With the latest firestorm in the media around Dr Oz, we decided to ask our members if they agreed that Dr. Oz should be removed from his position at Columbia University.  The results were definitive..

Of the 2,029 physicians who participated in our poll as to what Dr. Oz should do next, more than 1,500 physicians (78%) voted that he should resign from his faculty position at Columbia University.  More than 450 (24%) believe he should have his medical license revoked.  The poll is as follows:

Dr Oz should:

57% – resign from his faculty position at Columbia University (1128/1979)

3% – have his medical license revoked (66/1979)

21% – do both, resign from his position at Columbia and have his license revoked (411/1979)

19% – do nothing, I respect Dr Oz as a physician (374/1979)

Dr Oz can’t laugh this claim off as easily as he did on his show.  1,500 physicians is nothing to scoff at.  They’re not backed by big food or representing special interest groups, as he claims.  These are the clinicians and medical thought leaders across an entire spectrum of specialties and practice backgrounds, from rural generalists to his peers in cardiology.  These physicians are speaking up because they care about the information their patients get – PCPs who regularly combat all sorts of misinformation in the marketplace about vaccines and “magic pills”, ER doctors who drop everything to save anyone who’s coming in, with no secret agenda or undue influence from industry , surgeons  and other specialists who are caring for people with a wide variety of chronic ailments and are helping manage complex co-morbidities, or pediatricians who calm our fears as parents.  These doctors are the researchers who tirelessly work to cure MS and rare diseases (most of which affect children), the family practitioner who fights for patients when their insurance companies deny their claim, and perhaps less visible, they are the doctors advocating for truth and transparency about the information you’re fed from other physicians, their own peers, when they think someone of influence has it wrong.

Think viewers don’t take Dr Oz’s advice as gospel?  Think again.  One OBGYN shared:

“I have a patient with…menorrhagia, which she has been trying to manage with herbs over the last year.  So, while she refuses transfusion for no clear reason (not a {Jehovah’s} Witness), I am trying some tricks to get her ready for hysterectomy. When my nurse called to speak with her about other medical clearance the patient said…that YOU [Dr. Oz] are her managing doctor! So, my question is, where can I call to get her records and can you give her pre-op medical clearance?”

This is not uncommon.

We asked Dr Linda Girgis, SERMO member and Family Medicine physician for her thoughts.  She shared:

 “As doctors, patients trust us to pass on the best medical advice to them to enable them to make the best healthcare decisions. We have spent many years studying and training to learn the science behind what we are doing.  Legally, we are expected to practice within a certain standard of care (what other doctors are doing).

It is not acceptable for doctors to invent their own science. We have researchers and organizations that carry out clinical trials in order to keep patients safe. When we throw out that data, we are ignoring patient safety.”

It wasn’t all negative though.  19% of the SERMO doctors polled respect Dr Oz as a physician.  Most of the support voiced was because of his advocacy for GMO labeling.  Even his critics called for him to speak on behalf of physicians more, using his celebrity status for good.  Other physicians are torn, like one of his Cardiothoracic colleagues…

“I have watched Dr Oz operate and he is a good surgeon, seen him interact with patients and he truely cares about them, and performed well done medical research with him. As a heart/lung surgeon I respect him. However, when I watch his show I just cringe when he talks about a pill containing a combination of herbs/roots/chemicals to solve one or any problems or when he talks about womens’ orgasms! Does he (or anyone) really know what that pill does, it’s side/long term effects are, or alternatives to this pill? No good studies have been done on half those pills, and the other half maybe good science but of questionable or no benefit. Which to believe when he speaks? He is using his good and well deserved surgical reputation to mute any criticism or questioning of the promotions on the “show”. It truely is sad. Shame on Columbia for supporting this bad behaviour. Freedom of speech does allow snake oil salesmen to practice but it should not allow a trusted physician to do the same thing while being a physician or supported by a great medical school. Mehmet- if you really want to promote unproven therapies then resign from Columbia and us the small remaining medical capital. If you want to continue to be a trusted doc, then promote RESEARCH that proves these pills work and tell the truth about these products.”

We also asked SERMO doctors to share questions they’d ask Dr Oz, if given the chance.  Then we gave them the chance!  These questions were tweeted @DrOz and can be found at #SERMOasksOZ.

Here is a taste of what you’ll find:

It’s not easy to be a doctor and make money any other way because of the level of scrutiny you’re put under.  Our doctors understand that better than anyone else.  What is unacceptable is when unsubstantiated advice is given to the public, as a physician, for financial gain.

Dr Girgis shared:

 “A celebrity doctor should be held to the same standards as all doctors. Maybe even more since they are reaching a larger audience. When someone in that position starts giving advice that is not founded on science and has not been proven safe, it is not in the best interests of the well-being of the health of the viewing population.”

We’d like to invite Dr Oz to come in and do a Q&A with our community.  We’re not wielding pitchforks…we’re your colleagues and just want to separate fact from fiction, advocacy from advertisement and ensure that physicians are empowered to deliver the best, clearest, most responsible information we can to patients everywhere.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O. in the US or UK, please join us.

