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Category Archives: General Health
What is Missing in Doctors’ Toolkits
An excellent editorial provides insight into the complex interaction between social problems and health issues. In this age of widespread information availability, the biggest problems are not solved by knowing everything and memorizing facts. Solving problems with teamwork and identifying resources are increasingly important.
Here’s the link: NY Times: Giving New Doctors the Tolls They Need
Here’s an excerpt:
But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment…
The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.
Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.
Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.
A representative case of the complexity referred to in this blog post: NEJM 2016; 374: 1875-83. This figure of intestinal histology shows damaged surface epithelium. This is from a lady with new-onset psychosis associated with celiac disease who is not adherent with her gluten free diet
Workplace Violence in Health Care
A recent review article (JP Phillips. NEJM 2016; 374: 1661-9) discusses the topic of workplace violence against health care workers in the U.S. Fortunately, this is a topic of which I do not have any expertise. But, on reading, I was fascinated how common this occurs despite a high likelihood of being underreported and largely ignored.
For starters, there are four types of workplace violence. Type II, in which the perpetrator is a customer or patient of the workplace is thought to be most common. In hospitals, one survey indicated that this accounted for 93% of all assaults. Other types of violence include perpetrator who has no association to workplace/employee (type 1), perpetrator who is a current or former employee (type III), or a perpetrator with a personal relationship with employee, such as ex-husband (type IV).
Two areas in medicine experience the highest rates of violence: the emergency room and the psychiatry ward. In both situations, mental illness, narcotic-seeking behavior, and intoxication may play a role.
Statistics:
- Nurses and nursing aides are victimized at the highest rates, likely due to increased contact time. In the Minnesota Nurses’ Study, the annual incidence of verbal and physical assaults was 39% and 13% respectively.
- ER nurses had a 100% reporting verbal assault and 82.1% reporting physical assault during the previous year.
- Physicians: one-quarter of ER physicians reported being the targets of physical assault in the previous year. A much higher rate of verbal threats were noted within the previous 12 months: 75%.
- Weapons are used in <1% of type II episodes of violence in the health care workplace.
Solutions:
- There are no clear solutions.
- The author advocates not overlooking verbal threats. “The ‘broken windows’ principle, a criminal-justice theory that apathy toward low-level crimes creates a neighborhood conducive to more serious crime, also applies to workplace violence.” Addressing verbal threats may prevent escalation.
- To ensure a safe environment, more reporting on this problem is needed along with investigations of potential mitigating strategies.
My take: I have had been yelled at before and I was quite shocked. This is a topic that is not discussed widely in training and probably should be.
Gibbs Gardens
Expert Review: GMOs are safe
Here’s a link to NBC report on National Academies of Science review of Genetically Modified & Genetically Engineered crops: Genetically Modified Crops Are Safe
Here’s an excerpt:
Here’s a website with full report and data:
National Academies of Science Genetically Engineered Crop Website
Related blog post: War on Science and Genetically-Modified Food | gutsandgrowth
Report also covered by USATODAY:
John Oliver & Understanding Scientific Studies
A recent John Oliver segment (~20 minutes) provides a terrific look at how scientific studies need to be evaluated. Here’s the link: John Oliver Scientific Studies
His main points:
- Scientists are under pressure to publish and sometimes publish a study with a title to grab interest
- P-hacking can be done to find statistical significance/correlation that is bogus
- Reports are often distorted by the media to generate a buzz. Smelling farts does not prevent cancer (see image below).
- Some reports extrapolate findings in animals to humans without any studies and without mentioning that these were animal experiments; in addition, most treatments on lab mice do not work for humans.
- Many media reports do not mention whether the study was industry-funded or the size of the study. Reports with 10 or 20 people are more likely to lead to false conclusions
Related posts:
- Understanding science | gutsandgrowth NPR explains why the new study may be wrong
- Alan Alda (aka Hawkeye Pierce) on Communicating Science …
- Marketing to Doctors -Informative Satire | gutsandgrowth Another commentary on a terrific John Oliver segment
- Why I have always liked Arthur Caplan… | gutsandgrowth
Antibiotic Overuse and Allergic Antibiotic Challenge
A recent study by Fleming-Dutra K et al (JAMA, May 2016), that has been widely reported, estimates that 1 in 3 antibiotic prescriptions in U.S. are unnecessary. Here’s a CDC media release link: CDC: 1 in 3 antibiotic prescriptions unnecessary
“About 44 percent of outpatient antibiotic prescriptions are written to treat patients with acute respiratory conditions, such as sinus infections, middle ear infections, pharyngitis, viral upper respiratory infections (i.e., the common cold), bronchitis, bronchiolitis, asthma, allergies, influenza, and pneumonia. An estimated half of these outpatient prescriptions are unnecessary.”
Some of the downside of unnecessary antibiotics:
- Allergic reactions and other adverse reactions
- Infections become more difficult to treat due to increased resistance
- Expense
- Clostridium difficile infection
My take: This study’s findings are NOT surprising. Antibiotics are often prescribed without a clear indication.
Many children are labelled allergic to antibiotics like amoxicillin due to the development of a rash but have not undergone formal evaluation. However, a recent study (Mill C et al. JAMA Pediatr 2016 Apr 4) shows that an oral provocative challenge that most will be able to tolerate amoxicillin. Here is a summary of the article by DocAlert (forwarded to me by Mike Hart) -I highlighted in bold the key finding:
In an observational study, researchers offered a graded oral provocation test to all children referred to an allergy clinic in Montreal with suspected allergy to amoxicillin. Children were given 10% of the therapeutic dose of amoxicillin, observed for 20 minutes, then given 90% of the therapeutic dose and observed for at least 1 hour. Parents were instructed to report reactions that occurred the next week.
