Quick Blog #DDW12-Benefit to live tweeting?

I had a question.  Does live-tweeting help improve comprehension of a lecture?

I asked this question because I think it does.  I have to focus and process VERY quickly to live tweet.

I was curious to know if it had been studied formally.  I’m currently sitting in a DDW lecture (not listening b/c I”m not interested in this particular abstract).  So I’ll google it briefly

Search string: “does live tweeting improve comprehension”

Limiting to 2 google results pages (hey I’m at a conference here, no boos to my thoroughness)

Page 1:

Blog saying it’s distracting

http://commetrics.com/articles/forrester-conference-and-twitter-does-live-tweeting-help-engage-conference-delegates/

One article about lessons to learn before doing it

Everything else is unrelated

Page 2:

AHA!

http://theactiveclass.com/tag/mobile-technology/

Doctors, quality guides, and unnecessary tests: Don’t tell me what to do!

Wow.  We REALLY do not like being told what to do.

As a background, quality improvement is a major professional goal of mine.  I have had formal QI training, I’ve taken a lot of classes that explore the issues of quality in medicine, and a significant proportion of my time is spent thinking about how to improve and streamline our delivery of high quality care.

We should all want that, right?  Shouldn’t we all want to improve?

Yeah, you’d think.

Maybe not.  Or at least not in a way that feels like homework/grades/slaps on wrists/cookbooks/“The Man”/you can’t tell me what to do damnit!

An alarmingly large proportion of physicians in the Medscape 2012 annual physician compensation report seemed durn determined to do whatever they ~individually~ feel is best for their patient, ignoring the guidelines that their own professional societies created.  They seem to feel justified, though by stating they don’t think the guidelines are going to do any good/aren’t in their patient’s best interest.

Let’s look at a couple of slides (annotation is mine: locate source URL by clicking on the Medscape link above):

I know the challenges to implementing changes that can actually drive improvement.  These challenges plague each step of the process: What is quality of care?  How to you define it? How do you measure it?  How to you balance quality for the patient with quality for the physician and quality for our nation?  How do you pay for it?  How do you convince people less medicine is quality care?

I also know why doctors dislike guidelines: they want to make the decisions for themselves at the bedside, and they don’t want to deny interventions to patients when they think there’s a possible chance it could help.  Evidence-based medicine looks at things on a big scale, and docs want the freedom to think, “what if my patient in front of me really is the one that an Umpteenth Emergency Department CT abdomen Scan shows the as-yet-to-be-diagnosed cancer that caused the last 5 years of his/her abdominal pain?” (Yes I’m being facetious, OK, I’m trying to make a point).

I belong to several professional GI societies, and one of those societies, the American Gastroenterological Association (AGA) has recently joined many other professional societies in the Choosing Wisely campaign [see a JAMA viewpoint article here].  Together they are trying to come up with medical interventions that are IN GENERAL  unnecessary: tests or therapies that add very little to making people better.

For years the AGA, American College of Gastroenterology (ACG), and the American Society for Gastrointestinal Endoscopy (ASGE) have published guidelines that seek to provide the best possible evidence for what has been shown to help people.  DOCTORS WROTE THESE GUIDELINES, along with many other people (and sometimes laypeople).

They are also actively partnering with national non-profit organizations to create and promote better quality in healthcare.

Not that I didn’t know that a lot of doctors don’t like guidelines, or at least don’t like being forced to conform to guidelines.  No American likes being told what to do: patients, physicians alike.  I get it, but C’MON PEOPLE.  You/we are not perfect.  There are truly some things we need to do to get our butts in gear and accept we don’t always provide high quality care, and guidelines can be very helpful tools (when applied correctly) to get better at what we do.

There is still a huge amount of autonomy in the American practice of medicine.  Probably too much autonomy as physicians and patients have been allowed to willy-nilly demand pointless interventions that satisfy our guts (no pun intended) but do little to actually improve health.  We will pass the exhorbitant costs of this wasteful care onto our children who will eventually face a crisis of debt and widespread health disparities.

That is, if we don’t take the bull by the horns and do something about it.

