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Tuesday, February 28, 2012

Beautiful, tortured Tom Harrell

There could have been few better places to be on a recent Friday after dark than elbow to elbow with fellow disciples of jazz in the subterranean recesses of Manhattan's Iridium club.    The feeling was intimate, and the mood was warm.  The ensemble's lead was tall and gaunt, head flexed like a puppet revealing only what he wanted us to see, a dense mop of grey.   Standing statue straight and motionless in a rumpled back suit, he gave no hint that he was hearing the stream of sound, the cascade of notes and changing rhythms - not, at least, until he drew a pflugelhorn to his lips and began to play.  Neither did he let on that he was fighting down the voices, the scourge of those who suffer from paranoid schizophrenia.

Schizophrenia is, unfortunately, a fairly common condition, affecting more than 1 in 200 individuals overall.  Despite dramatic advances in the neurosciences, the causes of this disorder are only partly understood, and the mainstay of treatment - antipsychotic medication - mitigates symptoms but does not offer a cure.

Does the person own his chronic illness, or visa versa?  Our use of language has blurred this distinction for centuries.  Once there were consumptives and cripples; now there are asthmatics and diabetics.  There is a school of thought (to which I subscribe) which holds that terms like this submerge the person in the disease, are harmful for this reason, and should therefore be abandoned altogether.

The notes that flow out across the stage and over the audience make patterns within patterns, wild and unexpected scales, sliding and leaping beyond reason, making one excursion after another, traveling farther and father afield, notes that to the classical ear are crazy and dizzying, their thin tether to reality making a connection of delicate beauty.

Tom Harrell battles a brain disease. Listen to his new album, "The TIme of the Sun." Then consider whether one should describe him as "a schizophrenic."    

Wednesday, February 22, 2012

What's good and bad about modern healthcare? Ask mom.

I spent last evening in the Emergency Department of a regional medical center near my mother's home on Long Island.  She is a spry octogenarian who, wisely, can't stand doctors or hospitals (present company accepted, of course.)  Mom would be incensed to know I referred to her as spry. Suffice it to say that she had a little breathing problem.

Here's the good news.  The resident, the nurse and the radiology tech were fabulous. The latter came in smiling and asked "what is your name?  Can you tell me your birthday?" From mom's point of view this was a bit of a bore, since she'd been asked the same thing six times already.  Of course, this was for her own protection, since wrong patient events continue to plague healthcare, and rechecking before each intervention is protocol.  One check mark for safety!

The nurse was business-like, but polite.  It struck me, yet again, how different it is to be the one sitting at the bedside, waiting for things to happen.  I continue to believe that every physician and nurse should be assigned to this role, say twice annually, to be reminded how startlingly different the view is from this angle.

One notices, for example, that the Le Bon Pain coffee cup from the last patient was never removed.  And were private conversations going on between staff members, you can be sure that we would have heard them.  There weren't.

The resident was a blast!  He breezed in, took a look at the rings on mom's fingers and burst out, "Are you descended from royalty?"  It's funny how this sort of thing works, and part of the reason that we still refer to Medicine as an Art.  In the hands of some, a comment like that would raise suspicions that this doc was a nut job.  However, this particular young man carried it off brilliantly.  I know his program director and I've reminded myself to drop him a note of commendation.

The bad news?  It never crossed mom's mind to find out if her physician is available after hours, whom to call for advice if he isn't, or what to do if she needs a same-day appointment.  Nor, it seems, did the physician or his staff offer this advice preemtively. Knowing the answers would have avoided an ambulance ride, and a very expensive way to obtain two doses of a simple respiratory drug.  I'm not indicting the fellow: maybe mom was told but forgot.  However, I doubt it.

Sunday, February 19, 2012

Bad news from the doctor: my child is eating a normal diet.

Over the years, I've told thousands of parents that "there's nothing less healthy than a good, hearty breakfast!"  By that, of course, I'm referring to the typical hotel breakfast buffet:  eggs in every style, pancakes, muffins, and toast accompanied by sausage, ham and bacon.

