Thursday, March 26, 2015

Left atrial appendage closure

This article in CCJM reviews the evidence, with a focus on the transcutaneous devices. The evidence from clinical trials is somewhat mixed and preliminary. As with any device, improvements in the technology far outpace clinical trials. The bottom line for now is that it is an emerging option for certain patients unable to take oral anticoagulants.

The electrocardiographic findings in massive or submassive PE: it's not just S1Q3T3!

The pattern and timing of T wave inversion can also be helpful as discussed here and here at the EMS 12 Lead blog.

As Henry J. L. (Barney) Marriott used to say, when you see T wave abnormality suggestive of simultaneous anterior AND inferior ischemia think acute cor pulmonale, as in massive or submassive PE.

ECMO: what the hospitalist needs to know

Why would a hospitalist need to know about ECMO? The applications are expanding rapidly. Hospitalists are increasingly likely to be involved in the care of patients who need the procedure and may be involved, at least indirectly, in determining a patient's candidacy. Here is a very helpful free full text review.

Arterial lines: evidence based or not?

In this large propensity-matched cohort analysis no mortality benefit was seen.

Wednesday, March 25, 2015

Early post resuscitation cardiac catheterization

---is associated with improved survival, overall and neurologically intact, in this meta-analysis. The analysis was based on low level data. There were no randomized trials. The data were not restricted to patients who met STEMI criteria although, as one would expect, “STEMI patients” were subjected to early invasive treatment more often than others. The analysis led the authors to conclude that early cardiac catheterization is reasonable in post arrest patients in whom a cardiac cause is even suspected, and that the decision should not be based solely on the presence or absence of ECG STEMI findings.

Autoimmune pancreatitis

Review here. It is now recognized that there are two types of AIP and only type I is associated with IgG-4.

Tuesday, March 24, 2015

Why public reporting is meaningless

Recently I've been working through some required learning modules for clinical documentation and coding. Most physicians know that the wording used in progress notes and discharge summaries can modify the DRG payment and greatly impact the hospital's reimbursement. What may be less well appreciated is that these little documentation tweaks can also impact severity adjustment which in turn affects the physician's rating in public reporting sites. I was recently reminded that with a little creative writing just changing a word here and there, the provider can radically impact how a patient encounter looks to outsiders. For example, the same patient could be portrayed as a stable medical patient on the ward, or, with a few little tweaks and the help of your clinical documentation specialist, a critically ill patient in the ICU. The language you use in your chart documentation makes all the difference in your public reporting profile regardless of how good a doctor you are. Physicians, particularly hospitalists, are encouraged to develop this skill because the hospital's livelihood depends on it. Enhancement of the doctor's public reporting profile is a side benefit and has nothing to with his or her skill or effectiveness as a clinician. A physician who is well versed in this creative chart documentation may even push the envelope of fraud but the regulating authorities will likely never know. Having observed these things over the last few years I've become increasingly skeptical of the value of public reporting, yet many of our hospitalist leaders who have a strong focus on health care policy continue to drink this Kool-Aid and serve it up to others.  

From experienced clinician to master clinician

Dr. Gurpreet Dhaliwal, known by his colleagues as Goop, is regarded as one of the master clinicians in the department of Internal Medicine at UCSF. If you've attended very many SHM conferences you've probably been bedazzled watching him discuss a mystery case in CPC fashion.

How do you get to be a master clinician? Are some people just born that way? Goop has pondered this question and decided it's a matter of attitude and motivation as much as anything else. It's the subject of a talk he gave, which I was fortunate enough to attend, at the Society of Hospital Medicine national meeting last spring. That same talk, given as a guest medical grand rounds speaker at the University of Washington, is available for viewing here.

Goop tries to be evidence based in his talk but encounters a problem: there has been next to no research on this question in clinical medicine. In attempting to work around the problem Goop has to look to non medical fields, in which there is a fair body of research on what makes an expert. But such research tends to be unconvincing, as comparison of the art and science of medicine with the mechanics of industry falls short time after time. Fortunately though Goop sprinkles in plenty of personal insights he has gained on his journey to becoming a master clinician. I'll unpack a few things here that rang true to me although I recommend everyone watch the video in its entirety at the link above.

It's a lot about attitude.
Complacency is the enemy. The slide appearing about six minutes into the talk reflects the typical career learning curve. Early on the curve is steep. Everything is new and it's a struggle. After a while, though, things get easier. As experience accumulates we become comfortable and the curve flattens. This, according to Goop, is a zone of complacency where professional stagnation and eventual decline may ensue. The key to staying out of this rut is to keep the curve steep but it takes deliberate effort. If you're comfortable in a particular content area make it harder by inventing new challenges and go after them. Curiosity and humility, the realization of how little you know, are important drivers.

Practice must be deliberate.
Passive practice, the kind we get from seeing a lot of patients, is an inefficient learning method. Deliberate practice might mean, for example, making it a point to carefully review as many electrocardiograms (or rashes or images, etc) as possible during a given month along with related material in textbooks or review articles.

Make the most of case reports.
Though relegated to “low impact” status in medical journals, case reports can be powerful learning tools when read with deliberate learning objectives (not just casually). Case records and clinical problem solving exercises in the New England Journal of Medicine are but two examples.

