I first met Mr. GR in the emergency room (E.R.). As the cardiac ICU resident on call, I was urgently paged down to the E.R. for a “cath lab activation.” The “cath lab” (cardiac catherization laboratory) is where cardiologists balloon and stent open arteries using flexible instruments called catheters. A “cath lab activation” is an emergency call placed when a patient is suspected of having an acute heart attack. From the moment I saw him I knew Mr. GR’s chances of recovery were slim. He was “found down” by emergency medical services (EMS) without a pulse, shocked back to life, and then intubated on arrival to the E.R. Once stabilized a stat EKG was obtained. The diagnosis instantly became clear. From across the room “tombstones” could be seen marching across his EKG — concave-down electrical waves that are telltale signs of a major heart attack.

My team was called down, and he was taken emergently to the cath lab. (Picture a gurney whizzing down crowded corridors, me getting slammed against the wall at every sharp corner.) After wiring a series of catheters through his groin, cardiologists found a “tight” blockage of his LAD artery, which feeds most of the blood supply to the heart, and popped it open with a metallic stent. Still on the ventilator, he was then transferred to the cardiac ICU, where we infused ice cold water down his nose into his stomach to cool his core body temperature down to 32 degrees C (89.6 degrees F). His heart and his lungs had been stabilized, but after nearly 10 minutes without adequate blood flow to the brain, there was no telling if he would make any meaningful recovery.

Twenty-four hours later he was gradually rewarmed. The following day we weaned the heavy sedatives that allowed us to cool him, and held our breaths. Gradually, hour by hour, he showed signs of life. He began to take breaths on his own and make purposeful movements. The next day he followed simple commands, wiggling his toes and squeezing our hands, and was taken off the ventilator. He began talk, giving simple “yes” and “no” answers. By the time my rotation in the cardiac ICU was over, we were beginning to talk about transferring him to a rehabilitation facility. The extent of his neurologic recovery remained to be seen — while he was talking, he seemed to have limited short-term memory (every day we had to reorient him to place and time) and his mother lamented he didn’t seem to recognize her. But he was very much alive and getting better day by day.

–

It’s hard to convey how remarkable his story is. Even though I’m in medicine, I can’t help but marvel not only in our technical capacity to literally bring this man back from death but also in our successful and timely execution of an incredibly complicated set of tasks. Here is a brief reconstruction of the early hours of the case:

10.06 AM: Patient found down by strangers. 9-1-1 called for concern of “seizure.”

10:11 AM: EMS at the scene. Heart monitor placed, ventricular fibrillation detected. Patient shocked. Normal rhythm restored.

10:18 AM: Ambulance arrives in the E.R. Patient intubated, central line placed. EKG obtained. Cath lab activated.

10:41 AM: Patient in the cath lab. Coronary artery blockage identified and ballooned open.

11:15 AM: Patient in the cardiac ICU. Cooling initiated.

Stringing together this series of events required multiple systems of care. Onlookers who witnessed the patient collapse had to recognize his critical illness and know to call 9-1-1. EMS had to be immediately available and the phone call appropriately triaged as a medical emergency. The ambulance team had to have the right equipment and right training to immediately place a defibrillator, recognize a life-threatening heart rhythm, and deliver an electrical shock. The E.R. had to quickly stabilize the patient and amidst a chaotic situation recognize an acute heart attack. The cath lab had to have the equipment and staff on hand to immediately receive the patient and proceed to angiography. The hospital had to have a cooling protocol and the right equipment and staff to initiate it (at our hospital by paging “C-O-O-L”).

A breakdown in any of the steps above would have dramatically changed this patient’s course. The data is clear: every minute the patient is down without adequate oxygen delivery increases the risk of permanent brain damage and death. “Time is brain.” But for every success story like Mr. GR’s there are many more not don’t end well. As someone who practices medicine, these breakdowns are not hard to imagine. Onlookers think patient has only “passed out” and delay calling 9-1-1. There’s heavy traffic on the way to the hospital. The ER is busy with a trauma patient and an EKG is not ordered in time. It’s the middle of the night and the cath lab team takes over an hour to assemble. Cooling is not initiated because the right equipment is not available. That all these moving and imperfect parts came together to help Mr. GR is almost miraculous.

–

Through the week I spent taking care of Mr. GR, I had the opportunity to learn more about him from his family. Though he had a job and health insurance, Mr. GR did not have a regular doctor. He was a lifelong smoker and drank 5-6 beers on the weekends. He had high blood pressure but was never started on medications for it. Moreover, for the past 4 months, he had been complaining of episodes of abdominal pain that were brought on by exertion. He had sought care at a local hospital E.R. on more than one occasion but was told he had heartburn and prescribed an antacid. In hindsight, this abdominal pain was likely the earliest salvo of the heart attack that almost claimed his life.

I don’t blame the outside hospital E.R. for misdiagnosing his abdominal pain. Abdominal pain is common and it is difficult to know how Mr. GR presented at that time. Each time he went to the local E.R. he likely saw a different doctor. E.R.s are best designed to handle emergencies; chronic and refractory medical problems often slip through the cracks. In a primary care office, he may have initially been diagnosed with heartburn as well. But if his symptoms worsened despite appropriate medications, the primary care doctor would have been more likely to re-visit the initial diagnosis. He or she would have also addressed his controllable risk factors for coronary heart disease, including tobacco use and hypertension.

Mr. GR in many ways typifies the larger problems with our health care system. Our health care system is designed and is really best at acute care. This underlies our ability to coordinate and execute the incredibly complex series of steps needed to resuscitate Mr. GR. However, for all of our specialized and acute care, we have yet to figure out how to deliver primary and preventive health. We can shock, intubate and cath people who present with a cardiac arrest in under 90 minutes, but can’t get patients to see a regular doctor, to take their medications, to follow up when they aren’t doing well.

