JAMA article reports dramatic reduction in hip fracture in stroke patients with b12 and folate

A recent article from Japan by Sato et al reported an impressive 80% reduction in hip fractures in a two year trial with B 12 and folic acid in patients with poststroke hemiplegia.Interestingly there were no fewer falls in the treatment group and no change in measured bone density. A reviewer ( Dr. Steven R. Cummings) in ACP Journal Club commented "The huge reduction in risk defies explanation by current paradigms of pathogenesis and prevention of fractures." Actually, we can always make up some pathophysiology to "explain" the facts. Certainty on the face of it, one has to ask why fewer fractures if no fewer falls and no change in bone density. It may well be that the treatment somehow (maybe collagen cross-linkage improvement) may strengthen bone without a measurable difference in bone density. It is well recognized that the bone density measurement does not tell the whole story about likelihood of fracture given a fall, it is just the typically used clinical measure. So should we give B12 and folate try in stroke patients with hemiplegia? It seems safe and after all a RCT resides on top of the EBM epistomologic hierarchy so why not?

retired doc back after phone cable cut and Rita

For the past week, I have been off line thanks to a cable cut incident with SBC and then Rita storming into east Texas. There is a lot to catch up with and please stay tuned.

American Heart Association and ADA disagree on significance of metabolic syndrome

Recently the ADA issued a position statement challenging the validity of the concept of metabolic syndrome. Their statement can be found here. The ADA authors said that the syndrome lacks a precise definition, is of dubious value and its underlying pathophysiology is in question.
The AHA/NHLBI panel on the other hand said that they "found the ATP criteria for clinical diagnosis of the metabolic syndrome to be a robust and clinically useful tool." and " in the absence of compelling scientific reasons for change, the AHA and NHLBI affirm the overall utility and validity of the ATP III criteria..." The executive summary can be found here. The timing of the two publications is such that it is unlikely that the AHA could have prepared a rebuttal to the ADA paper as they were published within several weeks of each other
The clinical management recommended by the two groups is very similar- more so that their seemingly disparate characterizations of the constellation of findings designated as comprising the metabolic syndrome. Everyone seems to agree that you should treat the various risk factors per se and that there is no specific treatment for metabolic syndrome, i.e. no single pharmaceutical magic bullet to fix or mitigate the underlying pathophysiology if there is one. ADA's statement indicates they are much more skeptical that there is a unifying pathophysiology than is AHA.

American Journal Medicine article paints alarming picture of current Internal medicine residency

The September 2005 of AJM features an article (Internal medicine residency training in the 21st century: Aligning requirements with professional needs, Charap MH et al. Amer J med. 118, number 9, pg 1042, sept 2005) in their APM Perspectives section that characterizes current IM residency training as an almost mission- impossible type situation. The authors from New York University Department of Medicine describe in detail changes made by the ACGME and Residency Review committees (RRCs) since 1980. In 1980, IM training was 3 years as it is now, although at some earlier date (when I trained in the 60s) training was an internship and then three years of IM residency so that total post med school education was 4 years. There was more time then and clearly less to learn . Now the total time in training is less and the amount of time "allowed" during that time frame (i.e. "duty hours") has been mandated to be less.
The entire article is worth reading if you are involved in teaching residents or interested in post graduate education.(I am sent the journal but am unable to download the articles on line so I didn't give the URL).
I found the article very troubling. Most disconcerting to me was that the following statement is no longer included in the current RRC documentation."Physicians must have a keen sense of personal responsibility for continuing patient care and must recognize that their obligation to patients is not discharged at any given hour or any particular day of the week. In no case should the resident go off-duty until the proper care and welfare of the patient is ensured." Previously the RRC-IM was careful to include this caveat that the authors consider it the " touchstone " of the internist's world. This admonition apparently went south when , in 2003, resident duty hours were further restricted by the ACGME. The RRC-Im Program requirements documents for IM residency is now 21 pages having been a single page in 1980. In the last year, training for 6 "core competencies" was mandated including training is "system-based" practice and " practice-based learning" and scholarly activity is also required. The authors make the following alarming statement : "the reality is that residency programs simply cannot satisfy these ever-increasing requirements other than as paper achievements responding to paper audits."
They make several recommendations which include : Restoration of the above quoted "touchstone" statement, not adding more requirements unless they are linked to equivalent reductions, convening a blue ribbon panel ( not affiliated with ACGME) to review all of the RRC-IM requirements, allowing more flexibility in the program to meet the diverse career interests of current day residents.The authors definitely believe that changes must be made because " there is simply insufficient time to educate internal medicine residents in the present regulatory environment"

If you thought medical school was hard before (katrina)...