The post More than 1,500 Physicians Call for Dr. Oz to Resign appeared first on Sermo.

– by Dr. Irving Loh, MD

An interesting article (1) last month in Circulation: Cardiovascular Quality and Outcomes quantified something that has been quite subjective for experienced clinicians when dealing with coronary heart disease patients. When objectively diagnosed with stress and depression, CHD patients had a 48% higher risk of increased MI or death in 2.5 years of followup compared to the low stress and depression cohort. As a profession, it looks like we’re all in big trouble.

This study came out of Columbia University in New York and was lead by Dr. Carmela Alcántara. They examined the profiles of 4487 patients aged 45 or older enrolled in the Reasons for Geographic and Racial Differences in Stroke study and thus were known to have coronary heart disease. From 2003 to 2007, patients were interviewed at home or asked by questionnaires how often during the past week they felt depressed, lonely or sad, or had crying spells. They were also asked how often they felt unable to control important things in their lives, felt overwhelmed, felt confidence in their ability to handle personal problems and felt things were going their way during the past month. The implications of unrecognized or inadequately treated stress and depression can be manifested internally by adverse cardiovascular outcomes or externally as with the co-pilot of the Germanwings tragedy last month.

It was determined that it was the interaction between self-reported stress and depression, rather than just each independently that seemed to be related to the outcome measures, though no clear causal mechanism was discerned. Each of these symptoms separately did not seem to increase risk. Segregation of these factors as clinicians know is hardly a clean science, so their cohabitation in an affected patient is enough to warrant more focused attention on not only the patient’s cardiovascular risk factors, but on mitigating the psychosocial exacerbation of major cardiovascular adverse event risk. We all know about the sophisticated lifestyle and pharmacologic strategies needed to manage the classic cardiovascular risk factors. This study suggests that there may remain significant gaps in psychosocial care that may have similar implications for clinical outcomes. Indeed, coronary heart disease is a process that trends in the older population, and there are inadequately addressed issues in both the medical and sociological arenas that can alleviate the stress and depression that disproportionately afflict the elderly.

A multidisciplinary team approach with targeted care coordination is needed. Our society generally and our healthcare system specifically are not well prepared to effectively manage this scenario, but with a potentially manageable 50% increased risk, perhaps we need to implement concepts like care circles and care coordination tools like Tiatros™ (reader warning: I am a Tiatros™ advisor, so it’s one with which I am familiar, but there are other similar programs as well so no product endorsement should be interpreted or implied) that can help alert the care giver team. More research is required to determine mechanisms and optimal interventions to positively effect outcomes.
References:

1. http://bit.ly/1B1S14d Circulation: Cardiovascular Quality and Outcomes, online March 10, 2015

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.

The post Stress and Depression Increase Heart Risk appeared first on Sermo.

~ by Linda M. Girgis, MD

There is nothing sadder than the death of a child, except maybe a death that was preventable.  In the US, an average 5 children die every day as victims of child abuse.  While the US leads the world in innovation and technology, it lags behind many other countries in the protection of its children.  If you watch the media, people are outraged by a child allowed to play alone in the park, yet no one raises a voice for the children that are abused to death.

Why is it important to talk about child abuse on a medical blog?

The medical community is one layer of defense protecting these children.  Yet, doctors, nurses and healthcare workers often fail to identify these kids. Teachers are not finding these children at risk.  Society is not seeing the abuse happening.

Preventable deaths aside, why should doctors need to pinpoint these cases?   Perhaps, most importantly, one third of abused children go on to become abusers themselves. It is imperative that we break this cycle of violence.   Approximately, 14% of men and 36% of women in prison were abused as children. This is double what is observed in the general population.  Children who have been abused are 9 times more likely to become involved in criminal activities.  They are also 25% more likely to become pregnant as a teenager and engage in more high risk sexual behaviors. Additionally, almost 75% of those receiving treatment for drug abuse report a history of abuse or neglect.

Survivors of child abuse have complications lasting into adulthood. These adults tend to suffer from higher rates of mental health disorders. These include, but are not limited to, depression, personality disorders, anxiety disorders, PTSD, eating disorders, increased risk of suicide, dissociation and sexual difficulties.  It has been estimated by at least one source that 50% of those abused as children have 3 or more psychiatric disorders. Many survivors’ lives are defined by frequent crises leading to job dissatisfaction, failed relationships, frequent relocations, and financial setbacks. Many of these adults live in “crisis mode” and this can be quite disheartening and exhausting.

Similarly, these adults face more physical complications than those who were not abused as children.  These range through a whole gamut of diseases including diabetes, GI problems, heart disease, certain neurologic disease, etc.  The mechanism of why it occurs has several factors. The obvious is that some physical problems begin in childhood as a direct result of the abuse.  It has also been postulated that the stress caused by the early abuse alters the immune system and these changes play a role in the later development of these diseases.  There have also been studies  suggesting that childhood abuse affects the brain structure and the way neurons connect with each other. While the exact etiology is unclear, many studies clearly support that a history of child abuse clearly leads to increased chronic medical problems as adults.