–

I don’t want to dismiss what we did for Mr. GR this past week. Rather, our success in his case emboldens me to believe that with the right science and the right resources we can improve the delivery of primary and preventive health. It dares me to dream not just of a health care system that handles medical emergencies perfectly each and every time but of one that doesn’t have to. After all, the greatest save is not having to make a save at all.

- Shantanu Nundy, M.D.

As the senior resident on my hospital’s inpatient leukemia service this past month, this question troubled and intrigued me daily. Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness (patients with little to no functional immune system), I couldn’t help but marvel at how coordinated, integrated, and patient-centric the care was.

From the first day I saw that things in leukemia worked differently. Most inpatient ward teams consist of an attending, a senior medical resident, one or two interns, and medical students. Each member of the team is “on service” for 2-4 weeks after which they rotate to different parts of the hospital or to the outpatient or research setting. As a result a patient admitted to general medicine today is taken care of by a completely different team than took care of her 3 months earlier when she came in for the same problem. On leukemia, our medical team included an advanced practice nurse (APN) who did not rotate off and on service. Being on the inpatient leukemia team was her primary responsibility 365 days a year. When I wondered if a patient admitted for chemotherapy needed an interval CT scan, she would remind me that the patient had just received one a month earlier. When the patient later developed a rash that I considered getting a biopsy of, she reassured me that the rash looked no different than the one the patient had developed the last time she received chemotherapy. And when I was trying to determine which prophylactic antibiotics to discharge the patient on, she contacted the primary oncologist to get his opinion and, if necessary, arranged prior authorization for medications that her insurance company might otherwise deny coverage for. Perhaps most importantly, our APN was a constant presence for patients fighting a disease that wrecked havoc on their bodies and their lives. Often when the medical team finished examining a patient, the patient would ask to speak to our APN privately, no doubt to receive additional emotional and psychosocial support, something that is terribly lacking in many patients with chronic disease yet serves to reduce treatment breaks and improve adherence and identify co morbid conditions such as depression that are common but often go unnoticed.

Then there was the weekly leukemia conference I was reminded to attend. Thinking I was walking into another research lecture, I was surprised to learn that this meeting was really a “tumor board” in which new and active patients were discussed. Sitting around the expansive conference table were leukemia attendings and fellows, advanced practice nurses, social workers, case managers, and the inpatient leukemia team. We began by discussing the admitted patients with my team providing the updates and the outpatient oncologist providing context and overall direction. I left with a better understanding of my patients while my intern jotted down to-dos and made notes for herself. We then discussed the new patients — while multiple leukemia specialists went back and forth formulating the diagnostic plan and initial chemotherapy, the case managers and social workers figured out how to best coordinate the dozens of steps required to place a central line, draw routine blood tests at home, and schedule chemotherapy and follow up visits. Finally, everyone was encouraged to bring up concerns about any patient on the roster. In general medicine, doctors are often left to deal with complex medical and social issues with little input from others. Though I’m in a large group practice of over 100 primary care physicians we have no clear and formal mechanisms for asking and receiving advice from each other on individual patients. In addition, despite the fact that many of the day-to-day challenges of primary care center around not the medical but rather the socioeconomic determinants of health, I do not have access to dedicated social work and case management services.

At the conference we each received a roster of all the patients the group was actively managing. Each line of the roster included the patient’s name, date of birth, type of leukemia, and treatment plan – nothing surprising. But in addition, it included the name of any clinical trial or research protocol the patient was on. Flipping through the roster, I was stunned to see that virtually every patient was enrolled in a research study of one sort or another. Those who were not in a study of a new experimental chemotherapy or drug (Phase I or Phase II trial) were instead on a study to collect and track patient responses to an established leukemia treatment. General medicine is no less cutting edge than leukemia; many of our treatments have no good data supporting their use and new drugs come out each year. And yet, to my knowledge, I don’t have a single patient in my practice on a research protocol. Worse still, we don’t even analyze our own data. If you asked me what the average HbA1c is for my patients with diabetes, I couldn’t tell you. In comparison, the oncologists at my hospital can report their institutional survival rates for specific types of leukemia by age of diagnosis, gender, and ethnicity.

This dedication to building evidence was matched by a commitment to use the available evidence. At times it almost seemed as if they were speaking another language. Sentences often were punctuated by phrases such as “per the CALBG 10580 protocol” and frequently, recommendations were accompanied by specific citations from the oncology literature. In primary care, most of our recommendations are based on experience or habit; seldomly we may refer to a consensus guideline. It’s no wonder then that studies shows it takes 7-10 years after a new guideline or seminal study is released for practice patterns to change. It’s not that such data doesn’t exist — it’s just that often we just aren’t using it.