I was recently appointed to the AGA Institute Clinical Practice & Quality Management committee, and I was thrilled to be able to help shape these issues for our field and truly help bring GI into a higher standard of care.

Well, I guess I have my work cut out for me.  I’m going to become “The Man”, so to speak, the “Bad Guidelines Guy”, or umm “Gal”.

So, I guess my challenges in quality improvement are:

• To try to move that needle on those surveys and convince physicians that being mindful of evidence based medicine can improve population health and individual health
• To try to understand why so many doctors dismiss the guidelines they created
• Find out what they think really will help improve patient care
• To fight with insurance companies, government, and local administrators who apply these guidelines inappropriately (and just fuel those doubting doctor’s fears)
• To determine what really makes a difference in improving care and decreasing the economic burden of healthcare for my future children

Good luck to us all.

Cancer Phobe-A Doc faces her Breast Health Fears

Today is my second vacation day of the year.  No, i’m not in Bermuda ):

I’m taking two days to do the kind of stuff every human needs to do.  I’m organizing my life and checking off my personal “punch list”.

First on my list is making my yearly trips to the doctor.  Usually I see the dentist twice a year, but since I moved last year I’ve yet to re-establish care in ANYTHING.  Time to take control.

So, first thing this morning (after cereal and coffee of course) I called my own hospital’s scheduling line to find me some new doctors.

Since I plan to have children in the next few years, I’m going to keep my primary care with a generalist OB/Gyn.  I need a pap smear/pelvic and some general pre-(very VERY pre) natal counseling. CHECK! Got it with someone who has clinic on my research day so I can schedule follow ups conveniently.

I also scheduled my dental cleaning.  I hate it, but my teeth are now quite valuable if you count the thousands of dollars in braces, bionators, and veneers that have graced my pearly whites over the years.

Next I faced something I’ve been meaning to do for a few years–a cancer risk assessment clinic.

Let me just say I am a HUGE cancer phobe.  When I was in my fourth year of med school, I sat down in the MICU one day and rubbed my sore neck muscles–only to find a “larger than the upper limit of normal” lymph node.  I had a few in other areas as well, so like a good med student I flipped out and convinced myself I was going to die from lymphoma.  Ten-thousand dollars later (yes m’aam, 10K smackeroos before my co-pay), I had a lymph node biopsy to tell me I was OK.

Years before, I had had another cancer scare.  One that hit a little closer to home.  When I was 17, I found a lump in my breast in the shower.  Of course, I flipped out then as well.  I went to see a surgeon who did a breast ultrasound.  I had the lump removed and was reassured it was benign–a fibroadenoma.  Pretty common, I know now.

It hit close to home because breast cancer is prevalent in my paternal grandmother’s family.  She had a sister who died of it in her thirties, and a niece who developed it in her 40′s.  A few years later, she herself would get breast cancer.

Now, my grandmother was in her 70′s, and it was metastatic mostly because she never went to see doctors and ignored her cancer until it grew to the size of a baseball.

She ignored it probably because she was scared and knew it was cancer. 

Can I blame her?  No, I can’t.  I can’t without being a hypocrite.  I am terrified of breast cancer, and I don’t do breast self exams for that very reason.  As an anxious person anyway, I know I’m going to feel funny lumps and bumps and convince myself it’s cancer.  Again, just like the prior two times.

I’m not without some justification–screening brings a lot of anxiety and false positives.  There was even one large randomized controlled trial of breast self exams in China that didn’t show a benefit of mortality reduction and did show an increase in the diagnosis of benign breast lesions in those who perform BSE’s (“Randomized trial of breast self-examination in Shanghai: Final results,”Journal of the National Cancer Institute, Oct. 2 (vol. 94, issue 19) 2002).

But I can’t ignore some facts:  I’m over 30 and childless (increases chances).  My age at menarche also gets me a couple of notches.  The fibroadenoma as a teen moves me up even farther.  Finally there’s my paternal grandmother and her breast cancer clan.   Thank goodness neither of her two daughters, my aunts, have had any problems, and they are approaching their 60′s.

