CVS to stop selling tobacco products: some grass-roots contribution from the blogosphere?

In 2011 I posted this petition to try to get CVS and Rite Aid to stop stop selling tobacco (see my 2011 blog post). Although the petition closed in 2013 with just under 2800 signatures, today is finally the day I’ve been waiting for:

CVS has announced it will stop selling tobacco products!

Whether or not the petition has anything to do with it I will never know. Nonetheless this is a huge step forward. As @RichDuszak tweeted back to me this morning, this is truly a disruptive announcement and hopefully lead to other pharmacies and retailers following suit.

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I applaud CVS for taking this bold stance and eschewing approximately $2 billion in revenue to follow their healthcare mission.

Posted in cancer, patient care, public health, tobacco | Tagged , , , , | 3 Comments

Can you have your colonoscopy and endoscopy on the same day?

I’ve heard it dozens of times:

My gastroenterologist says s/he can’t do my endoscopy and colonoscopy on the same day.

Sometimes it’s because it was considered too “dangerous”. Occasionally it’s because “that’s not the way we do it”. Sorry, that doesn’t fly with me. And it shouldn’t with you.

Yes, there are true medical reasons that some people shouldn’t have an upper endoscopy and a colonoscopy (sometimes called “bidirectional endoscopy” or a “double dip“) on the same day. But these are few and far between.

Years ago, my mother told me the same thing…after her procedures. I nearly flipped out.

The real reason is that (in the USA) the doctor and/or the facility gets paid less for doing them on the same day than when they do them on different days.

What does having your 2 procedures done on separate days mean for you?

  • 2 days away from work or your personal life
  • Undergoing anesthesia/sedation twice
  • Getting someone else  to drive you to and from the procedure on 2 days
  • More money out of your pocket (or out of your insurance company’s)

If you do need to have both done, think carefully. A patient-center doctor would usually have no problem doing them both on the same day, instead of caring more about the bottom line.

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In The Absence of Evidence…

In this week’s JAMA, Scott Braithwaite, MD, MS wrote a Piece of My Mind editorial, “EBM’s Six Dangerous Words,” which made me think back to a former blog post of mine from 2011, “Doc, can I use this natural supplement?” What I omitted from the original blog post was germane to Dr. Braithwaite’s point.

In academic medicine, we often derate complementary/alternative therapies because of the lack of evidence for their benefits, until they are “proven” to be beneficial. Yet some patients rely on them because of the actual or perceived benefits the therapies provide, as my patient had done.

While I am not advocating the indiscriminate use of uninvestigated treatments in managing patients, I advocate maintaining an open mind about why our patients choose to use the remedies they do. On the other hand, we do not have to recommend or prescribe therapies that have no or little scientific evidence supporting their benefits, as some practitioners often do.

However, in the absence of significant harm, we should restrain ourselves from telling patients to stop or avoid such treatments if our patients feel they gain benefit from them.

“Absence of evidence is not evidence of absence” (Altman & Bland, BMJ 1995)

I have heard students, residents, and colleagues say the very words Dr. Braithwaite decries: “There is no evidence to suggest…” when deciding on treatment or in looking at another physician’s prior decisions when consulting on a new patient. As a clinician educator [and in full disclosure, I have probably said those very words myself], I often respond to their admonishments by citing the infamous Parachute article from the 2003 Christmas issue of the BMJ.

Most of what we do in medicine is unsupported by evidence. We need to keep this in mind as we see patients, especially as we teach and train the next generations of physicians.

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Presenting on a consult service: Rule number four

A while back, I posted three “rules” of presenting on a consult service. I’d now like to add a fourth rule.

Rule Number 4: In patients with chronic disorders, consider more than simply a “disease flare” in your differential diagnosis.

This rule follows up on Rule Number 3. The rule is most relevant to patients with underlying chronic disorders (e.g., inflammatory bowel disease, emphysema, ischemic cardiomyopathy) and is important for fleshing out a broad framework for a differential diagnosis.

