Saturday, October 13, 2012
Why the Stanford Medicine 25?
• We recognized that after a med school physical diagnosis course, there is little emphasis on these skills in the 3rd and 4th years of medical school or in an internal medicine residency.
• In the absence of a high-stakes clinical bedside final exam (as opposed to a high-stakes multiple choice exam), there is little impetus for people to learn and master bedside skills—truth is, you can be board certified in internal medicine and no one hasreally ascertained that your technique in doing an ankle reflex allows you to accurately say a reflex is truly absent. (You will be surprised how most 'absent' reflexes become 'present' when you learn good technique.) Does it matter? It does to us.
• In observing students and residents perform physical diagnosis maneuvers at the bedside, we observe that though they know the theory, their technique may prevent them from eliciting the sign reliably.
• We find a real hunger among our residents in internal medicine to sharpen their skills at the bedside.
• Many diseases (almost all of dermatology for instance) are diagnosed by bedside exam. In neurology for example, even if the CT and MRI reveals a lot to you, only your exam can tell you what the functional consequence is in terms of motor or sensory loss or cognitive deficit.
• For evidence-based medicine fans, a cautionary note here: we are not trying to prove anything, but we do want to be sure that when people write in the chart "reflexes intact" or "cranial nerves intact" or "S1 and S2 heard, no m or g" that it is not a form of fiction, but represents an accurate observation.
A good thyroid exam depends above all on knowledge of anatomy and proper technique.
Abnormal gaits are commonly seen in the hospital and elsewhere. Many of them should be recognizable on sight and it would be a shame to subject a person to a CAT or MRI for lack of recognition. We review a number of abnormal gaits and their disease associations.
Examination of the Spleen
An enlarged spleen can be easily missed. It is a prime example of how technique matters and even with the best technique, the spleen is not easily felt.
Examination of the Liver
The liver, unlike the spleen is easily located when enlarged and its surface can be readily felt.
Liver Disease, Head to Foot
Many if not most of the signs of liver disease are paradoxically to be found outside the abdomen. The clinician needs to be able to elicit and recognize these signs and here we review them from head to foot.
Ascites & Venous Patterns
The simple act of observing venous patterns and the direction of venous flow on the abdomen can help us to differentiate inferior vena cava obstruction from portal hypertension from portal hypertension. The techniques for detecting ascites are reviewed here.
The knee is one of the most common causes of joint pain. A good knee exam helps us to rule out serious conditions such as a septic or inflammatory joint space and can also help make an accurate anatomical diagnosis of ligament or meniscus injury.
Careful examination of the shoulder can provide valuable information and help the physician determine when image studies may or may not be helpful.
Lymph Node Exam
Do you know what a "shotty" lymph node is? Do you keep your nails neatly trimmed? Learn this and other tips from our experts and watch them perform a meticulous lymph node exam.
Deep Tendon Reflexes
Subtle changes in your technique can elicit an otherwise absent deep tendon reflex. Having a proper reflex hammer helps. Here we review those subtle techniques to improve on this import exam skill.
A number of signs and symptoms correlate with cerebellar disease and the clinician needs to be able to elicit them from head to foot.
When it comes to an ophthalmoscopic exam there's more to it than meets the eye! Here we take a look at the various ophthalmoscopes available to internists and review their proper use.
The pulmonary exam is more than simple auscultation--in fact percussion and inspection often tell you much more than auscultation. Knowing the normal boundaries of percussion and the surface anatomy is critical.
Palpation is a critical part of the cardiac exam. The size and the character of the PMI (PMI) can speak volumes and predict the presence of an S3 or 4.
Cardiac Second Sounds
The second sounds and their variations can tell us volumes about everything from pulmonary or systolic hypertension to bundle-branch block.
Neck Veins & Wave Forms
Identifying an elevated jugular venous pulse will almost always affect your management of a patient. An understanding of waveforms can help you recognize everything from canon "a" waves of complete heart block to "ventricularization" of the "v" wave in tricuspid regurgitation.