Knowing the devastating consequences of child abuse and neglect, why does society allow it to continue?

For one, it is often very well hidden. The perpetrators are careful to hide their crimes so it is not so easy to detect. It is also something that is so horrible that many people can’t believe this evil exists. It is easier to ignore the signs. But, we can no longer afford to that. Children suffer and die as we stand by.  And they suffer into adulthood. We, especially the healthcare workers among us, need to take greater measures to find these kids and save them, not only from the abuse, but the future risks of mental and physical diseases.

Child abuse is not so easily discoverable but any unexplained injuries or bruises should always be questioned. And ask yourself, does the injury match the mechanism of injury? Also, be on the lookout for bruises or burns that match the shape of an object. Conflicting reports from the child and adults should be a red flag. Changes in a child’s behavior are also a clue. Be concerned if you see a child suddenly become anxious, withdrawn or aggressive. Some children even return to earlier behaviors like thumb sucking and bed wetting.  Many of these children are afraid to go home and reluctant to leave school. They may appear frightened to go with the abuser. Changes in eating habits or weight can be seen. Sleep problems, such as nightmares, can frequently be observed. These kids may appear unusually tired or fatigued. Lack of personal hygiene is often seen as well.  Some of these kids engage in high risk behaviors or inappropriate sexual behaviors. It always better to err on the side of protecting a child than overlooking a case of abuse. If you have the least suspicion, contact CPS and let them investigate.

While the statistics are truly scary, there is nothing more frightening than to be a child living through the abuse. No can imagine what it is like to hide for fear of your life under your bed or learn to tolerate the taste of your own blood in your mouth.  I know because I lived that life.   Don’t kids deserve to be treated better and kept safe from harm?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O. in the US or UK, please join us.

Bio

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.

The post What kills an average of 5 children per day in the US? Child Abuse appeared first on Sermo.

~ by Linda M. Girgis, MD

Being a primary care doctor has never been more difficult. Not only do we have to be knowledgeable about new technologies and medical advances in every field of medicine, we are expected to be “gate-keepers”.  In the US system, this model of care was set up by HMOs in an effort to lower healthcare costs.  In the UK, physicians are expected to do the same under the National Health Services (NHS). All patients need to see their primary physician before going for specialized care.  While this certainly has advantages, it comes with significant oversight and regulations.  Primary care doctors on both sides of the Atlantic, in the US and UK, are being crushed under these systems.

In this model of care, medical decisions are increasingly made by third parties, whether a for- profit insurance company, the Medicare/Medicaid program, or the NHS. Doctors feel that giving the best care to patients is becoming an elusive concept.  According to a GP in this article in The Guardian, “Everyone necessary for that care co-operated for the good of the patient – they didn’t compete for the benefit of shareholders. Sadly, patients are now right to be suspicious of motives concerning decisions made about them, which until recently, almost uniquely in the world, have been purely in their best clinical interest. Most politicians understand little about general practice, have no idea about the importance of continuity of care and blame GPs for a rise in hospital work, even though this is a direct result of their policies.”

Doctors in the US feel the same. We offer our best care to patients, however, our decisions often get tossed out in the prior authorization process by insurance companies. Many medications never get filled because of insurance company formularies whose guidelines are created, for the most part, by non-physicians. Instead, they are influenced by big pharmaceutical companies.  Patients do not see all that goes into these decisions, so the blame falls at the doctors’ feet.

Doctors on both sides of the Atlantic feel that outside forces have too much influence in our medical decisions. This harms patient care and the doctor-patient relationship, which is one of the building blocks of primary care. Control of medicine has been snatched out of ours hands and we feel helpless watching while our systems fail to provide patients with the best care.

According to a recent report by London’s Assembly Health Committee, “a lot of London’s GPs are retiring or not far off it. About 16% of them are aged over 60 compared with 10% nationally. Many are taking early retirement and figures suggest growing numbers are considering emigrating. Meanwhile, GP practices are finding it harder to recruit partners.”  The US is seeing a similar situation.  Here, there is both a shortage of doctors in training opting to pursue a primary care career and more physicians retiring earlier.

As the population ages, the need for primary care doctors is flourishing. Yet, primary care doctors increasingly bear the brunt of flawed healthcare systems.  Shortages already exist on both sides of the Atlantic and this can only grow.   Overhauls are desperately required in the US and UK health systems to put quality patient healthcare back at the center of the healthcare equation.

Medicine and technology has never been so advanced as it is today. But, unless we give respect and decision- making powers back to the gate-keepers of healthcare (physicians), we will face a true crisis on both sides of the Atlantic. Healthcare systems need to keep pace with medical practices and join the 21^st Century.  Who wants to have the best medical tools in the world, and watch patients suffer for lack of access?