So, I’ve decided to go talk to someone.  I filled out my family tree at family history.hhs.org.  I was unhappy i couldn’t add to my grandmother’s side, though, so I’ll have to hand-write it onto the tree.  I’m sure there are other family history apps that could help out with this.

What I’m hoping to get is an opinion on whether I should begin screening with mammography at the recommended age of 40, or if I should start sooner with a different modality such as ultrasound or MRI.

For all of you out there who fear cancer, you are not alone.  Even us doctors can be illogical about cancer.  Don’t let your fear control you, though.  Take charge, take a deep breath, and talk to your doctor.

Sigh, I just remembered another fear–skin cancer (I have tons of moles).  Time to call Loyola again. This time for the dermatologist . . .

Naps-not just for trainees

During my internal medicine residency, I was one of the “subjects” in my then-attending Vinny Aurora’s (@futuredocs) experiments of residents and sleep.  I wore a little black watch looking thingy for about a month that tracked when (or not) I was sleeping.

I don’t sleep much.  Life is too full for sleep!  I get about 4.5-6 hours during the week.  I make up for it on the weekend; I like to get 8-10 then.

I am chronically sleep deprived.  I know it.  I feel it.  I fade most afternoons.  I usually don’t indulge in the p.m. coffee run, but most days it would be nice (like right now).

One thing I have found, though, is that a quick nap during my mid-week research day is OH, SO, NICE …..

On Wednesdays we have a 7 a.m. conference.  I get up at 5:20 to make it on time.  I usually go to bed between 11 and 12:30 the night before.  I barely stay awake for it, but waiting for me after that hour of knowledge building is a cozy, warm, quiet office.  Very Very Nice.  Very Very sleep inducing.

I know I shouldn’t sleep “on the job”, but isn’t that what some recent studies of work hours are suggesting?  I find my 20-40 minute naps (don’t ask me exactly where/how I take said nap) are excellent revivers.  I feel so much better afterwards, and I truly think it improves my focus and concentration.  It doesn’t impact how long I work, since “work” takes me well past 6 p.m. most nights.

I’m all for naps.  When I had to take them, I didn’t appreciate it.  Now, though, there are days in clinic when I long for a quick trip to my warm, quiet office . . .

Is BPA Bad? Lets find out Part 1

The JAMA article about the large increase in urinary Bisphenol A (BPA) levels after eating canned soup caught my eye because my husband and I eat a lot of canned soup.

[JAMA. 2011 Nov 23;306(20):2218-20. Canned soup consumption and urinary bisphenol A: a randomized crossover trial. Carwile JL, Ye X, Zhou X, Calafat AM, Michels KB. Source: Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.]

Naturally I was concerned, but my epidemiology background makes me a hearty skeptic when it comes to chemical/toxin “scares” from food.

My motto is “Show Me the Data”.  It is SO DURN HARD to perform a really good study of the isolated effects of isolated chemicals from isolated foods ON HUMANS NOT RATS that I rarely alter my normal food intake to avoid specific compounds unless a strong body of evidence suggests there’s really something to it.

I also know just how easy it is to get a really crappy epidemiologic study published (ahem, Andrew Wakefield?).

So, here’s my project: look into this BPA thing.  People take teams of researchers and spend months doing this.  This is time I do not have. So, I’ll do this in parts. Part I is literature search.

SO PUBMED, SHOW ME THE DATA:

1. Search string #1: BPA w/o limits = Results 2807 

2807 isn’t a manageable #.  I knew it wouldn’t be, but I was curious.  So, I need to refine my search.

2. Search string #2: BPA or Bisphenol A, limits: humans, english, search title only = Results 537

This still isn’t manageable for 1 person, unfortunately.  I.E. it would take about 9 hours to screen all these abstracts.  But, if I refine the search further, my search becomes more specific and less sensitive.  I might miss an important article.  So I’ll limit to full text only next, then screen the titles.

3. Search string #3: Search string #2 but with full text limit = Results 498

That isn’t too helpful.  Limiting to free full text would be very helpful (i.e. 154), but then I know I’ll miss some important things.  Ok, so let’s see how long it will take me to screen titles.

