http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 Most Recent Submissions from bgottlieb on Modern Medicine Community Thu, 05 Jan 2012 00:39:59 GMT Thu, 05 Jan 2012 00:39:59 GMT modmedadmin@advanstar.com (ModernMedicine) modmedadmin@advanstar.com (ModernMedicine) KickApps Feed Builder 2012-01-05T00:39:59Z 40 http://community.modernmedicine.com/service/searchEverything.kickAction?as=33379&includeVideo=on&includeAudio=on&includePhoto=on&includeBlog=on&sortType=recent 0 http://community.modernmedicine.com/_Primum-non-nocere-First-do-no-harm/blog/5691370/33379.html I have wanted to tell this patient’s story for a while. I have tried to convince her to tell it – because I believe it would somehow be therapeutic. But I haven’t been able to convince her yet. In the past week I met another patient who had a very similar story. When I learned that I would be writing my final official blog for ModernMedicine I decided that it was my opportunity to share this story. I have a patient who is, thankfully, quite healthy. At least I believe she is healthy. She won’t really let me do any testing. In fact, apart from delivering a wonderful holiday gift each year, it could be several years between visits. When I met her several decades ago she told me that she is deeply frightened of physicians and medical facilities. She recounted her story of having a condition as a child that was monitored regularly, according to the standards of the early 1950’s. Several times each year for most of her childhood and adolescence, she attended an outpatient clinic where she and dozens of others would be undressed, and sat on a row of benches in an unheated corridor, waiting to be called one by one to an equally cold office to be examined by a team of physicians. Few words were exchanged. Instead, she felt the stern glare of men in white coats as they scowled at the children and muttered among themselves. Parents sat somewhere outside this corridor—inaccessible. A day of school would be missed each time—adding to the weight of this ritual, but little was said before or after. Was this punishment for some unnamed infraction? Was there something terribly and irrevocably wrong with her body? With her person? To this day, she has not been able to submit to a mammogram, much less a colonoscopy. Her few pelvic exams have necessitated a hastily planned appointment when the health center doors open (an hour before scheduled appointments) so that her anxiety will not have time to mount and send her fleeing. I have been haunted by this story, and have tried unsuccessfully to help her address her fears. I hope that I am in practice long enough to witness some sort of resolution, some relief from the terror that has held her prisoner for so many years. Last week, while doing my weeks of in-patient attending, I met another patient, about the same age, who as a child required regular outpatient visits for a different medical problem. Her story was virtually identical: undressed, the cold corridor, the frowns and scowls, the mutterings, the self-doubts, self-blame. This patient was less fortunate in that a series of serious illnesses have brought her into the medical world throughout her life. Instead of fleeing, she seeks to take full control. She appears to be in a constant state of panic. She questions everything, writes everything down. But her questions and lists are panicked, often incoherent. She self-diagnoses and self-medicates because she doesn’t fully trust any of her many providers. Both women were cared for in “the best hospitals.” Both had parents who had probably sacrificed to get their daughters “the best care.” I assume that there was no malicious intent on the part of the physicians who took care of these young children. On the country, I assume that everyone thought they were doing their very best. That is actually what frightens me the most. These two women and I assume hundreds, maybe thousands, of children who received this type of care and treatment, have been scarred to some extent. In the past 100 years, and especially in the past 25 years, a great deal has been learned about trauma. A traumatic experience is one in which the victim feels frightened, often mortally so, feels that he or she has no control, and feels that his or her escape is blocked. We now know that trauma does not only come in the form of a monster, a rapist, or a murderer. Many seemingly ordinary experiences can be traumatic, including experiences in an environment that is supposed to be for one’s own good. In fact, a traumatic experience that comes at the hands of someone who is supposed to be a trusted and caring figure (such as a physician), particularly at a vulnerable age (childhood), or at a vulnerable time (undressed, in a strange environment) can be all the more traumatic. There are few traumatic experiences that lead to prolonged traumatic responses 100% of the time. I suspect that my 2 patients are unusual in their responses. But I doubt that they are alone. What do I learn from this? We all explicitly or implicitly vow Primum non nocere. Physicians in the 1940’s and 50’s undoubtedly took the same vow. However, we may not understand what the immediate and long term impact of some of our diagnostic and therapeutic actions may be. Recent generations of pediatricians have been taught to think about this. Parents accompany children to exams and procedures; sleep in their children’s hospital rooms. Child life specialists help children understand medical procedures, demystify needles and other medical devices. Children are not the only vulnerable group, however. Adults are vulnerable when they are ill. Many adults, even those who are well, are frightened when they undergo routine exams and procedures. Hospitals can be confusing, disorienting and frightening places. As providers we have to remember that our experience of exams, procedures, medical environments may be very different from our patients. We may fail to perceive the fear, the fright, and the potential for trauma. We may need to take more steps in order to not do harm at the same time as we try to do good. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I have wanted to tell this patient’s story for a while. I have tried to convince her to tell it – because I believe it would somehow be therapeutic. But I haven’t been able to convince her yet. In the past week I met another patient who had a very similar story. When I learned that I would be writing my final official blog for ModernMedicine I decided that it was my opportunity to share this story. I have a patient who is, thankfully, quite healthy. At least I believe she is healthy. She won’t really let me do any testing. In fact, apart from delivering a wonderful holiday gift each year, it could be several years between visits. When I met her several decades ago she told me that she is deeply frightened of physicians and medical facilities. She recounted her story of having a condition as a child that was monitored regularly, according to the standards of the early 1950’s. Several times each year for most of her childhood and adolescence, she attended an outpatient clinic where she and dozens of others would be undressed, and sat on a row of benches in an unheated corridor, waiting to be called one by one to an equally cold office to be examined by a team of physicians. Few words were exchanged. Instead, she felt the stern glare of men in white coats as they scowled at the children and muttered among themselves. Parents sat somewhere outside this corridor—inaccessible. A day of school would be missed each time—adding to the weight of this ritual, but little was said before or after. Was this punishment for some unnamed infraction? Was there something terribly and irrevocably wrong with her body? With her person? To this day, she has not been able to submit to a mammogram, much less a colonoscopy. Her few pelvic exams have necessitated a hastily planned appointment when the health center doors open (an hour before scheduled appointments) so that her anxiety will not have time to mount and send her fleeing. I have been haunted by this story, and have tried unsuccessfully to help her address her fears. I hope that I am in practice long enough to witness some sort of resolution, some relief from the terror that has held her prisoner for so many years. Last week, while doing my weeks of in-patient attending, I met another patient, about the same age, who as a child required regular outpatient visits for a different medical problem. Her story was virtually identical: undressed, the cold corridor, the frowns and scowls, the mutterings, the self-doubts, self-blame. This patient was less fortunate in that a series of serious illnesses have brought her into the medical world throughout her life. Instead of fleeing, she seeks to take full control. She appears to be in a constant state of panic. She questions everything, writes everything down. But her questions and lists are panicked, often incoherent. She self-diagnoses and self-medicates because she doesn’t fully trust any of her many providers. Both women were cared for in “the best hospitals.” Both had parents who had probably sacrificed to get their daughters “the best care.” I assume that there was no malicious intent on the part of the physicians who took care of these young children. On the country, I assume that everyone thought they were doing their very best. That is actually what frightens me the most. These two women and I assume hundreds, maybe thousands, of children who received this type of care and treatment, have been scarred to some extent. In the past 100 years, and especially in the past 25 years, a great deal has been learned about trauma. A traumatic experience is one in which the victim feels frightened, often mortally so, feels that he or she has no control, and feels that his or her escape is blocked. We now know that trauma does not only come in the form of a monster, a rapist, or a murderer. Many seemingly ordinary experiences can be traumatic, including experiences in an environment that is supposed to be for one’s own good. In fact, a traumatic experience that comes at the hands of someone who is supposed to be a trusted and caring figure (such as a physician), particularly at a vulnerable age (childhood), or at a vulnerable time (undressed, in a strange environment) can be all the more traumatic. There are few traumatic experiences that lead to prolonged traumatic responses 100% of the time. I suspect that my 2 patients are unusual in their responses. But I doubt that they are alone. What do I learn from this? We all explicitly or implicitly vow Primum non nocere. Physicians in the 1940’s and 50’s undoubtedly took the same vow. However, we may not understand what the immediate and long term impact of some of our diagnostic and therapeutic actions may be. Recent generations of pediatricians have been taught to think about this. Parents accompany children to exams and procedures; sleep in their children’s hospital rooms. Child life specialists help children understand medical procedures, demystify needles and other medical devices. Children are not the only vulnerable group, however. Adults are vulnerable when they are ill. Many adults, even those who are well, are frightened when they undergo routine exams and procedures. Hospitals can be confusing, disorienting and frightening places. As providers we have to remember that our experience of exams, procedures, medical environments may be very different from our patients. We may fail to perceive the fear, the fright, and the potential for trauma. We may need to take more steps in order to not do harm at the same time as we try to do good. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Thu, 05 Jan 2012 00:40:50 GMT http://community.modernmedicine.com/_Primum-non-nocere-First-do-no-harm/blog/5691370/33379.html bgottlieb 2012-01-05T00:39:59Z Primary Care Modern Medicine Community I have wanted to tell this patient’s story for a while. I have tried to convince her to tell it – because I believe it would somehow be therapeutic. But I haven’t been able to convince her yet. In the past week I met another patient who had a very similar story. When I learned that I would be writing my final official blog for ModernMedicine I decided that it was my opportunity to share this story. I have a patient who is, thankfully, quite healthy. At least I believe she is healthy. She won’t really let me do any testing. In fact, apart from delivering a wonderful holiday gift each year, it could be several years between visits. When I met her several decades ago she told me that she is deeply frightened of physicians and medical facilities. She recounted her story of having a condition as a child that was monitored regularly, according to the standards of the early 1950’s. Several times each year for most of her childhood and adolescence, she attended an outpatient clinic where she and dozens of others would be undressed, and sat on a row of benches in an unheated corridor, waiting to be called one by one to an equally cold office to be examined by a team of physicians. Few words were exchanged. Instead, she felt the stern glare of men in white coats as they scowled at the children and muttered among themselves. Parents sat somewhere outside this corridor—inaccessible. A day of school would be missed each time—adding to the weight of this ritual, but little was said before or after. Was this punishment for some unnamed infraction? Was there something terribly and irrevocably wrong with her body? With her person? To this day, she has not been able to submit to a mammogram, much less a colonoscopy. Her few pelvic exams have necessitated a hastily planned appointment when the health center doors open (an hour before scheduled appointments) so that her anxiety will not have time to mount and send her fleeing. I have been haunted by this story, and have tried unsuccessfully to help her address her fears. I hope that I am in practice long enough to witness some sort of resolution, some relief from the terror that has held her prisoner for so many years. Last week, while doing my weeks of in-patient attending, I met another patient, about the same age, who as a child required regular outpatient visits for a different medical problem. Her story was virtually identical: undressed, the cold corridor, the frowns and scowls, the mutterings, the self-doubts, self-blame. This patient was less fortunate in that a series of serious illnesses have brought her into the medical world throughout her life. Instead of fleeing, she seeks to take full control. She appears to be in a constant state of panic. She questions everything, writes everything down. But her questions and lists are panicked, often incoherent. She self-diagnoses and self-medicates because she doesn’t fully trust any of her many providers. Both women were cared for in “the best hospitals.” Both had parents who had probably sacrificed to get their daughters “the best care.” I assume that there was no malicious intent on the part of the physicians who took care of these young children. On the country, I assume that everyone thought they were doing their very best. That is actually what frightens me the most. These two women and I assume hundreds, maybe thousands, of children who received this type of care and treatment, have been scarred to some extent. In the past 100 years, and especially in the past 25 years, a great deal has been learned about trauma. A traumatic experience is one in which the victim feels frightened, often mortally so, feels that he or she has no control, and feels that his or her escape is blocked. We now know that trauma does not only come in the form of a monster, a rapist, or a murderer. Many seemingly ordinary experiences can be traumatic, including experiences in an environment that is supposed to be for one’s own good. In fact, a traumatic experience that comes at the hands of someone who is supposed to be a trusted and caring figure (such as a physician), particularly at a vulnerable age (childhood), or at a vulnerable time (undressed, in a strange environment) can be all the more traumatic. There are few traumatic experiences that lead to prolonged traumatic responses 100% of the time. I suspect that my 2 patients are unusual in their responses. But I doubt that they are alone. What do I learn from this? We all explicitly or implicitly vow Primum non nocere. Physicians in the 1940’s and 50’s undoubtedly took the same vow. However, we may not understand what the immediate and long term impact of some of our diagnostic and therapeutic actions may be. Recent generations of pediatricians have been taught to think about this. Parents accompany children to exams and procedures; sleep in their children’s hospital rooms. Child life specialists help children understand medical procedures, demystify needles and other medical devices. Children are not the only vulnerable group, however. Adults are vulnerable when they are ill. Many adults, even those who are well, are frightened when they undergo routine exams and procedures. Hospitals can be confusing, disorienting and frightening places. As providers we have to remember that our experience of exams, procedures, medical environments may be very different from our patients. We may fail to perceive the fear, the fright, and the potential for trauma. We may need to take more steps in order to not do harm at the same time as we try to do good. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] mmglobal, primary care nonadult false Primum non nocere (First do no harm) text blog mmglobal,primary care 3164 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 5691370 2771822 Member 0 http://community.modernmedicine.com/_Depression-A-Few-Male-Patients/blog/5643349/33379.html Depression affects an estimated 121 million people worldwide. Despite the fact that there are known, safe, and effective treatments using a variety of modalities, fewer than 1/4 of affected individuals have access to any of these. In some parts of the world that figure is 1/10. According to the World Health Organization, depression is the leading cause of YLD (Years Lived with Disability), and the 4th leading contributor to DALYs (Disability Adjusted Life Years) for all age groups, and the second leading cause of DALYs  for men and women ages 15-44 (year 2000). It is projected to be the second leading cause of DALYs in the year 2020.1 Primary care providers have a key role in both identifying and treating depression. The estimated prevalence in primary care settings is 5-13%2. Similar to other illnesses that are diagnosed in primary care, we treat 1/3 to ½ of depressed non-elderly adults.3  An even higher percentage of depressed elders who receive treatment are treated by primary care providers.4   Also similar to other illnesses, the severity of depression that we treat in primary care is comparable to that treated by psychiatrists. For example, 43% of depressed patients receiving care in primary care settings report suicidal thoughts in the previous week.5 At my health center, we screen all patients for depression and behavioral risks (substance abuse, exposure to violence) at initial and annual visits. Our practice is consistent with the US Preventive Services Task Force (USPSTF) 2002 recommendation that clinical practices that have systems for referral and follow-up screen for depression among adults. In my experience, the “yield” – the ability of a screening tool to detect a potential case of depression, improves as patients and practitioners become more familiar with it. I have been using our screening tool, which includes the PHQ-96 for depression and suicidal thoughts, for the past 5 years. However, it is only recently that I have begun to detect depressed mood among significant numbers of my male patients. One of my patients is an African-American man in his 50’s. He sustained a series of back injuries at his factory job, managing to keep working more than full time for several years despite his pain until a piece of equipment – a human lift – broke, causing him to fall and seriously damage his lumbar spine. He has lived with severe pain for 3 years despite aggressive pain management. His workplace will not accommodate his reduced physical capacity, so he will become permanently disabled. At his most recent annual visit, he screened positive for depressive symptoms, without suicidal thoughts or substance abuse.  