Bio

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.

The post General Medical Physicians Being Crushed on Both Sides of the Atlantic appeared first on Sermo.

~ Kathryn Hughes, MD, FACS

Advocating for patients is a core value in medicine, in patient care. Our legacy as patient advocates dates back to Hippocrates in 500 B.C.E., codified in the oath and teachings that have provided the moral and ethical foundation on which the profession has been built. Even the Code of Conduct for the American College of Surgeons includes as its first principle, “Serve as effective advocates of our patients’ needs.”

Physicians fundamentally care for patients, their families, our communities. We advocate on the small, individual scale for each patient, and we advocate on the large scale for the entire population of patients and society.

The physician is the ultimate patient advocate.

The entire purpose of my profession is to learn about humans—their biology and chemistry, their function in health, and dysfunction in illness and injury. We strive to understand the impact of health or illness and injury on the psyche and on social interactions. To learn about and discover treatments and interventions, and to provide compassion and comfort in applying them. To educate both patients and our society in order to prevent illness and injury, promote health. We are called to speak truth to power in order to accomplish these goals.

The foundation of all this is the relationship and trust between the physician and the patient. Central to this relationship, that trust is the role of the physicians as advocates for their patients.

But now the position of “Patient Advocate” has become ubiquitous among hospitals, insurance companies, and health systems. A Patient Advocate is a (lay) person/entity whose primary role is to protect the patient and their interests, but also to field complaints, advocate on behalf of the patient/family, and even go so far as to assist in decision-making regarding the treatment plan or course of care. They are supposed to help navigate the often complex and confusing healthcare system, and the interactions with doctors, hospitals and insurance companies.

Patient advocacy seems a noble pursuit, and often much needed. Patients and their families are distressed and vulnerable, even in good health; add illness, and the ability to navigate the system and the decision-making can be daunting if not impossible.

All well and good, but I wonder why there is this pressing need for an entire different profession, an additional layer, another buffer between the patient and the physician? Has the core principle of advocacy changed in my profession? Have we abdicated our responsibility, or is it something else? If it has not changed, if we have not abandoned our principles, what is it perceived as lacking?

As Voltaire (or Peter Parker/Spiderman’s Uncle Ben) says, “With great power comes great responsibility.” The powerful responsibility physicians have for the care of their patients remains, but the trust on which it is based has eroded. The bond between physician and patient — and between the medical profession and society — has become strained.

Individual patients, the general public, and the government have all become increasingly wary of physicians. Considerable effort and expense is employed to rein in the perceived power and control wielded by physicians, implying that there is little trust in the ethics, oaths, and codes that we have set for ourselves. Hospitals, healthcare organizations, insurance companies, and various branches of government and regulatory agencies, as well as licensing boards and health departments (not to mention lawyers) have bit by bit surrounded physicians and buried them under mountains of law and regulation, benchmarks and measures and protocols.

Health systems and insurance companies increasingly dehumanize physicians, treating the highly skilled and highly trained professionals like pawns on a chess board, faceless and interchangeable. Physicians drop on and off of “preferred provider” lists in arbitrary and capricious fashion, destroying any relationship and continuity built with the patient. Doctors are presented as interchangeable.

Worse, at times it seems that these groups are driving a wedge in the physician-patient relationship. As a consequence, patient trust and confidence is shaken. It is not much of a leap for the relationship to be framed then as adversarial rather than cooperative. If a doctor is no longer seen as the patient advocate, then of course the void must be filled.

But Patient Advocates generally haven’t the medical training or expertise. They may be also beholden to the system or entity that employs them. The most common and available advocates are generally working for a hospital or insurance company, whose priorities may not entirely align with patient and physician. This is problematic, of course, because it is often the hospital or insurance company the physician must stand up to on behalf of her patient.

It is imperative that physicians continue to shape our evolving healthcare system and promote that which preserves and protects our relationship with our patients. We must insist that we not only take a seat at the table among “stakeholders” in the healthcare system, but show that we are the best and more uniquely qualified to lead the efforts. We must again claim that space between patient and physician and remind not just our patients, but all others that indeed we are their advocates. The physician who fails to serve as an advocate for their patient also fails to serve as a physician to that patient. We must fight for the time we need, fight against the distractions, shore up the trust that has been strained so mightily.

There is nothing in the description of a patient advocate that isn’t already part of what we as physicians commit to do for our patients. We are, therefore, the first and the last patient advocate, their most effective advocate, the ultimate patient advocate.

I advocate for physicians to continue to claim the time and space to be effective advocates for our patients; and to embrace this responsibility, and not abdicate it to others. Taking the lead to work with, but not be replaced by patient advocates.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Dr. Kathryn A. (Kathy) Hughes is a board certified General Surgeon, who has spent the majority of her career in private practice in community hospitals.  She is a Fellow of the American College of Surgeons.  She is a member of the Association of Women Surgeons, The American Society of Breast Surgeons, and the American Medical Association.  She is a member of the Massachusetts Medical Society, and represents the North Essex District in the House of Delegates, and serves on the Committee on Women in Medicine.