After you have gone through a detailed presentation of a patient with a chronic disorder, the path of least resistance when a patient presents with similar signs, symptoms, and findings, is to diagnose a “disease flare.” However this knee-jerk reaction excludes a number of other broad options that may be going on.

Here is the framework I suggest in considering your differential diagnosis in a patient with a chronic underlying disorder. The presentation could be caused by:

  1. The disease;
  2. A complication of the disease;
  3. A complication of the treatment of the disease; and/or
  4. A completely unrelated disease

In virtually any patient, this general schema can be helpful to make sure that you do not anchor your diagnostic possibilities on the chronic disorder.

As an illustration of how I use the framework on teaching rounds, I’ll describe a typical (made-up) case we might see on the GI consult service, a 25-year old man with Crohn’s disease and a possible flare. He was diagnosed 6 months prior with inflammatory ileocecal Crohn’s disease after presenting with right lower quadrant abdominal pain and watery diarrhea. The colonoscopy at the time revealed severe inflammation in the cecum and terminal ileum. He has been treated with steroids and infliximab, and was brought into remission within 3 months. Now, he presents with 3 days of acute watery diarrhea and recurrent abdominal pain. Without giving any more details, here is how I might break down my thinking:

  1. The disease: Sure, it is easy to say that this is a “Crohn’s flare,” but then you’d have to ask yourself, “Why is the disease flaring?” Could the medications no longer be working? Has the patient been adhering the treatment regimen? Are the medication dosages too low? Nevertheless, this is an easy place to stop unless you consider the next 3 broad possibilities.
  2. A complication of the disease: Crohn disease can cause at least 2 complications that can lead to similar presentations: fistulae and strictures. Of course, you could argue that these are the disease itself, but I would refute the argument because the treatment of these complications can be different from treating the underlying inflammatory process itself.
  3. A complication of the treatment of the disease: As much as physicians don’t like to admit it, our therapies can definitely play a role in our patients’ worsening. Surgeons are quite attuned to looking for complications of their surgeries while their patients are recovering in the hospital, but medical therapies also have complications that should be considered, especially in the outpatient setting. In this case, the patient is on immunosuppressive agents. Could the treatment have led to an infectious disease, such as CMV colitis?
  4. A completely unrelated disease: Importantly, this element, sometimes known as “true, true, and unrelated,” is how we are taught to think when we are creating differential diagnoses in medical school and residency training, but can often get neglected in the presence of a chronic disorder. Does he have a young child in preschool, who could have contracted a Rotavirus infection and transmitted it to your patient? Could the patient have taken an antibiotic for a sinus infection and developed C difficile colitis? Here the differential diagnosis can be quite broad, but should certainly not be overlooked when the patient has a chronic disorder.

Acknowledgement: Dr. Arvey Rogers, my first clinical mentor, deserves the credit for teaching me this framework. He is a wonderful clinician, a thoughtful educator, and a gem of a person.

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An empirical scientific viewpoint about gun control

For just a moment, let’s take a scientific viewpoint about gun control here and try to leave emotions (and the Constitutional argument) out.

The best type of study to determine whether gun control and/or regulation would be a Randomized Trial:

  • Randomizing a state or country to regulation or not.

Since that’s not going to happen, the next best type of evidence we have to go by is observational, either case-control or cohort studies:

The exposure is: gun control regulation.

  • This could be considered dichotomously (Yes/No) or continuous (level of regulation from strict to lenient/none)

The outcome is: death by guns.

  • This could be considered in numerous ways: absolute numbers of gun deaths annually; relative numbers of gun deaths adjusting for size of population; number of gun massacres, etc.  We could even consider any violent deaths, if you want to be more general.

In a case-cohort study, we’d look at the outcome first (let’s say, massacres) and look backward for the exposure, then calculate an odds ratio that the outcome was significantly associated with the exposure.

In a cohort study, we’d look at the exposure first, looking at level of gun control as a continuous variable.  This could be done retrospectively or prospectively.  As of now, we could only do this retrospectively.  Then look for the outcomes (deaths, massacres, etc.), and determine a risk ratio that the outcome was associated with the exposure.

