Sermo Poll Results: Prescribing Antibiotics in the U.S.

antiobiotic poll

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There is no doubt that antibiotics save lives and stop infections. So why has the use of these drugs been a trending topic for debate?

According to the CDC, “…poor prescribing practices put hospital patients at risk for preventable allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile.  These practices also drive antibiotic resistance, further endangering the future of these miracle drugs and the patients who need them.”

We polled Sermo physicians about the practice of prescribing antibiotics in the U.S.  Of the 2,459 physicians that answered, an overwhelming 92 percent believed antibiotics were over-prescribed. This left only seven percent saying they were prescribed appropriately, and one percent saying they were under-prescribed.

The staggering reaction to our poll resulted in some followup questions:

1)  Why are antibiotics over-prescribed?  Is it because of patient demand? Do physicians need more education?  Is the problem with other prescribing HCPs who need education?

2)  How do we “right-size” antibiotic prescriptions? What criteria should be followed to give just enough?

After a robust conversation, the most common theme addressing the over-prescription trend was due to patient demand. One doctor wrote, “It’s the path of least resistance and sadly in the era of health care now being a customer service industry, patient satisfaction trumps evidence based medicine. A patient going into the office with the sniffles wants something tangible in hand to “fix their problem” not an explanation why nothing is needed and leave the visit, in their mind, empty handed.”

Another doctor compared prescribing to the McDonald’s view stating, “Most patients have a McDonald’s approach to antibiotics and other medical treatments. They want it their way and fast. In the past, they went to their health care provider for the providers knowledge and expertise. They did not come for simple self-resolving problems and they respected the doctor’s opinion. Now the McDonald’s mentality is to demand expensive tests or unnecessary meds.”

As a society of quick fixes and fast solutions, this conclusion does not come as a surprise.  Support for this view comes from an article presented by Medscape discussing a study which found that “…out of 3402 adults presenting to primary care with cough, roughly 45% “expected” antibiotics, 41% “hoped for” antibiotics, and 10% “asked for” antibiotics.”

So how can this issue be solved?

A family practice MD expressed her opinion of further education. “All of us need to do a better job and only prescribe antibiotics when it is clear that we believe there is a bacterial infection that we are trying to cure. Otherwise, antibiotics will no longer work.  I think doctors don’t need more education. The public does. We need to learn how to say no. The public needs to learn the difference between infections that are viral and bacterial and that antibiotics don’t cure all infections.”

What do you believe is the reason for over-prescribing? Do you have an idea of what can aid in decreasing this practice? If you are an MD or D.O. we will be continuing this conversation within Sermo.

 

Sources

The Origins of Emergency Medicine in the U.S.

bad knee

Broken arm, rapid blood loss, trouble breathing, or even a dangerously sick child, any or all of these patients could cross the threshold of an Emergency Room at any moment. Open 24 hours, seven days a week, 365 days of the year, Emergency room staff are there when we need them most.

Medical care as a specialty dates back to the early 1800s, however, emergency medicine only dates back 50 years, making it the youngest recognized specialty in the medical field.

So what happened before there was Emergency Medicine (EM)?

Early History ~ 1800s

  • Dominique Jean Larrey, Napoleon’s chief surgeon, noticed the lack of immediate care to soldiers on the field. He is credited with the concept of triage, developing a horse drawn ‘ambulance’ to gather the injured and transport them to a nearby treatment tent.
  • General Practice (GP) physicians were among the most common specialties available. As a result, GPs were often in charge of ‘emergency care’ in the form of house calls to patients round the clock.

Early 1900s

  • After World War II, doctors learned trauma procedures for patients on the field leading to a new specialty. As more specialized medical roles developed, it became apparent that treatment within a large hospital network was more beneficial than a private office. This lead to the creation of the emergency departments for patient admission.
  • Early emergency departments were run in one room. The department could be run by anyone, from interns in their first year, to a physician on call for the day such as a psychiatrist or dermatologist. On-call physicians were good at handling cases in their specialty, but not as strong with assisting other patients sometimes leading to delays in patient care or misdiagnoses.