4. Screening titles, using timer to measure time to screen one screen of titles = Results Page 1 = 2 min, Page 2 = 1.30 Page 3 = 1.20 Page 4 = 1 min

So, I can guesstimate that it would take me about 34 minutes at 80 seconds a page to screen the titles. Out of the first 80 I screened, I chose 30 titles to review.  If that is a steady ratio, I’ll pick 187 abstracts.

BUT then I have to read the abstracts to screen them (time estimate = 2 min/abstract = 6 hours), and THEN I’d have to read the actual articles.  Next would be the joy of getting the articles (some I’ll have access to through my job but I am anticipating quite a few I would have to inter-library-loan, ILL).  I don’t think that an estimate of 30%-50% needed through ILL is unreasonable based on my experience with the library so far.   Each ILL costs ~ $15-20.

Let’s recap:

• 6 hours to read abstracts.
• If I go on to choose 50% of those abstracts for review = 93
• Cost to get full text articles if 30% require ILL = $558
• Time to read 93 articles, [no clue really, big shot in the dark here] ? 10 min? = 15 hours

There’s NO WAY I can take the time or money to do this.

Luckily as I am scrolling, I can pass over the articles on how to measure BPA and the non-human studies that didn’t get weeded out by checking the “humans only” option.

But, perhaps more efficiently I can pick up other recent review articles about the human effects of BPA (and actually read the full JAMA article, which I have not done yet).  The danger in this is knowing whether the people who wrote those review articles have enough knowledge of epidemiology to accurately evaluate the quality of the studies.   Also here’s a WARNING about reading only the discussion section of journal articles: these ARE NOT SYSTEMATIC REVIEWS.  So, if you are “summarizing” the data, it is only natural to bias your summary to support your findings.  Since humans are humans, I don’t want to trust the JAMA article discussion without looking around myself.

See how difficult this can be?  It is SO much easier to glance through someone else’s review article and take their word for it that they evaluated this data objectively.

In the “good old days”, one was supposed to be able to trust the “name” or “reputation” of a journal and the authors.  Well, we know now that even the bastions of medical scientific writing (names like JAMA or NEJM) can let some data slip through that it shouldn’t. [There was an article on screening for lung cancer using CT scans that used historical controls to make comparisons, published in either JAMA or NEJM a few years ago.  While I was in grad school at UNC, one of my epidemiology journal clubs evaluated this article and we had serious issues with the strength and validity of their findings.  Sadly, I cannot find the citation within a a reasonable period of time to write this blog, so I'll have to get back to you.]

Who do you trust?  I don’t know.  I can only tell you what I do, and what I do changes depending on the time I have in which to do it.  Since I don’t intend to write up this exercise for anyone but myself and the readers of this blog, I’ll probably be less rigorous than I would like to be.

5. Search string #4″ Search string #3 with limits to free full text and limited to meta-analysis and review articles only, Results = 19!! Yay!!, kinda (see qualifications about about limiting it to this tight a search).

You know what?  Two of these articles are EXACTLY THE KIND OF STORY I was looking for.  I was amazed the first article ended up Freely Disseminated in Pub Med Central because it is written in 1st person by a mother and a scientist.

PLoS Biol. 2007 Jul;5(7):e200. Epub 2007 Jul 17. Babies, bottles, and bisphenol A: the story of a scientist-mother.  Quitmeyer A, Roberts R. S. Department of Biology, Ursinus College, Collegeville, Pennsylvania, United States of America.

In this article, an undergraduate biology student and her professor (who is also a scientist and mother) discuss the history of BPA, some of the studies of BPA effects, the legislation surrounding BPA (up to the time of publication, 2007).

“Many animal studies focus on the effect of BPA exposure during fetal development . . . A similar correlation to human development is plausible.   Indeed, BPA has been found in the bloodstream, placenta, cord blood, and fetal blood of humans at levels that are within the range studied in many of the animal models [16].”

