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A Prescription For Better Teaching, Stronger Doctors

The author's stethoscope from medical school stethoscope. (Courtesy)

The author’s stethoscope from medical school. (Courtesy)

By James Morris
Guest Contributor

Medicine, in many ways, is changing. Patient-centered care is all the rage and the old, iconic image of the all-knowing doctor is fading away.

In one concrete example of this shift, a new Medical College Admission Test (MCAT) is just around the corner. Starting in spring 2015 for the class that will enter medical school in the fall of 2016, the new MCAT promises a “better test for tomorrow’s doctors.”

Among other changes, it will have a new section focusing on the social determinants of health — essentially asking students to consider how income and social status, education, home and work environments and other factors shape health outcomes.

Premedical education takes place at the undergraduate level. I went to medical school, but now spend most of my time working with undergraduates in the classroom.  I often think about what I learned in medical school and how it translates — or doesn’t translate — to teaching, and why it matters.

Of course, there are the obvious connections. One of the classes I teach is comparative vertebrate anatomy, and I use what I learned about anatomy in medical school directly in this class.

But there are other lessons that don’t apply. Doctors often use three-letter abbreviations in their notes. HPI is the history of the present illness, the patient’s narrative of what brought them to the doctor’s office or hospital, as heard and interpreted by the physician.

CAD is coronary artery disease. TIA is a transient ischemic attack, a “mini-stroke.”

There is a saying I remember from medical school: Physicians are especially fond of TLA’s … three letter abbreviations.

I don’t use many acronyms in my teaching. But sometimes, it’s helpful: For problem sets, I sometimes use “PS.” However, when I do this, I am inundated with emails and questions asking what they mean.

In medical school, mnemonics are also widely used to help aspiring physicians learn and remember all kinds of information. The 12 cranial nerves can be recalled using the mnemonic “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops,” where the first letter of each word of the saying is the first letter of each of the cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory, glossopharyngeal, vagus, spinal accessory, and hypoglossal.

Or, for Harry Potter aficionados, there is “Only Owls Observe Them Traveling And Finding Voldemort Guarding Very Ambiguous Horcruxes.”

These are handy, but I learned so many mnemonics in medical school that I often had trouble remembering which mnemonic was used for what kind of information. Is that the mnemonic for the cranial nerves, or the bones in the wrist, or the femoral triangle, or the major branches of the aorta? Continue reading

Viewpoint: Consider Tough Penalties To Boost Disabled Patients’ Access To Care

We already know that patients with disabilities face major obstacles when trying to access basic medical care. Now, a team of researchers are proposing some novel strategies to help fix the system, including withholding payments to health care organizations and making accreditation contingent on compliance with disability law.

The researchers, Dr. Tara Lagu and colleagues at Baystate Medical Center, Tufts University School of Medicine, and a Massachusetts not-for-profit organization, the Disability Law Center, suggest that this is the first time these types of strategies have been proposed.

“The goal of this paper was to start the conversation,” says Dr. Lagu via email.

Dr. Tara Lagu, M.D., MPH (Courtesy)

Dr. Tara Lagu, M.D., MPH (Courtesy)

Lagu’s groundbreaking earlier study on access to care for people with disabilities found that even in the current high-tech health care environment, many elements of routine medical care — like getting a patient on to an exam table — remain elusive.

The latest article, published in JAMA Internal Medicine, describes the range of barriers, including:

“…physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities.

And here, Lagu offers some possible solutions:

As our study last year reported, patients with disabilities face real difficulties when they try to access health care. This suggested that our current strategy for enforcement, lawsuits, have fallen short. In part, this is because patients don’t want to bring lawsuits against doctors with whom they have an existing relationship and because lawsuits are extremely unpopular with physicians. More importantly, lawsuits have failed to initiate system-wide change: it is not clear that, in recent years, there have substantial improvements in access to care for patients with disabilities.

For these reasons, we believe that novel strategies are needed. As we considered what such strategies might look like, we considered other mechanisms of enforcement that have been successful at motivating change in health care settings, and we came to four possibilities: withholding payment, making accreditation contingent on compliance, regulation, and lawsuits at the state or national level aimed at initiating large-scale policy change. Continue reading

12 Tips For Nurses And Doctors Treating Transgender Patients

Massachusetts is drafting rules that will define the transgender services insurers will be required to cover. The Association of American Medical Colleges (AAMC) has just released guidance on training doctors to treat lesbian, gay, transgender and gender nonconforming patients. And Boston University Medical School has what Dr. Joshua Safer, a professor there, says is the nation’s first transgender medicine curriculum focused on the biology of gender identity.

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Dr. Joshua Safer and Dr. Jennifer Potter (Courtesy photos)

Like I said: brand new stuff. But what do all these new rules mean for the doctor or nurse, in an examination room, who meets their first transgender or gender-fluid patient?