She has her B.A. from Mount Holyoke College, and her M.D. degree from The George Washington University School of Medicine and Health Sciences in Washington, DC.  She started her Surgical Residency residency with the University of Nevada School of Medicine system before returning to Washington, DC to complete her residency at The George Washington University Hospital program.

She blogs regularly from Behind the Mask.

The post The Ultimate Patient Advocate appeared first on Sermo.

“so what’s with you guys removing all the ‘a’s from the English language?”

There was banter, bonhomie and bonding. There was even time to ask about the correct way to take high tea (at 3pm, with crustless cucumber sandwiches, Earl Grey leaves, and raspberry-laden scones). And then the patient cases started to come.

We know that SERMO is the number one social network for physicians in the US precisely because it allows doctors to be themselves. As Oscar Wilde wrote, “Be yourself, everyone else is taken” and such words of wisdom prevail every day within SERMO. In the first few weeks we have seen 11 percent of the medical community of the UK become members already; like their US counterparts, British doctors are keen to talk. Dialect, colloquialisms, healthcare organizations may differ between regions but the practice of medicine itself still has a common language. We saw one discussion thread where language differences were a barrier (French-English), but once the medical acronyms, lab tests and scientific procedures were detailed, members flocked to help, galvanized by the common medical cause; HCV, HbA1, ECG etc is global terminology – common talk for SERMO members.

Which is why we are excited about what’s now and what’s next. Already we are seeing the power of medical crowdsourcing provide solutions, irregardless of the origin of posting. And the humour segues to humility of physicians diligently transforming real world medicine together. Or should that be humor?

Coming soon on SERMO:

— The UK election; what do the political parties claim as part of their manifesto healthcare promises?

— Different guidelines, same patient: what experience would they have in the UK versus the US?

— Medicine – with an American accent or the Queen’s English; the differences, the similarities

If you’re an M.D. or D.O. in the US or UK, please join us inside SERMO.

The post SERMO: to talk or not to talk, that is the question appeared first on Sermo.

~Dennis Morgan, MD

Chemotherapy is one of the miracles of modern medicine. It is also the proverbial two-edged sword — curative or deadly. Doses, schedules and routes are carefully explored in clinical trials and guidelines published. But the actual administration is very complex and the margin for error very small. Despite abundant literature on how to reduce errors, dangers lurk within every infusion center. I recount here some experiences intended as an exercise in mindfulness — a reminder to learn and re-learn the principles of safe administration.

When I was a resident physician I was called one evening at midnight to administer a dose of vincristine. I met the nurse in the med room as she was loading a syringe. Handing it to me, she complained how cumbersome it was to draw up all ten vials that the pharmacy sent up. Some readers will gasp at this point. Vincristine comes in 2 mg vials. I was just handed 20 mg — a potentially fatal dose. The decimal point had not transferred to the carbon copy of the order.

The transcription error was caught because I had a pattern recognition for this drug. I knew the dose formula (1.4 mg/m2 — max 2 mg) and that it came in 2 mg vials. Early on in my residency I had taken an interest in oncology and was possibly the only house officer in that thousand bed hospital who knew instinctively that ten vials is a life-threatening dose. (Vincristine later became notorious for death due to inadvertent intrathecal administration).

This concept of a pattern recognition for the template of any given treatment shaped my habits in practice. I kept my repertoire of regimens as small as possible such that my staff and I were intimately familiar with each one. However some regimens are unavoidably complex. Experimental ones are fraught with peril since so few are familiar with the template. So it was in the notorious cases of a fatal overdose at a revered teaching hospital in Boston when a patient, a well-known health care reporter, died from an overdose due to misinterpretation of an order: 4 grams of cytoxan was given not over four days, but each day(1). The error was not recognized as a deviation by those downstream in the chain of treatment — it was masked by the eccentricity that attends experimental regimens.

There are plenty of cases where the wrong drug was given due to the problem of look-alike, sound-alike drugs (LASA)(2). As a fellow I was privy to a fatal case of a nursing home patient given daily Uracil mustard instead of the bladder analgesic Urised. There are many problematic pairs (e.g. vincristine — vinblastine)(). Precautions have included changing names (mithramycin was changed to plicamycin to distinguish it from mitomycin), the use of TALL MAN notation (vinCRIStine — vinBLAStine)(3), and computerized order entry (CPOE)(4). Entire drug regimens can suffer from this type of confusion. We had occasion to round with a nurse who had co-authored a well-known handbook on chemotherapy regimens. I declared I wanted to treat a patient with “COP-”.  She astutely pinned me down: did I mean to give COPP or COP (the later not to be confused with CVP — same drugs, different dose).