BP & Pulsus Paradoxus
An accurate and reproducible blood pressure reading is a basic clinical skill. We review that skill and discuss how to test for pulsus paradoxus.
Ankle Brachial Index
Measuring an ankle brachial index is a simple skill that can be done at the bedside and give you helpful information about a patient's peripheral circulation. This technique is reviewed here.
The Hand in Diagnosis
The hands are a window to the body, and changes in the hands are linked to a plethora of illnesses. Recognizing these phenotypic expressions of disease is a basic clinical skill.
With improvement in technology, the bedside ultrasound is becoming frequent in use. Here we discuss the principles and basics of bedside ultrasound.
A rectal exam is important to help rule out prostate issues, diagnosing causes of perirectal pain and looking for distal rectal masses. As the saying goes, "If you don't put your finger in, you will put your foot in!"
The pupillary response requires a complex integration of nerve fibers. An abnormal pupillary response can be a harbinger for disease or simply a benign process. We review the physiology behind this reflex and discuss situations where it will be abnormal.
There are many types of involuntary movements and the diagnosis rests on observation and knowledge of the types of involuntary movements and their causes.
Internal Capsule Stroke
A stroke within the internal capsule leads to a unique number of physical exam findings. We review these changes and compare them with strokes in other locations.
The Tongue in Diagnosis
Changes in the tongue occur in many situations. Systemic disease such as amyloidosis or lymphoma will affect its size and color. Localized infections may suggest underlying immune disorders. Nutritional deficiencies will cause abnormalities.
Friday, October 12, 2012
An anemia drug has likely harmed hundreds of thousands of patients, soiled the reputations of two Fortune 500 companies and shamed one of our legendary sports heroes, the cyclist Lance Armstrong. Only that last part was at issue in the United States Anti-Doping Agency report, released on Wednesday, that laid out the astonishing evidence against him. It didn't explain the seductive power of the drug — an artificial blood booster called erythropoietin, or EPO for short — or how our health care providers and our culture pushed its irresponsible use.
EPO is a naturally occurring hormone that stimulates the production of red blood cells. As any anemic can tell you, without sufficient red blood cells we become exhausted, unhealthy and depressed. Those who couldn't make natural EPO, like dialysis patients and people without functioning kidneys, had to rely on blood transfusions to get it.
But that changed during the biotech drug rush of the 1980s, when a start-up called Amgen found a way to genetically engineer the hormone. After patenting its artificial EPO, Amgen formed a partnership with the marketing mavens at Johnson & Johnson and boomed into the world's largest biotech company.
Hailed as a wonder drug, EPO looked innocuous — 3,000 units of clear liquid swirling in a glass vial. To athletes, those tinkling vials also represented a way to "goose" the oxygen-carrying component of blood, increasing stamina. And really, what red-blooded American doesn't crave more energy? Our literature is rife with fictional drugs that bestow superhuman abilities — like the "spice" found in Frank Herbert's "Dune" — and so is our history; leaders from Grover Cleveland to John F. Kennedy used cocaine, "pep pills" or amphetamines.
But those energy boosts came with bad side effects. Not so, it seemed, with EPO, which was seen as safer than ephedrine, less risky than coke and more effective than a double espresso.
Before long, Amgen and Johnson & Johnson were selling two EPO brands — Epogen and Procrit. (Those who biked the short races called criteriums joked it was for "pro-crit riders.") By the '90s, in addition to cyclists, runners, skiers and other endurance athletes were injecting the stuff regularly — and illegally. All they had to do was pay a black-market dealer in Amsterdam or Marseille, France.
But it wasn't until 1994 that the marketing of these drugs burst into the mainstream. Amgen and Johnson & Johnson began trying to expand the uses of their energy-boosting drugs to include treatment for fatigue, depression and quality-of-life issues. Commercials depicted old, slow-moving people who, after a shot of Procrit, displayed a zest for life, and a young cancer patient, who after an EPO injection happily returned to work.
The aggressive marketing worked. Soon, exhausted but otherwise healthy people were begging doctors for a shot of what one Amgen executive called "red juice."