He was not aware that he was depressed, only that he was “down.” I was surprised that he was as willing as he was to see a counselor. He reports that the support “really helps.” Another patient, Dominican, in his 40’s, has multiple chronic medical conditions. He has an elementary school education, speaks only Spanish and works two part-time jobs as a janitor. He is in the US as a legal immigrant, but his wife has been unable to get legal status. He is separated from her most of the year. He would return, but he is responsible for the care of his elderly, chronically ill mother (also my patient). He had not been sleeping well, and was suffering from fatigue and symptoms of anxiety. He had no suicidal thoughts, but his alcohol use had increased. When I told him that his screening test for depression was positive, he responded that he didn’t believe that he was depressed – just a bit worried. He did not want to see a counselor, nor was he interested in medication for depression, until I told him that there are medications that treating his depression might also help him sleep better. Last week, another patient actually came to me because he was concerned that “something might be wrong with my mind.” He is European, Italian, and has worked since he arrived in the US at the age of 12. He recently retired, and has been having difficulty falling asleep. He worries about his finances, about what it means to not be working. He worries about his 2 daughters (both grown, both my patients) and his ability to help them as their lone parent. (his wife, also my patient, died several years ago of cancer). He reconnected with a counselor whom he saw a few times when his wife died – and after a few visits feels “more like himself.” The following have been listed as indications for screening for depression in adults:7 Having a first degree biological relative with a history of depression 2 or more chronic diseases Obesity Chronic pain Financial strain Experiencing major life changes Pregnant or post partum Socially isolated Multiple vague symptoms (gastrointestinal, musculo-skeletal, neurologic) Fatigue or sleep disturbance Substance abuse – alcohol or use of street drugs Loss of interest in sexual activity Elderly age Most of these indications would apply to most of my patients – an argument that not only supports our screening practice, but suggests that we might screen even more frequently than annually – such as in the face of major life changes, chronic pain, financial strain – common scenarios in primary care, like my 3 patients. Even if my patients don’t immediately endorse the term depression, they express some degree of relief to learn that their distress is not simply a sign of weakness, a character flaw that they should just “get over.”  Often patients are surprised when I tell them that depression is like diabetes – there are specific ways of diagnosing it, describing it and measuring it, and most importantly, that it can be treated.  They are intrigued when I tell them that depression is a complex illness, with both genetic and environmental influences.8 While confronting the stigma associated with depression is important for everyone, it is particularly important for male patients who in many cultures are socialized to define themselves as emotionally “strong”, rational, and therefore not given to depression.  Perhaps as a clinician, the more males I see with diagnosable depression, the better I will get at diagnosing depression in males, even when its presentation is atypical. It is gratifying when people feel better.  Of my three anecdotal patients, two are feeling better. The third is not, yet.  But how are we doing with treating depression in primary care? The USPTSF specifies in its screening recommendation that sites that are capable of providing referral and follow-up screen their patients. Indeed, screening and case finding is not enough. There have been a number of studies that have reviewed outcomes for depression in primary care. There is compelling evidence that primary care programs that combine screening with feedback to providers and additional services and/or staff to support the primary care providers in caring for depressed patients improve the health of their patients. Programs that do not enhance the resources and/or staff available in primary care do not demonstrate benefit. The most effective programs are comprehensive and include the following elements: clinical training and specific treatment protocols carried out at the point of care, patient education materials, office staff training, post-visit follow-up, and mental health referrals or back-up to primary care clinicians.9 As for durability of effect and program sustainability, much of the evidence is based on short-term interventions and short-term benefits.  The Depression in Primary Care Study compared five primary care practices in the University of Michigan Health System with 5 matched control sites.10 Clinicians at intervention sites were free to refer all, some or none of their patients to a range of interventions that included telephone case management and monitoring by a mental health clinician with psychiatrist back-up, patient activation and self-management assistance using group visits and motivational interviewing techniques, and frequent updates to primary care clinicians.  Intervention patients demonstrated greater improvement in depression scores at 6 and 18 months than control subjects, with statistically significantly greater numbers in remission at 12 and 18 months than controls. Although this study was not a fully randomized, controlled clinical trial, it was a large study that involved clinical sites that serve medically and socially complex patients. The sites themselves were busy, with a great deal of staff turn-over and complex workflow. The authors note that the patients who were enrolled in the study had chronic depressive symptoms despite ongoing treatment. For these reasons, the study findings are potentially valid and applicable to many primary care settings, including my own.  In addition, the relatively low-resource requirements of telephone management and multiple check-ins with patients and providers is affordable and sustainable, and consistent with care management programs for a range of chronic diseases. Depression affects morbidity and mortality directly, through its immediate and long-term effect on well-being and its role in suicide. Depression also has an impact on health and well-being through its effects on risks, adherence to care, and its shared pathophysiologic pathways with many common chronic illnesses including cardiovascular disease, obesity and diabetes. When I introduced myself to the residents on my in-patient team last year, one asked, “What is your specialty?” I responded that I don’t have a specialty, that I am a generalist. After our first week together the same resident came to me and said, “I think I’ve figured out what your specialty is.” I was eager to hear. “You specialize in taking care of people with multiple, complex, chronic diseases.” I thought that captured my work. And all too often depression has a place on that long list of diseases. References 1. http://www.who.int/mental_health/management/depression/definition/en/ Accessed November 27, 2011 4:36 PM 2. Hain DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder; results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005: 62:1097-1106. 3. Pincus HA, Tanielian TL, Marcus SC et al. Prescribing trends in psychotropic medications: primary care, psychiatry and other medical specialties. JAMA. 1998; 279:526-531. 4. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006; 21:926-930. 5. Gaynes BN, Rush AJ, Trivedi MH, et al. Major depression symptoms in primary care and psychiatric care settings: A cross-sectional analysis. Ann Fam Med. 2007; 5:126-34. 6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med; 2001; 16(9):606-613. 7. Sharp LK, Lipsky MS. Screening for depression across the lifespan: A review of measures for use in primary care settings. Am Fam Physician; 2002; 66(6): 1001-1009. 8. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry; 2000; 157: 1552-1562. 9. O’Connor EA, Whitlock EP, Bell TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Ann Intern Med. 2009;151:793-803. 10. Klinkman MS, Bauroth S, Fedewa S. et al. Long-term clinical outcomes of care management for chronically depressed primary care patients: A report from the depression in primary care project. Annals of Family Medicine; 2010; 8(5):387-396. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.   [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Depression affects an estimated 121 million people worldwide. Despite the fact that there are known, safe, and effective treatments using a variety of modalities, fewer than 1/4 of affected individuals have access to any of these. In some parts of the world that figure is 1/10. According to the World Health Organization, depression is the leading cause of YLD (Years Lived with Disability), and the 4th leading contributor to DALYs (Disability Adjusted Life Years) for all age groups, and the second leading cause of DALYs  for men and women ages 15-44 (year 2000). It is projected to be the second leading cause of DALYs in the year 2020.1 Primary care providers have a key role in both identifying and treating depression. The estimated prevalence in primary care settings is 5-13%2. Similar to other illnesses that are diagnosed in primary care, we treat 1/3 to ½ of depressed non-elderly adults.3  An even higher percentage of depressed elders who receive treatment are treated by primary care providers.4   Also similar to other illnesses, the severity of depression that we treat in primary care is comparable to that treated by psychiatrists. For example, 43% of depressed patients receiving care in primary care settings report suicidal thoughts in the previous week.5 At my health center, we screen all patients for depression and behavioral risks (substance abuse, exposure to violence) at initial and annual visits. Our practice is consistent with the US Preventive Services Task Force (USPSTF) 2002 recommendation that clinical practices that have systems for referral and follow-up screen for depression among adults. In my experience, the “yield” – the ability of a screening tool to detect a potential case of depression, improves as patients and practitioners become more familiar with it. I have been using our screening tool, which includes the PHQ-96 for depression and suicidal thoughts, for the past 5 years. However, it is only recently that I have begun to detect depressed mood among significant numbers of my male patients. One of my patients is an African-American man in his 50’s. He sustained a series of back injuries at his factory job, managing to keep working more than full time for several years despite his pain until a piece of equipment – a human lift – broke, causing him to fall and seriously damage his lumbar spine. He has lived with severe pain for 3 years despite aggressive pain management. His workplace will not accommodate his reduced physical capacity, so he will become permanently disabled. At his most recent annual visit, he screened positive for depressive symptoms, without suicidal thoughts or substance abuse.  He was not aware that he was depressed, only that he was “down.” I was surprised that he was as willing as he was to see a counselor. He reports that the support “really helps.” Another patient, Dominican, in his 40’s, has multiple chronic medical conditions. He has an elementary school education, speaks only Spanish and works two part-time jobs as a janitor. He is in the US as a legal immigrant, but his wife has been unable to get legal status. He is separated from her most of the year. He would return, but he is responsible for the care of his elderly, chronically ill mother (also my patient). He had not been sleeping well, and was suffering from fatigue and symptoms of anxiety. He had no suicidal thoughts, but his alcohol use had increased. When I told him that his screening test for depression was positive, he responded that he didn’t believe that he was depressed – just a bit worried. He did not want to see a counselor, nor was he interested in medication for depression, until I told him that there are medications that treating his depression might also help him sleep better. Last week, another patient actually came to me because he was concerned that “something might be wrong with my mind.” He is European, Italian, and has worked since he arrived in the US at the age of 12. He recently retired, and has been having difficulty falling asleep. He worries about his finances, about what it means to not be working. He worries about his 2 daughters (both grown, both my patients) and his ability to help them as their lone parent. (his wife, also my patient, died several years ago of cancer). He reconnected with a counselor whom he saw a few times when his wife died – and after a few visits feels “more like himself.” The following have been listed as indications for screening for depression in adults:7 Having a first degree biological relative with a history of depression 2 or more chronic diseases Obesity Chronic pain Financial strain Experiencing major life changes Pregnant or post partum Socially isolated Multiple vague symptoms (gastrointestinal, musculo-skeletal, neurologic) Fatigue or sleep disturbance Substance abuse – alcohol or use of street drugs Loss of interest in sexual activity Elderly age Most of these indications would apply to most of my patients – an argument that not only supports our screening practice, but suggests that we might screen even more frequently than annually – such as in the face of major life changes, chronic pain, financial strain – common scenarios in primary care, like my 3 patients. Even if my patients don’t immediately endorse the term depression, they express some degree of relief to learn that their distress is not simply a sign of weakness, a character flaw that they should just “get over.”  Often patients are surprised when I tell them that depression is like diabetes – there are specific ways of diagnosing it, describing it and measuring it, and most importantly, that it can be treated.  They are intrigued when I tell them that depression is a complex illness, with both genetic and environmental influences.8 While confronting the stigma associated with depression is important for everyone, it is particularly important for male patients who in many cultures are socialized to define themselves as emotionally “strong”, rational, and therefore not given to depression.  Perhaps as a clinician, the more males I see with diagnosable depression, the better I will get at diagnosing depression in males, even when its presentation is atypical. It is gratifying when people feel better.  Of my three anecdotal patients, two are feeling better. The third is not, yet.  But how are we doing with treating depression in primary care? The USPTSF specifies in its screening recommendation that sites that are capable of providing referral and follow-up screen their patients. Indeed, screening and case finding is not enough. There have been a number of studies that have reviewed outcomes for depression in primary care. There is compelling evidence that primary care programs that combine screening with feedback to providers and additional services and/or staff to support the primary care providers in caring for depressed patients improve the health of their patients. Programs that do not enhance the resources and/or staff available in primary care do not demonstrate benefit. The most effective programs are comprehensive and include the following elements: clinical training and specific treatment protocols carried out at the point of care, patient education materials, office staff training, post-visit follow-up, and mental health referrals or back-up to primary care clinicians.9 As for durability of effect and program sustainability, much of the evidence is based on short-term interventions and short-term benefits.  The Depression in Primary Care Study compared five primary care practices in the University of Michigan Health System with 5 matched control sites.10 Clinicians at intervention sites were free to refer all, some or none of their patients to a range of interventions that included telephone case management and monitoring by a mental health clinician with psychiatrist back-up, patient activation and self-management assistance using group visits and motivational interviewing techniques, and frequent updates to primary care clinicians.  Intervention patients demonstrated greater improvement in depression scores at 6 and 18 months than control subjects, with statistically significantly greater numbers in remission at 12 and 18 months than controls. Although this study was not a fully randomized, controlled clinical trial, it was a large study that involved clinical sites that serve medically and socially complex patients. The sites themselves were busy, with a great deal of staff turn-over and complex workflow. The authors note that the patients who were enrolled in the study had chronic depressive symptoms despite ongoing treatment. For these reasons, the study findings are potentially valid and applicable to many primary care settings, including my own.  In addition, the relatively low-resource requirements of telephone management and multiple check-ins with patients and providers is affordable and sustainable, and consistent with care management programs for a range of chronic diseases. Depression affects morbidity and mortality directly, through its immediate and long-term effect on well-being and its role in suicide. Depression also has an impact on health and well-being through its effects on risks, adherence to care, and its shared pathophysiologic pathways with many common chronic illnesses including cardiovascular disease, obesity and diabetes. When I introduced myself to the residents on my in-patient team last year, one asked, “What is your specialty?” I responded that I don’t have a specialty, that I am a generalist. After our first week together the same resident came to me and said, “I think I’ve figured out what your specialty is.” I was eager to hear. “You specialize in taking care of people with multiple, complex, chronic diseases.” I thought that captured my work. And all too often depression has a place on that long list of diseases. References 1. http://www.who.int/mental_health/management/depression/definition/en/ Accessed November 27, 2011 4:36 PM 2. Hain DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder; results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005: 62:1097-1106. 3. Pincus HA, Tanielian TL, Marcus SC et al. Prescribing trends in psychotropic medications: primary care, psychiatry and other medical specialties. JAMA. 1998; 279:526-531. 4. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006; 21:926-930. 5. Gaynes BN, Rush AJ, Trivedi MH, et al. Major depression symptoms in primary care and psychiatric care settings: A cross-sectional analysis. Ann Fam Med. 2007; 5:126-34. 6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med; 2001; 16(9):606-613. 7. Sharp LK, Lipsky MS. Screening for depression across the lifespan: A review of measures for use in primary care settings. Am Fam Physician; 2002; 66(6): 1001-1009. 8. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry; 2000; 157: 1552-1562. 9. O’Connor EA, Whitlock EP, Bell TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Ann Intern Med. 2009;151:793-803. 10. Klinkman MS, Bauroth S, Fedewa S. et al. Long-term clinical outcomes of care management for chronically depressed primary care patients: A report from the depression in primary care project. Annals of Family Medicine; 2010; 8(5):387-396. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.   [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Wed, 14 Dec 2011 15:56:41 GMT http://community.modernmedicine.com/_Depression-A-Few-Male-Patients/blog/5643349/33379.html bgottlieb 2011-12-14T15:55:34Z Primary Care Modern Medicine Community Depression affects an estimated 121 million people worldwide. Despite the fact that there are known, safe, and effective treatments using a variety of modalities, fewer than 1/4 of affected individuals have access to any of these. In some parts of the world that figure is 1/10. According to the World Health Organization, depression is the leading cause of YLD (Years Lived with Disability), and the 4th leading contributor to DALYs (Disability Adjusted Life Years) for all age groups, and the second leading cause of DALYs  for men and women ages 15-44 (year 2000). It is projected to be the second leading cause of DALYs in the year 2020.1 Primary care providers have a key role in both identifying and treating depression. The estimated prevalence in primary care settings is 5-13%2. Similar to other illnesses that are diagnosed in primary care, we treat 1/3 to ½ of depressed non-elderly adults.3  An even higher percentage of depressed elders who receive treatment are treated by primary care providers.4   Also similar to other illnesses, the severity of depression that we treat in primary care is comparable to that treated by psychiatrists. For example, 43% of depressed patients receiving care in primary care settings report suicidal thoughts in the previous week.5 At my health center, we screen all patients for depression and behavioral risks (substance abuse, exposure to violence) at initial and annual visits. Our practice is consistent with the US Preventive Services Task Force (USPSTF) 2002 recommendation that clinical practices that have systems for referral and follow-up screen for depression among adults. In my experience, the “yield” – the ability of a screening tool to detect a potential case of depression, improves as patients and practitioners become more familiar with it. I have been using our screening tool, which includes the PHQ-96 for depression and suicidal thoughts, for the past 5 years. However, it is only recently that I have begun to detect depressed mood among significant numbers of my male patients. One of my patients is an African-American man in his 50’s. He sustained a series of back injuries at his factory job, managing to keep working more than full time for several years despite his pain until a piece of equipment – a human lift – broke, causing him to fall and seriously damage his lumbar spine. He has lived with severe pain for 3 years despite aggressive pain management. His workplace will not accommodate his reduced physical capacity, so he will become permanently disabled. At his most recent annual visit, he screened positive for depressive symptoms, without suicidal thoughts or substance abuse.  