A section in the Tulane Medical student web site for comments for the now Katrina displaced(to be largely relocated in Houston) students has the title "'If you thought Medical school was hard before". A sense of humor doesn't hurt. The exploits of Dr. Tyler Curiel-head of heme-oncology at Tulane- could be called " If you thought doing medical research was hard before...". His lab, like so many other labs at both Tulane and LSU, continue to be without power and much research material has either been ruined or will soon be. Some his work was preserved by using liquid nitrogen to freeze valuable samples before the power went out. The nitrogen induced freezing is finite ( maybe two weeks) and his efforts to return to New Orleans and refreeze valuable material are explained here. The logistics of returning to the Tulane Medical center and applying liquid nitrogen to storage chests in a building without power is daunting but apparently Curiel will ( or perhaps at this writing already had) pull it off. He acquired the aid of Phazar Aerocorp who has donated jets and employees to aid in the mission. It will involve carrying 400 lb. tanks of nitrogen up various flights of stairs to the various labs and working in the heat and dark. He and his wife, Dr. Ruth Berggren, spent endless days and nights caring for patients in the Tulane University Hospital and Charity Hospital before being evacuated to Fort Worth. The exemplary behavior of many of Tulane's faculty in that time of unprecedented crisis focused attention of some prime time role models for the Tulane Med students who no doubt have some major challenges to overcome this year to continue with their medical education.(The above referenced newspaper article is now several days old, if any readers have learned more recent information, please let me know).

Texas Medical Association skeptical of UHC's "Premium Designation Program"

UnitedHealthCare representatives have met with the Texas Medical Association's (TMA) leaders to introduce their program designated as Premium Designation Program which will hand out stars to good doctors. I still remember the stars I was awarded on my grade school papers. Physicians who meet either the quality standards or the efficiency standards that UHC devises with be designated as either having one or two stars (two if both criteria are met) and a triangle will be the scarlet letter for those whose data is insufficient to analyze or if their specialty is not included in the program. Apparently the grading system will be based on claims data.UHC said that initially the program won't be used to penalize or reward physicians monetarily. Writing in the September 2005 issue of Texas Medicine , the senior editor quoted a 7/21/05 letter from the TMA General Counsel to UHC in which the TMA wanted to make it clear they did not endorse the program. Several physicians who attended UHC briefing sessions complained that UHC either implied or stated that their program was endorsed by the TMA. A program in which a star is given on the basis of claims reviews for "efficiency" is not a quality initiative. It is a cost containment mechanism. The program as currently touted by UHC seems to contain none of the AMA 's five requirements for a quality improvement type P4P program. Typically, TMA has been a strong advocate for physicians and patient care and so far it is willing to point out exactly how the emperor is dressed. The insurance industry's Trojan horse of quality seemed to have been welcomed within the walled city of the American College of Physicians (ACP) and perhaps other national medical organizations. While I continue to hope that national organizations can make a difference, I believe that meaningful resistance to this latest cost containment-profit enhancing- initiative of big insurance will be at the level of the state and local medical societies.

No reduction in GI cancers from antioxidant supplements-caraway extract for IBS?