Returning to the dose issue, I became meticulous about accuracy. My policy was at least two qualified people doing calculations at least twice each. Nonetheless I once ordered a dose of bleomycin much bigger than indicated. I had referenced a handbook in common use — but there was a typographical error. The fault was a failure of pattern recognition on my part, for the first cycle anyway.

That it will be the intended patient who gets the treatment should not to be taken for granted — identity checks are crucial. Consider two extensions of the concept of “the right patient”. One is having the right diagnosis. When I was interning in pathology we encountered a case of a revised diagnosis. A medicine resident had received several months of chemotherapy for osteogenic sarcoma. The new chief of pathology recognized the true diagnosis — benign myositis ossificans. The other extension to ‘right patient’ is the ‘ready patient’. I suspect every oncologist has regretted at least once not having the chem profile or blood counts before the drug was given.

Aside from the issue of skill set, the following illustrates the value of the patient as a team member in reducing errors. I was as an expert witness in a case of severe extravasation. A physician had substituted on a weekend for the oncology nurse. While the doctor pushed on the syringe of mitomycin the patient said his arm hurt — but it never hurt before, when his nurse gave his medication from a hanging bag. The doctor persisted and the patient ended up with a hole in his arm. Fortunately, there is now a trend to actively recruit patients in the process of  trapping errors(5).

A recent study in a community outpatient infusion center concluded “The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders … to 0.1% with CPOE”(4). I suspect many infusion centers are not doing as well. Constant vigilance is required to reduce errors and even improve on a 0.1% rate of harm, including death. Remember if it happens to your patient it is 100% for them. The essential principles and procedures are delineated in the ASCO/ONS guidelines(6) and in a comprehensive handbook by the Director of Pharmacy at Fox Chase Cancer Center(7), amongst many others(8). Monitoring outpatient use of oral chemotherapy is a special challenge.

To engrain in them the habit of safety every fellow should ‘push chemo’ as part of their training. They should at least once experience their mind second-guessing each calculation and their eyes second-guessing the hands as they dilute and draw up a measure of drug with the power to cure or kill. The sensation of holding a two-edge sword by the blade should follow them through the years of wielding a prescription pen.

What experiences have informed your own approach to chemotherapy safety?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio

Dennis Morgan, MD is Assistant Clinical Professor University of Connecticut Health Center, Emeritus Staff Johnson Memorial Hospital and Medical Center Stafford CT and Past President Connecticut Oncology Association as well as Past Medical Director Phoenix Community Cancer Center, Enfield CT

References

(1) Betsy Lehman Center for Patient Safety and Medical Error Reduction

http://www.mass.gov/chia/consumer/betsy-lehman-…

(2) Look-alike, sound-alike drugs in oncology. Kovocic L, Chambers C. J Oncol Pharm Pract. 2011 Jun;17(2):104-18.

http://opp.sagepub.com/content/17/2/104.abstract

(3) Application of TALLman Lettering for Drugs Used in Oncology. ISMP Canada Safety Bulletin. Volume 10, Number 8 November 11, 2010.

http://www.ismp-canada.org/download/safetyBulle…

(4) Reduction in Chemotherapy Order Errors With Computerized Physician Order Entry. Meisenberg BR et al. JOP January 2014 vol. 10 no. 1 e5-e9.

http://jop.ascopubs.org/content/10/1/e5.abstract

(5) Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature. Schwappach DLB, Wernli M. (2010) European Journal of Cancer Care 19, 285–292.

http://onlinelibrary.wiley.com/doi/10.1111/j.13…

(6) 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. Neuss MN et al. J Oncol Pract. 2013 Mar;9(2 Suppl):5s-13s.

http://www.instituteforquality.org/sites/instit…

(7) Guide To The Prevention Of Chemotherapy Medication Errors, 2nd Edition. Kloth DD. McMahon Publishing, Abraxis BioScience. 2010.

http://www.clinicaloncology.com/download/pg1012…

(8) Preventing Medication Errors in Cancer Chemotherapy. (Textbook Chapter 16).Learning Aids: Medication Errors, 2nd Edition. Cohen MR, ed.  [See Lecture 6].

http://www.pharmacist.com/learning-aids-medicat…

The post Chemotherapy: Safety is No Accident appeared first on Sermo.

~Dr Cedric Cheung

We all know antibiotic resistance is a major health problem. Take, for example, resistant Acinetobacter baumanii (AB) ventilator-associated pneumonia and bacteremia that are major issues in hospitals all over the world. What should clinicians do when confronted with a sputum or blood culture that grows out multi-drug resistant (MDR) AB? What would you do? Hopefully you would call an ID consult (shameless plug), but what should ID do?

Unlike methicillin resistant Staphylococcus aureus infections where there are many recently developed antibiotics to choose from, the pipeline of novel agents to treat infections due to MDR AB and other gram-negative rods like Klebsiella pneumoniae and Pseudomonas aeruginosa has been dry for decades. We can only resort to dusting off some long forgotten antibiotics like colistin (with all its nephro and neurotoxicity) or as in the December 2014 supplemental issue of Clinical Infectious Diseases, using minocycline (a tetracycline class antibiotic) for resistant AB infection. That’s right, the antibiotic probably best known for treating teenage acne is actually being considered to combat one of the meanest, nastiest scourges of the ICU.