Here’s some advice from Dr. Safer, associate professor of medicine at Boston University Medical School, and Dr. Jennifer Potter, associate professor of medicine at Harvard Medical School. (Dr. Potter is a co-author of the AAMC guidelines.)

1) When greeting a new patient, or one you haven’t seen for some time, you cannot assume anything about their gender identity based on the masculinity or femininity of their appearance or the timbre of their voice. To avoid making mistakes, ask each new patient how they identify, what name they prefer to be called and what pronouns they want you to use. Note: Pronouns may be male (he), female (she), they or another gender-neutral option. Continue reading

Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

‘Good Death’ Still Eludes U.S. Health System Despite Decades Of Debate

reclaimedhome/flickr

reclaimedhome/flickr

By Richard Knox

Death is back in the news again. And it should be.

Death comes to us all. And in the U.S. at least, it’s increasingly likely to be inhumane, institutional and full of misery. That’s according to a growing body of evidence, including:

•A report last month from The National Institute of Medicine called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” It’s a 500-page indictment of U.S. end-of-life care.

•A new book by Boston writer-surgeon Atul Gawande on the subject called “Being Mortal: Medicine and What Matters in the End.”

•And recently, a must-read New York Times article — a powerful case study of how the American way of death has gone badly awry.

From these and other sources, one thing is clear: Too many Americans are still dying in hospitals and nursing homes; getting aggressive but futile care; and suffering more from the complications of treatment than from the pain of dying.

And with about 10,000 Baby Boomers turning 65 every day, it’s way past time to do something about it. “What is it going to take to ensure that patients in this country are receiving the right care at the right time in the right location, consistent with the right to choose?” Dr. Joan Teno wonders. “These are the things that keep me up at night.”

Teno, a Brown University faculty member, is among 21 authors of the recently issued Institute of Medicine report on dying in America. Continue reading

WSJ: Women At Risk, Doctors Split On Procedure Linked To Rare Cancer

Here’s another excellent Wall Street Journal report on the controversial procedure known as “morcellation.”  Reporter Jennifer Levitz notes that even after the FDA issued a warning on the practice (which involves a “laparoscopic power morcellator” that allows for less invasive surgery to remove fibroids by slicing them up, but can also potentially spread a rare type of cancer through the body) doctors are split on how to proceed.

According to the report:

The FDA said women undergoing surgery for what look like benign fibroids actually have a 1 in 350 risk of hosting an undetected cancer called a uterine sarcoma. Morcellating these tumors can spread cancerous tissue internally and significantly worsen the odds of long-term survival, the agency said.

So what are women to do when the medical community itself is divided? From the WSJ:

(wikimedia commons)

(wikimedia commons)

A number of doctors believe the FDA overreached, and think the cancer risk is so small that gynecologists can go an entire career without seeing a case. Others call the advisory a necessary precaution.

Hospitals and private practices are taking an array of approaches. The University of Pittsburgh Medical Center system, which has more than 50 obstetrics and gynecology practices, opted to continue using the device.

The medical system changed its informed-consent forms to include wording on cancer risk and told doctors to discuss the risk with patients. But Allen Hogge, chairman of obstetrics, gynecology and reproductive sciences there, questioned the data behind the FDA’s estimate. The FDA began looking at the issue after media reports late last year about a prominent Boston doctor who discovered she had sarcoma after morcellation.

“I think this is mostly public relations and not science,” Dr. Hogge said. In response, the FDA said it conducted a rigorous analysis of published literature.

The common practice of morcellation, which is often used for hysterectomies, came under fire when Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital and his wife, Dr. Amy Reed, an anesthesiologist at Beth Israel Deaconess Medical Center launched a publicity campaign aimed at stopping the procedure, Continue reading

The Global View: Lessons For Mass. Health Care From Abroad

By Dr. Jonathan D. Quick
Guest contributor

A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.

Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.

Dr. Jonathan Quick (Courtesy)

Dr. Jonathan Quick (Courtesy)

Here are four things Massachusetts could learn about health from developing countries:

1. Bring health care to the community level

Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.

CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.

2. Make it convenient

Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.

Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.

3. Generate revenue while saving lives

Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Continue reading

Midnight Friends: How Wired Patients Are Transforming Chronic Illness

(mic_000/Flickr)

(mic_000/Flickr)

By Nell Lake
Guest contributor

Over the years, I’ve watched my cousin Deborah Haber struggle with several chronic, painful medical conditions, including fibromyalgia and a rare incurable disorder called Ehlers-Danlos Syndrome, a connective tissue disease that causes profuse sweating, a high heart rate and insomnia, among its many symptoms.

Largely housebound, and managing the life of her 11-year-old daughter, Deborah faces social isolation and persistent pain.