Modern Day Advancement ~ 1960s

  • 1961: Recognizing the need for Emergency Medicine specialization, Dr. James D. Mills convinced three of his coworkers to leave their medical practice to develop an Emergency Department in Alexandria, VA. Just north of their efforts, a larger group of 23 physicians were doing the same in Pontiac, MI. This became known as the Alexandria-Pontiac plan. The Alexandria emergency department (ED) became the first organized group of physicians providing medical care in an ED setting.
  • 1966: Helping move the evolution of EM forward, a report documenting the lack of care available in the ED was published by National Academy of Sciences. During this time, medics on the field in the Vietnam War realized medical trauma care for soldiers in the field was more advanced than the care back home in the ED.
  • 1968: In Lansing, MI, eight physicians organized the first group focused on educating physicians on EM care named American College of Emergency Physicians (ACEP). This group was created with the belief that emergency medicine should qualify as a specialty for physicians.

1970s

  • 1970: Bruce Janiak enrolled at the University of Cincinnati becoming the first emergency resident trainee.
  • 1971: Three students enrolled at the University of Southern California in Los Angeles. This is now the oldest running program.
  • 1972: The American Medical Association (AMA) officially recognized EM as a specialty. This was no easy accomplishment. Some physicians opposed the new specialty saying a lack of focus made it unnecessary.
  • 1973: Just one year after officially inducting EM into the medical world, the federal Emergency Medical Services Systems was passed funding regional and local EMS services.
  • 1974: To unite the residents in training, Emergency Medicine Residents Association (EMRA) was formed.
  • 1976: The ACEP established the American Board of Emergency Medicine (ABEM) which was approved and became the twenty-third recognized medical specialty in the US just three years later.

1980s and 1990s

  • 1989: The ABEM was granted primary specialty which meant emergency medicine was no longer under any other focus, allowing it to develop subspecialties. Sub-specialties of emergency medicine in the U.S. include toxicology, pediatric emergency medicine, emergencies and disasters, critical care, hyperbaric medicine, administration/practice management and research.
  • 1990s: Emergency Medicine became more publicized through media with shows like ER.

The Current State of Emergency Medicine

According to an interview with Dr. Don Stader by WFAE, 20 percent of the US population will visit the Emergency Room at least once a year. Since the development of EM, the specialty continues to grow in education and treatments. Data collected in 2009 by the CDC show demand for emergency service increased by 35 percent from 1996, and the need continues to rise.

The demand of EM does not only come from patients, but from medical trainees as well. EM has become one of the most competitive specialties in the medical world, producing over 2,000 graduates every year.

The emergency room is no longer a small room, but instead an entire department complete with a staff of nurses and physicians specialized to treat in emergency situation. Visitors to the department   do not always have a life-threatening emergency, but patients use the ER as an after-hours clinic. The ER is also a place for patients with no insurance or limited health care.

As a physician, what role do you think Emergency Medicine will play in America’s future? What do you think are the biggest issues facing ERs today? If you work in this field, we would love to hear from you.

We will be discussing this and more inside Sermo, our physician community. If you’re an M.D. or D.O., please join us.

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Danger to Teens: What physicians look for in their patients

danger to teens We have an important poll today and wanted to send it out as a message to parents, guardians and other care givers who work with teenagers. We asked our physicians, what is the biggest danger to teens today?  Their answers largely focused on mind-altering substances;  82 percent of physicians chose among using illegal drugs, abusing prescription drugs, or drinking alcohol.   Smoking (9%), teenage pregnancy (6%) and contracting sexually transmitted diseases (3%) ranked far behind. The concern is warranted.  A recent survey showed that about 50 percent of teens have tried an illicit drug at least once before high school graduation and 80 percent had tried alcohol.   Risky behavior leads to true tragedy.  One study estimates that from 35,000 deaths between the ages of 15 and 24 about 20,000 could be prevented if teens and young adults made better choices. Another report from the U.S. Substance Abuse and Mental Health Services Administration shows the statistics of abuse and treatment.

  • 600,000 teens smoke pot
  • 400,000 teens drink alcohol
  • 71,000 in any given day will be in inpatient treatment programs
  • 10,000 a day in other substance abuse programs

Physicians and Teen Drug Abuse Physicians should regularly screen patients and their families about the potential of drug or alcohol abuse.  Changes in behavior, sleeping patterns, grades falling suddenly can all be clues substance abuse is present. This brief video discusses why physicians can sometimes get patients to open up when others can’t. Another big issue is the occasional drug or alcohol abuser who doesn’t display any outward symptoms but will occasionally participate in dangerous activities.  Physicians should work with families and the teen on prevention and on seeking help if needed. As a physician, how do you talk to teens about drug or alcohol abuse?  What have you found to be the most effective way to communicate with teenagers?  Do you find working with families as a whole more or less helpful than dealing with the teen one-on-one? We will discuss all this and more inside our Sermo community.  If you’re an M.D. or D.O. please join us. 