Normally, it is probably best to use combination therapy of a carbapenem or ampicillin/sulbactam and colistin for empiric treatment of AB infection, as in vitro studies have shown synergistic effect. If susceptibility results show sensitivity to ampicillin/sulbactam, cefepime, or a carbapenem, de-escalation to monotherapy is reasonable. However, if the susceptibility report comes back as MDR AB, you’ve got a problem, and this is not an uncommon problem. A study of over 5000 AB isolates collected from 2007 to 2011 from different regions of the world showed alarming resistance rates to ampicillin/sulbactam (75%) , imipenem (63%), cefepime (78%), and amikacin (65%) [1]. Thankfully, colistin still retains consistent activity against AB (99% susceptible), in addition, minocycline susceptibility was found to be decent (79%). Treating MDR AB is complicated, but most likely a combination of colistin plus something can be effective. This is where minocycline could come into play.

In a case series of 55 patients with MDR AB infection [2], the combination of colistin plus IV minocycline showed the best clinical success (74%). Other smaller case series showed similar results that seem to support the use of minocycline in these difficult to treat infections [3]. In fact, one center is using colistin and minocycline as empiric therapy of AB infections until antibiotic susceptibility is known [2].

I apologize if this article was a little too “hardcore ID” for you, but my intention is to highlight the difficulties in treating superbugs such as AB and the need for novel treatments. If I ended it here, this would be just another depressing lament about antibiotic resistance.  Stay tuned for part 2 of this article, where I will share the exciting story of the discovery of teixobactin published last month in Nature that could be a game changer.

Are resistant “superbugs” a real problem in your facility?  Which ones in particular?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

References

1. Castanheira M, Mendes, RE, Jones RN. Update on Acinetobacter Species: Mechanisms of Antimicrobial Resistance and Contemporary In Vitro Activity of Minocycline and Other Treatment Options. Clinical Infectious Diseases 2014;59(S6):S367-73.
2. Goff DA, Bauer KA, Mangino JE. Bad Bugs Need Old Drugs: A Stewardship Program’s Evaluation of Minocycline for Multidrug-Resistant Acinetobacter baumanii Infections. Clinical Infectious Diseases 2014;59(S6):S381-7.
3. Ritchie DJ, Garavaglia-Wison A. A Review of Intravenous Minocycline for the Treatment of Multidrug-Resistant Acinetobacter. Clinical Infectious Diseases 2014;59(S6):S374-80.

Dr Cedric Cheung Bio

After graduating from Johns Hopkins University Cedric attended Albert Einstein College of Medicine.  Fascinated by a 2 foot long Ascaris worm in a jar being passed around in parasitology class, he instantly fell in love with infectious diseases.  So after completing his residency in internal medicine from New York University he returned to Einstein for his ID fellowship.  He stayed in the Bronx working for St Barnabas Hospital in the Designated AIDS Center caring for HIV patients.  He currently the director of HIV services for MSI Professional Services in China.

The post Antibiotic resistance: desperate and hopeful times appeared first on Sermo.

~by Jennifer Hanrahan, D.O.

Whenever I talk to healthcare workers about vaccines, there is always a group of people waiting to inform me of the dangers of vaccines. The first time this happened, I was surprised. It seemed strange that people whose lives are dedicated to helping others based on science would become part of the anti-vaccine movement. I am going to speak about this topic, knowing that there will be some negative responses.

Nothing in modern medicine has saved as many lives as vaccines. Debilitating, fatal diseases are now often a thing of the past. The great success of vaccines has allowed us to forget about horrible diseases that used to occur regularly. Because we don’t have to see these diseases, we have the luxury to debate the merits of vaccines. Every time a new epidemic occurs, the first question is whether there is a vaccine or whether one could be developed. Thousands of lives and untold human suffering would have been spared if a vaccine for Ebola were available.

Before routine vaccination, there were 13,000-20,000 cases of paralytic polio in the U.S. every year. The last case occurred here in 1979. There were 20,000 cases of congenital rubella syndrome annually prior to rubella vaccination. Before routine measles vaccination, almost everyone in the U.S. got measles. Some went on to have terrible complications such as subacute sclerosing panencephalitis, which ended in death. Fortunately, measles is uncommon in developed countries now. In 2004, there were an estimated 454,000 measles deaths, which translates into more than 1,200 deaths every day or 50 people dying every hour from measles. In 2013, this number decreased to 16 deaths per hour from measles, due to ongoing vaccination efforts. Almost 16 million deaths were averted due to measles vaccines administered from 2000-2013.

Bacterial meningitis used to be an early childhood illness.  Due to vaccination programs for H. influenzae type B and pneumococcus, the average age of bacterial meningitis is now 41.9 years.

