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The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.

If you don’t know this about me by now, I need to confess something, I’m a bit of a geek. I love  Star Trek (all of em), and I regularly check the NASA website  to see how the Voyager pairs are doing. And yes, of course  I follow the Mars rover’s twitter feed, who wouldn’t?.  So as I was perusing my issue of Chest recently, there was a study that really got my attention. It wasn’t only because of the incredibly important  issue of Cystic Fibrosis and identifying what causes exacerbations. It was the novel way that the authors identified air pollution as a factor that contributed to CF exacerbations.

Air pollution has long been thought to play a role in leading to lung disease. Air pollution is also thought to contribute to exacerbations in people with known lung disease such as asthma, COPD, and Cystic Fibrosis. However, these correlations have been difficult to show,  and have primarily depended upon looking at admission rates for people with exacerbations  of lung disease during periods where there is a known environmental anomaly or excess pollution. Unfortunately such conditions are not very predictable.

A study published in this month’s issue of  Chest showed an intriguing relationship between  air pollution and exacerbations of cystic fibrosis. What was intriguing to me about this study was not only that the authors showed a relationship between CF exacerbations and environmental pollution, but also how they set about demonstrating an association between the two.

They first went back and identified  2204 individual CF exacerbations that occurred at their institution in Belgium. Using the patients’ home addresses, they  calculated concentrations of  particulate matter, ozone, and nitrogen dioxide the patients would have been exposed to around the time of their exacerbations. Continue reading “The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.”

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Why Medical Education Should Embrace Social Media

Social Media and Medical Education: Access Denied.

-By Rebecca Hastings, D.O.

I have never been very computer or tech savvy.  I’m not up-to-date on the latest technology, but I do have a smart phone and a laptop which I use for their very basic purposes; and I do admit I have a Facebook account, mostly for keeping in touch with friends and family and, you know, the daily grind.  Up until recently, I had no idea how to “Tweet” or what Twitter was really all about.  A physician mentor of mine suggested that I start a Twitter account and take advantage of the vast amount of knowledge floating around in Twitter world.  I was hesitant at first since my free time is limited and I didn’t really need any additional distractions from my fellowship.  Plus, I definitely didn’t need to join another social media network to share pictures and read about everyone’s daily happenings.  But, I trust my mentor and appreciate his guidance, so I signed up.  And WOW!  Information overload at my fingertips!!  Within a few minutes, I became a “follower” of JAMA, Chest, Cleveland Clinic, Johns Hopkins, New England Journal of Medicine, the Annals of Internal Medicine and numerous other large medical journals and institutions.  Granted, I may have also become a “follower” of a couple fitness magazines and my beloved Kansas Jayhawks, but the majority of my Twitter thread consists of these professional organizations.  I had immediate access to hundreds of tweets from these prestigious institutions across the world.  These world-renowned entities were “tweeting” about medical information, both past and present.  They were sharing everything from major review articles to personal reflections and comic strips.  Not only were the major institutions sharing these, but other physicians were sharing their professional opinions and other articles that they found important and interesting.  By signing up for Twitter, I had opened my eyes to a whole new world of medical education.

At first, I mostly just browsed articles and topics that were posted.  But the more I read, the more I wanted to share.  I felt like others were helping me, so why not share the knowledge.   One afternoon, I sat down in the fellow call room on a break.  I had been browsing my Twitter feed on my phone and there were a couple of interesting articles and commentaries I wanted to read.  But low and behold, when signing in, a big red box comes across the screen stating “Access Denied.”  Ok, so I know Twitter is technically considered social media, but why can’t social media be used as an educational tool?  Large renowned institutions and organizations are tweeting valuable information pertaining to my livelihood and I can’t access it “on the job” where I’m supposed to be gaining an education. Continue reading “Why Medical Education Should Embrace Social Media”

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Another Letter to Washington, from a Physician on the Front Lines.

 -by Matthew Moeller.

Due to the tremendous popularity of Dr. Moeller’s original post as well as some of the critiques and questions it raised, Dr. Moeller has written this follow-up post in response.