And many doctors went along with these off-label promotions, even though regulators hadn't approved them. Indeed, in March 2007, Congressional hearings revealed that many oncologists were profiting. The drug makers paid doctors to prescribe the blood booster in high doses to unwitting patients. Some earned honorariums for speaking to their peers about the unapproved, off-label uses; others pocketed "education grants," or joined marketing studies that never quite addressed the safety of high doses even as they recommended them. The two drug companies were told to stop paying doctors for overprescribing, but that flew in the face of our cultural belief: if a little of something is good, then a lot must be better.
Increasingly, scientists were discovering that EPO doping doesn't work so well — in fact it can be lethal. Yes, it multiplies your red blood cells. But too many red blood cells turn your blood to sludge and make the heart work overtime. The drug raised the risks of strokes, blood clots and heart attacks. Even worse was that EPO could potentially multiply cancer cells. In fact, just last year, regulators warned most patients they should try and stay off the red juice completely.
But it's too late. We live in a world where the 7-year-old reality TV star Honey Boo Boo feels the need to drink "go-go juice" (a blend of Mountain Dew and Red Bull) just to maintain her energy and ratings; where a seven-time winner of the Tour de France feels emboldened to lie repeatedly about doping; where doctors would risk the health of their patients to make them better, quicker, and to make themselves richer.
It's too bad about Lance Armstrong. But the real shame is that, in our get-rich, quick-fix, more-is-better culture, we are all culpable in this blood-doping scandal — both on and off the race course.
Thursday, October 11, 2012
Thursday's report by the Canadian Institute for Health Information showed differences in the use of all surgical treatments for breast cancer. About 22,000 women in Canada have surgery for breast cancer each year.
Most of the breast cancer patients studied were treated for invasive disease. (iStock)
"These findings raise questions about how Canadian women are exercising their treatment options and the resultant quality of care," the report's authors concluded, based on data from 2007–2008 to 2009–2010.
Mastectomy rates ranged from 69 per cent in Newfoundland and Labrador to 26 per cent in Quebec.
The differences decreased only slightly when age, income and travel time to a cancer centre were considered, the institute said.
Generally, clinical practice guidelines recommend breast conserving surgery, also called lumpectomy, and radiation therapy for the majority of women with breast cancer. Lumpectomy and radiation are less invasive and are associated with fewer complications with similar survival to mastectomy.
Dr. Geoff Porter, a professor of surgery at Dalhousie University in Halifax, called the report an important step in understanding differences in breast cancer surgery.
"We can only really understand where we're going if we know where we are," Porter said. "I think that's just very valuable when you think about optimizing the quality of breast cancer care. We need to know those patterns and trends so that we can see whether they're changing."
Porter said that the high rates of mastectomies and re-excisions or repeated surgeries if lab tests show that residual tumours may be present, could be higher in Newfoundland and Labrador because of differences in how the surgeries are counted in that province.
In many areas in Canada, core biopsies with a needle are used to make a diagnosis. In Newfoundland and Labrador, the tumour itself may be removed for the diagnosis and that surgery could be counted as the first one, he said.
Porter said the report offers a powerful way to look at breast cancer in the population. The tradeoff is that clinical data, such as the size of tumour and its stage, weren't included.
The type of surgery can also vary with income. In the report, women living in the least affluent areas had the highest rates of mastectomy. Long courses of radiation are generally recommended after lumpectomies and travel time appeared to significantly reduce use of less-invasive surgery, the authors said.
A third of mastectomies in Ontario were done as day surgeries but fewer than two per cent in Alberta and Saskatchewan were done that way.
"The extent of this variation raises interesting questions regarding the organization of care and resources issues."
The report was prepared by CIHI and the Canadian Partnership Against Cancer.
Wednesday, October 10, 2012
Contaminated drug draws attention to steroid injection procedure Physicians divided on value of low-back steroid injections - The Boston Globe
The demise of St. Vincent's Hospital in Greenwich Village two years ago has led to a struggle for health care supremacy in some of New York's most distinctive neighborhoods, offering a glimpse, in the process, at what might be the future of urban medicine.