Sermo Question and Answer with Dr. Sandeep Jauhar

Sandeep Jauhar, MD Cardiologist/Author

Sandeep Jauhar, MD Cardiologist/Author

Sandeep Jauhar MD’s latest book, “Doctored,” touched a nerve in the Sermo community.  Some physicians agreed with his bleak portrait of medicine in the US today, and some outright questioned his premise.  Recently, Jauhar had the opportunity to address the community and discuss their concerns.

The question and answer is below, edited only for brevity or clarity.

Sandeep Jauhar MD, cardiologist

First, I want to thank you for this opportunity to engage with my Sermo colleagues. I really am a big fan of this website. I’ve learned more about real-world medicine from Sermo than just about any other source.

Question from Emergency Medicine Physician:  Given the unequivocally serious challenges of the EMR rollout, its danger to patients and the obvious costs, which include risks to privacy, what solutions do you think require implementation to solve this? Several physicians on Sermo have recently voiced quitting a job (or even medicine!) over an unworkable EHR system, what can be done to prevent this?

Jauhar: I agree with you that a lot of EHR is total “cut-and-paste” crap. It encourages a lack of integrity in patient-doctor interactions. (Who really does a complete ROS or neuro exam on every patient?) The costs of EHR are astounding; you can’t blame self-employed docs for not wanting to implement it. Like so much in medicine, EHR is a good idea in theory, but horribly implemented in practice. I don’t have a solution, other than good old-fashioned iteration and improvement, with ample input from physicians. And perhaps hospitals, which have so much at stake in getting EHRs to their community doctors, need to subsidize the technology.

Question from an Endocrinologist: [referring to a recent Wall Street Journal post from Jauhar] While you (Dr. Jauhar) correctly identify the problem, you come up with solutions that have already failed miserably to enhance professional satisfaction for physicians and to demonstrate better care for patients.  Why do you hesitate to offer free-market based solutions associated with elimination of artificial creations such as closed networks (both private & public), CPT/ICD Codes and price-fixing?

Why do you not mention Medicare’s unfair & unconstitutional RAC audits, the monopolistic influence of Certification Boards & their disastrous impact of physicians’ livelihood, the Federal protections for hospital committees when it comes to sham peer-review, as major causes of physician stress, burnout and even suicide?

Jauhar: It was a 2,300-word article in the Wall Street Journal. Limited scope for covering all the things you mention. My book does delve into some of it, however, so you should read it before you pass judgment. I don’t espouse free-market solutions because I don’t think medicine is a free market; knowledge among the major players is too asymmetrical. As for the other things you mentioned, I am in agreement. MOC is mostly crap! (I have to recertify in cardiology this year and take my CHF boards; that’s $10,000 to cover exams, review courses, hotels, and flights.) Physicians have almost no say in the process, resulting in a feeling of powerlessness. Medicare audits drive many physicians into despair (I have both seen and experienced it). So I am very sympathetic to your disdain of bureaucracy. Bureaucracy is as much a part of my professional life as it is yours.

A Comment from an Obstetrician:  And all the $$ is going upstream. It’s not going to healthcare.

Jauhar:  The amount of money going to insurance executives IS nauseating! Part of me wants to see us doctors take charge of our financial house, but I also reckon that most doctors (either by lack of training or proclivity) are not well equipped to do so.

Question from an Ophthalmologist:Who should decide the treatment options offered to our patients?  Should an employed physician be constrained by the directives of the hospital, insurer or government who tells them what is in the best interest of their employer or the best interest of society, with respect to resource management?
I have remained in independent private practice for 25 years, as I am unable to resolve the ethical dilemma.  I feel ethically driven to put the interests of my patients first. I am a dying breed. I am worried by this trend. I don’t want government telling me I am too old for a hip replacement or that I must wait beyond my likely life expectancy for treatment of my illness.
Care driven by the needs of the individual is ethical care.