But along the way, my cousin has discovered a lifeline that’s lifted her outlook and improved her health. It combines the best qualities of a mother, best friend, therapist and trusted doctor to help her cope: it’s social media.

Deborah, 39, used to lie awake at night with “agonizing, shooting nerve pain,” feeling helpless and alone. She began going online, where she found others who were also awake and in pain; they became her midnight friends. “When you cannot sleep,” she says, “and you know your kid’s going to be up in a couple of hours, and you’re going to have to get her to school on time,” even if you’re exhausted — “knowing that you are not alone is a life-saver.”

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

Early on in her social media journey, Deborah mostly used Twitter. It was through people she met there that she learned about Ehlers-Danlos syndrome. She talked with her doctor, who did her own research and sent Haber to a specialist, who diagnosed the rare congenital disease. Deborah’s online activity, then, led directly to the diagnosis, which led to “far better care.”

Clearly, Deborah’s not alone: she’s part of a large and growing group of people with chronic illness in the U.S. who are using the Internet and other online technology to take charge of and improve their own health. This goes far beyond Googling your child’s weird rash: these millions of “empowered patients” are joining social-media communities, consulting online health databases, learning and sharing knowledge about drug side effects, crowdsourcing research studies, electronically monitoring their health and becoming health care activists who share what they’ve learned with their doctors.

Online patients with chronic illness use social media to improve both mental and physical health and to better connect with an understanding community, says Jennifer Covich Bordenick, chief executive officer of eHealth Initiative, which published a study earlier this year on patients’ social media patterns.

“It’s really incredible, if you look at what social media is allowing patients…to do right now,” she says. “It’s providing tremendous access to support, information, and it’s connecting people in a way that they haven’t been able to do before. … People with chronic illness are more motivated. … There’s an urgency there.” Continue reading

The Lowdown On ‘Low T': Men’s Health Craze Booming Despite Risks

NPR reports that sales continue to soar for prescription testosterone to treat men plagued by low energy and a sluggish sex drive even while doctors fret over risks:

The number of testosterone prescriptions written in the U.S. more than tripled in the past decade. But researchers suspect that much of the testosterone dispensed at low-T clinics isn’t tracked, since it’s often bought with cash. This unfettered flow of testosterone — officially a controlled substance — has raised concerns among doctors who specialize in hormonal problems.

“In most doctors’ offices, you don’t see a big shingle over their door saying, ‘Get your testosterone here!’ ” says Dr. Edward Karpman, a board certified urologist and the medical director of the Men’s Health Center at El Camino Hospital in Los Gatos, Calif. Karpman says low-T clinics aren’t in the business of treating the complex medical problems that often masquerade as low energy and decreased sex drive. Those can include sleep apnea, depression and, perhaps most importantly, heart disease.

(Linden Tea/flickr)

(Linden Tea/flickr)

“Any man who presents, especially in his 40s and 50s, with new onset erectile dysfunction is at an increased risk for cardiovascular disease and even heart attack or myocardial infarction,” says Karpman.

Hormone treatment itself isn’t without risk: A recent study of more than 55,000 men found a doubling of heart-attack risk among older men who used testosterone. Younger men who had a history of heart disease had a higher incidence of nonfatal heart attacks. In addition, men who are on prolonged high-level testosterone replacement therapy can experience testicular shrinkage.

Earlier this year, WBUR’s Tom Ashbrook highlighted the risks of prescription testosterone and explored the meteoric rise of the ‘Low T’ diagnosis. Continue reading

My Mother’s Surgery And One Doctor’s Substance Abuse

By Karen Shiffman
Guest contributor

USA Today reports more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction. This wasn’t news to my family.

Some 20 years ago, my mother was mauled by a dog. She was on vacation in Florida and went over to a friend’s house for dinner. To understand what happened next, you need to know a few crucial facts about her: She is afraid of dogs and barely five feet tall. When her friend opened the front door, her daughter’s dog — an Akita- tore out of the house and lunged . My mother turned away quickly. The dog lunged again. Because of her short stature, his teeth sunk into her calf. He all but ripped it off.

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

Blood everywhere. Screams. Tears. Ambulance. Thirty-nine stitches at the ER. She would need a skin graft.

And then there was the drama with the friend. Turns out, this wasn’t the first time the dog had bitten someone. Still, the family didn’t want the dog put down. Eventually, he was. My mother and her friend of 30 years never spoke again.

Back home in Boston, my mother was referred to a plastic surgeon at what is now Beth Israel Deaconess Medical Center. He was kind and I agreed with my mother that he should do the surgery.

The operation went well. I went with her to the post-surgery checkup. We both thanked the surgeon for doing such a great job and for taking such good care of my mother.

So, imagine my shock, in 2008, to read in The Boston Globe that my mother’s surgeon was fired for being impaired in the OR. And that he had been struggling with substance abuse for the past six years. Continue reading