Thank you to everyone for the positive feedback. Over 57,000 Facebook “likes”, tweets, and newspaper requests over the past week was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate. I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/ lawmakers to understand the perspective we face so that the best solution can be found to care for our population. I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide. In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%). This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group. It will take away the physician-patient relationship that is needed for great medical care. A recent Forbes article explains this. In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients. Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families. I have also learned a tremendous amount from my patients. I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients. I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need. Anyways, who would go into medicine in the first place with its long hours, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t true care about the human race? I am happy to say that most of my colleagues feel the same way. Our concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced.

Second, I was trying to speak for ALL doctors, not just GI doctors. People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians. Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists. The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves. I am not complaining about my current compensation. Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career. But I am concerned about the FUTURE CUTS that may force doctors to

either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor). I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt. This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing). Continue reading “Another Letter to Washington, from a Physician on the Front Lines.”

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Daily Docblock: EHR Style.

Its been a long road to readjusting to my EHR, and for the most part its been worth it. (see previous EHR articles). I’ve fine tuned my typing skills, I’ve become a black belt of check boxes, a jedi of templates, I whip through e-prescriptions and referral letters like Liam Neeson through eastern European bad guys. Yes, I am Neo, the promised one, of the EHR world. But a recent EHR update had me making yet another change to they way I see patients that I’m sad to say, has tripped me up. This relatively minor problem is that, with this recent update, my EHR takes too long to open after I log in.

Huge amounts have been written all over the web about the EHR and  how difficult it is to adapt to. To those EHR haters my response has always been this; The EHR is our new reality, if you just get used to the idea that you need to adapt to the computer and not the other way around, and just get on with the process of adapting your typical routine to this new reality, your life will be much better.
But this newest update has me questioning that philosophy. Yes I have adapted my workflow to the EHR, and made all of the changes I mentioned above. Now I have to make another change after a recent update that made only modest changes to the EHR’s functionality. The update has caused a 15 to 20 sec gap from when I log in to the time that I begin to enter information. I’ve tried to fill this time to prevent an inevitable awkward silence, but 20 seconds is a long time to make small talk. Plus I can only ask “how’s the weather outside” so many times per day.
On the other hand if I delve right into history taking, I’m then 20 seconds behind when I do start typing.
So thus far, my interim solution thus far has been to log in first and then go make physical contact with the patient before entering anything in the EHR. This usually involves  a handshake and maybe a few preliminary questions. In some cases, if I’m already familiar with the patient, I may begin my physical exam right away, before I even start entering data. In any case, if you’re one of my patients and you are reading this, I apologize that I am listening to your lungs before I finish getting your complete history, now you know the reason why. I’ll probably keep going with this interim solution until I find a better one, I’m more than open to ideas if anyone out there has any. Meanwhile I’m hoping all future programming updates don’t force me to change my workflow.
Incidentally, a similar problem has occurred at the hospital’s computer system. When logging onto the hospital’s system for the first time of the day, there is about a 30 to 45 sec wait before the program will open.  I now log in, hang up my coat, maybe get some coffee from the machine or check my mailbox, and then come back to the computer.
Either way, suffice it to say, this is getting kind of ridiculous. I am dearly hoping that all future updates will not similarly dictate a change in how I go about seeing patients. . . are you listening Allscripts?

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An Open Letter to Washington, D.C. From a Physician on the Front Lines.

-by Matthew Moeller M.D.

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle class family.  My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan.  I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine.  Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine.  I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school.  The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school).  After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others.  I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices.  Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition:  $27,000 of debt yearly for 4 years.  I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition.  I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school.  After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine.  After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor.  I recall a moment then, sitting with a group of students in a room with a financial adviser who was saying something about how to consolidate loans. I stared meekly at numbers on  a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000. Continue reading “An Open Letter to Washington, D.C. From a Physician on the Front Lines.”

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Why Physicians Should Learn to Pronounce Patient Names Properly

I have it on good authority that it’s not easy being green. But I’m willing to wager that it’s a whole lot easier when you have a lovable name like “Kermit”. Imagine being green (or brown) with a name like “Ramachandran”? Growing up with a name like mine certainly had its disadvantages. While most neighborhoods have a local bully who kicks ass and takes names, in my case, he would typically kick ass, but didn’t bother with the name part because he couldn’t pronounce it. Somehow I found that last part more insulting.