Either way, the data would indicate that countries with increased exposure (increasing regulation) is associated with a decreased odds/risk of the outcome (fewer deaths, massacres).

Please NOTE that I did NOT say that increasing regulation CAUSED fewer deaths, just that it was ASSOCIATED WITH fewer deaths.

Now, I do not have numerical data, so I am only going on what I understand to be true, the empirical data.  If those who would not believe this to be true, the best way to deal with this is to show data that decreasing the exposure to gun regulation (i.e., increasing the populace’s ability to acquire firearms legally) is associated with fewer gun deaths.

Therefore, my preference is the following: until evidence (not raw emotions, beliefs, or Constitutional Amendments) that decreased regulation (including eliminating gun zones) results in decreased odds/risk for the outcome (gun death) is found in other countries, then there is no reason to accept the notion that we need to stop advocating for strict gun control.  For that matter, stricter gun control has evidential support (even if not emotional support among some) and should be advanced.

If you choose to comment on this in the opposite direction, please think before you do. The anecdotal evidence currently being provided by those who would oppose strictuer regulations is purely speculative.  I am open to hearing the data to refute the above contention, but it needs to be at least as strong methodologically.  In other words, “case reports” (testimonials by individuals) or “case series” (testimonials by groups, including lobbyists) are weaker forms of evidence scientifically, and I will not consider them as valid as the comparative empirical data I have put forward as an argument.

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A Rapid Rescue for a New Mnemonic in BLS

In reviewing for my upcoming ACLS recertification through the American Heart Association‘s HeartCode ACLS program, I learned that the classic mnemonic for the Basic Life Support (BLS) primary survey, the “ABCs”, which stood for Airway, Breathing (including Look, Listen, and Feel) and Circulation, had recently been modified.  The purpose of the change was to decrease time until chest compressions and defibrillation.

However the change leaves us without a simple mnemonic for easy recall for the primary BLS survey.

Thus I introduce my mnemonic for the primary BLS survey, and how much more appropriate could it be:

R-A-P-I-D

  • R (Response): Assess the patient’s responsiveness. This includes scanning the chest for movement.
  • A (Activate/AED): Activate the Emergency Response System & get an AED (if available)
  • P (Pulse): Check for a pulse
  • I (Initiate): If there is no pulse, initiate high-quality CPR
  • D (Defibrillate): Check rhythm (via AED) and deliver a shock if indicated

You could also remember “RAPID Rescue”.  The addition of “Rescue” should help you remember that if you are successful in restoring spontaneous circulation, give Rescue Breaths.

Please disseminate…RAPID-ly!

Posted in medical education, patient care | Leave a comment

Are Twitter-savvy students “privileged”?

At this week’s AAMC meeting, Alex Djuricich (@MedPedsDoctor), Terry Kind (@Kind4Kids), and I presented a workshop that dealt with using Social Media/Twitter in our roles as medical educators.  During a breakout session within the workshop, I heard an interesting concern that I had not previously considered.

One participant’s administration was concerned that students who are not using Twitter, Facebook, or other social media venues would be excluded from the information provided by the faculty on these sources.  Their concern is that the students who are involved on social media would thus have an advantage over those who do not use the sites.

Although I understand the worry, I am not concerned. Social media is simply a different way that faculty and students can communicate.  After classes, students often come up ask questions or clarify areas of uncertainty with their teachers.  Many professors hold office hours, sometimes even with groups of students.  On a personal note, for years I have been answering students’ emails on a one-to-one basis.

If a significant area of concern arises, it surely is the faculty member’s responsibility to make sure the problem or misunderstanding is not a systemic issue that all students are having.  Social media simply expands the ability for students to communicate efficiently with their faculty.  The faculty members’ responsibilities to clarify information for all their students doesn’t change.  Social media simply helps break the barrier between the two groups, not increase it.

Posted in medical education, Social Media | 2 Comments