He was not aware that he was depressed, only that he was “down.” I was surprised that he was as willing as he was to see a counselor. He reports that the support “really helps.” Another patient, Dominican, in his 40’s, has multiple chronic medical conditions. He has an elementary school education, speaks only Spanish and works two part-time jobs as a janitor. He is in the US as a legal immigrant, but his wife has been unable to get legal status. He is separated from her most of the year. He would return, but he is responsible for the care of his elderly, chronically ill mother (also my patient). He had not been sleeping well, and was suffering from fatigue and symptoms of anxiety. He had no suicidal thoughts, but his alcohol use had increased. When I told him that his screening test for depression was positive, he responded that he didn’t believe that he was depressed – just a bit worried. He did not want to see a counselor, nor was he interested in medication for depression, until I told him that there are medications that treating his depression might also help him sleep better. Last week, another patient actually came to me because he was concerned that “something might be wrong with my mind.” He is European, Italian, and has worked since he arrived in the US at the age of 12. He recently retired, and has been having difficulty falling asleep. He worries about his finances, about what it means to not be working. He worries about his 2 daughters (both grown, both my patients) and his ability to help them as their lone parent. (his wife, also my patient, died several years ago of cancer). He reconnected with a counselor whom he saw a few times when his wife died – and after a few visits feels “more like himself.” The following have been listed as indications for screening for depression in adults:7 Having a first degree biological relative with a history of depression 2 or more chronic diseases Obesity Chronic pain Financial strain Experiencing major life changes Pregnant or post partum Socially isolated Multiple vague symptoms (gastrointestinal, musculo-skeletal, neurologic) Fatigue or sleep disturbance Substance abuse – alcohol or use of street drugs Loss of interest in sexual activity Elderly age Most of these indications would apply to most of my patients – an argument that not only supports our screening practice, but suggests that we might screen even more frequently than annually – such as in the face of major life changes, chronic pain, financial strain – common scenarios in primary care, like my 3 patients. Even if my patients don’t immediately endorse the term depression, they express some degree of relief to learn that their distress is not simply a sign of weakness, a character flaw that they should just “get over.”  Often patients are surprised when I tell them that depression is like diabetes – there are specific ways of diagnosing it, describing it and measuring it, and most importantly, that it can be treated.  They are intrigued when I tell them that depression is a complex illness, with both genetic and environmental influences.8 While confronting the stigma associated with depression is important for everyone, it is particularly important for male patients who in many cultures are socialized to define themselves as emotionally “strong”, rational, and therefore not given to depression.  Perhaps as a clinician, the more males I see with diagnosable depression, the better I will get at diagnosing depression in males, even when its presentation is atypical. It is gratifying when people feel better.  Of my three anecdotal patients, two are feeling better. The third is not, yet.  But how are we doing with treating depression in primary care? The USPTSF specifies in its screening recommendation that sites that are capable of providing referral and follow-up screen their patients. Indeed, screening and case finding is not enough. There have been a number of studies that have reviewed outcomes for depression in primary care. There is compelling evidence that primary care programs that combine screening with feedback to providers and additional services and/or staff to support the primary care providers in caring for depressed patients improve the health of their patients. Programs that do not enhance the resources and/or staff available in primary care do not demonstrate benefit. The most effective programs are comprehensive and include the following elements: clinical training and specific treatment protocols carried out at the point of care, patient education materials, office staff training, post-visit follow-up, and mental health referrals or back-up to primary care clinicians.9 As for durability of effect and program sustainability, much of the evidence is based on short-term interventions and short-term benefits.  The Depression in Primary Care Study compared five primary care practices in the University of Michigan Health System with 5 matched control sites.10 Clinicians at intervention sites were free to refer all, some or none of their patients to a range of interventions that included telephone case management and monitoring by a mental health clinician with psychiatrist back-up, patient activation and self-management assistance using group visits and motivational interviewing techniques, and frequent updates to primary care clinicians.  Intervention patients demonstrated greater improvement in depression scores at 6 and 18 months than control subjects, with statistically significantly greater numbers in remission at 12 and 18 months than controls. Although this study was not a fully randomized, controlled clinical trial, it was a large study that involved clinical sites that serve medically and socially complex patients. The sites themselves were busy, with a great deal of staff turn-over and complex workflow. The authors note that the patients who were enrolled in the study had chronic depressive symptoms despite ongoing treatment. For these reasons, the study findings are potentially valid and applicable to many primary care settings, including my own.  In addition, the relatively low-resource requirements of telephone management and multiple check-ins with patients and providers is affordable and sustainable, and consistent with care management programs for a range of chronic diseases. Depression affects morbidity and mortality directly, through its immediate and long-term effect on well-being and its role in suicide. Depression also has an impact on health and well-being through its effects on risks, adherence to care, and its shared pathophysiologic pathways with many common chronic illnesses including cardiovascular disease, obesity and diabetes. When I introduced myself to the residents on my in-patient team last year, one asked, “What is your specialty?” I responded that I don’t have a specialty, that I am a generalist. After our first week together the same resident came to me and said, “I think I’ve figured out what your specialty is.” I was eager to hear. “You specialize in taking care of people with multiple, complex, chronic diseases.” I thought that captured my work. And all too often depression has a place on that long list of diseases. References 1. http://www.who.int/mental_health/management/depression/definition/en/ Accessed November 27, 2011 4:36 PM 2. Hain DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder; results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005: 62:1097-1106. 3. Pincus HA, Tanielian TL, Marcus SC et al. Prescribing trends in psychotropic medications: primary care, psychiatry and other medical specialties. JAMA. 1998; 279:526-531. 4. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006; 21:926-930. 5. Gaynes BN, Rush AJ, Trivedi MH, et al. Major depression symptoms in primary care and psychiatric care settings: A cross-sectional analysis. Ann Fam Med. 2007; 5:126-34. 6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med; 2001; 16(9):606-613. 7. Sharp LK, Lipsky MS. Screening for depression across the lifespan: A review of measures for use in primary care settings. Am Fam Physician; 2002; 66(6): 1001-1009. 8. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry; 2000; 157: 1552-1562. 9. O’Connor EA, Whitlock EP, Bell TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Ann Intern Med. 2009;151:793-803. 10. Klinkman MS, Bauroth S, Fedewa S. et al. Long-term clinical outcomes of care management for chronically depressed primary care patients: A report from the depression in primary care project. Annals of Family Medicine; 2010; 8(5):387-396. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.   [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] depression, primary care nonadult false Depression: A Few Male Patients text blog depression,primary care 863 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 5643349 2771822 Member 0 http://community.modernmedicine.com/_Smoking-HistoryThe-5th-Vital-Sign/blog/5499425/33379.html I don’t know if my patients are representative of national trends, but it seems to me that I am seeing more people who smoke. I don’t mean brand new smokers. I mean people who used to smoke, who seemed to have quit solidly, and who are smoking again. The medical assistants at my health center obtain a smoking history (current, past, never) while they take vital signs.  This practice, imposed by our state’s department of public health, works.  Smoking history is recorded between blood pressure and LMP on the green cover sheet. It becomes, as it should, a piece of data that I must incorporate into each visit. It is, in a way, the 5th vital sign. Unlike the other vital signs, however, it is a bit less clear what I am supposed to do about this. Fever, tachycardia, hypertension…I know what to do next. Evidence-based practices and clinical protocols work best for problems whose resolution lie squarely in the physician’s hands. Even these are subject to individual variation, clinical inertia, omission in the face of competing clinical demands, and nuanced interpretation. But when the issue involves a patient’s behavior, especially one that involves addiction, habit and social meaning, the search for evidence-based practices that truly translate to this patient at this time comes up short. “Can’t you give me a pill?” some patients implore. And, of course, there are several. I have used chantix (varenicline). This has worked for some people. In my experience, it has been most successful for the smoker who truly enjoys smoking. If a person can tolerate the unsettling dreams (dream disorder 9-13%, insomnia 18-19% according to KnowledgeLink estimates), he or she is often able to get over that first hump of intense craving and feeling of loss as one puts aside a longstanding habit. These patients tell me that it is like losing a friend. I am honest with them: I’ll never know. I’ve never touched a cigarette. My grandfather died of lung cancer. My father lost a lung to a combination of smoking and years of welding in shipyards and unregulated factories. If I would have even considered smoking I would have risked immediate death at my parents’ hands! I have had some success with wellbutrin/zyban (buproprion.) My patients tell me that this helps with the compulsion to smoke, and their addiction to some of the rituals associated with tobacco use—the lighting up, the oral fixation. Although this medication carries the same black box warning that other antidepressants carry, that it can worsen depression and intensify suicidal ideation and impulses, these  have not been a problem in my experience.  It simply doesn’t work for very many people. So while I try to make all therapeutic recommendations with some degree of optimism, I always provide a note of realism:  “There isn’t anything that works for everyone; if this doesn’t work, we’ll keep trying.” It’s the same with nicotine patches, gum, sprays. They work for some people, sometimes. Hypnotism, acupuncture—less widely available—also work for some, not all. The unpredictability of success with any of the available strategies is one part of the challenge, and is, in a way, not unlike the challenge of controlling hypertension. You keep trying—if the patient can stick with it.  The larger challenge, however, is in addressing the social factors that compete with successful initial cessation and that continue to compete with maintenance of cessation. A British researcher Hilary Graham who wrote about smoking among women in the United Kingdom during the 1990’s provided me with a clinically useful insight when she noted that women often smoke as a break from children or work, a little gift amidst a stressful life. As a physician and public health practitioner, steeped in the evils of tobacco, I don’t automatically think of smoking in a positive light. But, of course! People generally do things for positive rather than negative reasons. It made me realize that unless I can understand what my smoking patients  get out of their habit in a positive sense and, more importantly, unless my patients understand, they probably won’t succeed, or won’t succeed for very long, at stopping. So—on my good days in clinic, when I have the time and when there aren’t 10 other things to do in my all-too-brief visit, I will ask. “What do you get out of smoking? What do you love—or at least—what do you like about it?” This will typically draw a surprised reaction. They were expecting me to ask what they hated about smoking, and were prepared with the familiar list: It’s a disgusting habit. It stinks. It’s bad for my health. It’s bad for my children’s health. They are always tentative as they begin to reveal their list of positives. Most of them have to do with stress reduction.  “Relief.” “ A break.” “Time for myself.” This discussion, more than a discussion in which they feel berated, or embarrassed that they do something that is clearly so bad for their health, opens the door. Now we can get into it. Behavior change is difficult. Most people will have difficulty sustaining a new behavior if they feel deprived. We discuss this, and I give them their first smoking cessation assignment: think about what you could give to yourself if you take away smoking. How can you get “relief?” How can you get a little “time for yourself?” This does not mean that following this discussion 100% of my patients quit smoking. Far from it. But this discussion does introduce a paradigm shift that seems to contribute directly or indirectly to important behavior change. I know this because it is one of the things that I hear about later. Perhaps at the next visit; perhaps as much as six months or a year later. Countless patients have said to me that they had never thought about smoking that way, and it helped them understand their habit, and what got in the way of changing it. Many of us have been taught that physicians can play a small but significant role in motivating patients to quit smoking.1 A recent Cochrane review of physician advice for smoking cessation evaluated the evidence to support this claim. The specific objective of the review was to “assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation; and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.”2 The authors reviewed 41 trials conducted from 1972-2007, involving over 31,000 smokers. They pooled data from 17 trials of brief advice versus no advice or usual care, and detected a significant increase in the rate of quitting (RR 1.66, 95% CI 1.42-1.94). In 11 trials that involved a more intensive intervention, the estimated effect was greater (RR 1.84, 95% CI 1.60-2.13). However, there was no statistical difference  between the intensive and the minimal subgroups. When intensive interventions were compared to minimal advice, there was a small advantage found for the intensive advice (RR 1.37, 95% CI 1.20-1.56). The authors found only 1 study that evaluated the effect of smoking advice on mortality. In this study, there was no statistically significant difference in death rate at 20 years. The authors’ conclusion was the following: “Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.” Sobering. Humbling. Rather than focusing on the modest size of this incremental benefit over unassisted quit rates, the authors focus on the one hand, on the lack of evidence for more intensive advice, and on the other—on the importance of making sure that those in need of physicians’ simple advice actually receive it. “The results of this review indicate the potential benefit from brief simple advice given by physicians to their smoking patients. The challenge as to whether or not this benefit will be realized depends on the extent to which physicians are prepared to systematically identify their smoking patients and offer them advice as a matter of routine.” Beyond advice, comes action on our part.  Studies indicate that providing nicotine replacement and/or bupropion may increase quit rates 1.5-2-fold.3 Other studies definitely support the role of the physician in identifying a smoker, assessing his or her willingness to quit, and providing additional resources and referrals.4 I look forward to more studies that guide my next action steps, and a wider array of resources to support my patients through their early steps into solid maintenance of smoking cessation. Considering the superlatives that are associated with nearly every statistic about tobacco use (relationship to cancer, cost, morbidity and mortality), tobacco use most certainly earns its place as a vital sign, right next to blood pressure, on my health center’s green cover sheet. References 1. Chapman S. The role of doctors in promoting smoking cessation. BMJ 1993;307; 518-9. 2. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD000165.DOI:10.1002/14651858.CD000165.pub3. 3. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue I. Art. No.: CD00031.DOI:10.1002/Issue 14651858.CD000031.pub3. 4. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. A Clinical Practice guideline. AHRQ Publication No. 00-0032.2000.  Rockville, MD: US Dept of Health and Human Services. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I don’t know if my patients are representative of national trends, but it seems to me that I am seeing more people who smoke. I don’t mean brand new smokers. I mean people who used to smoke, who seemed to have quit solidly, and who are smoking again. The medical assistants at my health center obtain a smoking history (current, past, never) while they take vital signs.  This practice, imposed by our state’s department of public health, works.  Smoking history is recorded between blood pressure and LMP on the green cover sheet. It becomes, as it should, a piece of data that I must incorporate into each visit. It is, in a way, the 5th vital sign. Unlike the other vital signs, however, it is a bit less clear what I am supposed to do about this. Fever, tachycardia, hypertension…I know what to do next. Evidence-based practices and clinical protocols work best for problems whose resolution lie squarely in the physician’s hands. Even these are subject to individual variation, clinical inertia, omission in the face of competing clinical demands, and nuanced interpretation. But when the issue involves a patient’s behavior, especially one that involves addiction, habit and social meaning, the search for evidence-based practices that truly translate to this patient at this time comes up short. “Can’t you give me a pill?” some patients implore. And, of course, there are several. I have used chantix (varenicline). This has worked for some people. In my experience, it has been most successful for the smoker who truly enjoys smoking. If a person can tolerate the unsettling dreams (dream disorder 9-13%, insomnia 18-19% according to KnowledgeLink estimates), he or she is often able to get over that first hump of intense craving and feeling of loss as one puts aside a longstanding habit. These patients tell me that it is like losing a friend. I am honest with them: I’ll never know. I’ve never touched a cigarette. My grandfather died of lung cancer. My father lost a lung to a combination of smoking and years of welding in shipyards and unregulated factories. If I would have even considered smoking I would have risked immediate death at my parents’ hands! I have had some success with wellbutrin/zyban (buproprion.) My patients tell me that this helps with the compulsion to smoke, and their addiction to some of the rituals associated with tobacco use—the lighting up, the oral fixation. Although this medication carries the same black box warning that other antidepressants carry, that it can worsen depression and intensify suicidal ideation and impulses, these  have not been a problem in my experience.  It simply doesn’t work for very many people. So while I try to make all therapeutic recommendations with some degree of optimism, I always provide a note of realism:  “There isn’t anything that works for everyone; if this doesn’t work, we’ll keep trying.” It’s the same with nicotine patches, gum, sprays. They work for some people, sometimes. Hypnotism, acupuncture—less widely available—also work for some, not all. The unpredictability of success with any of the available strategies is one part of the challenge, and is, in a way, not unlike the challenge of controlling hypertension. You keep trying—if the patient can stick with it.  