Perhaps the best evidence in support of the care we provided our leukemia patients came from my most startling observation: nearing the end of my 4-week rotation I have yet to admit a single patient from the emergency room. In general medicine, by contrast, well over 90% of admissions come from the ER. ER admissions are undesirable for a number of reasons. For one, everything in the ER costs more. Though I have never verified this myself, it is rumored that ERs routinely charge $200 for a single dose of aspirin. Furthermore, because ER doctors are trained to address the worst-case scenario and often know little about the patients besides what is written in the medical record, patients often get unnecessary and expensive tests and procedures in the emergency room. Finally, because leukemia is so super-specialized, leukemic patients are also at risk for substandard care from ER physicians who are generalists by nature. How are inconvenient, costly, and potentially suboptimal ER stays avoided in leukemia? At diagnosis and frequently thereafter patients with leukemia are educated about the signs and symptoms of serious complications such as infection. When fever or another acute issue arises, they have a clear care plan. They know who to call and can often reach their primary oncologist directly. Physicians that receive the call triage patients over the phone. If the patient needs to be admitted, she will be told to come into the hospital directly where an inpatient bed will have already been arranged and where the resident on call (e.g., me) will have already been made aware of the oncologist’s concerns and given an initial plan and workup. Patients that need to be seen urgently but necessarily admitted will be scheduled for a same day or next day appointment. Because every doctor in the group knows each patient (thanks to the weekly leukemia conference), even if the patient’s provider does not have a clinic spot available the patient can be seen by another provider.

___

So why do my primary care patients not get as good a care as my patients on leukemia? It’s not that primary care doctors are bad and leukemia doctors are good. Clearly it’s not that simple. Reimbursement in oncology is higher than in primary care, and in general oncology has a higher proportion of commercially insured rather than publicly insured patients. This gives oncologists resources primary care physicians can only dream of – outpatient laboratory services, IV infusion suites, advanced practice nurses, and dedicated case managers. Oncology also receives greater NIH funding, which supports research of new and existing treatments, and funding from philanthropic institutions and charity (think “Live Strong” and breast cancer awareness). It is also a more narrowly scoped field that requires fellowship training, compared to primary care which spans three different specialities (internal medicine, pediatrics, and family medicine) and includes general and subspecialty trainees. But some of it is cultural as well. When I asked one of my leukemia attendings to explain why there were so few ER admissions, his answer was that leukemia specialists viewed inpatient and outpatient care as part of the same continuum of care and took responsibility for patients over the full cycle of care. Comparatively, in general medicine, outpatient and inpatient care are treated quite separately, a reality that has been formalized by the growing hospitalist movement, in which patients admitted to the hospital are taken care of by a group of physicians wholly separate from their outpatient providers.

As primary care doctors, we often argue that we need more resources, better compensation, and greater reimbursement. I agree on all fronts, and in fact many of my observations above only support this notion. But I think even with the resources at hand there is much we can improve upon. We must become more scientific in our methods, more integrated in our care, and more patient-centric in our approach. We need not wait for change in Washington to get started. We can begin by taking a closer look at our peers and learning from their successes, starting (at least at my institution) with leukemia. This will provide useful answers to the important question of why the care of oncology patients seems to be better than that of general medicine patients. As I leave the world of oncology and return to general medicine, I can’t help but ask myself another question: what would happen if my primary care patients benefited from the same systems of care as my patients in oncology? How much better off would they be? I’m not sure of the answer, but given what I observed this past month, I would love to find out.

- Shantanu Nundy, M.D.

Glancing at the triage sheet as I knocked on the examine room door, I thought everything was checking out. Her BP was 132/82 and for chief complaint my nurse had scribbled “annual visit.” This meant her blood pressure was under control, and she didn’t have any urgent complaints. Perfect. This would be quick.

When I entered, she was ready for me with a list: medication refill, referral for Pap smear, mammogram scheduled, and her “yearly checkup and blood work.” And oh, almost forgetting, she had a back problem she wanted me to “take a look at.” She had her agenda and I had mine. As medical students we are repeatedly taught that “vital signs are vital.” Temperature, blood pressure, heart rate, respiratory rate — not surprisingly, all of these were fine. But I was worried about another, less established vital sign: her weight. Glancing at my last clinic summary, I saw her weight one year ago was 195 lbs. Today she was 204 lbs. At 5’ 5” her BMI was 33.9, well into the obese range.

I planned out the rest of the visit in my head. Though it may not be readily apparent, there are wide variations in what primary care doctors would do even in this run-of-the-mill scenario. I could focus on her concerns, which would take no more than 3-4 minutes and move on to my other patients. I could do a full physical exam, listening to her heart and lungs, examining her abdomen, though she had no somatic complaints other than back pain. I could ask her about her blood pressure medicine and assess for side effects and adherence. Or I could counsel her about her weight, and even then would need to choose between an almost infinite number of ways forward.

I chose to focus on her weight. There is no evidence to support annual blood work in this patient. A year earlier I had screened her for cholesterol disorders and prediabetes as well as evaluated her kidney function given her hypertension. Likewise, though routine, physical examination of asymptomatic patients is also unproven. Her back pain by history was most likely chronic and musculoskeletal. And while evaluating her hypertension and medication adherence is important, with her BP at goal these concerns were secondary.

I began by asking her what she thought about her weight. She thought she might be heavier than the year before but was surprised to learn how much she had truly gained. When I asked her why she thought her weight was up, she cited an increasingly sedentary lifestyle. I asked her about her diet, which she thought was good, but then probed further to ask about her last three meals. I offered my views on weight loss, emphasizing the importance of monitoring and recording weight and of reducing intake of carbohydrates and in particular refined carbohydrates.

As always I could have done more. But, as always, time was running short. I concluded by telling her that I would schedule her follow up in 3 months. She was taken aback: “Three months! I usually see my doctor every year. I thought everything was fine.”

Clearly I hadn’t gotten through. I tried a stronger message: “Obesity is a serious condition. If your blood pressure was elevated, you would expect to start a new blood pressure medication or watch your salt intake more closely, and then see me again in 3 months. This is no different. Obesity kills tens of thousands of people each year, and is a key driver of hypertension, diabetes, and heart disease. I really want to see you again in three months so we can make sure your weight is going in the right direction and if not, take more aggressive action.”

