ,during which temperature was as high as 86 degrees, which was only slightly cooler than Chicago, there was a report of four young female runners were hospitalized with severe, life threatening hyponatremia , all of whom were successfully treated.

I bet there will be many calls from patients with the diagnosis of MVP- many of whom have in fact very little wrong with their hearts- to their primary care doctors or to cardiologists.

Tuesday, October 09, 2007

Yet another reason why students do not choose primary care-from DrRich

Primary care providers-at least those with a M.D. degree- are seemingly moving along a path leading to extinction. In The Covert Rationing Blog, DrRich gives us an important essay describing another reason why docs will not be going into primary care and those who in doing it now will be more likely to opt out.

The latest reason is the rise ( I am not sure how widespread the practice really is) of something called care management consultants.

Go to his blog and read his comments and the reference to a Wall street Journal article on that topic.

This is still another chapter in the book entitled "Medicine is too important (read costly)to be left in the hands of the physicians and their patients".

Cynics would say that these management consultants are just another mechanism to decrease the expenditures of insurance companies while the "vision " statements of the companies proudly state they are trying to improving the quality of health care. To read details about how the big three insurers are improving quality for folks who signed up for the Medicare funded health plans go to this essay by Dr. Roy Poses.

Tuesday, October 02, 2007

Are physicians no longer "proud" and "Ethical"

The Covert Rationing Blog's author DrRick uses the phrase "Once-proud,once ethical" to refer to the medical profession. I certainly do not want to believe that the modifier "once" is correct.
However, there seems to be much awash in the land to push the vectors in the direction of less pride and less ethical behavior.

When a doc has to depend on a clerk in some distant place to tell her if she can order a certain test or prescribe a certain drug or perform a certain operation, obviously pride will suffer. What does it do to the ethical framework when a doc in tempted to game the system to make it possible that that test or that drug can be ordered or that operation be perform? How much pride can you feel when you rush through a 7 1/2 minute patient encounter when you realize there are issues that the patients brought up that you can only brush off and move on to the next overly-hurried,doomed to be incomplete patient encounter?

What happens to pride when your medical group agrees to mandate 32 patient encounters per day rather than the leisurely 30 you now plow through? Does your spider-sense ethics tingle
annoyingly when you realize you are setting the stage for even more inadequate medical practice solely because of the perceived need to increase volume? Does your pride titer decrease when you agree to no longer attend patients in the hospital, even though a major part of your internal medical training and to date professional experience has been caring for seriously ill,complicated patients in the hospital and you know that you can do a better job than the recently hired internist-self proclaimed hospitalist who is one year out of training solely because it appears to be economically advantageous to do so?

Does your pride suffer when you see the latest survey of professional compensation that illustrate that your years of training as a internist or psychiatrist or pediatrician or family physician earns you about the same as a CRNA?

What is the effect on your pride when you are labeled a "disruptive" physician because you repeatedly pointed out that the four-hour rule for treatment of pneumonia is wrong headed and likely to cause more harm than good?

I personally am not proud of the-what I consider to be a sea change-in the stated principles of medical training for internists? I refer to the deletion of what was the touchstone of an internist's training- "... in no case should the resident go off duty until the proper care and welfare of the patient is ensured."

I personally am not the proud of the concepts slithered into the new medical professionalism.I have written about this before .I refer to an attempt to substitute for the time honored and pride generating fiduciary duty to the patient a collectivist view of conserving society's resources.

Having said all of that, the really big elephant in the room derives from the fact that much of medical care is paid for with other people's money and as expected those other people want to spend less money and much of their concern seems manifest -as DrRich has eloquently explicated-by covert rationing. With those economic forces at work pride and traditional medical ethics are not likely to enjoy any resurgence any time soon.