Be very clear you understand their argument and rationale for their decisions:

• Studies of animal exposure indicate adverse effects for animal offspring.
• The same levels that are shown to be bad in rats (and other animals) have been found in humans.
• Therefore, if I believe that what is bad for a rat is bad for a human, then I believe that BPA is bad for human offspring.

They also discuss the few human studies that exist:

“Of the few human epidemiological studies, one revealed a relationship between BPA exposure and repeated miscarriage [9]. Additionally, BPA causes a human breast cancer cell line to proliferate, indicating that estrogen-sensitive tissues and cells in the body may react similarly [10]“

They decide to apply the effects of animal studies to humans, incorporate the human studies they reviewed, and thus they believe that current human levels of BPA exposure are too high and can be harmful.

I think it is important not to arbitrarily apply rat studies to humans.  I think we should use animal studies to warn us of potential harmful human effects, then try to see if those effects do indeed show up in humans.  Epidemiology allows us to address these questions in humans without subjecting us to trials where we ingest a potentially toxic substance.  The caveat is that good epidemiology studies of chemicals are hard to come by–there is the potential for SO MUCH BIAS that one must be very careful when designing this type of study.  You can get completely wacko results and needlessly scare a lot of people (ahem, Andrew Wakefield?).

Since the above article is now 4 years old, I want to find some more HUMAN reviews to help me form my own opinion.

Next I will turn to an article published in Germany :

Critical evaluation of key evidence on the human health hazards of exposure to bisphenol A. JG Hengstler et al. Crit Rev Toxicol. 2011 Apr;41(4):263-91

Leibniz Research Centre for Working Environment and Human Factors (IfADo), University of Dortmund, Dortmund, Germany, Institute of Environmental Toxicology, University of Halle, Halle/Saale, Germany, Federal Institute for Occupational Safety and Health, Dortmund, German, Research and Development, Merck Serono, Darmstadt, Germany, Dr. Lilienblum Consulting Toxicology LiCoTox, Hemmingen/Han, Germany, Global Early Development, Bayer Schering Pharma AG, Berlin, Germany, Bavarian Health and Food Safety Authority, Munich, Germany, Lower Saxony Governmental Institute of Public Health, Hannover, Germany, Federal Institute for Risk Assessment (BfR), Berlin, Germany

I read the abstract for this, but I haven’t read the paper yet. Basically this was a panel in Germany that was tasked with deciding if BPA is good or bad for you, and if bad, how much is OK.  I’m going to hope that since they were a panel, and that they took dedicated time to address the same question I’m addressing, that their conclusions will be valid.  However, as pointed out in article #1, I will have to decide if politics, lobbying, and business interests play at all into this panel’s decision.

Since I have spent close to two hours on this exercise today and will now have to go back to finishing my clinic notes, working on my presentation for research conference this Friday, re-writing a paper for publication and working on my next research project, it is time to stop my BPA exploration until next time.

Stay tuned . . .

Not-So-Lonely-Dinner: Brown Butter Sage Cabbage

I just tweeted about our current Sunday night dinner, but the hubby wasn’t as pleased with today’s offering.  He has a mental block against meat replacements (tempeh, tofu, quorn, morningstar in any form . . .)  It’s frustrating to say the least because a lot of these protein sources have a more favorable calorie-fat-protein profile.

So, I thought I’d try to remember what I did the first time that he loved so much.

Hmm, So I think I browned butter in my All-clad 4 in deep pan and then added a lot of sage.  Then I put in the cabbage and sauteed that.  At some point I added onion powder (cause I didn’t have any fresh onions), nutmeg (freshly grated), pepper, craisins, and celery seeds.  After it had sauteed for awhile, I put rice vinegar and water in until it was covered and simmering.  I let it simmer with some chicken sausage for about 30 minutes.  Most of the cabbage recipes I read simmered the cabbage for a lot longer.

The hubby loved this one.  I hope I can replicate it!

Professional Societies: The Cost of Belonging

What does it cost to belong to professional societies?

I think it is important to belong to one’s professional societies for numerous reasons: ongoing education, networking, leadership roles, and the opportunity to have a voice in how our profession is regulated.  Collective voices (and collective pocket books) are louder than individual voices (and individual pocketbooks).