As the visit came to a close, the conversation became more relaxed. She asked me about my wife, and I asked her how she was enjoying the beautiful Chicago summer. Having re-established ourselves as peers, I felt a little guilty for getting so worked up about her weight. “Sorry to be so tough on you,” I said somewhat sheepishly. “It’s okay. You weren’t tough at all. It was more of a gentle scolding. I needed it.”

To most people, this visit would seem incredibly routine. Mrs. MJ didn’t have an obscure diagnosis, wasn’t acutely ill, and didn’t suffer from a complex set of psychosocial issues. But its “routine-ness” is what makes it so concerning. The obesity epidemic has left thousands of Americans standing with Mrs. MJ at the crossroads between relative health and serious medical illness. And yet, our approach to these patients is non-standardized and highly fragmented. We continue to focus on urgent complaints not overall health, pharmacologic treatment over counseling, and tradition rather than science. When we do address weight gain head on, we use blunt instruments and clumsily at that.

Given that primary care stands at the intersection of medicine and public health, if I feel inept to contend with obesity, where does that leave Mrs. MJ? Let’s hope for her sake that my “gentle scoldings” add up to something real.

- Shantanu Nundy, M.D.

a bus-side advertisement for a local hospital (sadly, not mine) claiming that it was “home to the city’s best transplant outcomes.” Normally I drive right by these moving billboards without paying much attention. But this time I immediately got excited, whipped out my cell phone and snapped a picture through my passenger side door window.

Why you may ask? Because, at the risk of being overly dramatic, this advertisement represents our best hope for true health care reform.

Though we don’t often think about it this way, competition is in many ways what makes America great. Competition is what has led to transformative changes in information technology. It’s largely why my new laptop is faster, more powerful, and less expensive than the laptop I bought 5 years ago when I started medical school; which in turn was faster, more powerful, and less expensive than the  laptop I bought 4 years earlier when I started college. Competition isn’t a zero-sum game. Contrary to popular belief, it doesn’t create winner and losers. Competition makes everyone better. Think about what the iPhone has done to the mobile phone industry, or what Tiger Woods did in golf.

We may not like to admit it, but doctors, clinics, and hospitals compete too. That’s the whole reason why you see advertisements like the one above. Centers are competing for patients (especially commercially-insured patients). But, if the health care industry is competitive, why hasn’t it gotten better and cheaper? Why do ten of thousands of  patients die from preventable errors and the costs of health care continue to skyrocket? The answer is the health care industry competes on all the wrong things.  Anyone who has flown a long-distance flight knows firsthand what happens when you compete on the wrong things. The airline industry competes mostly on price, not comfort or quality. As a result flights have gotten cheaper but at the expense of leg room. At the same time, flights haven’t gotten any faster (think about it: it takes the same amount of time to fly from the U.S. to Europe today as it did 20 years ago). Imagine what would happen instead if airlines competed on flight times. The industry would invest in new engine technology instead of hiring consultants to figure out how to charge for carry-on baggage. Flights would get faster (though perhaps at the cost of cheap airfare). In competition, like many things in life, you get what you ask for.

You don’t have to look far to see what the health care industry competes on. At its worst, it competes on technology (e.g., “we have the city’s highest resolution CT scanner”) or hospitality services (e.g., plasma screen TV in every room). Competing on technology has created an arms race, in which hospitals buy expensive equipment that has little proven marginal value and then overuse them in order to recover capital costs. And while patient comfort is important, competing on hospitality often comes at the expense of investments that would improve care, but aren’t as easily posted on a billboard. Slightly better but not ideal, they compete on patient satisfaction (e.g., customer surveys), reputation (e.g., U.S. News and World Report rankings), or procedural volume (e.g., most number of heart surgeries). While these are steps in the right direction, they side step what we really care about — getting the best care possible. If we are healthy, we want to stay healthy; if we are sick, we want to get better. While having a nice television, a famous doctor, and an experienced center are all well and good, they are secondary to going to the center with the best outcomes. By competing on the wrong things, we create the messy health care system we have. We get less leg room.

Imagine a world where doctors, clinics, and hospitals measured and reported outcomes. Doctors and the organizations they worked in would be accountable for how their patients did. Consumers would compare centers against one another and vote with their feet. To get his diabetes under control, instead of going to the doctor his insurance company picked out, Mr. Jones would go the doctor with the lowest average HbA1c (three-month running average of sugar control). When Mrs. Smith is diagnosed with breast cancer, instead of going to the cancer doctor her primary care doctor knows from medical school, she would go to the cancer center with the highest 5-year cancer-free survival rates. In the static view, the best centers would get rewarded with more patients; the worst would be at risk for going out of business. In the dynamic view, every center would improve. Instead of a new CT scanner, centers would make investments that improved care. The worst centers would copy the best centers, and the best centers would innovate to be even better. We’d get the iPhone, and a better Blackberry too.

The advertisement I saw last week gives us hope of this utopia. The hospital is trying to persuade us that they are the best place to get a transplant done not because they have the nicest rooms or most high-tech operating rooms but because their patients do really well, better in fact than similar patients transplanted at other hospitals in the city. This means not only that they measure and report their outcomes, but that other centers in the area do too. That this advertisement was about transplant is not surprising. Thanks to UNOS (United Network for Organ Sharing) all transplant centers in the country are required to collect and report their outcomes. By going to this website: http://optn.transplant.hrsa.gov/organDatasource/stateData.asp?type=state&mqsd=1&display=KidneyPancreas, for example, one can look up a given transplant center’s 1-yr, 3-yr and 5-yr survival rates for kidney transplants. (Equally not surprising is that since mandating reporting transplant has seen dramatic improvements in patient survival across the country.)