The Sept. 6 issue of the Annals Internal Medicine reviews an earlier Lancet article ( Bjelakovic, G et al-Lancet 2004:364;1219-1228) which not only concluded that antioxidants do not prevent GI cancers but may increase the risk. The data clearly did not show cancer reducing benefit form the supplements included (various vitamins and selenium) but the conclusion of possible increased risk seems unwarranted as the Annals reviewer explains in his analysis. The increased risk (R.R=1.06) was found in a fixed-effects model which is said to be used if the data appear to be homogeneous but 7 of the trials seemed to be heterogeneous. The random effects model analysis did not show an increase in all-cause mortality and that type of analysis is usually what is employed with heterogeneous data.
The same review section ( Update in Gastroenterology and Hepatology) includes an article of a RCT evaluating the use of herbal preparation for the treatment of IBS. 208 patients were assigned to receive 1 of 4 regimens. An abdominal symptom score was the endpoint of interest. 2 of the 4 regimens were said to bring about significant improvement in symptoms scores.Both regimens contained peppermint and caraway fruit. The reviewer concludes that practitioners "should consider" these herbal preparations to their armamentarium for IBS. I know there is considerable energy in the efforts to make respectable complementary and alternative medicine but one small RCT seems to me inadequate evidence to include these herbs in your treatment choice bag just yet. (There are a few other small trials using the combination of these two herbs for treatment of "non-ulcer dyspepsia" but are we seeing a type of affirmative action for alternative medicine . FDA approval would not be granted for a prescription medication based entirely on one RCT.)

Disease Mongering-One more obstacle in the search for medical knowledge?

Recently, the American Diabetes Association (ADA) issued a statement casting doubt on the validity and usefulness of the concept of metabolic syndrome and suggesting that physicians not make that diagnosis. One of the news articles about this statement used the term disease mongering.I had not previously been aware of that term. Mongering has two dictionary definitions:
1) to deal in a commodity 2) to promote something undesirable or discreditable. A 2002 BMJ article deals with disease mongering which describe as follows: " Some forms of "medicalization" may now be better described as " disease mongering"- extending the boundaries of treatable illness to expand markets for new products.
A 1992 book entitled "Disease-Mongers" by Lynn Payer, health editor of the New York Times, provides an early application of that characterization.Two years earlier, Ivan Illich's often quoted "Limits to Medicine" had dealt in part with that subject.
The BMJ article speaks of disease awareness campaigns that are linked to companies' marketing strategies and company sponsored advisory boards, risk conceptualized as diseases and disease prevalence estimates constructed to maximize the impact and importance of a given medical issue.
Osteoporosis was given as a example of a risk conceptualized as a disease. A diagnosis of osteoporosis can be made on the basis of a bone mineral density (BMD) test if the patients' test results vary sufficiently from that of a normal young woman. BMD is one of the risk factors for osteoporotic fractures but in this formulation a low BMD becomes a disease worthy of ICD coding, prescription medication and continuing followup with more BMD determinations. The authors reference the role of drug companies in sponsoring meetings where the disease was defined, and funded studies of therapies and patient groups and and disease foundations.There has definitely been a paradigm shift, patients at some higher level of risk for fracture have been defined as having osteoporosis and there is widespread knowledge of the test, the new definition and patient acceptance of prescription medication.
All of this has to give a physician some cause for concern. Have we been bamboozeled by Big Pharma, have patients and physicians been sold a bill of goods? The authors would say yes, but I do not believe it is that simple. Trying to disentangle the facts from drug company hype and spin in a literature so often highly influenced by those drug companies is no easy task.
The treatment of osteoporosis has a sound foundation. 25 years ago we had no treatment for the painful complications of osteoprosis, we do now. That is not the issue. The issue is are we preemptively " treating" a low BMW to prevent clinical osteoporosis because we have been convinced that this is the appropriate thing to do by pharma hype. Maybe so, but that does not necessarily mean we shouldn't do it. Risk of fracture is clearly reduced by bisposphonates. Bisphosphonates appear safe and effacious and for a patient at an increased risk of osteoporotic fracture it is reasonable to offer that patient the option of prescription medication to mitigate that risk even though we may have not reached that point if not for the promotional efforts of drug companies. With the spotlight that has been focused on Pharma's antics, I want to believe there will be less disease mongering and both physicians and patients will be more skeptical and immune to influence.
Specifically in regard to the metabolic syndrome and relevant to disease mongering discussions, at least one drug company cannot be pleased with ADA's recent statement challenging the validity of the concept. I read today a two page ad from Sanofi Aventis in which "a newly discovered physiologic system" is highlighted, namely the endocannabinoid system which is alleged to be overactive in the metabolic syndrome Their drug, rimonibant is an antagonist of this system and FDA approval for treatment of the metabolic syndrome would be more valuable than treatment for obesity alone an application for which it has demonstrated some usefulness.
Fox Mulder believed the truth is out there somewhere.Physicians typically do as well, but it is harder to grasp the truth when we have serious doubts about the veracity of the data underlying our practice decisions.