Of 818 participants (mean age, 1.7 years), 94% tolerated the provocation test and therefore were not allergic to amoxicillin. Of the others, 2% had immediate reactions (within 1 hour of the last dose) — all mild urticaria that resolved with antihistamines — and 4% had nonimmediate reactions (median of 12 hours after the last dose) — all mild maculopapular rash. Only 1 of the 17 children with immediate reactions tested positive on skin prick and intradermal testing 2 to 3 months later.
History of a rash lasting longer than 7 days and parental history of drug allergy were associated with nonimmediate reactions on the provocation test (adjusted odds ratios, 5 and 3, respectively); history of allergic reaction within 5 minutes was associated with immediate reactions (AOR, 10). During 3-year follow-up of children who tolerated the test, 55 received a subsequent full course of amoxicillin and 6 (11%) had nonimmediate reactions. All patients with reactions to amoxicillin tolerated cefixime.
My take (from summary): An oral provocation challenge to confirm either an immediate or nonimmediate allergic reaction to amoxicillin was found to be safe and more accurate than skin testing.
“What Do I Need to Learn Today?”
A recent commentary (GT McMahon. NEJM 2016; 374: 1403-5) provides some perspective on adult learning. In this era of ubiquitous information, developing the right strategy for learning is crucial, not just in medicine but globally. Key points:
- “Physicians seeking professional development can recognize when they’re actively learning and tend to embrace activities that allow them to do so.”
- “Many clinicians appreciate learning alongside their peers but may struggle with the feeling that times spent in group educational settings is not efficient or productive enough to be worthwhile.”
- “CME is most effective in changing physician performance and patient health outcomes if it is interactive.”
- “Adults prefer education that’s self-directed, based on needs they have identified, goal-oriented, relevant, and practical.”
- Learning facilitated by working in small groups to solve problems and with interaction (eg. smartphone polls). Other strategies include simulation programs and social media.
- Working at getting CME to count towards other regulatory burdens (eg. maintenance of board certification), can “reduce the burden on physicians and promote lifelong learning.”
My take (with help from author): Incorporating educational innovation is important to improve physician performance and patient care. “All of that change begins with each of us having the humility and presence of mind to ask ourselves, ‘What do I need to learn today?’”
Vik Muniz Art. George Stinney Jr, the youngest person executed in U.S. at age 14 years. This artwork is composed of hundreds of pictures.
Persistent Symptoms after Lyme Disease
A new study has shown that long-term antibiotic therapy for Lyme disease is not helpful.
Here’s a link to a quick summary (1:37 min): Randomized Trial of Longer-Term Therapy for Symptoms Attributed to Lyme Disease
In the associated editorial (MT Melia, PG Auwaeter, NEJM 2016; 374: 1277-8), it is noted that 10-20% of treated patients (after initial antibiotics) “may have lingering symptoms of fatigue, musculoskeletal pains…The plausible idea that additional antimicrobial therapy for potentially persistent bacterial infection would foster improvement has been a touchstone of hope in the 40 years since discovery of the disease in the mid-1970s.”
My take (from editorial): “Prolonged antibiotic therapy is not the answer” for lingering symptoms after Lyme disease. “We do not know what is truly helpful”
Related blog post: Facts and fiction with Lyme disease gutsandgrowth
Best Way to Quit Smoking
According to a recent study (N Lindson-Hawley et al.
Ann Intern Med. Published online 15 March 2016 doi:10.7326/M14-2805), for patients interested in quitting smoking, the best way is to do this abruptly rather than gradually (25% more successful). Apparently, the gradual approach adds work to the process.
From Abstract:
Results: At 4 weeks, 39.2% (95% CI, 34.0% to 44.4%) of the participants in the gradual-cessation group were abstinent compared with 49.0% (CI, 43.8% to 54.2%) in the abrupt-cessation group (relative risk, 0.80 [CI, 0.66 to 0.93]). At 6 months, 15.5% (CI, 12.0% to 19.7%) of the participants in the gradual-cessation group were abstinent compared with 22.0% (CI, 18.0% to 26.6%) in the abrupt-cessation group (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who preferred gradual cessation were significantly less likely to be abstinent at 4 weeks than those who preferred abrupt cessation (38.3% vs 52.2%; P = 0.007).
Here’s a link to a 4 minute summary: Gradual versus Abrupt Smoking Cessation
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Gibbs Gardens
Patient Assistance for Lab Testing
Since 2015, “a partnership of several leading consumer health organizations announced the launch of Patient Assistance for Lab Services (PALS).” (Gastroenterol & Endoscopy News, March 2016, pg 54). PALS offers access to more than 85 lab tests, most costing only $5 and all of the tests at a fraction of the cost of pricing at competing labs. (See request-a-test for competing costs: requestatest.com)
PALS website: Patient Assistance for Lab Services
Some examples of costs:
$5 tests: (There is a $15 shipping fee as well which covers all testing)
- Hepatic Function Panel
- CBC/d
- Complete Metabolic Panel (CMP)
- Hemoglobin A1C
- Cholesterol
- TSH w reflex to T4
Some tests are more expensive but still heavily discounted:
- Hepatitis C RNA PCR Quantitative $100
The process of filling out the paperwork & having signed by a physician along with getting the testing complete will likely take a few weeks; so this testing right now is not useful for urgent testing.
My take: Due to cost constraints, some patients are not receiving lab monitoring as frequently as recommended. This discounted testing could be a useful for option in this scenario.
Key words:
- Patient assistance
- Cheap
- Inexpensive
- Lab test
- Bloodwork
- No insurance
Related blog post: What physicians can learn from fast-food restaurants and …
Gibbs Gardens
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