But transplant is the exception not the rule. For a variety of reasons (largely excuses), most fields in medicine do not report outcomes, or collect them for that matter. Most of them fly blind, not knowing how they perform relative to their peers, which leaves patients and third-party payers at a loss for real information to guide their decision-making. They continue to compete — make no mistake about that — but just on things that don’t matter.

I usually pay little attention to the ads that pass me by on the way to work. But this was one I couldn’t ignore. The sake of our health care system I hope I’m not the only one.

- Shantanu Nundy, M.D.

It wasn’t the kind of thing you hear in the medicine, let alone in the ICU. Usually, rounds in the ICU are a string of numbers punctuated by phrases in the passive voice such as “anesthesia was called,” “pressors were started,” and “patient was then coded and died.” But here amongst our General Electric ventilators, continuous heart rate monitors, and dialysis machines, in front of an ICU team of over a dozen doctors, nurses, and pharmacists, the attending physician was suggesting that it wasn’t going to be technology or specialized medical knowledge that ultimately saved this patient’s life; rather it was going to be the people in his life. He went on to ask my intern and I to sit down with Mr. HD and his mother to discuss his illness and suggest they reach out to local churches or other organizations to help him stay healthy and out of the hospital.

It’s not every patient that stands so clearly on the edge of a long life and imminent death. Many, if not most, of the patients we care for in the ICU suffer from chronic, irreversible conditions such as end-stage COPD or untreatable, metastatic cancer. At best many of them are looking at a few months of life left, in spite of the heroic measures we take in the ICU. But Mr. HD was different. At 32 years old, he was as far as he knew healthy until just 4 months earlier. He was losing weight and occasionally woke up in sweat but otherwise was doing okay. But then, almost suddenly, he began to feel short of breath and developed fevers. Reluctantly, he went to an outside hospital ER, where he was admitted to hospital and eventually taken to the ICU and intubated. He awoke days later from the ventilator to learn that he was HIV positive. HIV had not only devastated his immune system, which caused him to develop a life-threatening pneumonia, but had also ravaged his kidney and heart. In addition to AIDS, Mr. HD now had to contend with end-stage kidney disease (ESRD) and heart failure.

Since then Mr. HD had been in and out of hospitals with pneumonia and other complications of his multiple severe illnesses. HIV/AIDS, ESRD, and heart failure are treatable. But Mr. HD had never been ill before and was “not compliant” with this treatment regimen. He often missed doses of his HAART (highly active retroviral therapy, pronounced “heart”) that would have combated the HIV virus and allowed his immune system to recover; he refused to go to dialysis and have a machine do what his kidneys could no longer do for him until absolutely necessary; and he continued to eat what he wanted and miss his doctor appointments that would have kept his heart failure at bay.

So on a recent trip to Chicago to visit his mother, he once again became acutely short of breath. When he finally got to our ER, his lungs were tiring out, and he was immediately intubated. Four days later, after treating his pneumonia with broad spectrum antibiotics and pulling liters of fluid off his lungs, I finally had the opportunity to introduce myself as one of his ICU doctors once he recovered enough to have the breathing tube removed.

With his acute illness resolving, the question was what to do next. We were proud to have brought Mr. HD back from the brink of death, but at the same time knew what would happen if we didn’t reach out to him and help him better manage his chronic illnesses. Here in the ICU he never missed a dose of medication, always went to dialysis, and ate whatever he gave him, but what would happen once he got back home? And with three very treatable illnesses, the opportunity to make an impact could not be any greater. People with ESRD can live for years on dialysis; life expectancy for people adherent with their HIV/AIDS regimen is now well over 65 years; and heart failure is a readily managed condition. But without better self care, Mr. HD was life-threatening illness away from death.

Though less dramatically, this is the same problem faced by the millions of people with chronic illnesses. Chronic illness is not managed in the clinic, the hospital or the ICU. People live and die by their chronic illnesses by what they do at home. Right now, only a fraction of people with chronic disease take their medications as prescribed, make the right lifestyle changes, and follow up with their doctors regularly; they in fact are the minority. Most people need additional support, but tragically, the health care system is designed around doctors and clinics, not patients and communities.

The question for these millions of people with chronic disease, and for Mr. HD, is how to better support self-management. In my research, as a way to extend the reach of the health care system into people’s homes, I am using checklists to translate complex medical care into simple to-do lists and automated text messages to remind people to take their medications. But in thinking about Mr. HD, I realize that for many people even these innovative approaches won’t be enough. As my attending suggested, what would make a difference is connecting Mr. HD to his community. People with chronic illness not only manage their diseases largely outside of the health care system, but also largely do it alone. What we need for people like Mr. HD is a community-based approach to health care: a care van that takes him to his dialysis sessions, lay health workers who check up on him from time to time, and peers with whom he share the experience of living with HIV.

After a couple more days in the ICU and then a week on the general medicine floor, Mr. HD went home with his mother. As his health care team we took a number of steps to ready him for the transition. At varying points in his hospital care over a dozen doctors, nurses, medical students, and social workers sat down with Mr. HD to talk about his medical condition. They found him a new dialysis center closer to his mother’s home, set up additional services at home including physical therapy, and counseled him for hours about the importance of following his medical regimen.

But it wasn’t enough. Yesterday, early morning, Mr. HD returned to the ER short of breath. Again, sensing impending respiratory failure, the doctors in the ER immediately intubated him. He’s now back in the medical ICU comatose on the ventilator. Like millions of others living with poorly controlled chronic illness, it’s going to take a village to keep Mr. HD healthy and out of the hospital. Let’s hope he finds his village before it’s too late.

- Shantanu Nundy, M.D.