But one recent report takes us far beyond this catastrophe in a chafing dish. According to the National Health and Nutritional Evaluation Survey, the average US child consumes more fruit juice, starchy vegetables and white bread than recommended, and less in the way of fruits, dark green vegetables and whole grains. "Energy dense" foods like pizza, chips and desserts comprise almost twice the fraction of our diets that they did in 1980.  At the same time, sodas and other sugary drinks make up half of all beverages consumed by children and teenagers - dramatically more than ever before.

Which leads me to one conclusion.  If we want to stay healthy, we have to eat differently than the average American.  If obesity, diabetes and heart disease are the "new normal," we had better commit ourselves and our children to an "abnormal" diet. 

Where is your family on the road from "normal" to healthy?

  • Normal:  No time for breakfast
  • Healthy:  Your family eats breakfast, and enjoys the energy boost!  No, not a donut.  Your M.O. is skimmed milk or non-fat yogurt, fresh fruit, whole grain cereal or a couple of egg whites.  
  • Normal:  Pizza with pepperoni for lunch...and maybe a chocolate chip cookie for dessert
  • Healthy:  You'll encourage your student to go for that slice once in a while, so long as he ditches the meat topping for veggies.  Most days, however, his backpack is transporting a whole wheat sandwich with a low fat cheese slice, tomatoes and sprouts.  Turkey or chicken show up from time to time.  
  • Normal:  Snapple is a staple.
  • Healthy:  "I'm sure our supermarket has a beverage isle; we just don't go there!"  (There IS a beverage that is sugar-free, caffeine-free, preservative-free and a great thirst quencher.  It's called water.)

Nutrition experts tell us that we can't get to healthy by way of self denial.   For most of us, eating is, and should be, fun.   Eating together as a family is good for many reasons (just as eating in front of a screen is bad for many reasons.)   Watch portion size, but don't just take away the fav's - find nutritious substitutes.  Remember that sleep deprivation makes us hungry for all the wrong foods.  And finally, during a winter as warm as this one,  go ride a bike or walk the dog or just go look at the clear blue sky.   It's all part of enjoying - and encouraging - good health.

Monday, February 13, 2012

The cure for normal infancy?

Just when I think I'm running out of less-is-more examples in pediatric healthcare, here comes a review of acid-blocking medications and their use in newborns diagnosed with "acid reflux."

What would cause one to consider the diagnosis of acid reflux (also known as gastroesophageal reflux disease, or GERD) in a newborn?  This entity is known to cause a variety of symptoms, from strange arching postures, cough and wheeze to apnea with blue spells.  But mostly, GERD is diagnosed in infants with spitting up, excessive fussiness and crying.  Hmmm.  How, you might ask, does one differentiate this condition from, well, normal infant behavior? 

As it turns out, not easily.  A lab test? There isn't one.  What about imaging?  Well, a barium swallow could help, but there's radiation and the study is hard to interpret.  So most pediatricians go with "empiric therapy" which is Greek for "let's do an experiment and see what happens."  The rationale for this stratagem is that acid blocking medications are basically harmless.

Except for the following.  As noted by Dr. Eric Hassall recently in the Journal of Pediatrics, these medications have now been linked to increase risks for pneumonia, candidemia, necrotising enterocolitis and C. difficile infection of the intestinal tract.  These are in addition to risks already documented in older patients including osteoporosis and impaired absorption of calcium and magnesium, minerals critical to health.  As it turns out, stomach acid is there for a reason, and eliminating it comes at a larger biological cost than most of us imagined.

I have been curious about this whole neonatal "reflux" thing for quite a while.  For one thing, we seem to have overlooked it for several decades without apparent harm.  It is also interesting that the diagnosis of "infant colic" has disappeared over the same time period that the incidence of newborn reflux has exploded.  Something, I dare say, is rotten in Denmark.  But maybe not so surprising.  How is colic different from reflux?  Simple.  One is treated with a car ride, the other with medication.  And if you wait a few weeks, both most often go away.   

By the way, I DO recommend pharmacotherapy for this condition:  my favorite regimen includes 4 oz of a chilled Muscadet per orum for each parent.

