Category Archives: General Health

Workplace Violence in Health Care

Posted on by

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

Gibbs Gardens

Expert Review: GMOs are safe

Posted on by

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:

Screen Shot 2016-05-18 at 9.39.35 PM

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:

Screen Shot 2016-05-18 at 9.44.10 PM

John Oliver & Understanding Scientific Studies

Posted on by

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:

Screen Shot 2016-05-09 at 6.00.08 PM

 

Antibiotic Overuse and Allergic Antibiotic Challenge

Posted on by

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.

Screen Shot 2016-05-03 at 8.35.56 PM

 

 

“What Do I Need to Learn Today?”

Posted on by

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.

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.

GeorgeStinneyJrInfo

Persistent Symptoms after Lyme Disease

Posted on by

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

 

Screen Shot 2016-03-31 at 6.33.43 PM

Best Way to Quit Smoking

Posted on by

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

Related blog posts:

Gibbs Gardens

Gibbs Gardens

Patient Assistance for Lab Testing

Posted on by

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

Gibbs Gardens

Better Discharge Planning Needed

Posted on by

An interesting commentary in NY Times: Most Dangerous Time at the Hospital? May be When You Leave

An excerpt:

One-fifth of Medicare beneficiaries are readmitted within 30 days of discharge, and one-third are readmitted within 90 days. One studyfound that 20 percent of patients have a complication within three weeks of leaving the hospital — more than half of which could have been prevented or ameliorated. Thankfully most complications are minor, but some can be serious, leading to permanent disability or death. All told, Medicare spends $26 billion annually on readmissions, $17 billion of which is for readmissions that are considered preventable…

there’s often a rush toward the end of hospitalization — when a patient wants to leave or a rehab bed opens up — leading to a haphazard set of final conversations, appointments and prescriptions. And because the exact time of discharge is uncertain, the doctor discharging a patient may not be the one who knows the patient best.

It’s also often not clear exactly when a patient should be discharged….

the remaining diagnostics and treatments are often completed after discharge. But this is where we struggle most. Research suggests direct communication between hospital doctors and primary care doctorsoccurs infrequently and that discharge summaries — detailed records of a patient’s hospital course — are often unavailable at a patient’s first post-hospital visit. Almost 30 percent of patients are discharged with a plan to continue workups after hospitalization, but more than one-third of these are never completed. Similarly, more than 40 percent of patients have lab tests pending at the time of discharge — with 10 percent requiring action—but most physicians remain unaware of them.

My take: This is indeed an area where checklists and attention should be focused.  My top three:

  • Making sure a list of discharged medications is compared to admission medications
  • Identifying outstanding tests and arranging followup workup
  • Direct communication with outpatient physician(s)
Gibbs Gardens

Gibbs Gardens

Pharmaceutical Prescription Practices Tied to Pharmaceutical Payments to Doctors

Posted on by

A recent buzz has developed regarding a ProPublica study showing an association between the amount of money physicians receive from pharmaceutical companies and their likelihood of recommending brand (rather than generic) prescription drugs.

Here’s a link to the full story: Now There’s Proof: Docs Who Take Company Cash Tend to Prescribe More Brand-Name Meds

“The more money doctors receive from drug and medical device companies, the more brand-name drugs they tend to prescribe, a new ProPublica analysis shows. Even a meal can make a difference.”

Here’s a link to NPR’s summary:  Drug-Company Payments Mirror Doctors’ Brand-Name Prescribing  An excerpt:

“A ProPublica analysis has found that doctors who receive payments from the medical industry do indeed prescribe drugs differently on average than their colleagues who don’t. And the more money they receive, the more brand-name medications they tend to prescribe.

We matched records on payments from pharmaceutical and medical device makers in 2014 with corresponding data on doctors’ medication choices in Medicare’s prescription drug program.

Doctors who got money from drug and device makers prescribed a higher percentage of brand-name drugs overall than doctors who didn’t, our analysis showed. Even those who simply got meals from companies prescribed more brand-name drugs, on average.”

My take: Prescription patterns vary widely among physicians and often for good reason.  At the same time, it is likely that in many cases variation in prescription patterns is influenced by frequent contact with pharmaceutical companies.  As a consequence, this has the potential to make patients question whether their physician always has their best interest in mind and the potential to increase healthcare costs.

Related blog posts:

Law Library Ceiling, Univ Michigan

Law Library Ceiling, Univ Michigan