I met Mrs. TR in clinic for the first time last week. At 72, she looked great. As she bounced from the examining table to the chair next to me, she told me how busy her life was. Though she retired from nursing years ago, she helps out in her church every day of the week except Saturday and has 10 grandchildren and great-grandchildren she spends her evenings with.

Mrs. TR was referred to me by a breast surgeon after her previous primary care doctor passed away. She didn’t have a history of breast cancer herself, but had a strong family history. One of her sisters died of metastatic breast cancer, diagnosed at age 58; a second sister passed at age 70 of an unknown cancer. In reviewing her record, I was impressed at how aggressive her screening regimen was. She received a mammogram and a breast MRI every year and was evaluated by a breast surgeon twice per year. “I’m really scared about getting cancer and want to do everything to make sure I don’t get it,” she explained.

When she said this, my mind immediately jumped to tamoxifen. Unlike screening, which can only detect breast cancer earlier, tamoxifen can actually prevent breast cancer from developing. Used for years for the treatment of breast cancer, tamoxifen has now been tested and approved by the FDA for the breast cancer prevention (called chemoprevention). Remarkably, studies show that in women at increased risk tamoxifen and its cousin raloxifene prevent 50 percent of invasive breast cancers. Half.

Tamoxifen

Mrs. TR didn’t recall ever being counseled about tamoxifen before. Unlike screening, breast cancer chemoprevention has not received widespread attention and usage. If you were to ask a room full of women whether we have a pill that prevents breast cancer, I suspect many would say no; they would be surprised to learn that for well over a decade we have had not one but two medications that taken daily safely cut a woman’s risk of developing breast cancer by half. On the other side of equation, primary care doctors have been gun shy about recommending these medications, largely because they don’t have much experience prescribing them (this, of course, is a circular argument), despite the fact that counseling women at high risk of breast cancer about tamoxifen is supported by the United States Preventive Services Task Force (USPSTF).1

The benefit of tamoxifen varies with a woman’s risk of the disease — the greater the risk of breast cancer, the greater the benefit. Similar to the Framingham risk calculator for heart disease, scientists have created “risk calculators” that allow doctors to estimate a woman’s risk of developing breast cancer. To calculate Mrs. TR’s risk, I went to the  the National Cancer Institute website (http://www.cancer.gov/bcrisktool/).2 After inputting information about her age, race, family history, and menstrual history I found out that she has a 4.8% risk of breast cancer over the next 5 years and a lifetime risk of 11.7%. I told Mrs. TR that she had a 1 in 10 chance of developing breast cancer in her lifetime and that tamoxifen would reduce this risk to 1 in 20. Then I explained the risks of the medication. Because it blocks the effects of estrogen, tamoxifen can cause symptoms of menopause such as hot flashes. More rarely, tamoxifen increases the risk of blood clots similar to oral contraceptives and the risk of uterine cancer. These risks are not small, I noted, and must be balanced against the potential benefits of therapy.

Despite her assertion that she wanted to do everything possible to prevent breast cancer, Mrs. TR balked at tamoxifen. The idea of taking a medication, especially one that had potential for serious side effects, for a disease she might never get was untenable to her. Looking at her other medications — a statin, two blood pressure-lowering medications, and three vitamins — I was caught off guard by this reasoning. Dyslipidemia isn’t itself a life-threatening disease; she was taking a cholesterol-lowering medication every day to reduce her risk of heart disease. Statins furthermore are not without side effects; though rare, they have been associated with serious medical conditions such as rhabdomyolysis and liver failure. Likewise, though elevated blood pressures may itself sometimes cause health problems, doctors treat hypertension primarily to reduce cardiovascular disease. And vitamins, except for vitamin D, are largely unproven in her age group, yet they too are a pill one must take every day.

In the end, Mrs. TR agreed to be referred to our high-risk breast cancer clinic for further counseling about chemoprevention. It is certainly not my intent to get her on tamoxifen therapy. It is drug not without cost and harm, and in the end it is her choice to make. However, given her keen desire to prevent breast cancer, I was struck that she would be willing to bear the risk, cost, and inconvenience of cholesterol-lowering medications and antihypertensives to prevent a disease she is at no higher risk of than most women her age and yet not be interested in a medication to prevent breast cancer, a disease she is at increased risk of. Moreover, she is pursuing an aggressive screening regimen for breast cancer, one that is not well proven, carries its own risks, and that at best will identify breast cancer earlier than it would be found otherwise.

Mrs. TR is not alone. Support for tamoxifen in breast cancer prevention is bafflingly low amongst both doctors and patients, though it is routinely used for treatment. There is a pill out there to prevent breast cancer — it’s just that most women are finding it hard to swallow.

- Shantanu Nundy, M.D.

1 http://www.ahrq.gov/clinic/uspstf/uspsbrpv.htm

2 calculations performed May 7th 2010

* For a recent article on breast cancer prevention, see the NY Times article “Medicines to Deter Cancer Are Not Wanted”.

** To learn more about tamoxifen, visit a National Cancer Institute patient page.

In case you missed it, salt is the new fat. It seems that everybody from the FDA to Steven Colbert of the Colbert Report (see here) has set their sights on limiting our consumption of salt. In the past week, I’ve seen dozens of articles from the blogosphere to the front page of the USA Today and the May 17th 2010 edition of Time on reducing our alarming levels of salt consumption.

