A Gentle Scolding

Posted on July 25, 2010 by admin

At the end of a busy afternoon, Mrs. MJ was exactly the kind of case I needed. Two of my patients had come in late but needed to be seen and another was acutely short of breath and refusing to be admitted to the hospital. The chaos had put me almost an hour behind schedule, and I still had to return to the wards to round on my cancer patients. Fortunately Mrs. MJ was on time and at 52 years old “incredibly healthy” (in a relative manner of speaking). The last time I saw her was a year ago when she presented as a new patient. Other than some hypertension and weight issues she was fine.

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.

Posted in Patient Stories | 1 Comment

Competing on Outcomes, The Way to True Health Care Reform

Posted on July 17, 2010 by admin

On my drive in to work this past week I came across this:

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.

Posted in Thinking Out Loud | Tagged , , , , , | 2 Comments

Sometimes It Takes A Village

Posted on June 15, 2010 by admin

“You know, what Mr. HD really needs is for his mom or somebody to chain herself to him…” [the ICU team laughs] …”But seriously, he needs to be watched over, he needs to be talked to. He needs someone to give him his medications, someone to take him to his appointments, someone to take care of him. With that somebody he can live for years to come. Without that somebody he will die next week.”

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.

Posted in Patient Stories, Thinking Out Loud | Tagged , , , , , | 2 Comments

Why is a Pill to Prevent Breast Cancer So Hard to Swallow?

Posted on May 20, 2010 by admin

Cancer prevention is built around screening. In screening, the hope is to catch cancer at an earlier stage than it would be found otherwise and increase options for treatment and chances of cure. In some cases, screening prevents cancer — for example, when a precancerous polyp is removed from the colon during colonoscopy — but generally it is aimed at early detection. What if instead we could prevent cancer from developing altogether?

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.

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Salt- The Other “Pure, White and Deadly”

Posted on May 11, 2010 by admin

In an earlier post, I talked about the dangers of sugar (see here), which John Yudkin described in his book by the same name in 1974 as “pure, white and deadly.” In this post, I talk about a similar-looking and similarly harmful common food item, salt.

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”.

Posted in Healthy Living, Heart Disease Prevention | Tagged , , , , , | Leave a comment