I believe in the principle behind practice guidelines. That is, I believe there is value in compiling the best available evidence related to treatment options for a particular condition and synthesizing it into a series of recommendations for clinicians. There are certainly potential pitfalls in developing guidelines, but I still think that a high quality guideline, applied critically and with respect for patient preferences, can improve care.
One objection that clinicians often raise about guidelines is really not about the guidelines themselves, but rather about being judged on the extent to which their management matches guideline recommendations. The argument is pretty straightforward: management depends both on the physician’s recommendations and the patient’s adherence, and physicians can’t control the latter. I have argued that physicians have more influence on adherence than they may care to be accountable for, but the point is well taken. There are limits to how much physicians can influence patients’ behavior. Are there other means for improving adherence?
A novel collaboration between the American College of Cardiology (ACC) and Google is based on the assumption that patients can be engaged and activated if they have easier access to high quality information.
Continue reading Patient Engagement
My first posting on this blog explained why I chose to name it “Auscultation.” I wrote that I wanted to promote a conversation, and that listening was essential to doing so. I went on to write: “With an obvious nod to my being a cardiologist, I believe auscultation has long been an act that defines us as physicians and connects us in a profound way with our patients. The act of leaning in, touching the patient, listening, concentrating, and interpreting is a powerful metaphor for the entire clinical encounter: getting close to the patient and listening.”
It is therefore no wonder that I was really pleased to read “The Physical Examination and the Fifth Maneuver” by Thomas Metkus in a recent issue of the Journal of the American College of Cardiology. The piece appeared in the “fellows in training and early career page” in the Journal, which regularly features articles by trainees about their experiences, and was a mature and robust defense of the importance of developing auscultatory skills. Metkus alludes to Osler’s model of physical diagnosis, the first four maneuvers of which are inspection, percussion, palpation and auscultation. The fifth – and arguably most important – is cognition, the intellectual exercise of putting it all together.
Continue reading Listen More
I have never been a fan of dietary supplements. In fact, I have spent many hours trying to talk my patients out of taking nearly all of them. My reasons for doing so are based on both my conservative approach to medical therapies in general, and on my skepticism about these products in particular. A recent article in the New England Journal of Medicine gave me more ammunition to oppose their use.
Here’s what I mean by a “conservative approach” to medical therapies. I believe that there should be a good reason, backed by good evidence, to take any medication – prescribed or over the counter. Since every medication (or supplement, herb, vitamin, mineral, etc.) carries some risk of adverse side effects, and costs some money, I have never ascribed to the “it can’t hurt” school of thought. “Why not?” has never seemed to me a compelling reason to recommend or prescribe anything. There is a profound lack of reliable evidence supporting the use of the vast majority of OTC supplements that patients take.
This is of course compounded in the common scenario where people are taking multiple prescribed medications or OTC products, in which there is also a real risk of unanticipated interactions among compounds.
Continue reading More Ammunition
There were several news stories last week that reported that Pfizer had abandoned its efforts to have its Lipitor brand of atorvastatin made available over the counter, without a prescription. I was never a big fan of OTC statins (more on that later) but I was struck by the reason that Pfizer put out:
The study did not meet its primary objectives of demonstrating patient compliance with the direction to check their low-density lipoprotein cholesterol (LDL-C) level and, after checking their LDL-C level, take appropriate action based on their test results.
Left unstated (and unclear) in this is exactly what the appropriate action was supposed to be. I guess they were implying that patients were supposed to check how they responded to the drug and then figure out if they should keep taking it, change the dose or seek professional advice about next steps.
Continue reading Right Call; Wrong Reason
What does someone having a heart attack look like? I think the New York Times captured what many of us probably have in mind, when they published this picture as part of a recent series on advances in cardiovascular care:
Mark Makela for The New York Times. Retrieved from http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html
Here is the iconic middle-aged guy, in extremis, pointing to his chest, with a team of health care professionals at the bedside. There are also signs of initial management – he has ECG electrodes on his chest, an IV in his left arm, what looks like monitor/defibrillator pads on his right chest and below his left arm and, of course, an oxygen mask.
What is wrong with this picture?
Continue reading Rethinking a No-Brainer
A recent FDA advisory panel recommended the approval of 2 new agents in a novel class of cholesterol lowering drugs known as PCSK-9 inhibitors. What makes this remarkable is that these drugs illustrate all the promise and pitfalls of modern pharmaceutical development.
First, a little science. The target of the new drugs – a protein named proprotein convertase subtilisin/kexin type 9 (PCSK-9) – was discovered in 2001. Two years later, investigators reported that “gain-of-function” mutations in the gene that codes for PCSK-9 were associated with familial hypercholesterolemia and high rates of atherosclerotic vascular disease. Mutations of the gene that led to reductions in the function of PCSK-9 were associated with low LDL-cholesterol levels, and a lower incidence of vascular disease. That made the compelling case that PCSK-9 had a counter-regulatory function in LDL-cholesterol metabolism, so that interfering with its function would lead to lower cholesterol levels.
Continue reading The New Paradigm
I have written previously about the potential impact of mobile apps and ubiquitous computing on health and healthcare delivery, but I admit I did not see this one coming. The current issue of The New England Journal of Medicine has a report from a research group in Sweden that developed a system – and tested it in a randomized controlled trial – to use smartphones to alert CPR-trained bystanders when there was a nearby cardiac arrest. This figure from the paper describes how it works:
Continue reading Crowdsourcing CPR
I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).
Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.
Fast forward to now.
Continue reading Congress and Dr. Bayes
I was disturbed by a recent article in the New York Times about the Texas Medical Board. The piece described the decision by the Board to sharply curtail the use of telemedicine in the state. Specifically, the Board mandated that telemedicine services could only be provided in the context of a pre-existing patient/physician relationship, and that such a relationship must be established face-to-face, and not via electronic means. According to the Times, the restrictions were strongly supported by the Texas Medical Association.
This seems to me to be a wrongheaded, backward looking and overall pretty lame attempt to stem the inexorable tide of patients and physicians connecting in new ways. I really wish I could believe the Board member who said he voted for the new restriction because he was “terribly, terribly worried about the absence of responsibility and accountability” in electronic encounters. It sounded to me, instead, that he was “terribly, terribly worried” about a new business model for medical care that provides greater convenience and lower cost to patients than traditional office visits.
Continue reading Patient Advocates? Really?
I recently wrote about the wonderfully inspirational documentary Rx: The Quiet Revolution, which tells the story of how four different groups are transforming health care for the better. Each group has some pretty amazing physicians who are committed to putting the patient at the center of the system, and they all have a lot to teach the rest of us about truly caring for patients as we “deliver care.” That got me thinking about physicians in our own Health System who are role-models for great care, and also about assuring that future physicians are just as caring and empathetic.
Well, as far as role-models go, it is hard to imagine a better group than the winners of this year’s Patients’ Choice Awards, given to those members of our Medical Group who achieved the highest scores on their patient experience surveys. They are:
Continue reading Great Doctors of Today and Tomorrow