The larger challenge, however, is in addressing the social factors that compete with successful initial cessation and that continue to compete with maintenance of cessation. A British researcher Hilary Graham who wrote about smoking among women in the United Kingdom during the 1990’s provided me with a clinically useful insight when she noted that women often smoke as a break from children or work, a little gift amidst a stressful life. As a physician and public health practitioner, steeped in the evils of tobacco, I don’t automatically think of smoking in a positive light. But, of course! People generally do things for positive rather than negative reasons. It made me realize that unless I can understand what my smoking patients  get out of their habit in a positive sense and, more importantly, unless my patients understand, they probably won’t succeed, or won’t succeed for very long, at stopping. So—on my good days in clinic, when I have the time and when there aren’t 10 other things to do in my all-too-brief visit, I will ask. “What do you get out of smoking? What do you love—or at least—what do you like about it?” This will typically draw a surprised reaction. They were expecting me to ask what they hated about smoking, and were prepared with the familiar list: It’s a disgusting habit. It stinks. It’s bad for my health. It’s bad for my children’s health. They are always tentative as they begin to reveal their list of positives. Most of them have to do with stress reduction.  “Relief.” “ A break.” “Time for myself.” This discussion, more than a discussion in which they feel berated, or embarrassed that they do something that is clearly so bad for their health, opens the door. Now we can get into it. Behavior change is difficult. Most people will have difficulty sustaining a new behavior if they feel deprived. We discuss this, and I give them their first smoking cessation assignment: think about what you could give to yourself if you take away smoking. How can you get “relief?” How can you get a little “time for yourself?” This does not mean that following this discussion 100% of my patients quit smoking. Far from it. But this discussion does introduce a paradigm shift that seems to contribute directly or indirectly to important behavior change. I know this because it is one of the things that I hear about later. Perhaps at the next visit; perhaps as much as six months or a year later. Countless patients have said to me that they had never thought about smoking that way, and it helped them understand their habit, and what got in the way of changing it. Many of us have been taught that physicians can play a small but significant role in motivating patients to quit smoking.1 A recent Cochrane review of physician advice for smoking cessation evaluated the evidence to support this claim. The specific objective of the review was to “assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation; and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.”2 The authors reviewed 41 trials conducted from 1972-2007, involving over 31,000 smokers. They pooled data from 17 trials of brief advice versus no advice or usual care, and detected a significant increase in the rate of quitting (RR 1.66, 95% CI 1.42-1.94). In 11 trials that involved a more intensive intervention, the estimated effect was greater (RR 1.84, 95% CI 1.60-2.13). However, there was no statistical difference  between the intensive and the minimal subgroups. When intensive interventions were compared to minimal advice, there was a small advantage found for the intensive advice (RR 1.37, 95% CI 1.20-1.56). The authors found only 1 study that evaluated the effect of smoking advice on mortality. In this study, there was no statistically significant difference in death rate at 20 years. The authors’ conclusion was the following: “Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.” Sobering. Humbling. Rather than focusing on the modest size of this incremental benefit over unassisted quit rates, the authors focus on the one hand, on the lack of evidence for more intensive advice, and on the other—on the importance of making sure that those in need of physicians’ simple advice actually receive it. “The results of this review indicate the potential benefit from brief simple advice given by physicians to their smoking patients. The challenge as to whether or not this benefit will be realized depends on the extent to which physicians are prepared to systematically identify their smoking patients and offer them advice as a matter of routine.” Beyond advice, comes action on our part.  Studies indicate that providing nicotine replacement and/or bupropion may increase quit rates 1.5-2-fold.3 Other studies definitely support the role of the physician in identifying a smoker, assessing his or her willingness to quit, and providing additional resources and referrals.4 I look forward to more studies that guide my next action steps, and a wider array of resources to support my patients through their early steps into solid maintenance of smoking cessation. Considering the superlatives that are associated with nearly every statistic about tobacco use (relationship to cancer, cost, morbidity and mortality), tobacco use most certainly earns its place as a vital sign, right next to blood pressure, on my health center’s green cover sheet. References 1. Chapman S. The role of doctors in promoting smoking cessation. BMJ 1993;307; 518-9. 2. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD000165.DOI:10.1002/14651858.CD000165.pub3. 3. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue I. Art. No.: CD00031.DOI:10.1002/Issue 14651858.CD000031.pub3. 4. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. A Clinical Practice guideline. AHRQ Publication No. 00-0032.2000.  Rockville, MD: US Dept of Health and Human Services. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Mon, 21 Nov 2011 16:16:01 GMT http://community.modernmedicine.com/_Smoking-HistoryThe-5th-Vital-Sign/blog/5499425/33379.html bgottlieb 2011-11-21T16:14:38Z Primary Care Modern Medicine Community I don’t know if my patients are representative of national trends, but it seems to me that I am seeing more people who smoke. I don’t mean brand new smokers. I mean people who used to smoke, who seemed to have quit solidly, and who are smoking again. The medical assistants at my health center obtain a smoking history (current, past, never) while they take vital signs.  This practice, imposed by our state’s department of public health, works.  Smoking history is recorded between blood pressure and LMP on the green cover sheet. It becomes, as it should, a piece of data that I must incorporate into each visit. It is, in a way, the 5th vital sign. Unlike the other vital signs, however, it is a bit less clear what I am supposed to do about this. Fever, tachycardia, hypertension…I know what to do next. Evidence-based practices and clinical protocols work best for problems whose resolution lie squarely in the physician’s hands. Even these are subject to individual variation, clinical inertia, omission in the face of competing clinical demands, and nuanced interpretation. But when the issue involves a patient’s behavior, especially one that involves addiction, habit and social meaning, the search for evidence-based practices that truly translate to this patient at this time comes up short. “Can’t you give me a pill?” some patients implore. And, of course, there are several. I have used chantix (varenicline). This has worked for some people. In my experience, it has been most successful for the smoker who truly enjoys smoking. If a person can tolerate the unsettling dreams (dream disorder 9-13%, insomnia 18-19% according to KnowledgeLink estimates), he or she is often able to get over that first hump of intense craving and feeling of loss as one puts aside a longstanding habit. These patients tell me that it is like losing a friend. I am honest with them: I’ll never know. I’ve never touched a cigarette. My grandfather died of lung cancer. My father lost a lung to a combination of smoking and years of welding in shipyards and unregulated factories. If I would have even considered smoking I would have risked immediate death at my parents’ hands! I have had some success with wellbutrin/zyban (buproprion.) My patients tell me that this helps with the compulsion to smoke, and their addiction to some of the rituals associated with tobacco use—the lighting up, the oral fixation. Although this medication carries the same black box warning that other antidepressants carry, that it can worsen depression and intensify suicidal ideation and impulses, these  have not been a problem in my experience.  It simply doesn’t work for very many people. So while I try to make all therapeutic recommendations with some degree of optimism, I always provide a note of realism:  “There isn’t anything that works for everyone; if this doesn’t work, we’ll keep trying.” It’s the same with nicotine patches, gum, sprays. They work for some people, sometimes. Hypnotism, acupuncture—less widely available—also work for some, not all. The unpredictability of success with any of the available strategies is one part of the challenge, and is, in a way, not unlike the challenge of controlling hypertension. You keep trying—if the patient can stick with it.  The larger challenge, however, is in addressing the social factors that compete with successful initial cessation and that continue to compete with maintenance of cessation. A British researcher Hilary Graham who wrote about smoking among women in the United Kingdom during the 1990’s provided me with a clinically useful insight when she noted that women often smoke as a break from children or work, a little gift amidst a stressful life. As a physician and public health practitioner, steeped in the evils of tobacco, I don’t automatically think of smoking in a positive light. But, of course! People generally do things for positive rather than negative reasons. It made me realize that unless I can understand what my smoking patients  get out of their habit in a positive sense and, more importantly, unless my patients understand, they probably won’t succeed, or won’t succeed for very long, at stopping. So—on my good days in clinic, when I have the time and when there aren’t 10 other things to do in my all-too-brief visit, I will ask. “What do you get out of smoking? What do you love—or at least—what do you like about it?” This will typically draw a surprised reaction. They were expecting me to ask what they hated about smoking, and were prepared with the familiar list: It’s a disgusting habit. It stinks. It’s bad for my health. It’s bad for my children’s health. They are always tentative as they begin to reveal their list of positives. Most of them have to do with stress reduction.  “Relief.” “ A break.” “Time for myself.” This discussion, more than a discussion in which they feel berated, or embarrassed that they do something that is clearly so bad for their health, opens the door. Now we can get into it. Behavior change is difficult. Most people will have difficulty sustaining a new behavior if they feel deprived. We discuss this, and I give them their first smoking cessation assignment: think about what you could give to yourself if you take away smoking. How can you get “relief?” How can you get a little “time for yourself?” This does not mean that following this discussion 100% of my patients quit smoking. Far from it. But this discussion does introduce a paradigm shift that seems to contribute directly or indirectly to important behavior change. I know this because it is one of the things that I hear about later. Perhaps at the next visit; perhaps as much as six months or a year later. Countless patients have said to me that they had never thought about smoking that way, and it helped them understand their habit, and what got in the way of changing it. Many of us have been taught that physicians can play a small but significant role in motivating patients to quit smoking.1 A recent Cochrane review of physician advice for smoking cessation evaluated the evidence to support this claim. The specific objective of the review was to “assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation; and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.”2 The authors reviewed 41 trials conducted from 1972-2007, involving over 31,000 smokers. They pooled data from 17 trials of brief advice versus no advice or usual care, and detected a significant increase in the rate of quitting (RR 1.66, 95% CI 1.42-1.94). In 11 trials that involved a more intensive intervention, the estimated effect was greater (RR 1.84, 95% CI 1.60-2.13). However, there was no statistical difference  between the intensive and the minimal subgroups. When intensive interventions were compared to minimal advice, there was a small advantage found for the intensive advice (RR 1.37, 95% CI 1.20-1.56). The authors found only 1 study that evaluated the effect of smoking advice on mortality. In this study, there was no statistically significant difference in death rate at 20 years. The authors’ conclusion was the following: “Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.” Sobering. Humbling. Rather than focusing on the modest size of this incremental benefit over unassisted quit rates, the authors focus on the one hand, on the lack of evidence for more intensive advice, and on the other—on the importance of making sure that those in need of physicians’ simple advice actually receive it. “The results of this review indicate the potential benefit from brief simple advice given by physicians to their smoking patients. The challenge as to whether or not this benefit will be realized depends on the extent to which physicians are prepared to systematically identify their smoking patients and offer them advice as a matter of routine.” Beyond advice, comes action on our part.  Studies indicate that providing nicotine replacement and/or bupropion may increase quit rates 1.5-2-fold.3 Other studies definitely support the role of the physician in identifying a smoker, assessing his or her willingness to quit, and providing additional resources and referrals.4 I look forward to more studies that guide my next action steps, and a wider array of resources to support my patients through their early steps into solid maintenance of smoking cessation. Considering the superlatives that are associated with nearly every statistic about tobacco use (relationship to cancer, cost, morbidity and mortality), tobacco use most certainly earns its place as a vital sign, right next to blood pressure, on my health center’s green cover sheet. References 1. Chapman S. The role of doctors in promoting smoking cessation. BMJ 1993;307; 518-9. 2. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD000165.DOI:10.1002/14651858.CD000165.pub3. 3. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue I. Art. No.: CD00031.DOI:10.1002/Issue 14651858.CD000031.pub3. 4. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. A Clinical Practice guideline. AHRQ Publication No. 00-0032.2000.  Rockville, MD: US Dept of Health and Human Services. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] cessation, primary care, smoking, vital signs nonadult false Smoking History—The 5th Vital Sign text blog cessation,primary care,smoking,vital signs 855 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 5499425 2771822 Member 0 http://community.modernmedicine.com/_Uganda-In-Three-Movements/blog/5082125/33379.html 1. I was recently invited to participate in a symposium on global mental health held in Uganda. Consistent with the pragmatic optimism manifested by the study participants from several sub-Saharan African nations, the conference theme was collaboration, challenges, and opportunities. What other agenda could you possibly have when the typical budget for mental health in these fractured systems is 1% of an already pitiful health budget, and 90% of that is taken up by in-patient psychiatry and other programs for “major mental illness”? Ten percent of that 1% is not very much to take care of the mood disorders, often referred to as the “common cold of mental illness,” post traumatic stress disorders, attention deficit, traumatic brain injury, and other disorders that abound in conditions of war, famine, natural disasters, ethnic violence, internal displacement and political instability. Some countries represented had 1 practicing psychiatrist. (The sad joke was that now they have none, because he’s here at the meeting.) Other countries’ numbers reach into the double digits, meaning that psychiatrists might even have colleagues, and might be able to settle into sub-specialty niches. The shortages of psychologists, psychiatric nurses, social workers, and other mental health providers are equally stark. Surprisingly, however, many of the discussions we had in Uganda were identical to the emerging discussions here about the integration of mental health and primary care. There, they also recognize that mental health problems, primarily mood disorders, not only contribute to morbidity and mortality in their own right, but add to the burden of other chronic diseases because of their impact on behavior, motivation and adherence. Even they say that mental health problems are the elephant in the room. They, too, believe that primary care is the logical place to screen for and address the bulk of mental health problems.  They, too, recognize that effective interventions don’t always need a psychiatrist. In fact they don’t always need a professional. Paraprofessionals, community health workers, traditional healers, and personnel outside of health such as teachers and religious leaders, can be the key forces of a mental health program. They also recognize that a generalist’s approach to diagnostic categories, in which depression, anxiety, distress, and many post-trauma disorders have blurry boundaries, seems to fit the empirical findings better than a taxonomy with sharp boundaries and rigid criteria. They notice that these families of disorders all seem to respond to similar types of interventions—social support, stabilization of the immediate environment, sound sleep, relief from physical pain, and sometimes medications.  The lack of a mental health system seems a little less daunting when you realize that existing systems of primary care and community health can be a foundation, or at least a starting point. I don’t mean to be primary care-centric.  My new colleagues made a convincing case for the need of the kind of care and treatments that only psychiatrists can provide for schizophrenia, epilepsy (the domain of psychiatrists in Africa), childhood learning disorders, autism, to name a few prevalent, nuanced, and complex disorders. We know the burden that these conditions can present to a family and to a community in the developed world. Imagine the impact of this burden in the developing world! There is a need for research on the confluence of conditions that abound in Africa—the mental health manifestations of HIV, the manifestations of dementia as it develops in populations burdened by nutritional deficiencies, high rates of infectious diseases, head injuries, burgeoning rates of chronic diseases such as diabetes and vascular disease, and the longterm outcomes of exposure to individual and mass violence on a large scale… just to list a few areas of basic and translational inquiry that would not only inform mental health programs and systems in sub-Saharan Africa, but would advance scientific and medical knowledge about the brain, human behavior, the dynamic interplay of mind and body, illness and wellness, nature and nurture, for all humankind. 2. I rarely take face-on photographs of people when I am a visitor. This young girl gave me no choice. We visited a project in which researchers and community members collaborate to enhance family economic stability through short term microloans, and thereby improve family physical and mental health, and community stability and cohesion. As always when foreigners arrive in communities an hour off of the nearest flat road, a commotion of children appear, as if from the clouds of dust that rise from the road. A jumble of long legs, attached to bare feet, outrun the minivan. Cotton clothing cast off from the west, or from India, soft stripes, faded flower prints, a thin strand of lace, hang from too prominent bones.  The fastest among the children manage to grab hold of the side mirror, hitch a ride on the bumper, the side door. How many they are! Where are the mothers and fathers? Any grown ups? Is this entire village children? [image] Did I imagine it or did my friend fix her gaze on me first? And in response I set my compass on her, my true north in this settlement. I shifted and briefly noticed the other children, the mud huts, the chickens and goats. I listened to the proud testimony of program participants, and believed the dictum that the best mental health intervention is a job; the best mental health program a stable economy. But her visage, open like a child’s, wise like an elder’s, pulled me back into its orbit. Silently she willed me…Take me home. Tell my story. 