Saturday, February 11, 2012

Taking on medication errors

One per patient per day.  That is the number of medication errors of all kinds that occur in hospitals, according to a 2007 report by the prestigious Institute of Medicine.  These include errors of omission and commission, wrong time, wrong dose, wrong route and wrong patient events.  The overwhelming majority are inconsequential; nonetheless, researchers have estimated that upwards of 380,000 to 450,000 episodes of medication-associated harm occur each year.

Opportunities to create - or prevent - errors occur at every step in the process from the time the physician orders a medication, through communication to the Pharmacy, dispensing, and administration at the bedside.  Some medications are more dangerous than others - those that are more toxic, more complicated to dose, those that look like or sound like other, dissimilar medications, and those prescribed for the most vulnerable patients (including children) deserve special attention.

Among our most serious challenges is addressing the risk of error when patients transition from one environment from another - home to hospital, or hospital to rehab, for example.  There is even a risk when the patient moves from one unit to another in the same hospital - ICU to floor, for example.

Yesterday I listened to two presentation from working groups within our Health System.  Their goal: figure out how to make sure that at the time of hospital admission, every patient's home medications are either continued, discontinued or modified as the result of a conscious action - rather than by accident.  The experience was inspiring and humbling at the same time.  Each team was comprised of the right people with the right tools.  Physicians. Nurses. Pharmacists. Experts in process design.  And all of them skilled, experienced and highly motivated. They had a year to work.  And their efforts were magnificent.  Nonetheless,  their statistical results told us that they were only modestly successful in reaching their goals.

Driving home, I had three thoughts.  First, a decade after the first halting efforts led to a national, and then an international movement to make healthcare safer, we still have a long way to go.  Second, as in every other aspect of patient safety, there is no substitute for patient and family engagement.  Hospitals and health systems can build databases and computerized decision support to try to prevent errors, but there is nothing like an involved son, daughter or spouse keeping careful track of what medications have been prescribed and in what doses, why they were prescribed, what side effects to watch out for.

Finally, and here's the pediatrician talking, it wouldn't be so darn hard to keep track of each patient's medications if we didn't prescribe so many.  This isn't so trivial a point as it sounds.  A number of studies have cited the untoward effects of "polypharmacy," especially in the elderly.  And investigators have found in these cases that a large proportion of medications could be discontinued without ill effect.  Yes, once again, in healthcare, less CAN be more.

Wednesday, February 8, 2012

Why be a physician?

There is a huge bouquet of flowers in our living room, and they came from a patient.  Not a patient of mine, mind you, but one of my wife's patients.  Well not the patient herself, actually (we're both pediatricians) but the patient's mother.  We say this a lot about pediatrics - we never treat one patient at a time.  It's the individual with the medical problem (in this case a teenage girl) and the parents.  And, sometimes other relatives as well.

Back to the bouquet.  It was the result of a series of fortunate events.  An adolescent comes to the doctor with a sore throat.  The sore throat is nothing much.  The doctor performs a very good physical examination and discovers a mass in the pelvis.  It is a tumor.  Imaging is performed, a surgical referral occurs, the mass is surgically excised and it is benign.  It could have caused problems, nonetheless, if not tended to.  The patient is fine and the parents are extremely grateful.  If the emotional life of a physician were a bank account, and late night phone calls, insurance forms and missed family events were small withdrawals, then a moment like this one would be like a windfall, a huge inheritance from a relative you've never heard of.  Moments like this are one of the reasons we become physicians.

Then there is the intellectual challenge.  I was reminded some years ago that doing a good job as a diagnostician doesn't necessarily get you a bouquet.  I was seeing a little boy, probably four or five years of age.  He had a lump in his neck, in the space under the chin and on one side that we call the anterior triangle.  I obtained a history: how long has it been? Does it hurt? Any fevers?  Do you have a pet rabbit? Any travel? And a dozen other questions.  I was on a quest, and although I may not have been conscious of it at the time, I was rather enjoying myself.  This is what it is like to be a diagnostic sleuth, a real-life House.