The doctors and Nurses of New Orleans Charity Hospital

Fox News interviewed a nurse at New Orleans Charity Hospital last night. She and her fellow nurses and the physicians had been fighting against everything for the last few days, disease, injury, diminishing supplies and food and water living and working in a island without outside help.
She said they kept it all going because that is what doctors and nurses do and what they accomplished was done without help from the city, state, FEMA or anyone else. That dedication and focus on patient care is what doctors and nurses are all about. Making patient care and welfare first is what was imprinted in my limbic cortex at the same institution over 35 years ago. My wife and I became doctors there at LSU and Tulane Medical School and "Big Charity" and our hearts are breaking as we sit glued to the TV and Web absorbed in the misery as memories flood our minds of a time of youth and promise as we underwent the transformation from young adults in our early twenties to physicians. We are so proud of the current generation of faculty and students at the two med schools fighting the good fight in the face of impossible conditions and risk to themselves. Dr. Roy Poses and others on their web sites do a great service by pointing out and fighting against the outside forces that erode the core values of physicians but , by God, when the chips are down, the core values are there as the actions of the doctors at Charity and other N.O. hospitals illustrate so heroically.

ADA statement- metabolic syndrome not a useful concept any longer

In what will be to many a surprising comment,The American Diabetes Association issued a statement challenging the value of the metabolic syndrome label. Their chief scientific and medical officer was quoted in USA-Today as saying "We don't believe there 's a syndrome"
The ADA is quoted as saying that each of the conditions that make up the syndrome are potentially life threatening but there is no evidence to suggest that someone with multiple factors is any sicker . Headlines aside, the ADA position is put forth in an ADA Statement published in Diabetes Care 28:2289-2304, 2005. It is a length and scholarly review of the subject and is worth plowing through because this clustering of cardiovascular disease (CVD) risk factors has reached "disease equivalent" status replete with a ICD-9 code and has become part of the medical vocabulary of patients as well as physicians. Here are some of the key points of the statement.
Although certain CVD risk factors are prone to cluster, there is considerable doubt as to the predictive value of the syndrome, i.e. does the syndrome impart any risk greater than its individual components.
In regard to whether metabolic syndrome is a coronary risk equivalent, the authors quote a study by Wilson et. al. which showed that when an elevated blood sugar is taken out of the definition, the 10 yr. Framingham risk does not reach the ATP III's threshold for risk
equivalent. So using the NCEP definition of Metabolic Syndrome, it matters which of the 3 out 5 criteria are present as data suggest that all combination of factors leading to the syndrome diagnosis do not convey equal risk.
There is considerable uncertainty regarding the syndrome's pathogenesis, i.e.everyone with the label-and there are various definitions proposed-may not have the putative underlying mechanism which is thought to be insulin resistance.
In short, the syndrome lacks a precise definition, is of doubtful value as a CVD marker and its underlying pathophysiology is dubious.
The ADA therefore recommends for physicians to treated all CVD risk factors per se and not label patients with the term metabolic syndrome because that may give the impression that the syndrome denotes a greater risk than its components which is a conclusion for which the evidence is not convincing. The term has been a useful paradigm to the extent that atttention was drawn to the fact that some CVD risk factors cluster in patients so predisposed and doctors need to evaluate a patient who has one major CVD risk factor for other risk factors.
The statement is likely to have wide impact as ADA is well respected and their European cohorts (European Association for the study of Diabetes) published the same statment in the journal Diabetologia.
One of the news reports mentioned the term "disease mongering" referring to drug companies' promotion of the syndrome to develop markets for its treatment. This is a concept that has received considerable interest in Australia and in the pages of the BMJ and that deserves a posting of its own at a later date.

A follow up to restless leg syndrome post and comments

Medscape has an article explaining new warnings issued by the FDA on Requip.RebelDoctor Weblog had commented on my earlier blog indicating that he too felt RLS was probably under-diagnosed and mentioned his approach to therapy . Unfortunately, I had to delete the comments for that blog- including his- as my site was bombarded with spam-comments. (I also put up the usual anti-spam- comments protections.) I did not want the good Doctor from Mississippi to think that I did not appreciate his comments.
Medscape indicates the reason for the new warnings on Requip relate to the sudden
"falling asleep" apparently without warnings that have been reported in patients taking Requip. Physicians in Canada had been alerted to this issue as early as 2000. (for some reason I have been unable to get back to Medscape to set up a link). The major issue, here, is should patients on that medication be driving. The PDR section on Requip indicates that patients should not drive until they determine that the drug does not cause drowsiness and if they do experience drowsiness doing everyday activities they should not drive.