What will it cost my pocketbook, though, to join all the societies I wish to join?  Let’s see:

• AGA = Application Fee $40; Annual Dues $395
• ACG = Application Fee $195 (1st yr dues); Annual Dues $325
• ASGE = Initiation Fee $100; Annual Dues $350
• CCFA = Participating Physician $300
• ACP = Annual Dues < 8 years post training $285
• AMA= Annual Reg Membership, 1st year in practice $210

Whipping out my calculator, I get a bottom line of $1965.  OUCH.

(I think my application fees for ACG & AGA are waived since I was a member in fellowship.  At least one of the GI societies has a 1st year in practice discount also, I just can’t remember which one).

This is on top of my boards (pray I passed), $2165

Hmm, I think some of those are going to have to wait.

I know there are very good reasons why membership fees exist.  These organizations do a lot for our profession.  The cost of publishing the journals alone must be huge.  However,  I know MY budget and income, and for now I’ll have to pick and choose what professional societies are the most important to me this year.

Maybe next year I can add more letters to the C.V. . . .

For older MDs who question [our younger MDs] dedication to medicine, I’m still here

I’m still here and it’s 7:13.   (My office).

I’m still here because I spent 3/4 of my “research” day today taking care of patients.

I’m still here despite a 35-50 minute commute home, more work to do when I get there, as well as a wake-up time of 5:20 a.m.

I’m still here because I went to see an outpatient of mine who was admitted today.  I went after our afternoon conference, around 6 p.m (after calling to talk with another patient about labs).  I did it because it needed to be done.  It couldn’t be done by the housestaff or the hospitalists.  It couldn’t be done by the inpatient GI consult team.  I went because it was appropriate for me to go.

It’s my job.  It’s the right thing to do.  It was what the patient needed.

I have my board exams in 5 days.  Failing that test would be catastrophic and cost thousands of dollars.  I should be studying, but I’M STILL HERE.

I don’t have kids yet because I devoted my entire young life to my career (so I don’t have to pick anyone up from daycare at 6p.m).   I lived  800 miles away from my (now) husband for 4 years for my career.  It was an honor to be accepted to my fellowship, so much so I put up with 48 hour visits and thousands of dollars in plane flights just to stay in that program.  My husband sacrificed as well.

I work between 65 and ~85 hours a week.  In fellowship, my “duty hours” took me well beyond the 80 hour limit.

Can I keep this up forever?  Hell no.  Do I intend to? Uh uh.  I will never shirk my duties to my patients, but I’ll fight tooth and nail for a balanced life so that I can provide the best care to those patients.  My sound mental health allows me to minister to their mental health (and their gut).

For a previous generation of physicians (recent blog post from @skepticscalpal and NY times op-ed from a fellow female doc) who doubt my generation’s motivation and dedication to our jobs,  I say this:

I’m still here.

(and now it’s 7:45, sigh)

Colon cleansing: At best a loss of $100, at worst a loss of life

I have strong opinions about ‘snake oil salesman’ medicine.  My husband and I have vociferous debates about this.   I think he drinks the kool-aid a little too much, and he thinks I place too much weight on evidence-based medicine.

Colon cleansing, or colonics, are a prime example of a much-touted “medical therapy”, purported to cure a variety of gastrointestinal ailments.  From what I’ve read, outpatient hydrotherapy colonics cost about $100/session.  Do-it-yourself kits and extended “spa stays” run the gamut of expense.   I can’t even watch the commercials put on by colon cleansing salesman because they simply make me too angry, and I am afraid I will punch my TV in frustration (I like my TV.  I don’t get paid enough to replace it every time a medical fallacy comes on TV).

I cannot stand to watch overt consumer manipulation and lying.

Colon cleansing promises to cleanse your body of all of the dangerous toxins that have been building up in your system for years, claiming you have industrial/toxic sludge lining the inside of your intestine.  You didn’t even know that you had toxic sludge in your intestine, did you?  Some of them also promise to provide weight loss, improved energy, and “cures” for constipation.