 I’ve long since outgrown the sensitivities about my name (although I still make any telemarketer pronounce it properly before talking with them). For most patients and those with whom I only occasionally associate, I go by “Dr. Ram”, which works fine by me. But perhaps those early experiences left me with an impression about how people can be affected in positive ways by getting the pronunciation of their name right, or at least trying to get it right. As well as the negative ways in which people can be affected by getting the pronunciation wrong, or by not even bothering to try.

So I would like to direct a message to those care providers out there with easy to pronounce names, because this  is something that you probably don’t  know. Getting the pronunciation of somebody’s name correctly (or at least trying to) is important. These people often wave you through that initial awkward part of an encounter, simply because they’ve given up hope that people are going to get it right. They tell you it does not matter only because they have already spent too much time in trying to get the name pronounced properly, only to have it reduced to a few letters. They wave away the mispronunciations because they’ve learned to accept that no one is going to invest the few seconds that it will take to pronounce it correctly. But they do care, and make no mistake, it is very important to them. Not taking the time to learn the pronunciation of someone’s name sends a powerful message. It says “We don’t know you, you’re a stranger here” And doing it repeatedly says “I still don’t know you, and I’m too busy to bother to try”. The subconscious message that the patient takes from these encounters is “these people don’t know who I am”. Conversely, taking the time to try to learn the proper pronunciation of a name  says “I’m listening to you” and “I want to know who you are”. Continue reading “Why Physicians Should Learn to Pronounce Patient Names Properly”

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My EHR Tells Me I’m a Bad Doctor.

I’ve written before about our EHR and all the the things that I really like about it. Add to that list the fact that we can now get incentive payments from Medicare (or Medicaid) for buying and using an EHR (we were early adopters of the technology before the current incentives came out). But in order to qualify as an electronic health record in the government’s eyes, the federal government determined that everyone’s systems must meet certain minimum functionality requirements, what they call “meaningful use”. This is where things are getting tricky. . . because my beloved EHR is telling me that my medical records are are not meaningfully useful, and in fact are meaninglessly useful, or meaningfully useless, one or the other, or perhaps both.
As if that was not enough of a slap in the face after all the love and adoration I’ve showered upon the system, there’s this bitter morsel. I’m being told that the manner in which I’ve been deficient is in the department of documentation of smoking. Can you believe that? Smoking! Me! The super-anti-smoking guy! The one who wrote this article. And then the other one. Plus, remember that other one? Seriously?
Could I truly be deficient in my smoking documentation? Refusing to believe such blasphemy, I delved into the medical records. No, see, there it is? Right there.  Under HPI, “patient has no history of smoke exposure”. And there again, in the next chart, more extensive smoking data meticulously typed into the history. I knew that I was documenting this stuff. What could the problem possibly be? Continue reading “My EHR Tells Me I’m a Bad Doctor.”

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Should a Medical College Dean Take Money from Pharma?

One of the first posts I wrote here, was a about how pharmaceutical reps provide lunch for physicians while presenting information about a medication that they are promoting.  The post, and others like it, have generated visceral reactions on the part of the public. A similar article to the one that I wrote (also on kevinmd) prompted comments like “Get over yourself and buy your own lunch” and “I’m certainly glad that you are not my doctor”.

The opinions were so strong I was invited to speak on CNN about the topic. In particular, I was asked to speak about all the other extravagant things that physicians get from drug companies. I ultimately did not do the interview on account of me not having any experience with receiving any of the extravagant things they were talking about. It seemed to me that individual physicians receiving lunch was (excuse the pun) small potatoes compared to what happens behind closed doors in the halls of power. While upcoming rules will soon provide the public with a window into the value of goods provided to physicians by drug companies, they will provide little insight about where pharma has its greatest and most effective influence: behind the closed doors of those halls with thought leaders, opinion makers and legislators.

To that point, a story came to my attention recently that reminded me about that fact. The Dean of Weill Cornell Medical College, a prestigious and highly regarded medical school, has apparently kept close financial ties with industry, as reported in the the college’s newspaper.  The college’s Dean, a highly accomplished and awarded physician researcher, has retained positions with a major pharmaceutical company and a laboratory equipment company. In these roles last year she reportedly received about $260,000 from one of the companies and about $277,000 from the other last year. The Cornell Daily Sun also reports that she has apparently received millions of dollars in compensation from both companies over the years as well as more than a million dollars worth of shares and stock options in the companies. Continue reading “Should a Medical College Dean Take Money from Pharma?”