Many of us are aware that salt is bad for us. This isn’t really new news (if it is, please see the piece I wrote last year for World Hypertension Day here). What has seemed to kick off this latest salt outcry was a report put forth April 20th by the Institute of Medicine (IOM) calling for the FDA to set new federal regulations on the amount of salt that food manufacturers, food service companies, and restaurants can add to their products (see here). This has not only reignited (in a good way) public health advocates who have been calling for decreasing levels of salt consumption for years but also (in a bad way) many others who see this as yet another example of big government infringing on our personal lives.

Side-stepping these issues for a moment, what is the evidence behind lowering salt intake? Salt (or sodium) is essential for life, but study after study has demonstrated that excess salt intake is also a major risk factor for hypertension (or high blood pressure). Not surprisingly, many Americans consume more than the recommended amount of sodium. Experts recommend that we consume no more than 2,300 mg of sodium per day (or 1 teaspoon of salt per day); however, the average American consumes about 3,400 mg of sodium per day and some much, much more. Don’t eat a lot of salt, you say? The problem is that only about one-tenth of the sodium we consume is from salt added at the table. The majority is from salt that is already added to foods during the manufacturing process or at restaurants before it gets to our plates. That’s why after looking at decades of rising salt consumption (see below), despite increasing public awareness of its hazards, the IOM concluded it had to go to the source and recommend limiting the amount of salt food suppliers add to foods.

Simply reducing sodium consumption across the U.S. to the recommended levels would save over 100,000 lives per year. But what does this mean to the individual? Studies show that reducing salt consumption reduces systolic blood pressure by about 5 mmHg in people with hypertension and 2 mmHg in people with normal blood pressures. As a brief refresher, a healthy blood pressure is one with a systolic (top number) of less than 120 mmHg; between 120-139 mmHg is prehypertension; and above 140 mmHg is hypertension. From this alone, it’s readily apparent that decreasing salt consumption alone won’t cure hypertension. This led Gary Taubes in Good Calories, Bad Calories to remark “…so cutting our salt intake in half and decreasing our systolic blood pressure by 4 to 5 mmHg makes little difference.”*

So which is it? Will reducing salt intake save 100,000 lives or does it make “little difference?” The answer oddly is both. On a population level reducing salt intake will have a dramatic effect but to the individual the difference is small. As a doctor, I take Gary Taubes to task for saying it makes “little difference.” I have many patients with borderline hypertension would could get themselves into the prehypertensive range and avoid taking an anti-hypertensive medication if they reduce salt intake, and in fact, many do. But at the same time, his broader point that salt consumption is not the “cause” of hypertension is valid. Thus reducing salt intake — while it makes a difference and we should definitely do it — will itself not “cure” hypertension.

This brings us back to the most important scientific question of our time — what is the ultimate cause of the metabolic syndrome and the chronic diseases associated with it including obesity, hypertension, and diabetes? Is it, as the medical establishment would say, due to eating too much and exercising too little? Is it, as Gary Taubes would say, eating too many carbohydrates and particularly refined carbohydrates? Or is it, as Michael Pollan would suggest, eating too many processed foods and not heeding the dictum “eat food; not too much; mostly plants”?**

Whatever your view take heart that reducing your salt intake is a good idea. It’s just that — despite what the current media attention might suggest — it probably won’t save your life.

- Shantanu Nundy, M.D.

* Gary Taubes, “Good Calories, Bad Calories”. pg. 146

** Michael Pollan, “In Defense of Food”.

I decided to post the presentation as my first official video blog post. Though it’s much less interactive as a video, I hope that it’s still informative and interesting. Enjoy!

- Shantanu Nundy, M.D.

(If you have difficulty viewing it from here go to http://beyondapples.org/video.)

Mr. GR, as I will call him, had recently turned 60 years young. Though he had been in good health, the notion that he was “getting old” was beginning to settle in, and so Mr. GR came to me interested in finding out what more he could do to stay healthy. In discussing various preventive health measures, I pointed out that he would benefit from getting vaccinated against shingles. Shingles, I explained, is a painful skin condition that in 1 in every 3 people can expect to develop in their lifetime. For most people an episode of shingles lasts a few weeks, but in 1 in every 5 affected individuals the condition becomes permanent and debilitating (called post-herpetic neuralgia). The shingles vaccine can reduce the risk of shingles by half and of post-herpetic neuralgia by two-thirds, which is why the Centers for Disease Control and Prevention (CDC) recommends vaccination for everyone ages 60 and older.

After our discussion, Mr. GR was convinced the merits of the shingle vaccine were worth the discomfort and small risks of vaccination. But then he found out his insurance company didn’t cover the vaccine. Mr. GR immediately changed his mind: “If it’s not covered by insurance, I don’t want it.”

This is an all too common scenario. Patients don’t want health care that isn’t paid for by insurers. It is a sentiment shared by many of my patients and one I am empathetic toward. If not CDC recommended preventive health measures, what exactly is health insurance coverage for? At the same time, another part of me believes that while we should be indignant towards our health insurance companies for the decisions they make, this alone should not preclude us from doing the right thing for our health. As individuals we spend money on many things, not all of which is essential, so why the reluctance to spend money for better health?

In this case, the shingles vaccine costed a whopping $844. No small change, to be sure, for somebody to pay for in one setting. But what if we thought about it another way? What if instead of considering the vaccine as a one-time cost we thought of it as a daily expense — the cost per day of reducing my risk of a painful, potentially disabling medical condition? After all, the benefits of vaccination accrue daily so why not consider the costs daily. If we assume that Mr. GR lives until age 76 (the life-expectancy for men in the United States) the cost of the shingles vaccine amounts to $52.75/year or 14 cents per day. (For those of you are into finance, a more appropriate method of estimation would be to use discounting. After all, a dollar today is worth more than a dollar tomorrow. Assuming a 5 percent discount rate, $844 today is equivalent to spending 21 cents per day for 16 years.*)

Explained this way Mr. GR had a real choice on his hands – were the health benefits of vaccination worth more than 14 cents per day? To my delight, Mr. GR changed his mind. He still wasn’t happy about dishing out over $800 for something that he felt his health insurance company should cover but the simple back-of-the-envelope math we did helped him better understand the decision he faced.