3. On top of everything else we learned that Africa loses 20,000 physicians each year. They come to the US, to Europe, to Australia. I was only there for a few days. I offer no easy answers, no quick fixes to this, or anything else. Yet I came away hopeful.  One of our hosts shared his perspective. “In Africa we call it a problem if the sun doesn’t rise. Everything else is a challenge.” Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] 1. I was recently invited to participate in a symposium on global mental health held in Uganda. Consistent with the pragmatic optimism manifested by the study participants from several sub-Saharan African nations, the conference theme was collaboration, challenges, and opportunities. What other agenda could you possibly have when the typical budget for mental health in these fractured systems is 1% of an already pitiful health budget, and 90% of that is taken up by in-patient psychiatry and other programs for “major mental illness”? Ten percent of that 1% is not very much to take care of the mood disorders, often referred to as the “common cold of mental illness,” post traumatic stress disorders, attention deficit, traumatic brain injury, and other disorders that abound in conditions of war, famine, natural disasters, ethnic violence, internal displacement and political instability. Some countries represented had 1 practicing psychiatrist. (The sad joke was that now they have none, because he’s here at the meeting.) Other countries’ numbers reach into the double digits, meaning that psychiatrists might even have colleagues, and might be able to settle into sub-specialty niches. The shortages of psychologists, psychiatric nurses, social workers, and other mental health providers are equally stark. Surprisingly, however, many of the discussions we had in Uganda were identical to the emerging discussions here about the integration of mental health and primary care. There, they also recognize that mental health problems, primarily mood disorders, not only contribute to morbidity and mortality in their own right, but add to the burden of other chronic diseases because of their impact on behavior, motivation and adherence. Even they say that mental health problems are the elephant in the room. They, too, believe that primary care is the logical place to screen for and address the bulk of mental health problems.  They, too, recognize that effective interventions don’t always need a psychiatrist. In fact they don’t always need a professional. Paraprofessionals, community health workers, traditional healers, and personnel outside of health such as teachers and religious leaders, can be the key forces of a mental health program. They also recognize that a generalist’s approach to diagnostic categories, in which depression, anxiety, distress, and many post-trauma disorders have blurry boundaries, seems to fit the empirical findings better than a taxonomy with sharp boundaries and rigid criteria. They notice that these families of disorders all seem to respond to similar types of interventions—social support, stabilization of the immediate environment, sound sleep, relief from physical pain, and sometimes medications.  The lack of a mental health system seems a little less daunting when you realize that existing systems of primary care and community health can be a foundation, or at least a starting point. I don’t mean to be primary care-centric.  My new colleagues made a convincing case for the need of the kind of care and treatments that only psychiatrists can provide for schizophrenia, epilepsy (the domain of psychiatrists in Africa), childhood learning disorders, autism, to name a few prevalent, nuanced, and complex disorders. We know the burden that these conditions can present to a family and to a community in the developed world. Imagine the impact of this burden in the developing world! There is a need for research on the confluence of conditions that abound in Africa—the mental health manifestations of HIV, the manifestations of dementia as it develops in populations burdened by nutritional deficiencies, high rates of infectious diseases, head injuries, burgeoning rates of chronic diseases such as diabetes and vascular disease, and the longterm outcomes of exposure to individual and mass violence on a large scale… just to list a few areas of basic and translational inquiry that would not only inform mental health programs and systems in sub-Saharan Africa, but would advance scientific and medical knowledge about the brain, human behavior, the dynamic interplay of mind and body, illness and wellness, nature and nurture, for all humankind. 2. I rarely take face-on photographs of people when I am a visitor. This young girl gave me no choice. We visited a project in which researchers and community members collaborate to enhance family economic stability through short term microloans, and thereby improve family physical and mental health, and community stability and cohesion. As always when foreigners arrive in communities an hour off of the nearest flat road, a commotion of children appear, as if from the clouds of dust that rise from the road. A jumble of long legs, attached to bare feet, outrun the minivan. Cotton clothing cast off from the west, or from India, soft stripes, faded flower prints, a thin strand of lace, hang from too prominent bones.  The fastest among the children manage to grab hold of the side mirror, hitch a ride on the bumper, the side door. How many they are! Where are the mothers and fathers? Any grown ups? Is this entire village children? [image] Did I imagine it or did my friend fix her gaze on me first? And in response I set my compass on her, my true north in this settlement. I shifted and briefly noticed the other children, the mud huts, the chickens and goats. I listened to the proud testimony of program participants, and believed the dictum that the best mental health intervention is a job; the best mental health program a stable economy. But her visage, open like a child’s, wise like an elder’s, pulled me back into its orbit. Silently she willed me…Take me home. Tell my story. 3. On top of everything else we learned that Africa loses 20,000 physicians each year. They come to the US, to Europe, to Australia. I was only there for a few days. I offer no easy answers, no quick fixes to this, or anything else. Yet I came away hopeful.  One of our hosts shared his perspective. “In Africa we call it a problem if the sun doesn’t rise. Everything else is a challenge.” Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Thu, 01 Sep 2011 00:07:26 GMT http://community.modernmedicine.com/_Uganda-In-Three-Movements/blog/5082125/33379.html bgottlieb 2011-08-31T23:48:00Z Psychiatry & Behavioral Health Modern Medicine Community 1. I was recently invited to participate in a symposium on global mental health held in Uganda. Consistent with the pragmatic optimism manifested by the study participants from several sub-Saharan African nations, the conference theme was collaboration, challenges, and opportunities. What other agenda could you possibly have when the typical budget for mental health in these fractured systems is 1% of an already pitiful health budget, and 90% of that is taken up by in-patient psychiatry and other programs for “major mental illness”? Ten percent of that 1% is not very much to take care of the mood disorders, often referred to as the “common cold of mental illness,” post traumatic stress disorders, attention deficit, traumatic brain injury, and other disorders that abound in conditions of war, famine, natural disasters, ethnic violence, internal displacement and political instability. Some countries represented had 1 practicing psychiatrist. (The sad joke was that now they have none, because he’s here at the meeting.) Other countries’ numbers reach into the double digits, meaning that psychiatrists might even have colleagues, and might be able to settle into sub-specialty niches. The shortages of psychologists, psychiatric nurses, social workers, and other mental health providers are equally stark. Surprisingly, however, many of the discussions we had in Uganda were identical to the emerging discussions here about the integration of mental health and primary care. There, they also recognize that mental health problems, primarily mood disorders, not only contribute to morbidity and mortality in their own right, but add to the burden of other chronic diseases because of their impact on behavior, motivation and adherence. Even they say that mental health problems are the elephant in the room. They, too, believe that primary care is the logical place to screen for and address the bulk of mental health problems.  They, too, recognize that effective interventions don’t always need a psychiatrist. In fact they don’t always need a professional. Paraprofessionals, community health workers, traditional healers, and personnel outside of health such as teachers and religious leaders, can be the key forces of a mental health program. They also recognize that a generalist’s approach to diagnostic categories, in which depression, anxiety, distress, and many post-trauma disorders have blurry boundaries, seems to fit the empirical findings better than a taxonomy with sharp boundaries and rigid criteria. They notice that these families of disorders all seem to respond to similar types of interventions—social support, stabilization of the immediate environment, sound sleep, relief from physical pain, and sometimes medications.  The lack of a mental health system seems a little less daunting when you realize that existing systems of primary care and community health can be a foundation, or at least a starting point. I don’t mean to be primary care-centric.  My new colleagues made a convincing case for the need of the kind of care and treatments that only psychiatrists can provide for schizophrenia, epilepsy (the domain of psychiatrists in Africa), childhood learning disorders, autism, to name a few prevalent, nuanced, and complex disorders. We know the burden that these conditions can present to a family and to a community in the developed world. Imagine the impact of this burden in the developing world! There is a need for research on the confluence of conditions that abound in Africa—the mental health manifestations of HIV, the manifestations of dementia as it develops in populations burdened by nutritional deficiencies, high rates of infectious diseases, head injuries, burgeoning rates of chronic diseases such as diabetes and vascular disease, and the longterm outcomes of exposure to individual and mass violence on a large scale… just to list a few areas of basic and translational inquiry that would not only inform mental health programs and systems in sub-Saharan Africa, but would advance scientific and medical knowledge about the brain, human behavior, the dynamic interplay of mind and body, illness and wellness, nature and nurture, for all humankind. 2. I rarely take face-on photographs of people when I am a visitor. This young girl gave me no choice. We visited a project in which researchers and community members collaborate to enhance family economic stability through short term microloans, and thereby improve family physical and mental health, and community stability and cohesion. As always when foreigners arrive in communities an hour off of the nearest flat road, a commotion of children appear, as if from the clouds of dust that rise from the road. A jumble of long legs, attached to bare feet, outrun the minivan. Cotton clothing cast off from the west, or from India, soft stripes, faded flower prints, a thin strand of lace, hang from too prominent bones.  The fastest among the children manage to grab hold of the side mirror, hitch a ride on the bumper, the side door. How many they are! Where are the mothers and fathers? Any grown ups? Is this entire village children? [image] Did I imagine it or did my friend fix her gaze on me first? And in response I set my compass on her, my true north in this settlement. I shifted and briefly noticed the other children, the mud huts, the chickens and goats. I listened to the proud testimony of program participants, and believed the dictum that the best mental health intervention is a job; the best mental health program a stable economy. But her visage, open like a child’s, wise like an elder’s, pulled me back into its orbit. Silently she willed me…Take me home. Tell my story. 3. On top of everything else we learned that Africa loses 20,000 physicians each year. They come to the US, to Europe, to Australia. I was only there for a few days. I offer no easy answers, no quick fixes to this, or anything else. Yet I came away hopeful.  One of our hosts shared his perspective. “In Africa we call it a problem if the sun doesn’t rise. Everything else is a challenge.” Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] primary care, psychiatry & behavioral health nonadult false Uganda In Three Movements text blog primary care,psychiatry & behavioral health 457 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Psychiatry & Behavioral Health 0 5082125 2771822 Member 0 http://community.modernmedicine.com/_Preventive-Care-for-Women/blog/4976112/33379.html For the most part, my patients and I have gotten older together. Most have stepped into their grandparent/elder statesman role gracefully, willingly abandoning the wilder, risk-taking  days of their youth. We have developed a comfortable rhythm of preventive care. I don’t have to spend a lot of time convincing, educating, cajoling, or begging. Except for the bad publicity surrounding the H1N1 vaccine, my patients believe in flu shots. “Isn’t it almost time?” they begin to ask in July, August…. “What about my mammogram?”  “What do you mean I don’t need to have a pap test every year?” I never thought I would have patients ask for their next colonoscopy, but I find myself justifying the 10 year interval for most people at least as often as I have to explain why it is recommended in the first place.  “I hear they have a better drink, now. I wouldn’t mind trying it!”(Really?) When it comes to the yearly seat belt question, more and more people announce proudly that they now use one all the time. “I remember what you said last year and figured it must be important if you bothered to say it.” “Three drinks in a day, 7 in a week, that’s what you’ve been telling me and now I never have more than that.” I could pat myself on the back and take credit for the successful assimilation of these preventive health messages, but I know better. I know that beyond the yearly repetition by me, the yearly reinforcement, my patients’ lives have become somewhat less complex, less stressful and overwhelming, more settled.  They can, in fact, begin to take better care of themselves. Not so for the younger adults. O is 22 years old. She comes in several times a month for vaginal itch and discharge. She wants to be “tested for everything.”  Does she use condoms? “Usually, but not the last time I had sex. And I read on the internet that the yellow discharge could be gonorrhea, Chlamydia, yeast, bacteria or even HIV.” Fortunately, she has never had a sexually transmitted disease. But how good a job am I doing in educating her and motivating her to always protect herself, to not have relations with partners she doesn’t know well, and doesn’t trust? She told me that she couldn’t help worrying about these things because she is the “worrying type.” A few days ago I suggested that it might be a better idea to worry first and not expose herself to the risk of a sexually transmitted disease, than to expose herself and then worry.  But even as they escaped my lips I knew that these wouldn’t be the magic words. The dazzling light has yet to shine. I’m sure I will see her in a week. Maybe two. D is 27. She has 3 children, none planned, but at least all wanted and loved. She doesn’t intend to have more, but she does not have a steady partner, and “wants to keep things open.”  She schedules appointments for physical exams, but something comes up and she has missed 3 in a row. She comes in instead every few months for an urgent visit when she is afraid she might be pregnant. So far, the tests have been negative. She does not want to use contraception, can’t remember to take vitamins, and knows that she should stop smoking. I saw Y, a 29 year old, a few weeks ago for knee pain. I noticed that she hadn’t been in to see me since her pregnancy several years ago in which she had an anencephalic baby. The baby died shortly after birth. She was seen a few times by the midwives and then stopped coming in. She wants to get pregnant again, but is understandably afraid. She remembers being told to take folic acid or a multivitamin, but can’t remember why. Women’s preventive care is fragmented. It is delivered by multiple types of providers, in multiple settings, and in various times of the life course. Often, preventive care is an add-on to an urgent visit. Despite the fact that women frequently appear in medical settings for urgent visits for themselves, or preventive or urgent visits for their children, many common, routine screenings and preventive care tasks are not carried out at all, or not performed in a timely manner. Late or absent preventive care can have an impact on women’s health in the short run (risk of sexually transmitted illnesses, unintended or mis-timed pregnancies), and in the long run (infertility, chronic illnesses such as diabetes and coronary artery disease). Pregnancy outcomes can also be affected as opportunities to reduce the risk of neural tube defects, low birth weight, gestational diabetes, congenital HIV, are missed or delayed. On July 20, 2011, the Institute of Medicine (IOM) released guidelines for preventive services for women, Clinical Preventive Services for Women: Closing The Gaps.1 In response to the Patient Protection and Affordable Care Act of 2010, the Office of the Assistant Secretary for Planning and Evaluation of Health and Human  Services (HHS) funded the IOM to conduct a review of effective processes to ensure women’s health and well-being. A committee was appointed to review guidelines already in place by the US Preventive Services Task Force (USPSTF) and identify gaps in recommendations for services and screenings for adult women and adolescent girls. The guidelines are parallel to those for other populations, including adolescents and elders, and are intended to place preventive care at the center of US health insurance plans. The committee was not charged with breaking new scientific ground. In its relatively brief tenure, the committee reviewed what was known, what was already recommended, and identified critical gaps that if addressed through programs and services could potentially make substantial improvements in women’s health. The guidelines are very relevant to patients O, D, and Y: Screening for gestational diabetes for all women between 24 and 28 weeks of gestation, and at the first prenatal visit for women identified as high risk Testing for human papilloma virus starting at age 30 and every 3 years after that Counseling for sexually transmitted infection every year for sexually active women HIV counseling and screening yearly for sexually active women Contraception counseling regarding the full range of FDA approved methods and devices of contraception and sterilization for all women with reproductive capacity Breast feeding/lactation counseling, and access to supplies in order to support successful initiation of and maximal duration of breast feeding Screening and counseling regarding domestic violence for adolescent girls and adult women that is supportive and culturally sensitive Well woman visits – at least one per year – to provide preventive care services and screenings. These might include preconception and prenatal care, and may require more than one visit per year to accomplish all tasks, depending on the individual’s needs. I was excited to see these guidelines, and to read the full report. I was particularly pleased to see that a venue for preventive care – well woman visits – was endorsed by the committee. But guidelines are only a beginning. My health center, like many practice sites, is trying to develop our model of a “medical home.” This involves wrap-around care for individuals as well as population management.  For O, D and Y, we will clearly need tracking systems and outreach. We will need to know who our patients are, what they need, and actively initiate contact rather than wait for them to initiate care. Consistent efforts on our part will, over time, communicate that we care about prevention. The members of the committee apparently agree that guidelines are only a beginning. The IOM report begins with these cautionary words from Goethe: Knowing is not enough; we must apply. Willing is not enough; we must do. Reference Institute of Medicine, Clinical Preventive Services for Women: Closing the Gap. Washington,DC.: The National Academies Press, 225 pp. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] For the most part, my patients and I have gotten older together. Most have stepped into their grandparent/elder statesman role gracefully, willingly abandoning the wilder, risk-taking  days of their youth. We have developed a comfortable rhythm of preventive care. I don’t have to spend a lot of time convincing, educating, cajoling, or begging. Except for the bad publicity surrounding the H1N1 vaccine, my patients believe in flu shots. “Isn’t it almost time?” they begin to ask in July, August…. “What about my mammogram?”  “What do you mean I don’t need to have a pap test every year?” I never thought I would have patients ask for their next colonoscopy, but I find myself justifying the 10 year interval for most people at least as often as I have to explain why it is recommended in the first place.  “I hear they have a better drink, now. I wouldn’t mind trying it!”(Really?) When it comes to the yearly seat belt question, more and more people announce proudly that they now use one all the time. “I remember what you said last year and figured it must be important if you bothered to say it.” “Three drinks in a day, 7 in a week, that’s what you’ve been telling me and now I never have more than that.” I could pat myself on the back and take credit for the successful assimilation of these preventive health messages, but I know better. I know that beyond the yearly repetition by me, the yearly reinforcement, my patients’ lives have become somewhat less complex, less stressful and overwhelming, more settled.  They can, in fact, begin to take better care of themselves. Not so for the younger adults. O is 22 years old. She comes in several times a month for vaginal itch and discharge. She wants to be “tested for everything.”  Does she use condoms? “Usually, but not the last time I had sex. And I read on the internet that the yellow discharge could be gonorrhea, Chlamydia, yeast, bacteria or even HIV.” Fortunately, she has never had a sexually transmitted disease. But how good a job am I doing in educating her and motivating her to always protect herself, to not have relations with partners she doesn’t know well, and doesn’t trust? She told me that she couldn’t help worrying about these things because she is the “worrying type.” A few days ago I suggested that it might be a better idea to worry first and not expose herself to the risk of a sexually transmitted disease, than to expose herself and then worry.  But even as they escaped my lips I knew that these wouldn’t be the magic words. The dazzling light has yet to shine. I’m sure I will see her in a week. Maybe two. D is 27. She has 3 children, none planned, but at least all wanted and loved. She doesn’t intend to have more, but she does not have a steady partner, and “wants to keep things open.”  She schedules appointments for physical exams, but something comes up and she has missed 3 in a row. She comes in instead every few months for an urgent visit when she is afraid she might be pregnant. So far, the tests have been negative. She does not want to use contraception, can’t remember to take vitamins, and knows that she should stop smoking. I saw Y, a 29 year old, a few weeks ago for knee pain. I noticed that she hadn’t been in to see me since her pregnancy several years ago in which she had an anencephalic baby. The baby died shortly after birth. She was seen a few times by the midwives and then stopped coming in. She wants to get pregnant again, but is understandably afraid. She remembers being told to take folic acid or a multivitamin, but can’t remember why. Women’s preventive care is fragmented. It is delivered by multiple types of providers, in multiple settings, and in various times of the life course. Often, preventive care is an add-on to an urgent visit. Despite the fact that women frequently appear in medical settings for urgent visits for themselves, or preventive or urgent visits for their children, many common, routine screenings and preventive care tasks are not carried out at all, or not performed in a timely manner. Late or absent preventive care can have an impact on women’s health in the short run (risk of sexually transmitted illnesses, unintended or mis-timed pregnancies), and in the long run (infertility, chronic illnesses such as diabetes and coronary artery disease). Pregnancy outcomes can also be affected as opportunities to reduce the risk of neural tube defects, low birth weight, gestational diabetes, congenital HIV, are missed or delayed. On July 20, 2011, the Institute of Medicine (IOM) released guidelines for preventive services for women, Clinical Preventive Services for Women: Closing The Gaps.1 In response to the Patient Protection and Affordable Care Act of 2010, the Office of the Assistant Secretary for Planning and Evaluation of Health and Human  Services (HHS) funded the IOM to conduct a review of effective processes to ensure women’s health and well-being. A committee was appointed to review guidelines already in place by the US Preventive Services Task Force (USPSTF) and identify gaps in recommendations for services and screenings for adult women and adolescent girls. The guidelines are parallel to those for other populations, including adolescents and elders, and are intended to place preventive care at the center of US health insurance plans. The committee was not charged with breaking new scientific ground. In its relatively brief tenure, the committee reviewed what was known, what was already recommended, and identified critical gaps that if addressed through programs and services could potentially make substantial improvements in women’s health. The guidelines are very relevant to patients O, D, and Y: Screening for gestational diabetes for all women between 24 and 28 weeks of gestation, and at the first prenatal visit for women identified as high risk Testing for human papilloma virus starting at age 30 and every 3 years after that Counseling for sexually transmitted infection every year for sexually active women HIV counseling and screening yearly for sexually active women Contraception counseling regarding the full range of FDA approved methods and devices of contraception and sterilization for all women with reproductive capacity Breast feeding/lactation counseling, and access to supplies in order to support successful initiation of and maximal duration of breast feeding Screening and counseling regarding domestic violence for adolescent girls and adult women that is supportive and culturally sensitive Well woman visits – at least one per year – to provide preventive care services and screenings. These might include preconception and prenatal care, and may require more than one visit per year to accomplish all tasks, depending on the individual’s needs. I was excited to see these guidelines, and to read the full report. I was particularly pleased to see that a venue for preventive care – well woman visits – was endorsed by the committee. But guidelines are only a beginning. My health center, like many practice sites, is trying to develop our model of a “medical home.” This involves wrap-around care for individuals as well as population management.  For O, D and Y, we will clearly need tracking systems and outreach. We will need to know who our patients are, what they need, and actively initiate contact rather than wait for them to initiate care. Consistent efforts on our part will, over time, communicate that we care about prevention. The members of the committee apparently agree that guidelines are only a beginning. The IOM report begins with these cautionary words from Goethe: Knowing is not enough; we must apply. Willing is not enough; we must do. Reference Institute of Medicine, Clinical Preventive Services for Women: Closing the Gap. Washington,DC.: The National Academies Press, 225 pp. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 29 Jul 2011 16:16:02 GMT http://community.modernmedicine.com/_Preventive-Care-for-Women/blog/4976112/33379.html bgottlieb 2011-07-29T15:56:30Z Primary Care Modern Medicine Community For the most part, my patients and I have gotten older together. Most have stepped into their grandparent/elder statesman role gracefully, willingly abandoning the wilder, risk-taking  days of their youth. We have developed a comfortable rhythm of preventive care. I don’t have to spend a lot of time convincing, educating, cajoling, or begging. Except for the bad publicity surrounding the H1N1 vaccine, my patients believe in flu shots. “Isn’t it almost time?” they begin to ask in July, August…. “What about my mammogram?”  “What do you mean I don’t need to have a pap test every year?” I never thought I would have patients ask for their next colonoscopy, but I find myself justifying the 10 year interval for most people at least as often as I have to explain why it is recommended in the first place.  “I hear they have a better drink, now. I wouldn’t mind trying it!”(Really?) When it comes to the yearly seat belt question, more and more people announce proudly that they now use one all the time. “I remember what you said last year and figured it must be important if you bothered to say it.” “Three drinks in a day, 7 in a week, that’s what you’ve been telling me and now I never have more than that.” I could pat myself on the back and take credit for the successful assimilation of these preventive health messages, but I know better. I know that beyond the yearly repetition by me, the yearly reinforcement, my patients’ lives have become somewhat less complex, less stressful and overwhelming, more settled.  They can, in fact, begin to take better care of themselves. Not so for the younger adults. O is 22 years old. She comes in several times a month for vaginal itch and discharge. She wants to be “tested for everything.”  Does she use condoms? “Usually, but not the last time I had sex. And I read on the internet that the yellow discharge could be gonorrhea, Chlamydia, yeast, bacteria or even HIV.” Fortunately, she has never had a sexually transmitted disease. But how good a job am I doing in educating her and motivating her to always protect herself, to not have relations with partners she doesn’t know well, and doesn’t trust? She told me that she couldn’t help worrying about these things because she is the “worrying type.” A few days ago I suggested that it might be a better idea to worry first and not expose herself to the risk of a sexually transmitted disease, than to expose herself and then worry.  But even as they escaped my lips I knew that these wouldn’t be the magic words. The dazzling light has yet to shine. I’m sure I will see her in a week. Maybe two. D is 27. She has 3 children, none planned, but at least all wanted and loved. She doesn’t intend to have more, but she does not have a steady partner, and “wants to keep things open.”  She schedules appointments for physical exams, but something comes up and she has missed 3 in a row. She comes in instead every few months for an urgent visit when she is afraid she might be pregnant. So far, the tests have been negative. She does not want to use contraception, can’t remember to take vitamins, and knows that she should stop smoking. I saw Y, a 29 year old, a few weeks ago for knee pain. I noticed that she hadn’t been in to see me since her pregnancy several years ago in which she had an anencephalic baby. The baby died shortly after birth. She was seen a few times by the midwives and then stopped coming in. She wants to get pregnant again, but is understandably afraid. She remembers being told to take folic acid or a multivitamin, but can’t remember why. Women’s preventive care is fragmented. It is delivered by multiple types of providers, in multiple settings, and in various times of the life course. Often, preventive care is an add-on to an urgent visit. Despite the fact that women frequently appear in medical settings for urgent visits for themselves, or preventive or urgent visits for their children, many common, routine screenings and preventive care tasks are not carried out at all, or not performed in a timely manner. Late or absent preventive care can have an impact on women’s health in the short run (risk of sexually transmitted illnesses, unintended or mis-timed pregnancies), and in the long run (infertility, chronic illnesses such as diabetes and coronary artery disease). Pregnancy outcomes can also be affected as opportunities to reduce the risk of neural tube defects, low birth weight, gestational diabetes, congenital HIV, are missed or delayed. On July 20, 2011, the Institute of Medicine (IOM) released guidelines for preventive services for women, Clinical Preventive Services for Women: Closing The Gaps.1 In response to the Patient Protection and Affordable Care Act of 2010, the Office of the Assistant Secretary for Planning and Evaluation of Health and Human  Services (HHS) funded the IOM to conduct a review of effective processes to ensure women’s health and well-being. A committee was appointed to review guidelines already in place by the US Preventive Services Task Force (USPSTF) and identify gaps in recommendations for services and screenings for adult women and adolescent girls. The guidelines are parallel to those for other populations, including adolescents and elders, and are intended to place preventive care at the center of US health insurance plans. The committee was not charged with breaking new scientific ground. In its relatively brief tenure, the committee reviewed what was known, what was already recommended, and identified critical gaps that if addressed through programs and services could potentially make substantial improvements in women’s health. The guidelines are very relevant to patients O, D, and Y: Screening for gestational diabetes for all women between 24 and 28 weeks of gestation, and at the first prenatal visit for women identified as high risk Testing for human papilloma virus starting at age 30 and every 3 years after that Counseling for sexually transmitted infection every year for sexually active women HIV counseling and screening yearly for sexually active women Contraception counseling regarding the full range of FDA approved methods and devices of contraception and sterilization for all women with reproductive capacity Breast feeding/lactation counseling, and access to supplies in order to support successful initiation of and maximal duration of breast feeding Screening and counseling regarding domestic violence for adolescent girls and adult women that is supportive and culturally sensitive Well woman visits – at least one per year – to provide preventive care services and screenings. These might include preconception and prenatal care, and may require more than one visit per year to accomplish all tasks, depending on the individual’s needs. I was excited to see these guidelines, and to read the full report. I was particularly pleased to see that a venue for preventive care – well woman visits – was endorsed by the committee. But guidelines are only a beginning. My health center, like many practice sites, is trying to develop our model of a “medical home.” This involves wrap-around care for individuals as well as population management.  For O, D and Y, we will clearly need tracking systems and outreach. We will need to know who our patients are, what they need, and actively initiate contact rather than wait for them to initiate care. Consistent efforts on our part will, over time, communicate that we care about prevention. The members of the committee apparently agree that guidelines are only a beginning. The IOM report begins with these cautionary words from Goethe: Knowing is not enough; we must apply. Willing is not enough; we must do. Reference Institute of Medicine, Clinical Preventive Services for Women: Closing the Gap. Washington,DC.: The National Academies Press, 225 pp. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] preventive care, primary care, well woman nonadult false Preventive Care for Women text blog preventive care,primary care,well woman 303 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 4976112 2771822 Member 0 http://community.modernmedicine.com/_Crossing-the-line-dealing-with-difficult-patients-in-primary-care/blog/4610551/33379.html It has been a rough couple of weeks. Full moon? Bad economy? Whatever it is, there has been a flurry of bad behavior on the part of patients. One patient became furious and verbally abusive when I wasn’t prepared to order an MRI to evaluate her back pain after I carefully laid out a plan for treating and following her symptoms, including further diagnostic studies if and when things didn’t improve. Another patient came without an appointment and while waiting for the nurse to help her became impatient and threw the clipboard (on which she was writing her name and reason for visit) at the secretary, in full view of all of the other patients in the waiting room. Yesterday, another patient became angry after waiting for 5 minutes, became more incensed as staff members tried to speak with her, and finally left in a fury, threatening staff and security guards. In preparation for a staff training and developing an agreed-upon approach in our practice, I decided to look into this problem a bit further. What search term do I use? The term “difficult patient” yielded some relevant literature, as well as a long string of articles in which “difficult” referred to the complexity of the diagnosis rather than the patient’s behavior. The patients I am referring to have been given a variety of labels: hateful, frustrating, problem and, in predictably more evocative British terminology, “heartsink” patients; “those who provoke distress in their physician that exceeds the expected and accepted level of difficulty.”1 In nursing literature, a difficult patient is “a person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the care-giver, and who causes the caregiver to experience self-doubt.”2 Whether one focuses on the patient’s actions and emotional make-up, the providers’ expectations and reactions or the patient-provider relationship, an estimated 15-30% of encounters in primary care settings are characterized as difficult or troubling.34 Much of the literature focuses on the clinical encounter, as the first example illustrates, in which the patient became angry and demanding when the clinical plan failed to meet her expectations. In these situations, providers are admonished to apply general principles of good patient care to these more extreme and stressful circumstances: recognize that the patient’s behavior and emotions are not about you, the physician, to listen carefully to the patient, to be empathic, to communicate clearly, to follow-up with the patient, and to seek help and support from colleagues.5 Perhaps more than in most clinical encounters, it is critical to be aware of one’s responses to the difficult patient, particularly anger, frustration, and/or negative judgment, and to be conscious of the way one’s own emotions may further escalate the patient’s behavior.6 These skills and approaches are what we do all the time in patient-centered care—although it’s admittedly a bit more trying in these circumstances. Today’s residents are provided additional tools. They are taught to see difficult patients through the lens of literature and narrative, which can provide insight into the patients as well as themselves.7 There is less written about the patients’ interactions with and mistreatment of staff members. Risk management literature addresses situations, criteria and processes for terminating patients. For most physicians, particularly those of us who are safety-net providers, whose patients have limited options for care, termination is an undesirable last resort. However, the safety, security and freedom from fear on the part of staff members must at times trump the needs of patients – much as we hope to prevent things from reaching this point. My patient with back pain apologized when she returned for her follow-up visit.  She was insightful about the reasons for her anger, and truly remorseful about her abusive language toward me. We talked about triggers for her anger, and discussed strategies for anger management. She could not promise that she would never act in such a way, but we have created a common language for this and future episodes, and perhaps can catch the emotion before it escalates. As for the second and third patients, I am less hopeful. In my opinion they crossed a different, and less forgivable, line. References 1. Hahn,SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Int Med 2001;134:897-904. 2. Macdonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003; 17:305-310. 3. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract 1980; 11:933-938/ 4. An PG, Rabatin JS, Manwell LB et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009; 169 (4):410-414. 5. Pomm HA, Shahady E, Pomm RM. The CALMER approach: Teaching learners six steps to serenity when dealing with difficult patients. Fam Med, 2004; 36 (7) 467-469. 6. Mathers N, Jones N, Hannay D. Hearsink patients: a study of their general practitioners. Br J Gen Pract. 1995; 45:293-296. 