Homeopathy-Lancet article critical-NHS pays for it

A recent article in Lancet appropriately criticizes homeopathy and concludes there is no scientific basis for it and it does not work. This is no surprise. It is surprising that the NHS pays for it and the Lancet article ( registration required) quotes a WHO draft report supporting homeopathy claiming there is valid evidence of its efficacy. For some reason I would expect better from WHO.

Restless leg syndrome-unrecognized epidemic or drug company hype

This sounds a lot like my recent posting on bipo*r disease and allegation of physician underdiagnosis and it should since it is another example of the same issue.
This time we look at an article in a recent Archives of Internal medicine and a reporting of that article in Internal Medicine World Report ( August 2005).16,00 patients were given questionnaires re:RLS. Weekly symptoms were reported by 773 patients ( 5 % of the 15, 391 patients who completed the questionnaires.) Apparently 337 reported discussing their symptoms with their physician but only 21 had received a diagnosis of RLS.
Realizing full well that the plural of anecdote is not data, I still have a urge to relate my experience in seeing patients in an internal medicine practice for over 35 years. No patient had a complaint that could be referable to RLS diagnosis ( not to say they didn't have it , they just didn't complain of it) and only two gave me the history of that disorder having been diagnosed elsewhere and were on treatment. One of the two gave me a web site to learn about the disorder. A 3/4 page ad is found in the same issue of Internal Medicine World report informing the reader about the "first and only FDA-approved treatment for moderate to severe Primary RLS", namely ropinirole- trade name Requip which is a dopamine agonist.FDA gave approval in May 2005. The manufacturer of ropinirole is listed as a source of funding for the study; its name is not mentioned in the article. To the extent that patients complain of RLS symptoms and are not counseled about it and perhaps offered the option of medication and have their serum iron levels measured, the physicians are not doing their job.(articles and lectures on RLS-locally there have been a number of "free" dinner lectures on RLS by a local movement disorder specialist-seem to not emphasize in their mentioning of the association of RLS and low iron that at least post menopausal women and all men should be evaluated for GI bleeding if the iron is
low.)
Maybe there is an almost epidemic of RLS and maybe docs are fairly clueless about the whole thing, but in light of the events of the last few years regarding revelations about drug company manipulation of the medical informational process, you just have to be a little skeptical.
On a possibly related note, there seems to be a flurry of recent publications-typically from the medical education companies-about the putative mechanistic reason(s) behind the reported increased prevalence of macrolide resistance and the apparent theoretical advantage of a new antibiotic class-the ketolides- in that regard.

Canadian Supreme Court ruling,CMA recent vote-is private care on the way in Canada?

Delegates at the Canadian Medical Association 's recent meeting voted to not reject the alternative of private care in Canada if waiting times are prohibitive. A recent CBC article describes various medical services already in Canada that seem more private than public including employer based health insurance that may provide ammenities outside of the benefits covered by the provencial plans. Canadians who can afford it sometimes also vote for private care. They vote when they buy insurance that will help pay for surgeries south of the border if the wait is too long. Many Canadian physicians also voted already when they left home and moved to the U.S. to practice pirvate medicine.

Dueling medical mathematical models- to choose- An act of faith?

The August 16, 2005 issue of the Annals of Internal Medicine published an article by Dr. David M. E. Eddy et al using a mathematical model called the Archimedes model. This computer based model was applied to the question of is it more cost effective to give metformin or to employ the methods of the Diabetes Prevention program (DPP) of lifestyle modification to prevent or delay the onset of diabetes in high-risk individuals.

 The DPP had shown that over the almost three years of the trial there was a relative risk reduction of 58% from life-style and 31% for metformin. An earlier article in the same journal used a different model (Markow model) to attempt to answer the same question. The authors concluded that the lifestyle modification was more cost effective. The Eddy article found the opposite to be the case.