In the end, whether or not we like to consider it this way, health care decisions are also financial decisions. We make plenty of financial decisions that pertain to our health: whether we buy organic food, get membership at a gym, or drive a car with more safety features. I certainly won’t argue against health insurance companies’ providing better coverage for preventive health care or against the government increasing programs to support prevention. But while we wait for change to come, we cannot afford to put our health on hold.

At less than a quarter a day the shingles vaccine is a downright bargain. And having done similar calculations for other areas of prevention so are many other established preventive health services. So go on, treat yourself to better health.

- Shantanu Nundy, M.D.

* Calculation courtesy of my dad, Rajiv Nundy, an actuary for the Asian Development Bank.

First of, what are added sugars? Added sugars simply put are sugars that are added into foods (in contrast to naturally-occurring sugars that you find in fruits). The JAMA article writes that added sugars are “defined as caloric sweeteners used by the food industry and consumers as ingredients in processed or prepared foods to increase the desirability of these foods.” The most commonly added sugars are sucrose (table sugar) and high-fructose corn syrup, the primary form of sugar in sodas and processed foods. The concept of added sugars is easy to understand. Carbohydrates are more vague. Plenty of carbs are good for you, like those you find in apples or vegetables; others are a mixed bag like whole wheat bread; and then some are just downright bad like Coca Cola. With added sugars you just have to think about where the sugars came from. If they are natural, that’s okay; if they are artificially added, then they should be avoided.

In the study, part of the National Health and Nutrition Examination Survey (NHANES), researchers surveyed 4605 non-pregnant adults ages 18 and older who were not on cholesterol-lowering medications. Each person was asked to describe what he or she ate in the previous 24 hours. Using standardized tables the researchers calculated how many calories in added sugars these foods added up to. They then asked participants a wide-range of questions from their age and weight to whether they had high blood pressure. These were analyzed along with data from blood samples that were taken to measure cholesterol levels.

Besides the bottom line — people who consume more added sugars have worse cholesterol — the study had many important findings. First is the proportion of the average person’s daily calories that comes from added sugars. The answer: a whopping 15.8%. Put another way, 1 in every 7 calories the average American consumes is from added sugars! For those who still aren’t impressed consider the following. First, for thousands of years, the proportion of our diet that came from added sugars was zero. Zero. This is because up until a hundred years ago we didn’t have the technology to mass produce sucrose and high-fructose corn syrup. And in fact if you go to less “Westernized” parts of the world, as I did a few weeks ago to rural Uganda, this is still true today. Second, added sugars are empty calories. They have absolutely no nutritional value — no vitamins, no minerals, no essential amino acids. Thus 1 in every 7 calories we ingest is nothing but calories.

The investigators divided the participants into groups based on the percent of their total daily calories that came from added sugars. There were 5 groups: people who consumed less than 5% of total calories from added sugars, people who consumed between 5-10% of their calories from added sugars, people with 10-17.5% added sugars, people with 17.5-25% added sugars, and people with over 25% of their total calories from added sugars. (It’s surprising to see that of the 4605 participants 893 (or 19.4%) had less than 5% of their calories from added sugars whereas 1135 (24.6%) had over 25% of their calories from added sugars. If anything, this shows that it is definitely possible in our modern society to consume low levels of added sugar.)

A few findings stand out. One, whereas 14% of those who consume less than 5% of their calories from added sugars live below the poverty line, 23% of those consuming over 25% from added sugars live below the poverty line. This makes sense because it’s often cheaper to eat processed foods that are loaded with added sugars than fresh foods, not to mention that the difficulty of finding anything but fast food restaurants and convenience stores in low-income urban areas. Still the data offers hope because it shows that 194 people (14%) consumed less than 5% of their calories from added sugars despite being poor. Two, while the less than 5% group and the greater than 25% group had similar body mass index and waist circumference, the less than 5% group reported losing 0.3 lbs over the past year while the greater than 25% group gained 2.8 lbs. This suggests that over time consuming added sugars leads to significant weight gain.

Finally, let’s look at the core finding of the study. Using the same grouping as above, the investigators looked at the proportion of people in each group who had abnormal cholesterols levels. What they found was that going from the less than 5% group to the over 25% group the proportion of people with low HDL (good) cholesterol increased from 22.4% to 43.9%. Adjusting for potential confounders factors such as age, gender, physical activity, calorie intake and weight, they found that the relationship still held. Looking at other types of cholesterol, they found that consuming higher levels of added sugars increased triglyceride levels (adjusted odds ratio 1.3); however added sugars were not significantly associated with LDL (bad) cholesterol.

This study is not perfect by any means. It is not a randomized controlled trial or even a prospective cohort. It can only tell us about associations; correlations not causations. In addition, it looked at a surrogate marker of heart disease, cholesterol levels, when I am more interested in how added sugars may affect my chances of having a heart attack. But, to me, the case against added sugars is adding up. At the least, we know that added sugars aren’t doing anything good for our health — they are simply empty calories. But we are increasingly appreciating that besides adding calories they are having other harmful effects on our health. It’s about time that we subtract added sugars from our diets.

- Shantanu Nundy, M.D.

* JA Welsh et al. Caloric Sweetener Consumption and Dyslipidemia Among US Adults. JAMA. 2010;303(15):1490-1497.