Measles, Rubella, Smallpox, Polio, bacterial meningitis in children- all of these are almost diseases of the past, because vaccines work. Despite their great success, people are eager to believe myths about vaccines, and choose not to get themselves, or their children vaccinated. Keeping all of these diseases in the past requires herd immunity. Even a small decrease in herd immunity leads to reemergence of disease.

After the publication of a paper in Lancet in 1998 by Wakefield, et al. vaccination rates decreased, and in 2008, measles and rubella were declared endemic again in the U.K.

This paper was fabricated by the author and was retracted by Lancet. The authors were investigated and barred from practicing medicine in the U.K. Still; many people choose to believe that there is a link between vaccines and autism, as well as myriad other ailments.

How people make decisions has little to do with data, and more to do with emotions. This topic is investigated and described in a great book, “Mistakes were made, but not by me,” by Carol Tavris and Elliot Aronson. Once a decision is made, all additional data is used to support the decision. Even data that clearly goes against the opinion is used as further support. Physicians are, unfortunately, not immune to this phenomena.

A new vaccine was just released for prevention of HPV. Gardasil 9 includes five additional strains of HPV. Many of the patients I see, who would have been eligible for vaccination, have not received HPV vaccines, and by the time I see them, they are older than 26, and no longer eligible. I am hoping that doctors will think more about immunizing adults, and help to prevent suffering.

What are your experiences with anti-vaxxers? Do you find it difficult to keep up with all of the changing recommendations for vaccinations?

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

References:

1. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)11096-0/abstract

2. http://www.who.int/mediacentre/factsheets/fs286/en/

3. Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364:2016-25.

4. http://www.americanscientist.org/bookshelf/pub/an-interview-with-carol-tavris

Jennifer Hanrahan, D.O. is an infectious disease physician at MetroHealth Medical Center and is medical director of infection prevention at MetroHealth Medical Center. She has served as co-medical director of the Cleveland Department of Public Health, and has extensive experience teaching residents, fellows and medical students. Her areas of expertise include influenza, hospital-acquired infections, legionella, HIV/AIDS, and hospital preparedness for infectious diseases.

The post Vaccines: the most important part of modern Medicine appeared first on Sermo.

~ by Linda M. Girgis, MD

We have started to explore the complications obesity can cause. This post will look at its association with sleep apnea. The role of obesity in sleep apnea has been well established in adults and children alike. Its rate has been climbing.

The prevalence of OSA in obese patients is nearly twice that of normal weight patients. Patients with mild OSA who gain 10% of their baseline weight have at a sixfold-increased risk of progression of OSA.  Similarly, a loss of an equal amount of weight can lead to more than 20% improvement in OSA severity. Some recent studies show that obese children have a 46% prevalence of OSA when compared with children seen in a general pediatric clinic (33%).

Why does obesity cause OSA?

It is felt that deposits of fat in specific areas play a key in determining whether someone develops OSA. For instance, fat deposits in the tissues surrounding the upper airways can result in a narrower lumen and increased collapsibility of the upper airway.  In addition, truncal obesity reduces chest compliance, functional residual capacity, and increased demand for oxygen.  Nevertheless, the relationship between OSA and obesity is much more complex.  Patients with OSA tend to have reduced physical activity and cravings for carbohydrates that tend to exacerbate the obesity.  CPAP has been shown to reduce the visceral fat in some patients.  There have been some studies showing an interplay of obesity and OSA as a result of genetic factors, specifically polymorphisms of the leptin receptor.

It is even more alarming that we see  this more frequently in children and adolescents.  In one study, 46 children were evaluated. These subjects were recruited from a pediatric obesity clinic at a university hospital. They had been referred there by their primary care providers. They were compared to 44 normal weight subjects who were matched for other characteristics, such as sex and age.  This study showed that mild breathing disruptions, however, they were more significant in obese subjects. It was also shown that many of them had enlarged tonsils and adenoids, so suggested ENT consult in cases of OSA in children despite their BMI. An interesting observation in this study is that oxygen desaturations were not as severe as in adults with OSA and, therefore, children with OSA did not suffer from daytime sleepiness as much.

The Sleep AHEAD study showed that there was a clear improvement in OSA in patients who lost weight.  This study included 264 subjects in 4 different centers.  Their average BMI was 36.7 and average apnea-hypopnea index (API) 23.2 events per hour. This study showed that clearly weight loss improved OSA, especially in men and those with higher AHI scores.   In patients who maintained their weight for one year, they maintained their benefits of their weight loss as evidenced by their repeated AHI scores.

Obesity clearly plays an etiologic role in OSA in both adults and children. We are learning the dangers of OSA as time goes on, in terms of hypertension and cardiovascular disease.  While obesity itself has a clear cause of producing OSB, it appears to be multi-factorial. Weight loss has been clearly demonstrated to improve OSA in many studies. The treatment should start with lifestyle changes and weight loss.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Bio

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.

The post Obesity and Sleep Apnea appeared first on Sermo.