The views of two editorialists were sought and published in the August Annals issue in an apparent attempt to place things in context.

One editorial author was Dr. Michael M. Engelgau who was one of the researchers in earlier study that found lifestyle modifications more cost effective. Not surprisingly he criticizes the Eddy model saying in part " I believe Eddy and colleagues' criticisms [of his model] are based on inaccurate descriptions of the DPPRG model". Eddy et al in their introduction state their method is " more thorough,clinically realistic and independently validated".
So whose model is better? Whose conclusion is correct? Is there a "correct"? Dueling experts with opposing conclusions.

The Archimedes model also found that it would be more cost effective to wait until a person developed diabetes before instituting either metformin or lifestyle modification. It will be interesting to see what the folks at the America Diabetes Association or Joslin Clinic say about that.
In real life, of course, a physician will attempt to convince the "pre-diabetic" to loose weight and exercise and may even in addition suggest metformin. But these models are less used to aid individuals docs and individual patients decide what to do that they are to make policy decisions for large organizations in regard to how to allocate funds.

The line between "pre diabetes" and diabetes is arbitrary and the definitions of these two conditions change with the edicts of the ADA and the physiological processes that Eddy claims to model with differential equations are poorly understood and always in flux as new biological insight are gleaned. The output of these models is quality-adjusted life-years (QALY) in which researchers claim to be able to measure and average the "quality" of a person's life. I have posted before on the topic of QALY and cost effectiveness articles.

These models have assumptions on top of assumptions, offer little transparency, are essentially mysterious black boxes to all but a few of the researchers who are expert in such matters and for physicians , or for that matter, policy makers to accept these at face value ( and here how can you when two studies are so contradictory?) requires faith.

"Addicted" to sun bathing ? Arch. Dermatology article

A recent study published in the Archives of Dermatology investigated the use of the CAGE-alcohol abuse screening too, somewhat modified- and another similar tool in beachgoers on a Texas beach. The authors reported that 26% of participants could be classified as having a "substance-related disorder" on the basis of the CAGE screening tool and 53% using the modified DSM-IV-R diagnostic criteria
Some skeptics might say that this is really a stretch and one more example of a hypertrophied tendency to medicalize every human behavior and trait and a rampant nanny-ism wherein we must figure out a way to stop everyone from doing anything that might be considered foolish, unhealthy or contrary to what the nagging nannies would have us do or not do.
The Archives article suggested that the recognition of tanning as substance-related disorder opens the door to possible new techniques to curb the practice, particularly in regard to tanning salons and the legal prohibition of children using them. They say outdoor UV exposure control might be more problematic ( Ya think).
Hello, I'm Kevin, I'm a u-v light exposure holic. Hello Kevin. (And another thing is U-V light exposure a substance?

Bipol*r disease, unrecognized epidemic or drug company hype

Several months ago at a local internist's club meeting we had a presentation by a psychiatrist about bipolar disorder. He is a co-director of a mood disorder program at a local medical school. (yes, it was sponsored by a pharmaceutical company)The take home messages appeared to be, it is far more common than generally recognized, suspect it if a young person is "depressed" or has a history of depression as a teenager, or has ' racing thoughts" and some of these newer atypical antipsychotic drugs are useful.In 35 plus years of practice, in one form or another, I have probably been aware of less than 10 patients with manic-depressive disorder.The other five internists at my table expressed a similar experience. I do realize that these patients can be very difficult to manage and may impose considerable burden on their family and friends. Typically,internists do not come home at the end of the day saying "another day, another 4 bipolars in the office". Ads from a major drug company (Astr*Zen**ca) tell us that 49% of people with bipolar disorder are undiagnosed and send the reader to a web site for a "validated screener" This screen is 13 questions ending with "have you ever been told you have bipolar disease?" It is said to be based on a paper by PM Hirschfield in Am. J. Psy 2000: 157 (11) 1873- 1875).That web site then can send you to a dosing schedule for an atypical antipsychotic manufactured by that drug company.I cannot imagine an internist or FP doctor taking on the assignment of treating a bipolar patient with a relatively new drug which it is very likely that he has only recently heard of. At the meeting re bipolar, a number of the internists were surprised to learn that if a patient with bipolar disorder is clinically depressed that the treatment is not an antidepressant but a mood stablizer. This might give you some hint as to the general level of expertise an internist has in this area.
But I cannot but wonder that if we see a obviously depressed patient in the office maybe we should use that or some other screen for bipolar and if there is any hint of it on the answers get the patient off to a psychiatrist rather than reaching for the SSRI prescription.
If any psychiatric bloggers out there could offer a puzzled internist some thoughts on this I would appreciate it.