Jauhar: Hospital directives are often unethical! When a hospital signs up an inferior but cheaper stent for financial reasons, few raise a hue and cry. If a doctor does it, he is labeled fraudulent, and incurs opprobrium or even jail time. Where I differ with you is about that hip replacement (or whatever) for the 90-year-old. Healthcare is already bankrupting the country. We need to make choices (and de facto rationing is already going on).

Question from an Emergency Room Physician: How do you justify your desire for more money and the unethical behavior that came from your sense of entitlement? Do you recognize the role that attitude plays in undermining health care policy debate? Do you understand that at your very lowest income you earn more than 99% of Americans?

Jauhar: Fine, agreed on the money thing. I have learned to tamp down my expectations, and I am happier for it. If you’ve read the book, you’ll already know that there is some redemption at the end. My starting salary as an academic cardiologist was about the average salary of a PCP today, and with educational debt, a new baby, and a wife who wasn’t working, it didn’t seem as large an amount as I had thought it would be when I was in training. It wasn’t enough to cover my expenses.

Question from a Pediatric Psychiatrist: What do you suggest we do to educate people about the tremendous waste of time, energy, and resources of defensive medicine? What do you say to people about all of the ways the government bureaucracy, the insurance companies and especially attorneys create hyper-vigilance, paranoia and over-attention to charts instead of patients for doctors?

Jauhar: Defensive medicine too often seems like a necessary evil to many of my colleagues. That message is getting out there, but the dissemination has been slow.

Question from Family Practitioner:  You seem to say all doctors are looking for “loopholes” to make more profit. Do you think all of us doctors are so unethical? Do you see how spreading that accusation is harmful to the doctor-patient relationship and the healthcare system in general?  It would be hard for us primary care docs to do procedures to drive up our bottom line. Also, you seem to indicate that there is no way to stay in business unless you do procedures for profit. Do you think that is true across the board?

Jauhar:  I don’t think most doctors are unethical. Most doctors are good! (I say it in my book.) But there is a subset I have come across that behaves fraudulently. Has that not been the case in your experience?

I wrote a piece in the New York Times recently in which I note that physician incomes make up only 10-20% of healthcare costs. However, our decisions (whether to hospitalize a patient, order that MRI, etc) determine close to 80% of healthcare spending. Take doctors off the office treadmill – the biggest driver of that treadmill is decreasing reimbursements – and you will likely see healthcare savings. So I think doctors, especially PCPs, should be paid more, not less.

Question for Pain Medicine Physician: “Why is profit bad? Why should we be ashamed of making a profit? Is it inherently evil to exchange services for money? Are you selling your book at cost?”

Jauhar:  Profit isn’t bad. But the pervading commercial consciousness, driven in large part by reimbursement cuts and a need to keep practices afloat, has created a lot of misery in the profession. I didn’t go into medicine to constantly have to think about money and business, and I suspect most of my colleagues didn’t either.

Comment from a Physician of Occupational Medicine: The problem is not Profit, the real problem is lack of accountability of all players in healthcare but physicians, so any solution that doesn’t hold all the stake holders accountable will fail.

Jauhar:  We need accountability for all the players, including patients. The moral hazard of third-party payment is painfully obvious, and results in terrible waste. No doubt patients need more skin in the game.

 

As a physician do you have an opinion about Jauhar’s experience as a peer?  Do you think his book “Doctored” portrays an accurate experience in medicine today?  Sermo is an active community discussing the above topics and more.  If you’re an M.D. or D.O. please join us.

 

SandeepBio:  Sandeep Jauhar is a practicing cardiologist and the author of “Intern: A Doctor’s Initiation” and the recent New York Times bestseller “Doctored: The Disillusionment of an American Physician.” He lives on Long Island with his wife and children.

 

 

 

 

Becoming a Clinical Investigator – Finding the Patients

patients

 

This is perhaps the most important installment in our series on becoming a clinical researcher.  In my prior posts, we have covered why one should consider doing clinical research, your optimal credentials to be accepted as an investigator, your site’s requirements, and how to find the trials.  This is the money installment where all of the preceding discussion culminates in your ability to deliver the subjects you indicated to the sponsors and Contract/Academic Research Organizations that you could and would.  Not only does your remuneration depend on being successful in this aspect, but your obtaining future research work as well.  If you fail (badly) to deliver, a second date is much less likely. So if you have been following along with this series, this is the one to pay the most attention to if you are indeed serious about becoming a successful clinical investigator.