Is this the next version of MOC? It's a lot of work but there is a key difference. Unlike MOC this is self motivated and self directed. And it's a much more robust form of learning than that which is imposed by some outsider who knows nothing of your educational needs.


Deployment related lung disease---recent insights

Here is an update from Current Opinion in Pulmonary Medicine.

Background from previous posts on this topic can be found here.

Atrial fibrillation and silent cerebral infarction (SCI)

There is a two fold increase in the odds for SCI attributable to atrial fibrillation in this systematic review and meta-analysis.

Monday, March 23, 2015

Hypertensive emergencies and severe asymptomatic hypertension

This post from S.O.A.P. nicely covers true hypertensive emergencies and their distinction from severe asymptomatic hypertension.

D 10 versus D 50 for treatment of severe hypoglycemia

D 10 may be as good or better. Via Academic Life in Emergency Medicine.

A systematic review of four popular weight loss diets

Recent findings:
Background—We conducted a systematic review to examine the efficacy of the Atkins, South Beach, Weight Watchers (WW), and Zone diets...

Conclusions—Head-to-head RCTs, providing the most robust evidence available, demonstrated that Atkins, WW, and Zone achieved modest and similar long-term weight loss. Despite millions of dollars spent on popular commercial diets, data are conflicting and insufficient to identify one popular diet as being more beneficial than the others.

Saturday, March 21, 2015

Diagnosis takes a back seat under administrative pressures

A pithy little note over at DB's Medical Rants got me thinking. From the post:

Diagnosis generally dominates the first few admission days. We cannot really develop a good treatment plan until we solve the diagnostic dilemma.

I agree. But given typical lengths of stay of three or four days that means the majority time spent in the hospital should be devoted to just getting the right diagnosis for many patients. Worse, a significant number will leave the hospital without being correctly diagnosed at all.

But today's external pressures drive us in another direction, which is to force a diagnostic label on the patient too early. First the emergency physician is pressured to label the patient in order to convince the hospitalist to accept the patient for admission. Then the hospitalist has to assign a “principle problem.” If the problem statement is vague (such as a symptom), as is often appropriate, pressure comes from the coding and quality people to make the diagnosis more specific and get the patient on a care pathway. The performance incentives that follow are meaningless if the resulting diagnosis is incorrect.

Dr. Lawrence Weed, originator of the problem oriented medical record, appreciated this fact decades ago when he gave us this rule: in stating the patient's problem do not go beyond the level or resolution you have at the time. If that means listing the problem as “funny looking EKG” so state it until further data and expertise become available.

More tweaks proposed for the hospitalist model of care

The hospitalist model came into being with the hope that it would result in improved quality and cost efficiency. That hope did not withstand scientific scrutiny despite the persistent claims of some. While many hospitalists ascend a long and steep learning curve, thereby becoming quite skilled in the management of inpatients, that advantage may be outweighed by the discontinuity that is built into the system.

Concerns about this discontinuity prompted some leaders to propose modifications which would in effect dismantle the model. Some, for example, have suggested that hospitalists spend part of their time in the clinic. A few years ago AAFP promulgated guidelines calling for PCPs to collaborate with ER doctors before their patients are admitted to hospitalists, and to be involved in their patients' hospital stays. None of these ideas were widely adopted.

Now a Perspective piece in the New England Journal of Medicine proposes taking things a step further:

Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after admission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient's workup and care. The PCP would write a succinct consultation note, highlighting key elements of the patient's history (including pertinent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagnosis and recommendations for personalized inpatient evaluation and management. The hospitalist team would still retain full attending-physician responsibilities.

The initial consultation — contributing insights from an established doctor–patient relationship — would be designed to complement and help inform the hospitalist's admission workup and care plan, aiming to reduce hospitalist workload while increasing personalization of care. Subsequent to the admission consultative visit, the PCP would be available to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program.

This means the PCP would round at least twice during the patient's hospital stay. Given a typical length of stay of about 4 days that means he or she would be rounding at least half the time. Although most hospitalists I know would be delighted to see the PCPs reaching inside the walls of hospitals this proposal would dismantle the hospitalist model as we now know it. It would take a radical payment shift to create enough incentive to bring something like this about and, despite the optimism in today's reform climate I don't see it happening any time soon.



Guidelines for intravascular catheter related infections

These guidelines from the IDSA were released in 2009. Though they may seem dated they are the most current guidelines form IDSA on the topic. No new version is expected anytime soon.

There are almost endless clinical scenarios (suspected versus established infection, type of organism, patient characteristics, type of catheter) and treatment options (duration and type of antibiotic, lock therapy, removal versus retention). The guidelines, accordingly, are quite complicated, a bit more than you could be expected to remember. This is a reference the hospitalist needs to have handy.

Weight loss drugs: risks versus benefits

Throughout their history weight loss drugs have taken off pounds but ultimately proved harmful. Here is a free full text review which traces the multiple generations of these agents and evaluates the latest offerings. Even these purportedly safer drugs have concerns and have yet to be adequately tested for long term cardiovascular outcomes.