7. Shapiro J, Lie D. Using literature to help physician-learners understand and manage “difficult” patients. Acad Med. 2000; 75 (7) 765-768. It has been a rough couple of weeks. Full moon? Bad economy? Whatever it is, there has been a flurry of bad behavior on the part of patients. One patient became furious and verbally abusive when I wasn’t prepared to order an MRI to evaluate her back pain after I carefully laid out a plan for treating and following her symptoms, including further diagnostic studies if and when things didn’t improve. Another patient came without an appointment and while waiting for the nurse to help her became impatient and threw the clipboard (on which she was writing her name and reason for visit) at the secretary, in full view of all of the other patients in the waiting room. Yesterday, another patient became angry after waiting for 5 minutes, became more incensed as staff members tried to speak with her, and finally left in a fury, threatening staff and security guards. In preparation for a staff training and developing an agreed-upon approach in our practice, I decided to look into this problem a bit further. What search term do I use? The term “difficult patient” yielded some relevant literature, as well as a long string of articles in which “difficult” referred to the complexity of the diagnosis rather than the patient’s behavior. The patients I am referring to have been given a variety of labels: hateful, frustrating, problem and, in predictably more evocative British terminology, “heartsink” patients; “those who provoke distress in their physician that exceeds the expected and accepted level of difficulty.”1 In nursing literature, a difficult patient is “a person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the care-giver, and who causes the caregiver to experience self-doubt.”2 Whether one focuses on the patient’s actions and emotional make-up, the providers’ expectations and reactions or the patient-provider relationship, an estimated 15-30% of encounters in primary care settings are characterized as difficult or troubling.34 Much of the literature focuses on the clinical encounter, as the first example illustrates, in which the patient became angry and demanding when the clinical plan failed to meet her expectations. In these situations, providers are admonished to apply general principles of good patient care to these more extreme and stressful circumstances: recognize that the patient’s behavior and emotions are not about you, the physician, to listen carefully to the patient, to be empathic, to communicate clearly, to follow-up with the patient, and to seek help and support from colleagues.5 Perhaps more than in most clinical encounters, it is critical to be aware of one’s responses to the difficult patient, particularly anger, frustration, and/or negative judgment, and to be conscious of the way one’s own emotions may further escalate the patient’s behavior.6 These skills and approaches are what we do all the time in patient-centered care—although it’s admittedly a bit more trying in these circumstances. Today’s residents are provided additional tools. They are taught to see difficult patients through the lens of literature and narrative, which can provide insight into the patients as well as themselves.7 There is less written about the patients’ interactions with and mistreatment of staff members. Risk management literature addresses situations, criteria and processes for terminating patients. For most physicians, particularly those of us who are safety-net providers, whose patients have limited options for care, termination is an undesirable last resort. However, the safety, security and freedom from fear on the part of staff members must at times trump the needs of patients – much as we hope to prevent things from reaching this point. My patient with back pain apologized when she returned for her follow-up visit.  She was insightful about the reasons for her anger, and truly remorseful about her abusive language toward me. We talked about triggers for her anger, and discussed strategies for anger management. She could not promise that she would never act in such a way, but we have created a common language for this and future episodes, and perhaps can catch the emotion before it escalates. As for the second and third patients, I am less hopeful. In my opinion they crossed a different, and less forgivable, line. References 1. Hahn,SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Int Med 2001;134:897-904. 2. Macdonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003; 17:305-310. 3. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract 1980; 11:933-938/ 4. An PG, Rabatin JS, Manwell LB et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009; 169 (4):410-414. 5. Pomm HA, Shahady E, Pomm RM. The CALMER approach: Teaching learners six steps to serenity when dealing with difficult patients. Fam Med, 2004; 36 (7) 467-469. 6. Mathers N, Jones N, Hannay D. Hearsink patients: a study of their general practitioners. Br J Gen Pract. 1995; 45:293-296. 7. Shapiro J, Lie D. Using literature to help physician-learners understand and manage “difficult” patients. Acad Med. 2000; 75 (7) 765-768. Thu, 30 Jun 2011 19:39:07 GMT http://community.modernmedicine.com/_Crossing-the-line-dealing-with-difficult-patients-in-primary-care/blog/4610551/33379.html bgottlieb 2011-06-30T18:39:26Z Managing Your Practice Modern Medicine Community It has been a rough couple of weeks. Full moon? Bad economy? Whatever it is, there has been a flurry of bad behavior on the part of patients. One patient became furious and verbally abusive when I wasn’t prepared to order an MRI to evaluate her back pain after I carefully laid out a plan for treating and following her symptoms, including further diagnostic studies if and when things didn’t improve. Another patient came without an appointment and while waiting for the nurse to help her became impatient and threw the clipboard (on which she was writing her name and reason for visit) at the secretary, in full view of all of the other patients in the waiting room. Yesterday, another patient became angry after waiting for 5 minutes, became more incensed as staff members tried to speak with her, and finally left in a fury, threatening staff and security guards. In preparation for a staff training and developing an agreed-upon approach in our practice, I decided to look into this problem a bit further. What search term do I use? The term “difficult patient” yielded some relevant literature, as well as a long string of articles in which “difficult” referred to the complexity of the diagnosis rather than the patient’s behavior. The patients I am referring to have been given a variety of labels: hateful, frustrating, problem and, in predictably more evocative British terminology, “heartsink” patients; “those who provoke distress in their physician that exceeds the expected and accepted level of difficulty.”1 In nursing literature, a difficult patient is “a person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the care-giver, and who causes the caregiver to experience self-doubt.”2 Whether one focuses on the patient’s actions and emotional make-up, the providers’ expectations and reactions or the patient-provider relationship, an estimated 15-30% of encounters in primary care settings are characterized as difficult or troubling.34 Much of the literature focuses on the clinical encounter, as the first example illustrates, in which the patient became angry and demanding when the clinical plan failed to meet her expectations. In these situations, providers are admonished to apply general principles of good patient care to these more extreme and stressful circumstances: recognize that the patient’s behavior and emotions are not about you, the physician, to listen carefully to the patient, to be empathic, to communicate clearly, to follow-up with the patient, and to seek help and support from colleagues.5 Perhaps more than in most clinical encounters, it is critical to be aware of one’s responses to the difficult patient, particularly anger, frustration, and/or negative judgment, and to be conscious of the way one’s own emotions may further escalate the patient’s behavior.6 These skills and approaches are what we do all the time in patient-centered care—although it’s admittedly a bit more trying in these circumstances. Today’s residents are provided additional tools. They are taught to see difficult patients through the lens of literature and narrative, which can provide insight into the patients as well as themselves.7 There is less written about the patients’ interactions with and mistreatment of staff members. Risk management literature addresses situations, criteria and processes for terminating patients. For most physicians, particularly those of us who are safety-net providers, whose patients have limited options for care, termination is an undesirable last resort. However, the safety, security and freedom from fear on the part of staff members must at times trump the needs of patients – much as we hope to prevent things from reaching this point. My patient with back pain apologized when she returned for her follow-up visit.  She was insightful about the reasons for her anger, and truly remorseful about her abusive language toward me. We talked about triggers for her anger, and discussed strategies for anger management. She could not promise that she would never act in such a way, but we have created a common language for this and future episodes, and perhaps can catch the emotion before it escalates. As for the second and third patients, I am less hopeful. In my opinion they crossed a different, and less forgivable, line. References 1. Hahn,SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Int Med 2001;134:897-904. 2. Macdonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003; 17:305-310. 3. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract 1980; 11:933-938/ 4. An PG, Rabatin JS, Manwell LB et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009; 169 (4):410-414. 5. Pomm HA, Shahady E, Pomm RM. The CALMER approach: Teaching learners six steps to serenity when dealing with difficult patients. Fam Med, 2004; 36 (7) 467-469. 6. Mathers N, Jones N, Hannay D. Hearsink patients: a study of their general practitioners. Br J Gen Pract. 1995; 45:293-296. 7. Shapiro J, Lie D. Using literature to help physician-learners understand and manage “difficult” patients. Acad Med. 2000; 75 (7) 765-768. difficult patients, managing your practice nonadult false Crossing the line – dealing with “difficult” patients in primary care text blog difficult patients,managing your practice 1114 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Managing Your Practice 0 4610551 2771822 Member 0 http://community.modernmedicine.com/_Anorexia-nervosa-A-Primary-Care-Physicians-Lens/blog/4207578/33379.html My first view of her is always in profile, slumped in the chair, eyes cast into her lap in a tired gaze. Darting between exam rooms, my own unfocused glance registers a form without mass—an unfurled S melts from the chair to the floor. Medium length hair, uneven at the ends, falls limply down her back. Hair, skin, eyes, clothing drained of color. The room takes on a listless yellow hue.   Even before her name registers in my consciousness I'm gripped by a tightness in my stomach. A familiar dread washes over me.  After 30 years of practicing primary care I am used to the hard things—pain, suffering, deprivation, violence, loss, hardship, injustice. I can usually find my footing in delivering bad news, receiving patients’ sadness, anger and fear. As a physician, I often feel sadness about the things I can’t control, change, or do for patients, but I can usually find a way to take some next steps. What is it about anorexia nervosa that stops me in my tracks? Is it that she is 20-something, no longer a teenager, beyond pretending that she will “grow out of this?” It is as if I take in her own hopelessness with each breath I take in her presence. The lifetime prevalence of anorexia nervosa in women is estimated to be 0.5%-to 3.7%,1,2 most commonly seen and diagnosed in adolescent girls and young women. At least half are first diagnosed in primary care settings.3 My own practice, in a low-income, multi-ethnic community of immigrants, while not the stereotypic demographic of eating disorders, has been no exception. And, as with many complex medical and mental health conditions, economic and social disadvantage contribute to the morbidity, compromise the outcomes, and leave me, the PCP, with greater responsibility for coordination and management than might be the case if my patients had access to greater resources. Although eating disorders may sometimes declare themselves loud and clear, it is important to be vigilant, and to screen for early and subclinical manifestations of these common and potentially devastating disorders. An estimated 1% of the US population suffers from sort of eating disorder.4 There are several validated screening tools for eating disorders. In 1999, Morgan, et al, developed the SCOFF questionnaire,5 which is easy to use in primary care: Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (14 pounds) in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? Scoring is equally easy: each positive response counts as 1 point. A score of 2 or more is indicates a strong likelihood of anorexia nervosa or bulimia. The literature is much more disappointing when it comes to successful treatment options. Despite the therapeutic success of SSRI’s in a range of conditions characterized by compulsive behaviors, there is no evidence that they are useful in treating active anorexia nervosa or in preventing relapse in stabilized patients.6  This may be because anorexic patients are likely to be tryptophan deficient because of calorie restriction from carbohydrates, thus rendering the SSRI ineffective.7  Family therapy and CBT modalities lead to improvement in some patients but, to say the least, there is no “magic bullet.” Rates of remission and long-term recovery are estimated to be between 35-85%, with high rates of relapse.8 Anorexia nervosa is among the most difficult to treat disorders, with high rates of morbidity and mortality associated with its metabolic and physical consequences and co-morbid mental disorders including depression and suicidality. In fact, anorexia nervosa has the highest rate of premature mortality of any psychiatric disorder.9 Although evidence-based treatment guidelines are sparse, most recommendations emphasize multi-modality, multi-disciplinary efforts. This makes intuitive sense to me, given the potential physical, mental, and social consequences of anorexia nervosa, particularly once it has become chronic. The problem is finding such treatment options, coordinating them, and paying for them. There are so many cracks to slip through: many comprehensive programs have a minimum BMI that excludes many active cases; anorexic patients burn therapeutic bridges by failing to meet therapeutic “contracts”, “manipulating” and misrepresenting their weight and current eating behaviors. Caught up in their compulsive behaviors, anorexic patients drop out of school and work, lose their independent source of health insurance, age out of their parents’ insurance, and are left uninsured or poorly insured and unable to pay out-of-pocket for coordinated, comprehensive care. After recounting the grim prognosis for patients with anorexia and other eating disorders, the sparse and unimpressive therapeutic modalities, the authors of a recent review in Mayo Clinic Proceedings conclude, “Eating disorders are severe psychological illnesses associated with a host of adverse medical morbidities, negative psychological sequelae, and substantial reductions in quality of life. Given these consequences and the fact that health service utilization among people with eating disorders is relatively high, it is particularly important for physicians to adequately assess for these disorders….The unflappable, nonjudgmental health care professional, armed with a plan for recovery, can make a real difference to such patients.”10 I prepare to see my patient. I think I can manage to be nonjudgmental. Can I be that “unflappable health care professional?” Can I “arm myself with a plan for recovery” that is practical, plausible, reality-based, and achievable? I’ll try. And at minimum, I will try to take another few small steps to establish trust, seeking first to do no harm. I know her weight before I enter the room. Less than 1 pound lost in a month. Today’s report is delivered in short phrases in an inexplicably cheerful voice: there has been some progress made in family therapy; behavioral commitments from the previous visit have been met.  A second  “good visit.” Another slender cross-piece added to the scaffold of trust between us. We plan our next visit. 1) Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry. 2007;61(3):348-358. 2) Yager J, Andersen A, Devlin M, et al: Practice guideline for the treatment of patients with eating disorders (Revision). Am J Psychiatry (Suppl)57:1–39, 2000 3) Walsh JM, Wheat ME, Freund K. Detection, evaluation and treatment of eating disorders: the role of the primary care physician. J Gen Intern Med. 2000;15(8):577-590. 4) Op cit Yager 2000. 5) Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467. 6) Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006;295(22): 2605-2612. 7) Kaye W, Gendall K, Strober M: Serotonin neuronal function and selective serotonin inhibitor treatment in anorexia and bulimia nervosa. Biol Psychiatry 44:825–838, 1998 8) Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord. 1997;22(3):339-360. 9) Vitiello B, Lederhendler I: Research on eating disorders: Current status and future prospects. Biol Psychiatry 47:777–786, 2000 10) Sim LA, McAlpine DE, Grothe KB et al. Treatment of eating disorders in the primary care setting. Mayo Clin Proc. 2010;85(8): 746-751. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] My first view of her is always in profile, slumped in the chair, eyes cast into her lap in a tired gaze. Darting between exam rooms, my own unfocused glance registers a form without mass—an unfurled S melts from the chair to the floor. Medium length hair, uneven at the ends, falls limply down her back. Hair, skin, eyes, clothing drained of color. The room takes on a listless yellow hue.   Even before her name registers in my consciousness I'm gripped by a tightness in my stomach. A familiar dread washes over me.  After 30 years of practicing primary care I am used to the hard things—pain, suffering, deprivation, violence, loss, hardship, injustice. I can usually find my footing in delivering bad news, receiving patients’ sadness, anger and fear. As a physician, I often feel sadness about the things I can’t control, change, or do for patients, but I can usually find a way to take some next steps. What is it about anorexia nervosa that stops me in my tracks? Is it that she is 20-something, no longer a teenager, beyond pretending that she will “grow out of this?” It is as if I take in her own hopelessness with each breath I take in her presence. The lifetime prevalence of anorexia nervosa in women is estimated to be 0.5%-to 3.7%,1,2 most commonly seen and diagnosed in adolescent girls and young women. At least half are first diagnosed in primary care settings.3 My own practice, in a low-income, multi-ethnic community of immigrants, while not the stereotypic demographic of eating disorders, has been no exception. And, as with many complex medical and mental health conditions, economic and social disadvantage contribute to the morbidity, compromise the outcomes, and leave me, the PCP, with greater responsibility for coordination and management than might be the case if my patients had access to greater resources. Although eating disorders may sometimes declare themselves loud and clear, it is important to be vigilant, and to screen for early and subclinical manifestations of these common and potentially devastating disorders. An estimated 1% of the US population suffers from sort of eating disorder.4 There are several validated screening tools for eating disorders. In 1999, Morgan, et al, developed the SCOFF questionnaire,5 which is easy to use in primary care: Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (14 pounds) in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? Scoring is equally easy: each positive response counts as 1 point. A score of 2 or more is indicates a strong likelihood of anorexia nervosa or bulimia. The literature is much more disappointing when it comes to successful treatment options. Despite the therapeutic success of SSRI’s in a range of conditions characterized by compulsive behaviors, there is no evidence that they are useful in treating active anorexia nervosa or in preventing relapse in stabilized patients.6  This may be because anorexic patients are likely to be tryptophan deficient because of calorie restriction from carbohydrates, thus rendering the SSRI ineffective.7  Family therapy and CBT modalities lead to improvement in some patients but, to say the least, there is no “magic bullet.” Rates of remission and long-term recovery are estimated to be between 35-85%, with high rates of relapse.8 Anorexia nervosa is among the most difficult to treat disorders, with high rates of morbidity and mortality associated with its metabolic and physical consequences and co-morbid mental disorders including depression and suicidality. In fact, anorexia nervosa has the highest rate of premature mortality of any psychiatric disorder.9 Although evidence-based treatment guidelines are sparse, most recommendations emphasize multi-modality, multi-disciplinary efforts. This makes intuitive sense to me, given the potential physical, mental, and social consequences of anorexia nervosa, particularly once it has become chronic. The problem is finding such treatment options, coordinating them, and paying for them. There are so many cracks to slip through: many comprehensive programs have a minimum BMI that excludes many active cases; anorexic patients burn therapeutic bridges by failing to meet therapeutic “contracts”, “manipulating” and misrepresenting their weight and current eating behaviors. Caught up in their compulsive behaviors, anorexic patients drop out of school and work, lose their independent source of health insurance, age out of their parents’ insurance, and are left uninsured or poorly insured and unable to pay out-of-pocket for coordinated, comprehensive care. After recounting the grim prognosis for patients with anorexia and other eating disorders, the sparse and unimpressive therapeutic modalities, the authors of a recent review in Mayo Clinic Proceedings conclude, “Eating disorders are severe psychological illnesses associated with a host of adverse medical morbidities, negative psychological sequelae, and substantial reductions in quality of life. Given these consequences and the fact that health service utilization among people with eating disorders is relatively high, it is particularly important for physicians to adequately assess for these disorders….The unflappable, nonjudgmental health care professional, armed with a plan for recovery, can make a real difference to such patients.”10 I prepare to see my patient. I think I can manage to be nonjudgmental. Can I be that “unflappable health care professional?” Can I “arm myself with a plan for recovery” that is practical, plausible, reality-based, and achievable? I’ll try. And at minimum, I will try to take another few small steps to establish trust, seeking first to do no harm. I know her weight before I enter the room. Less than 1 pound lost in a month. Today’s report is delivered in short phrases in an inexplicably cheerful voice: there has been some progress made in family therapy; behavioral commitments from the previous visit have been met.  