First, be picky.  Do NOT accept any clinical trial offered to you unless you are satisfied that you actually have patients that will qualify for the study.  Clearly you have to pay attention to the Inclusion Criteria (what elements are sine qua non for identifying appropriate subjects), but even MORE important, pay attention to the Exclusion Criteria (the disqualifying elements that preclude randomization of the potential subject).  You initially will be very excited to participate because you have many patients with the condition of interest, but it will be the exclusion criteria that will limit subjects to those that actually qualify for randomization.  Inadvertent inclusion of non-qualifying subjects that are detected during research monitor visits or during an audit are major black marks on a site that call into question your site’s suitability for continued participation and future trials.  Although your clinical research coordinator bears much of the responsibility for sorting out subject eligibility, it is your signature on the FDA1572 that makes you ultimately responsible for such protocol violations.  The ritual known as obtaining informed consent is absolutely critical in this process and can make or break your site.  Your research coordinators have to be meticulous and rigorous in this process if it is part of their job, but again, you also will be signing the document and it may be optimal to have you, as the principal investigator, obtain consent from the potential subjects.

Although you will have many patients that come to mind with the condition being investigated, having a searchable database is invaluable, especially if you can search by diagnosis, CPT or ICD 9/10 codes.  One handy observation is that although our colleagues may sometimes be a bit late with clinical documentation, they are almost never late in submitting billing codes.  So, for example, if there is a study looking for patients with acute coronary syndromes, the billing software can flag those patients with those codes for your review as the PI.

Colleagues can be invaluable, but politics can be a formidable obstacle that you will need to sort out.  If you have partners that are in the same specialty or even in a multispecialty group, some revenue-sharing arrangement will enhance the likelihood of internal referral.  The caché of doing clinical research may enhance the practice profile and be a further incentive to colleagues contributing their patients to the common success.

Or not.  If you are in a competitive environment with other specialists with significant numbers of patients with the condition under investigation, it may be very difficult (read impossible) to have any patient referrals to your site unless you are very friendly with other groups.  From their perspective, there is little to be gained and much to be lost if their patients see your group as being more advanced or prestigious than their current providers.  Site selection decisions from sponsors/CRO/ARO’s often do not take into account the local politics when identifying a research site.  Selecting two competing sites in the same catchment area is a recipe for a Hatfield-McCoy scenario.  As groups coalesce under the aegis of an ACO or hospital system, it may actually enhance the ability to find cooperating larger sites as the abrasive aspects of the local political environment are mitigated…maybe.

Rewards can be used as well for office managers, hospital based clinical coordinators, or nurses who see potentially eligible patients and refer them.  Simple rewards can be Starbucks or iTunes cards for good leads, and act as a positive reinforcement for future referrals.  This also assumes that you have done some in-service education or a conference for your colleagues, emphasizing the science, clinical importance, non-proprietary aspects of the investigational product, and especially the inclusion and exclusion criteria.  The sponsor may have some turnkey materials that may be suitable for such programs.  Find out and use them.

Advertising in my experience has been of limited value.  Many people respond but very few turn out to be ultimately eligible, and much valuable time is spent sorting out inclusion and especially the exclusion criteria.  It does serve a positive marketing role to raise awareness of the condition and of your group, but, as a specific recruiting tool, is of limited value.  If you can identify an enriched environment in which to advertise rather than general radio, TV or newspaper pieces, that may something that you can present to the sponsor for a budgetary amendment to cover the incremental cost.

But there is an exception to this marketing caveat.  Some sponsors have utilized intermediaries to do targeted advertising with toll free numbers, websites or social media sites.  In this way, potential patients or often their family members can explore participation, gaining hopefully useful information that may help patients, and the site managers can carefully cull respondents for the pertinent inclusion and exclusion criteria.  They can then refer this enriched pool of ostensibly eligible individuals to the nearest research site for further evaluation, at no cost to the site itself.

 

In about a month, the next installment in this clinical research series will cover subject retention, another extremely important part of the process that will enhance your profile and continued success.

credit:  Irving Kent Loh

Bio:
Dr. Irving Kent Loh
MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.