And so, in an effort to be "informative" (but maybe just to show off a little) I heard myself reviewing a list of five or six diagnostic possibilities - what we call the "differential" in the jargon of Medicine - with the patient's mother, all the while writing out tests, a blood count, tuberculin test, various antibody levels and so on, that I recommended we obtain right away.  I felt very much in control of the situation and pleased to use a few more brain cells than are required to diagnose the common cold.

On the way out of the office, my nurse, a thirty year veteran, asked the mother in her typically kind way, "so is everything all right?  What did Dr. G. say?"  I was utterly surprised, but shouldn't have been, when the mom turned and said, "well, it seems he hasn't the slightest idea what it is!"

A dose of validation can do wonders for us, but a bite of humble pie is also therapeutic.  See you next time.

Sunday, February 5, 2012

More on the art and science of healthcare

Yesterday I suggested that there is a role for measurement and standardization in our quest to make healthcare effective, efficient and safe.  This is Medicine's "left brain."  But leaving the issue there dooms us to healthcare delivered with "half a brain."

The fact is that without the "art," the "science" doesn't work.  The science doesn't address the question, for example, of how physicians make a diagnosis in the first place.   It remains true, even in the age of advanced imaging, that the most informative data for determining what is the matter with the patient come from the medical history.  The process by which the skilled physician obtains this history is highly individualized and nuanced.  It is a dance and an acrobatic balancing act.  If the physician interrupts too much, he prevents the patient from sharing key material.  If he doesn't ask questions at all, critical clues will go unreported.  More than a century ago, William Osler, a founder of modern American medicine said with deceptive simplicity: "listen to the patient and he will tell you the diagnosis."

I like to tell our students and residents that EVERY interaction with the patient, every word we say, in fact, is either therapeutic or anti-therapeutic.  There is no middle ground.  Medicine (and, for that matter Nursing) is an inherently relation-based endeavor.  How we greet a new patient ("what seems to be the matter?"), how we explain a finding, even how we frame questions.  Imagine palpating an enlarged lymph node in the neck of a teenager most likely suffering from a routine case of mono and asking while doing so... "any family history of cancer?"  You get the picture.

These interactions have effects, for better or worse, building trust, empowering patients, encouraging healthy behaviors, allaying anxiety - or the reverse of each and every one.  A re-examination of the relational nature of healthcare, and more exactly the role of "story" in healthcare, is at the center of an exciting new program now known as Narrative Medicine.  More on that soon.

Saturday, February 4, 2012

The art and science of healthcare - and why we need both!

A cornerstone of the "quality" movement in healthcare is the idea that we can't improve what we don't measure.  This has led to any number of achievements that would have been impossible otherwise: reducing hospital infections, improving surgical outcomes and a host of others.  The concept is pretty straightforward.  Absent a good way to measure, reasonable clinicians can (and will) argue incessantly about whether any particular bad outcome was random, or something else.  (A surprising number of physicians - even some with a strong track record of secularism - will attribute the worst outcomes to "God's will."  Go figure.)  But if one hospital's, or one team's, or one surgeon's results are statistically different than another's - whether better or worse - well, then something interesting may be going on.

Another such hallmark is standardization.  Treating the same problem the same way seems pretty logical.  Even when there is more than one right way to do something, standardizing practice keeps down unnecessary complexity in the system, reducing both cost and the likelihood of error.  (For more on the latter, see my last post.) Like measurement, however, the idea of standardizing practices in healthcare brings surprisingly mixed reviews.   We've all heard the mantra:  "practicing medicine is an art."  This happens to be a true statement. However, there is a counter-statement that is just as relevant:  "all that is unscientific isn't necessarily art!"  What IS true is that providing the best healthcare requires that doctors adapt the treatment plan to meet the individual needs (and preferences and values) of each individual patient.   This is what I would call "beneficial variation."

Unfortunately, much of the actual variation in our healthcare system is not of this kind.  It turns out that when different doctors choose different antibiotics to treat the same kind of infection or suggest one operation over another, too often the reason has more to do with the doctor than the patient.  (Question to doc: "Why did you choose this approach?"  Answer:  "Well, that was the way I was trained."  Hearing this expression continues to cause my hair to stand on end.)

Is there, then, any room for "art" in Medicine?  Yes, and the need has never been greater.  More on that tomorrow.