IM and EM residents and EKG reading-overall competency score is low-AJM article

A disconcerting article appeared in the August 2005 issue of the American Journal Of Medicine.
87 internal medicine residents and 33 emergency medicine residents were given 12 test ekgs to read. The residents were from two institutions and all residents were exposed to formal training in EKG reading. Unfortunately the manner in which the results are displayed is a bit confusing, it uses a"proficiency score",which to me obscures more information than it illuminates, but the bottom line is that neither group did very well. One table shows that of all the residents (IM and EM in one grouping) only 40% had the correct answer for an acute MI.(52% had a partially correct answer-what ever that is and only 8 percent had it wrong, apparently they gave partial credit.) So it is hard to figure out how many could or could not recognize an acute MI. But the authors, who we assume did understand the data, concluded the overall competency score was low. Further,they reported that their results were similar to several other studies that evaluated EKG reading skills in house staff.
I find it amazing that any number of IM residents greater than zero were unable to diagnose a typical acute MI or V. Tach. In medical school, our senior year we had a course in EKG interpretation and we all purchased a small text by Dr.George Burch on that subject. As IM residents we were conversant in the details of the proposed minutiae of the differential diagnoses of V. Tach. vrs supraventricular tachycardia with aberration.Interestingly, we had no formal courses on EKG interpretation as residents. Further,The chief of surgery made sure that his residents could recognize the EKG patterns of acute MI as he walked the walk of his theme that surgeons were physicians who knew how to operate.
I am reminded of a blog reference to an article in which it was noted that of 259 IM residents who were tested regarding ventilator use, about half did not know how to set the tidal volume in an ARDS patient. I also recall an Annals of Internal Medicine article which-although it emphasized other aspects of the story-revealed the apparent ignorance of house staff in realizing the importance of evaluating a upper lobe infiltrate in an alcoholic with weight loss and cough for TB.
I realize these are limited, possibly biased samples and from them it may be not appropriate to hypothesize a trend that suggests woefully inadequate training in internal medicine. I really do not want to believe that. I read about an IM program that is now two years post internship rather than three. I read that ACGME has devised requirements that necessitate more being crammed into this shorter time frame. Residents must now learn "system based practice" and quality improvement projects may be required and the time they can spend in the hospitals is restricted and , yes, there is simply more medical knowledge out there to learn.
I know that older professionals in many fields seem to always think the newer generations cannot live up to the standards that the old guard set, that the new kids have it easier, are soft and do not know as much. I'm sure I am guilty of that mind set, but-my goodness-an internist has to know how to read a EKG and if I were an EM resident knowing I would see chest pain patients every day, I would make sure I could recognize an acute MI ekg pattern and not wait to have a lecture on the topic to become proficient. I hope that this article does not accurately reflect the ekg interpretation skills of residents in IM and EM.
And another thing, sometimes I think that physicians believe that reference to evidence based medicine must always be made even if the application seems gratuitous. The authors of the article say in the purpose section " yet there are no evidence based guidelines for assessing [ekg reading] competency". How about just giving them ekgs and seeing if they can interpret them? We really don't need and will never have EBM guidelines for everything.

Practice guidelines in patients with multiple diseases not just inappropriate -may be harmful-JAMA article and editorial