Like the long-standing habit of douching, which falsely claims to provide similar benefits for the female genital region, this practice simply doesn’t do what it says it does.  Not only is ineffective for many of its claimed therapies, it can be a very dangerous thing to do.

A recent article published in The Journal of Family Practice (Mishori et al. August 2011 · Vol. 60, No. 08: 454-457) is an excellent and short report detailing a history of colonics, the process, and the lack of evidence for benefits.  This is a really good summary, and the authors looked very hard for anything to support colonics and hydrotherapy.

They just didn’t find it.

What they did find however, were patients who are seriously harmed from participating in this type of nonsense.

Today, the wildly popular consumer site Angie’s List also published an article about colon cleansing.  (Where I got the JFP source).  I belong to Angie’s List, and you can bet that my Gastroenterology hackles were up when I saw the title.

I have to applaud Angie’s list, though, for being fair and balanced in their opinion.  They reported individual patient experiences (positive) as well as negative aspects such as lack of regulation of centers, deaths [DEATHS] associated with hydrotherapy and colonics, lawsuits against practitioners, and repeated FDA warnings.  Only one state (Florida) requires a license to provide this therapy.   Luckily my own state (Illinois) requires a doctor’s oversight before getting the hydrotherapy procedure.

Western medicine is our worst enemy when is comes to the popularity of treatments such as these.  We have failed our patients in so many ways, and it is only natural that they seek alternative methods for their common problems we cannot “fix” (i put “fix” in quotes because some of my patient’s problems are ones I consider normal annoyances of being human, particularly over-indulgence, and not pathological problems that need a cure).

Complementary and alternative medicines are widely used by Americans and people around the world.  Native medical traditions, including Ayurveda in India and Sri Lanka and traditional Chinese medicine, have been addressing patient illnesses for thousands of years in ways that have not been embraced (and rarely studied) by the West.

I have no beef with these traditions.  I think they can truly provide relief to patients in need who have not found help from the type of medicine I practice.  I even encourage patients to consider alternative therapies when I don’t think these therapies cause harm and when I feel like they can be adjunctive to other things that I prescribed.

Colon cleansing does not fall into this category.   It is simply not physiologic to claim that a person has toxins built up “for years” inside their system that needed to be cleansed by whatever herbal therapy is being advertised that day.  The intestine clears itself of what we eat in a systematic fashion.  (You want less toxins? EAT LESS CRAP).  The time that it takes individuals to do this this is quite variable, but the majority of people will clear within 24-48 hours.  There are some people with severe constipation and motility disorders, though, who take much longer than this and it is this group of people for whom I am willing to admit that hydrotherapy can be a PART of the treatment process.

I’m talking about straight up water hydrotherapy, and NOT herbal oral or rectal colonics.  Herbal colonics should never be done, EVER.  These treatments can put you in the hospital with dehydration, fluid/electrolyte disturbances, and chemical colitis.  Severe electrolyte problems, particularly potassium problems, can kill you.

Hydrotherapy is like an enema on steroids, and it carries a small risk of perforation.  Infections and electrolyte imbalances can result from this type of therapy, too, given the massive amounts of water instilled with force into the colon and the potential for contaminated equipment.  Some people, though, have REALLY severe constipation and this is better to them than drinking liters of Miralax (an over-the-counter, generally safe laxative) or other oral laxatives and standard enemas.  I have had some patients who find them beneficial.

It is not a cure for constipation.  It will not make your colon squeeze more quickly than its squeezes.  But if you find that traditional laxatives do not provide you enough relief, and you are willing to take the risks of hydrotherapy, then you can talk to your doctor about it.

You should NOT do this without talking to your doctor first, particularly if you have had extensive surgery on your bowels.  You probably should not do this at all if you have an inflammatory bowel problem like Ulcerative Colitis or Crohn’s disease due to the risk of causing a flare or a tear in your intestine.

Please be skeptical of any therapy that promises benefits above and beyond what a reasonable doctor can give you.  There are very few “miracle cures” in life.  Do your research before undertaking any therapy, and accept the risks that come with participating in a non-studied, non-standard, and sometimes dangerous practice.