Without building a hospital, one large chain, Continuum Health Partners, is establishing a beachhead in Chelsea and the Village by connecting with outpatient clinics, trying to dominate the market and create a feeder network for its hospitals in other neighborhoods. It is joining forces not just with traditional clinics but also with newer experiments like doctors working out of drugstores. A competitor, NYU Langone Medical Center, is expanding its physician practices downtown, and like Continuum, it has hired dozens of stranded St. Vincent's doctors.
Several walk-in "urgent care" centers have also rushed into the vacuum left by St. Vincent's in Lower Manhattan, hoping to show that they are more efficient and consumer-friendly than a hospital-based system, but some have already begun to form relationships with the hospitals.
"We are still trying to figure out if we are a threat or an asset to each other, and we are probably both," said Dr. Alicia Salzer, co-founder of Medhattan, an urgent care center that opened in 2011 near ground zero at Liberty Street and Trinity Place.
The immediate fight is to win market share, the loyalty and business of the area's many affluent and well-insured residents. But the demise of St. Vincent's has also turned Lower Manhattan into a laboratory for health care reform. The new clinics and the maneuvering by large chains are anticipating an expansion of the number of people with insurance and changes in the way that health care is delivered and paid for. And they are testing the notion, long held by health planners, that the city can survive with fewer hospitals.
Many doctors and some Village residents were dismayed when St. Vincent's went bankrupt and closed, and consider the new health care choices in the area to be less than adequate.
"As a physician and general internist, other than a laceration, I would never send a patient to the urgent care center," said Dr. David Kaufman, who trained at St. Vincent's and spent more than 30 years working there.
But in its waning days, St. Vincent's was filling far fewer beds than it did during the AIDS crisis, and as is the case at other hospitals, many patients using its emergency room did not need emergency care, driving up costs.
While it is impossible to know whether local residents are worse off without the hospital, one 2009 study by analysts for the RAND Corporation found no adverse impact on quality, and significant cost savings, in the newer models of care.
The study looked at patients in a large Minnesota health plan who received care for sore throats, ear infections and urinary tract infections — common complaints at retail clinics like the ones in drugstores. It found that the cost of care was 30 percent to 40 percent lower in those clinics than in physician's offices and urgent care centers, and 80 percent lower than in emergency departments, mainly because of lower reimbursement rates and less laboratory testing. It found that the rate of preventive care and overall quality of care was actually worse for patients who patronized emergency rooms for those ailments.
The researchers did raise concerns that the proliferation of urgent and retail care might lead people who otherwise would nurse minor illnesses at home to seek medical attention, raising the costs of health care to society. And they suggested that without good communication between different types of care, the health system might become even more fragmented.
"So you have more cooks over the pot, and that lack of continuity is a real frustration," said Dr. Ateev Mehrotra, a policy analyst at RAND, an associate professor at the University of Pittsburgh School of Medicine and the lead author of the study, published in the Annals of Internal Medicine.
As for worries that urgent care or retail clinics might miss serious diseases like cancer, Dr. Mehrotra said that the rarity of complications made that concern hard to assess, but that "there would be a lot of malpractice suits, and we haven't seen that."
Executives at Continuum, which runs five hospitals in New York City, say they expect their expansion into the community to form the foundation of an accountable care organization, a new model of care supported by the federal law that seeks to move patients out of hospitals as much as possible, and to reward health care organizations for working together to improve quality and cut costs.
From Eighth Street in the Village to 26th Street in Chelsea, between Ninth Avenue and Union Square, a patient can now choose from a dozen clinics or medical practices that have been opened or expanded by Continuum or are affiliated with it.
Continuum has also taken over the former St. Vincent's cancer center on 15th Street, and it has established a clinic with a focus on H.I.V. patients on 17th Street, renovating several floors and filling them with colorful pop art. Half of the doctors at the clinic, called the Center for Comprehensive Care, were hired from the old St. Vincent's H.I.V. program.