That single disease guidelines may be harmful in multi-disease patients is a topic I have talked about before. Dr. Mary Tinetti published an excellent article on that topic in the NEJM in 2004.
An important and hopefully influential article on this same general issue was published in the August 10, 2005 issue of JAMA by Dr. Cynthia Boyd and colleagues. Their bottom line,take home message is The use of practice guidelines as the basis for pay-for-performance initiatives that focus on single disease treatments are not suited for patients with multiple diseases may well be harmful and this particularly impacts the elderly. Current single disease guidelines as applied to multi-disease patients are not ready for prime time and because of their naive simplicity will never be.
I would put it this way : The fact that a given treatment for a given disease in a certain selected study population is demonstrated to be efficacious and safe is not sufficient reason to apply that treatment to a given patient with co-existing other diseases. It follows that a physician should not be subject to economic sanctions on the basis of adherence to single disease practice guidelines in a patient with multiple comorbidities.
The editorialist, Dr. Patrick J. O'Conner,makes recommendations for guidelines that clearly imply guidelines as they currently exist are not adequate. He says, " Strategies to address the limitations of current CPG's (clinical practice guidelines) need to be developed and implemented,including providing recommendations based on level of evidence for particular patient groups and considering the potential economic and personal burden on the patient and caregiver as well as potential interactions with comorbid conditions".
Representatives of organized medicine who will meet with and negotiate with representatives of big insurance and Medicare have a very strong argument to make. As Dr. Dr. Boyd et. al. said:
the guidelines are not designed for quality assessment,they are recommendations based on varying levels of evidence by committees largely dominated by specialty groups for the management of single diseases, their application could lead to " perverse" economic incentives to emphasize the wrong aspects of care and the guidelines assume that clinical judgment and patient preferences will be incorporated into clinical decisions and yet when these guidelines are applied for quality grading no allowance is made for clinical judgement or patient preference. To apply single disease guidelines to patients with multiple diseases should not be negotiable.
The arguments of Dr. Boyd et al and Dr. O'Conner are cogent, important and should be acted on by resisting on whatever fronts present themselves any pay-for-performance schemes which ignore the complexity of human illnesses and desires and circumstance and judge clinical quality by adherence to simplistic single disease management rules and guidelines which themselves may be limited by the often flawed evidence underlying them.
As much as I agree with the arguments of the two articles, I am troubled by the assumption that both authors seem to make, namely that pay-for-performance is inevitable. I am reminded of the flurry of articles in the early years of the "gate-keeping" fallacy that it will occur, it is occurring and you doctors out there better get on the bandwagon or be left out. There was no shortage of players in medical academia who-for whatever motivations and some may have been well intended-who were complicit with the insurance industry. Pay-for performance may be one of those things that we would be better off being left out.

AMA News: Docs urged to detect RX drug abuse

The war on drugs continues.New theaters of operation are always opening up even though the enemy in older venues of combat have not been defeated.Emphasis is currently on the amphetamine issue and more recently CASA ( Center on Addiction and Substance Abuse) targeted prescription drug abuse, said by them to involve 15.1 million Americans in 2003.Since this is an activity that the perpetrators strive to keep secret and admittedly use all manner of lying, cheating and subtifuge to evade detection one cannot help but question the accuracy of this number particularly when done by an agency who has no interest in underestimating the number. This number appears, however, without editorial critique, in the August 8, 2005 issue of AMA News (no link given as this publication is now open to AMA members only). For some reason I cannot hear the term "drug abuse" without thinking of someone hitting a capsule with a hammer or shouting at a pill saying "you dumb SOB, you made me nauseated".I mention this CASA news article only to highlight a recent rant by DB's Medical Rants on the drug war.I agree with his comments completely.
William F. Buckley Jr., of National Review fame,lead a symposium in July 1996 which concluded that the war on drugs had failed. Thomas Szasz in that symposium said that Dr. William Bennett-former drug czar(It was never explained why a government official in the U.S. would be referred to as a czar)-was right when he said that drug use and drug controls were primarily moral issues. Bennett saw self medication as wicked and criminalization of that behavior as virtuous while Szasz saw self medication as a basic right and drug use criminalization as hypocritical and unenforceable.Everyone will not agree with Szasz's libertarian views but Buckley is no libertarian. You do not have to agree with Szasz's views on what he describes as the "myth of mental illness" to appreciate his thoughts on the drug war.
Decades earlier Dr. Milton Friedman said that the deleterious effects of the drug war would be the same or worse that those noted in the Prohibition, which finally got so bad the law was repealed.
The AMA news article was replete with suggestions for doctors to better detect Rx drug abuse such as calling the patient's old doctor, asking the patient if he has a history of drug abuse ( that should work) and medical educators were admonished to do a better job teaching medical students how to detect such behavior.