#TowardsHealing: How Doctors Can Help the Country After the 2016 Election

Healing is a matter of time, but it is sometimes also a matter of opportunity.” — Hippocrates

Doctors help the body heal. The body does the work, we just provide the help.

It is now time for us to help the country heal. The country must do the work, but we can still provide the help.

Now is the opportunity.

This morning, I read a wonderful blog by Aaron Stupple, MD et al (“Doctors to Donald Trump: First do no harm“), which inspired me to move.

Yes, our country is divided. Very divided. More divided than ever in my own lifetime. And those divisions have caused immense damage to our country.

You and I might not agree, but I would like to have a civil discourse with you. Communication. Conversation. Open-mindedness. Our country cannot heal until we begin to embrace these notions.

Let us reach out to those with whom we disagree and tell them that we are with them as Americans. Let us tell them what we will do to help our country move #TowardsHealing. Let us ask them what they will do to help our country move #TowardsHealing.

We have no greater calling on this planet than to help others. We are trained to help other people. Let us use this calling to help the country by joining together #TowardsHealing.

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Live tweeting from a meeting: A brief tutorial to help structure tweets

After 5 years of live-tweeting several academic meetings, I am pleased to see its exponential growth. Yet physicians who are new to this practice frequently struggle to get started, especially without any live peer guidance. With that in mind, here is a simple proposal to help you get started by providing a structure for your live-tweets, based on what I do (not that it is the only way):

  • Figure out the “official” hashtag of the meeting and include it in all of your tweets from the meeting. For this blog, I’ll use #DDW15 (Digestive Disease Week 2015)
  • Announce to your followers that your Twitter stream will be including a lot of tweets from the meeting
  • Sometimes I will start by identifying the specific session I’m tweeting from:Screenshot 2016-05-21 14.09.44
  • If possible, when there is a new speaker, introduce the presentation, including the speaker’s name, topic, and abstract/presentation identifier:Screenshot 2016-05-21 14.17.49
  • When you tweet information, attribute it to the speaker for the remainder of the presentation. I find it helpful to include the identifier so the series of tweets can be linked. I use this template: [Speaker] #[ID]: [Information] #[Hashtag]Screenshot 2016-05-21 14.17.59
    • Hint: As the presenter is speaking, I will often create a blank tweet structure specific to the presentation (e.g., Kestens #52:  #DDW15) leaving 2 spaces after the colon so that I can paste it into my tweet, click between the 2 spaces, then begin typing.

What you should tweet really depends on your personal or professional goals. I like to tweet important points or new information, but be aware that abstract presentations have not necessarily been subjected to the same peer-review process of a scientific paper. Good luck and happy tweeting!

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Let’s stop using adjectives to identify patients

We have all heard it, we have probably all said it:

  • “My diabetics never follow my instructions”
  • “That schizophrenic is back in the hospital again”
  • “How should I screen cirrhotics?”
  • “Did you hear about my CHF-er?”

It might be easy to say but it certainly isn’t patient-friendly. Patients are people. Sometimes they have diseases or syndromes or symptoms. But diseases shouldn’t describe our patients. Patients are not a disease, and certainly they aren’t the “adjectival” form of the disease (e.g. “diabetic” for the disease diabetes).  Ascribing these words and phrases to people can have a few effects:

  • It anchors the doctors and/or the patients on the disease or diagnosis, when the diagnosis may not be correct or complete
  • It changes our focus from the person to the disease
  • It changes patient perception of the medical profession
  • And worst of all…It demeans patients

So let’s think about rephrasing the above:

  • “The patients with diabetes in my practice often have difficulty…”
  • “The man with schizophrenia we both recently treated has been readmitted.”
  • “How should l screen patients who have cirrhosis?”
  • “Did you hear about Mrs. X, the patient with CHF I treated last week?”

Yes, it may seem like semantics. Yes, it takes a few extra seconds and a little bit of effort. I’ve personally had to focus on changing my own lexicon and occasionally find myself resorting to my older habits. But if you pay a bit of attention to colleagues from here on out, you might start thinking about how it sounds and try to make the change yourself.

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Are we really training learners to manage diseases?

If you pay close attention to medical education and training, you have surely read something like this as an goal or learning objective:

“Manage inflammatory bowel disease and its complications”

However, this is not exactly what our goals should be. One push in the patient-centered care community has been changing the focus from managing the disease to managing the patient who has (or might have) the disease. The difference in wording is subtle, but it gets more closely at what we are trying to get our learners to do.

The diseases about which we teach and train do not occur in isolation. They do not occur ex vivo. For all intents and purposes, doctors cannot “manage” GERD, nephrotic syndrome, or an abnormal ANA. But we can manage the patient with GERD, nephrotic syndrome, or the abnormal ANA.

Continue reading

Posted in cancer, gastroenterology, GERD, Heartburn, IBD, medical education, patient care | Tagged , , , , , , , , , , , | 3 Comments

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.

Screen Shot 2014-02-05 at 9.21.11 AM
I applaud CVS for taking this bold stance and eschewing approximately $2 billion in revenue to follow their healthcare mission.

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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.

Posted on by Ryan Madanick, MD | 3 Comments

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.  For 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 stricter 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.


Update: July 20, 2016

A large study with sound methodology has been published in JAMA this week with data backing up this blog post.

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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 (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!

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