"Urgent care centers are opening at the pace of Starbucks, and we are affiliating with as many of them as we can," said Adam Henick, senior vice president of Ambulatory Care and Medical Enterprise for Continuum.
Continuum has also become affiliated with doctors practicing out of 13 Duane Reade drugstores in Manhattan and Brooklyn, and has a contract to expand to 20 within the next year or so, and to 50 within four years, said Dr. James A. D'Orta, chairman and chief executive of Consumer Health Services, which manages the practices in the pharmacies.
No money changes hands in the Duane Reade affiliations, Mr. Henick said, but there are indirect benefits for both sides. The hospital system checks doctors' credentials and provides — and bills for — laboratory, radiology and imaging services prescribed by the Duane Reade doctors. The system also gets a potential trove of patients referred by the clinics. The Duane Reade clinics earn the cachet of being associated with major hospitals, and as with other affiliated practices, the Duane Reade patients are given expedited access to Continuum specialists and direct access to hospital admission if needed.
While one goal of the federal health care overhaul is to move nonemergency patients from hospitals to cheaper outpatient care, there is significant cost variation among clinics, even among those that are part of Continuum's loose network. In a byzantine patchwork of state and federal law, some specialized clinics — especially those treating H.I.V. or geriatric patients — can be reimbursed several times as much for a patient visit as are private practices and urgent care centers.
Officials at NYU Langone Medical Center on the East Side said that they, too, were trying to expand their downtown market.
"Everything is intensely competitive and everyone is everywhere," said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.
The hospital system with perhaps the most to lose from the competition is the North Shore-Long Island Jewish Health System. It is renovating the 160,000-square-foot O'Toole building, across from the old St. Vincent's, as a free-standing emergency room, which expects to handle 50,000 visits a year. It will operate as an extension of Lenox Hill Hospital, a North Shore affiliate on the Upper East Side.
But the emergency room is not scheduled to open until 2014. Over the summer, North Shore was forced to close an interim clinic it had opened in Chelsea with a $9.4 million state grant. The clinic attracted an average of only two patients a day, which a hospital spokesman, Terry Lynam, attributed to its limited hours and "the proliferation of urgent care" in the neighborhood.
Michael J. Dowling, chief executive of North Shore, said he believed there was room to work collaboratively with Continuum and other health care providers in the neighborhood.
"Good hospitals are important, but you don't need more than you need," Mr. Dowling said. "In many cases, we've been addicted to inpatient beds. We can't be addicted to them in the future."
Word of the new options is trickling out, and some patients say they are not mourning St. Vincent's.
Michelle McKenzie, a social worker, said going to the St. Vincent's emergency room often meant hours of waiting and, in recent years, run-down facilities. She found Medhattan, the urgent care center, advertised on the bulletin board at Public School 3, where her 7-year-old son, Ian Etheridge, is a student. She has gone there to be treated for an allergic breakout of hives, and her husband took their son there a few months ago when he cut his forehead on the playground and needed stitches.
"I was seen immediately," Ms. McKenzie said. "It wasn't crazy chaotic like St. Vincent's was. I only had to tell my story once, and I was treated by the same physician I told my story to."
Dr. Charles Carpati, former chief of intensive care at St. Vincent's, now at Lenox Hill Hospital, said the community seemed to be coping without the old hospital.
"It's been very hard to show that people are dying because St. Vincent's is no longer there," Dr. Carpati said.
Tuesday, October 9, 2012
Bayer aspirin: How a struggling painkiller was reborn as a heart medicine and earned billions for Bayer. - Slate Magazine
An independent not-for-profit organization based in Cambridge, Massachusetts, IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.
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Many of the studies that the IOM undertakes begin as specific mandates from Congress; still others are requested by federal agencies and independent organizations. While our expert, consensus committees are vital to our advisory role, the IOM also convenes a series of forums, roundtables, and standing committees, as well as other activities, to facilitate discussion, discovery, and critical, cross-disciplinary thinking.