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This is What Remains of a Shattered Mental Health System in Newtown. Could it Have Helped Adam Lanza?

I wrote in a previous post  about what life was like growing up in Newtown, Connecticut. It truly is a picturesque New England town. But what might be surprising is that within that town sat a gem. A hundred acres of wooded rolling hills within which sat an inner campus of professionally landscaped and meticulously manicured grounds  crowned with stately and handsome brick buildings in a colonial architectural style.  These were the grounds of Fairfield Hills Hospital, a state run mental health facility located in Newtown, about 3 miles from Sandy Hook Elementary School. The hospital closed its doors in 1995.

To tell the tale of Fairfield Hills Hospital is to tell a tale of two nations. The first, a new economic and financial superpower, a country with an increasingly aspirational middle class toiling in a system that rewarded their hard work with a level of wealth and a standard of living never seen before in human history.  The second, a country struggling to balance the opposing pressures of a demographic bubble and crushing debt levels the likes of which have also never been seen in human history. Continue reading “This is What Remains of a Shattered Mental Health System in Newtown. Could it Have Helped Adam Lanza?”

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Offer Hospice Patients a Smile.

Hospitals are busy places to work. The work is fast paced, and never seems to stop. For most physicians, the work ends when the work is done, or until you fall over, whichever comes first. So as a consultant, when I am seeing a patient wherein there is no longer anything that I am contributing to a patient’s care it’s routine that a physician would “sign off” the case, meaning I would not continue to see the patient on a daily basis but would be available if I were needed. Sure, I might have a good repoire with a patient, and some even tell me that I have a nice smile, but it hardly seems like a reason to continue to bill their insurance company without actually contributing any expertise. Despite how nice I think my smile is, I have yet to find an insurance company  willing to pay to see it.

It’s no surprise then, that in such a busy workplace the physicians-in-training that I regularly work with would want to sign off a case as soon as possible. Unlike most of their bosses, they get paid the same no matter how many patients they see. There’s no incentive for them to see more, and if they see too many, it becomes difficult to learn anything.

So for many specialists who round on patients in a hospital, and for physicians in training in particular, the typical approach to a patient who has enrolled in hospice or decided to otherwise stop all treatments other than comfort measures, is to sign off the case.

For those patients, the thought is, most of them are waiting to be discharged home or to another facility, and have accepted that the end of life is coming. In such situations families are typically grieving, making end of life arrangements or simply trying to spend as much time with their loved one as possible before the end comes. Why would it be necessary then for a specialist or a team of physicians to enter the room of such a person, ask a plethora of unnecessary questions, perform an exam and offer meaningless platitudes like “hang in there! you’re doing great!”?.  All this to a person whose one certainty is that they’re not doing great, and they’re most definitely not going to be able to “hang in there”!

Thus my approach has been to sign off such patients, and based on what I’ve seen, it’s the approach of most other physicians as well. I had always thought that ridding people of my pestering presence at the end of their lives was the most reasonable and humane thing I could do.

But things changed for me recently, when my own father entered hospice. He was in the hospital for a few weeks, and being a physician himself, he knew the end was coming. My mother, of course found it difficult to let go. After 50 years together, who could blame her? She agreed grudgingly to hospice, but needed constant reassurance that it was the right thing to do. I remember the constant look of consternation and worry etched on her face in the days after he was enrolled in hospice (but was still in the hospital). One by one, the physicians who had convinced her that there was nothing more to be done, disappeared. The physicians who reassured her that he would be well taken care of no longer visited, at just the time that she needed their reassurance more than ever. Her face wore a look that said, “Are we doing the right thing? Are they just trying to get rid of us?” Despite having a pulmonary, critical care physician for a son, there are some things you just need to hear from your doctors, the people who have been taking care of you, the professionals who know you.

Ultimately she came to accept the inevitable, she’s a strong person, and she knew she had no choice. He passed away peacefully.

But that experience taught me to change something in my own practice. I still round with my physicians-in-training, as I always have, we still sign off those patients who are going into hospice as we always have, so  the team does not needlessly pester a person at the end of their life. Instead, I walk into the room by myself, I perform no exam, I ask no medical questions. I offer them nothing but my smile. And it’s for free.

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