Also bookmark the fantastic website QuackWatch.  Read his take on colon cleansing here.  This website was created by a psychiatrist, Stephen Barrett, with a long career evaluating medical therapies.  With a healthy dose of skepticism and humor, he evaluates various “alternative” therapies.  Read it and form your own opinions.  (He also lived in Chapel Hill, go HEELS!)

Do Physicians Provide Too Much Medical Care?

Today I opened my AGA and AMA E-mail to see the headline:

Survey: Patients may be getting too much medical care

This was a blurb about a study in the Archives of Internal Medicine published online on September 26 which surveyed US doctors regarding the amount and aggressiveness of the care they provide to patients (http://www.nationaljournal.com/healthcare/survey-shows-doctors-admit-to-overtreating-patients-20110926).

The results of the study are no surprise to anyone who practices medicine the US currently.  We all order more tests than we think are necessary, but most of us feel compelled to do so either by our litigious environment, our abject fear of “missing something”, or our overly concerned patients.

That last part is what I’d like to focus on for a bit, simply because I think no one mentions it when this topic is raised.

I just graduated to “attending” level, and finally I provide care directly instead of running everything by a superior.  Even though I have been a practicing physician for 7 years, this new title confers me within an increased responsibility for my patients as well as an increased responsibility for the “health” of our medical center. I want my patients to know they are cared for and listened to.  Providing good customer service is also good business practice.  It’s the right thing to do, and it improves our standing in the community.

However, as one who has studied quality of care in a formal setting, I know that patient perceptions of quality of care do not necessarily echo physician perceptions of quality of care. During my graduate studies in the Gilling’s School of Public Health at UNC Chapel Hill, I took several classes quality of care.  In one class focusing on the research and theoretical basis of the quality of care movement, I was asked to write a short brief about whether patient satisfaction equaled quality of care.  My conclusion was that while patient satisfaction is an important component of high quality medical care, it was not a substitute for other markers of quality of care.  One simple reason is this: often the highest quality care is no “care” (i.e. more tests), and this leaves many patients feeling neglected or ignored.

This directly relates back to headlines I saw last week regarding one physician’s cry for the need to teach financial responsibility to medical residents (http://www.latimes.com/health/boostershots/la-heb-health-care-costs-residents-20110919,0,5453286.story).  I did not read the article, and I probably won’t.  Don’t get to me wrong, I think it’s tragic how little physicians in training are taught about the economics of healthcare in this country.  However, I go to clinic every week, I think about every test I order, and I feel strongly that one of the main barriers impeding my ability to provide cost effective, high-quality care is the patient themselves.

Patients come to me with their concerns and fears.  They are just as heavily entrenched in the structure of our US healthcare model that incentivizes “doing stuff” as we are.  Patients expect this “stuff” to happen in the normal course of seeking care.  Every physician knows that patients believe that if doctors aren’t “doing something”, they are not good doctors.  We subspecialists are particularly used to hearing patients report they felt their previous doctors didn’t listen to them and didn’t do anything about their complaints.

So what am I to do?  Even if I gently counsel patients that I don’t think the tests are necessary, I can see the skepticism plainly on their faces.  They feel bad, and are convinced something dire is wrong.

After their reactions, I generally give in and order the tests if there is any justification for doing so (I put my foot down on testing that carries more than minimal risks and has absolutely no indication).  How can I explain pre-test probability, utility of tests, false positive/negative, medication complications yada yada yada adequately to a normal non-medical individual (particularly in my 40 minute new patient time slot?) Even I have to look up those concepts sometimes, and I have an advanced degree in it!

Hopefully with time I will learn to be a better counselor, and my patients will take my words as reassurance that they will be okay without a blood draw or endoscopy test telling them so.

Until we as a community address our patients’ desire for more aggressive care, as well as our desire to avoid lawsuits against us when we fail to meet their desires, no physician can be the ultimate arbitrar of reducing healthcare costs in this country.  Indeed, I’m not sure how anyone expects to reduce healthcare costs until the American public is willing to accept that “less is more” when it comes to their health.