A second  “good visit.” Another slender cross-piece added to the scaffold of trust between us. We plan our next visit. 1) Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry. 2007;61(3):348-358. 2) Yager J, Andersen A, Devlin M, et al: Practice guideline for the treatment of patients with eating disorders (Revision). Am J Psychiatry (Suppl)57:1–39, 2000 3) Walsh JM, Wheat ME, Freund K. Detection, evaluation and treatment of eating disorders: the role of the primary care physician. J Gen Intern Med. 2000;15(8):577-590. 4) Op cit Yager 2000. 5) Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467. 6) Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006;295(22): 2605-2612. 7) Kaye W, Gendall K, Strober M: Serotonin neuronal function and selective serotonin inhibitor treatment in anorexia and bulimia nervosa. Biol Psychiatry 44:825–838, 1998 8) Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord. 1997;22(3):339-360. 9) Vitiello B, Lederhendler I: Research on eating disorders: Current status and future prospects. Biol Psychiatry 47:777–786, 2000 10) Sim LA, McAlpine DE, Grothe KB et al. Treatment of eating disorders in the primary care setting. Mayo Clin Proc. 2010;85(8): 746-751. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 17 Jun 2011 19:34:51 GMT http://community.modernmedicine.com/_Anorexia-nervosa-A-Primary-Care-Physicians-Lens/blog/4207578/33379.html bgottlieb 2011-06-17T19:32:05Z Primary Care Modern Medicine Community My first view of her is always in profile, slumped in the chair, eyes cast into her lap in a tired gaze. Darting between exam rooms, my own unfocused glance registers a form without mass—an unfurled S melts from the chair to the floor. Medium length hair, uneven at the ends, falls limply down her back. Hair, skin, eyes, clothing drained of color. The room takes on a listless yellow hue.   Even before her name registers in my consciousness I'm gripped by a tightness in my stomach. A familiar dread washes over me.  After 30 years of practicing primary care I am used to the hard things—pain, suffering, deprivation, violence, loss, hardship, injustice. I can usually find my footing in delivering bad news, receiving patients’ sadness, anger and fear. As a physician, I often feel sadness about the things I can’t control, change, or do for patients, but I can usually find a way to take some next steps. What is it about anorexia nervosa that stops me in my tracks? Is it that she is 20-something, no longer a teenager, beyond pretending that she will “grow out of this?” It is as if I take in her own hopelessness with each breath I take in her presence. The lifetime prevalence of anorexia nervosa in women is estimated to be 0.5%-to 3.7%,1,2 most commonly seen and diagnosed in adolescent girls and young women. At least half are first diagnosed in primary care settings.3 My own practice, in a low-income, multi-ethnic community of immigrants, while not the stereotypic demographic of eating disorders, has been no exception. And, as with many complex medical and mental health conditions, economic and social disadvantage contribute to the morbidity, compromise the outcomes, and leave me, the PCP, with greater responsibility for coordination and management than might be the case if my patients had access to greater resources. Although eating disorders may sometimes declare themselves loud and clear, it is important to be vigilant, and to screen for early and subclinical manifestations of these common and potentially devastating disorders. An estimated 1% of the US population suffers from sort of eating disorder.4 There are several validated screening tools for eating disorders. In 1999, Morgan, et al, developed the SCOFF questionnaire,5 which is easy to use in primary care: Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (14 pounds) in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? Scoring is equally easy: each positive response counts as 1 point. A score of 2 or more is indicates a strong likelihood of anorexia nervosa or bulimia. The literature is much more disappointing when it comes to successful treatment options. Despite the therapeutic success of SSRI’s in a range of conditions characterized by compulsive behaviors, there is no evidence that they are useful in treating active anorexia nervosa or in preventing relapse in stabilized patients.6  This may be because anorexic patients are likely to be tryptophan deficient because of calorie restriction from carbohydrates, thus rendering the SSRI ineffective.7  Family therapy and CBT modalities lead to improvement in some patients but, to say the least, there is no “magic bullet.” Rates of remission and long-term recovery are estimated to be between 35-85%, with high rates of relapse.8 Anorexia nervosa is among the most difficult to treat disorders, with high rates of morbidity and mortality associated with its metabolic and physical consequences and co-morbid mental disorders including depression and suicidality. In fact, anorexia nervosa has the highest rate of premature mortality of any psychiatric disorder.9 Although evidence-based treatment guidelines are sparse, most recommendations emphasize multi-modality, multi-disciplinary efforts. This makes intuitive sense to me, given the potential physical, mental, and social consequences of anorexia nervosa, particularly once it has become chronic. The problem is finding such treatment options, coordinating them, and paying for them. There are so many cracks to slip through: many comprehensive programs have a minimum BMI that excludes many active cases; anorexic patients burn therapeutic bridges by failing to meet therapeutic “contracts”, “manipulating” and misrepresenting their weight and current eating behaviors. Caught up in their compulsive behaviors, anorexic patients drop out of school and work, lose their independent source of health insurance, age out of their parents’ insurance, and are left uninsured or poorly insured and unable to pay out-of-pocket for coordinated, comprehensive care. After recounting the grim prognosis for patients with anorexia and other eating disorders, the sparse and unimpressive therapeutic modalities, the authors of a recent review in Mayo Clinic Proceedings conclude, “Eating disorders are severe psychological illnesses associated with a host of adverse medical morbidities, negative psychological sequelae, and substantial reductions in quality of life. Given these consequences and the fact that health service utilization among people with eating disorders is relatively high, it is particularly important for physicians to adequately assess for these disorders….The unflappable, nonjudgmental health care professional, armed with a plan for recovery, can make a real difference to such patients.”10 I prepare to see my patient. I think I can manage to be nonjudgmental. Can I be that “unflappable health care professional?” Can I “arm myself with a plan for recovery” that is practical, plausible, reality-based, and achievable? I’ll try. And at minimum, I will try to take another few small steps to establish trust, seeking first to do no harm. I know her weight before I enter the room. Less than 1 pound lost in a month. Today’s report is delivered in short phrases in an inexplicably cheerful voice: there has been some progress made in family therapy; behavioral commitments from the previous visit have been met.  A second  “good visit.” Another slender cross-piece added to the scaffold of trust between us. We plan our next visit. 1) Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry. 2007;61(3):348-358. 2) Yager J, Andersen A, Devlin M, et al: Practice guideline for the treatment of patients with eating disorders (Revision). Am J Psychiatry (Suppl)57:1–39, 2000 3) Walsh JM, Wheat ME, Freund K. Detection, evaluation and treatment of eating disorders: the role of the primary care physician. J Gen Intern Med. 2000;15(8):577-590. 4) Op cit Yager 2000. 5) Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467. 6) Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006;295(22): 2605-2612. 7) Kaye W, Gendall K, Strober M: Serotonin neuronal function and selective serotonin inhibitor treatment in anorexia and bulimia nervosa. Biol Psychiatry 44:825–838, 1998 8) Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord. 1997;22(3):339-360. 9) Vitiello B, Lederhendler I: Research on eating disorders: Current status and future prospects. Biol Psychiatry 47:777–786, 2000 10) Sim LA, McAlpine DE, Grothe KB et al. Treatment of eating disorders in the primary care setting. Mayo Clin Proc. 2010;85(8): 746-751. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] anorexia, bulimia, eating disorders, nervosa, primary care, scoff nonadult false Anorexia nervosa. A Primary Care Physician’s Lens text blog anorexia,bulimia,eating disorders,nervosa,primary care,scoff 823 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 4207578 2771822 Member 0 http://community.modernmedicine.com/_Bisphosphanate-associated-osteonecrosis-of-the-jawRare-events-lots-of-worry-What-is-a-provider-to-do/blog/3544115/33379.html Over the past few weeks, I have been dealing with a clinical situation that raises a lot of questions about data, medical “news” in the lay press, clinical judgment, and communication. Ms E is in her late 50’s. Her menopause came in her mid-forties, and she has a strong family history of osteoporosis.  She wanted to measure her bone density shortly after menopause and did, in fact, have osteopenia that reached the threshold for treatment. After reviewing the risks and benefits of bisphosphonates, she chose not to be treated for a number of years despite declining bone density. However, at the age of 56, when her bone density declined drastically and crossed the threshold for osteoporosis, she decided to begin alendronate. I try to educate patients about new medications, but have to admit that I took particular care with this patient who has the skepticism and critical mind of a scientist (which she is), and perhaps more than the typical overlay of anxiety and pessimism. She believes that if there are rare adverse side effects she will be the one in a million. We reviewed the potential risks and side effects. As I review my notes, I see that I actually documented the rare association with osteonecrosis of the jaw (ONJ), something that I had read about more in the newspaper than in the medical literature. At the time, ONJ was described in case reports and retrospective series in the medical literature, but bad publicity and threats of law suits loomed like a dark cloud in the lay press. We decided that her risk of serious fractures outweighed the potential risks of side effects. Fast forward to several weeks ago. She was taking alendronate as directed. Fortunately, she did not seem to have the relatively common GI side effects, nor the less common and more subtle bone pain and body aches.  However, she then developed a serious dental problem. Her oral surgeon was concerned about doing invasive oral surgery because of the alendronate. She wanted to know how long she needed to stop the medication before surgery. She wanted a serum C-telopeptide  test. She wanted my advice. What exactly is the story with bisphosphonates and ONJ? I learned that ONJ was first described as case reports in a letter to the editor in the Journal of Oral and Maxillofacial Surgery in 2003.1 Although alarmingly described as a “growing epidemic,” the report described 36 patients, all of whom had received high dose intravenous bisphosphonates, and 35 of whom were being treated for cancer-related conditions. There have been subsequent case reports and retrospective reviews. According to Lewiecki of the New Mexico Clinical Research and Osteoporosis Center in Albuquerque, accurate determination of incidence and prevalence of ONJ in the general population “has  been confounded by factors that include duplication of reported cases, variable terminology for describing the disorder, variable case definitions for ONJ and differences in study methodologies.”2 In order to address this problem, the American Society for Bone and Mineral Research convened a task force charged with developing a consensus definition of ONJ, and reviewing the existing literature and evidence. Bisphosphonate-associated ONJ is now defined as “exposed bone in the maxillofacial region with no healing within 8 weeks of identification by a healthcare provider, in a patient with exposure to a bisphosphonate and no history of radiation therapy to the cranio-facial area.”3 Then, based on the best available data,  the task force stratified the population and estimated the risk for patients being treated for osteoporosis as 1 in 10,000 or < 1 per 100,000 patient-treatment years. As in the initial reports, they noted that 95% of reported cases of ONJ were in cancer patients receiving high-dose intravenous bisphosphonates for prevention or treatment of cancer-related bone disease. Lewiecki then reviews the evidence for serum C-telopeptide (CTX) as a potential guide for assessing the risk of ONJ. He sites a study stratifying risk according to the level of CTX, recommending that invasive oral surgery be deferred in patients treated with bisphosphonates if the serum CTX is < 150 pg/ml, checking serial results until the level is > 150 pg/ml.4  However, these recommendations were made on the bases of an analysis of 30 patients. Subsequent studies raise serious doubts as to the clinical utility of serum CTX to stratify ONJ risk.5 My patient’s CTX level is well over 150 pg/ml – a result that I suppose should be reassuring, but honestly, who knows? The evidence base and knowledge about bisphosphonate-induced ONJ will undoubtedly expand over the next few years. And, based on the best knowledge and evidence to date, it seems that my patient would be at very low risk for this problem. However, the Guidelines of the American Association of Oral and Maxillofacial Surgeons recommend that oral bisphosphonates be discontinued 3 months prior to and 3 months following invasive oral surgery in order to possibly reduce the risk of ONJ, despite their admission that there is no direct evidence to support this practice.6 So – if the surgery can be postponed, I will recommend that it be postponed. I’ll stop the alendronate. My gut tells me that this is unduly cautious. I look forward to guidelines that are based on clearer evidence. References 1. Marx RE, Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61 (9): 115-7. 2. Lewiecki EM, Long-term bisphosphonate therapy for the management of osteoporosis. Drugs 2011; 71 (6): 791-814. 3. Khosla S, Burr D, Cauley J et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2007; 22 (10): 1479-89. 4. Marx RE, Cillo JR JE, Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral MAxillofac Surg 2007; 65(12): 2397-2410. 5. Baim S, Miller PD. Assessing the clinical utility of serum CTX in postmenopausal osteoporosis and its use in predicting risk of osteonecrosis of the jaw. J Bone Miner Res 2009: 24(4): 561-574. 6. Ruggier SL, Dodson TB, Assael LA, et al. American Association of Oral and Maxillorfacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws: 2009 update. J Oral Maxillofac Surg 2009; 67 (5 Suppl): 2-12. Barbara R Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Over the past few weeks, I have been dealing with a clinical situation that raises a lot of questions about data, medical “news” in the lay press, clinical judgment, and communication. Ms E is in her late 50’s. Her menopause came in her mid-forties, and she has a strong family history of osteoporosis.  She wanted to measure her bone density shortly after menopause and did, in fact, have osteopenia that reached the threshold for treatment. After reviewing the risks and benefits of bisphosphonates, she chose not to be treated for a number of years despite declining bone density. However, at the age of 56, when her bone density declined drastically and crossed the threshold for osteoporosis, she decided to begin alendronate. I try to educate patients about new medications, but have to admit that I took particular care with this patient who has the skepticism and critical mind of a scientist (which she is), and perhaps more than the typical overlay of anxiety and pessimism. She believes that if there are rare adverse side effects she will be the one in a million. We reviewed the potential risks and side effects. As I review my notes, I see that I actually documented the rare association with osteonecrosis of the jaw (ONJ), something that I had read about more in the newspaper than in the medical literature. At the time, ONJ was described in case reports and retrospective series in the medical literature, but bad publicity and threats of law suits loomed like a dark cloud in the lay press. We decided that her risk of serious fractures outweighed the potential risks of side effects. Fast forward to several weeks ago. She was taking alendronate as directed. Fortunately, she did not seem to have the relatively common GI side effects, nor the less common and more subtle bone pain and body aches.  However, she then developed a serious dental problem. Her oral surgeon was concerned about doing invasive oral surgery because of the alendronate. She wanted to know how long she needed to stop the medication before surgery. She wanted a serum C-telopeptide  test. She wanted my advice. What exactly is the story with bisphosphonates and ONJ? I learned that ONJ was first described as case reports in a letter to the editor in the Journal of Oral and Maxillofacial Surgery in 2003.1 Although alarmingly described as a “growing epidemic,” the report described 36 patients, all of whom had received high dose intravenous bisphosphonates, and 35 of whom were being treated for cancer-related conditions. There have been subsequent case reports and retrospective reviews. According to Lewiecki of the New Mexico Clinical Research and Osteoporosis Center in Albuquerque, accurate determination of incidence and prevalence of ONJ in the general population “has  been confounded by factors that include duplication of reported cases, variable terminology for describing the disorder, variable case definitions for ONJ and differences in study methodologies.”2 In order to address this problem, the American Society for Bone and Mineral Research convened a task force charged with developing a consensus definition of ONJ, and reviewing the existing literature and evidence. Bisphosphonate-associated ONJ is now defined as “exposed bone in the maxillofacial region with no healing within 8 weeks of identification by a healthcare provider, in a patient with exposure to a bisphosphonate and no history of radiation therapy to the cranio-facial area.”3 Then, based on the best available data,  the task force stratified the population and estimated the risk for patients being treated for osteoporosis as 1 in 10,000 or < 1 per 100,000 patient-treatment years. As in the initial reports, they noted that 95% of reported cases of ONJ were in cancer patients receiving high-dose intravenous bisphosphonates for prevention or treatment of cancer-related bone disease. Lewiecki then reviews the evidence for serum C-telopeptide (CTX) as a potential guide for assessing the risk of ONJ. He sites a study stratifying risk according to the level of CTX, recommending that invasive oral surgery be deferred in patients treated with bisphosphonates if the serum CTX is < 150 pg/ml, checking serial results until the level is > 150 pg/ml.4  However, these recommendations were made on the bases of an analysis of 30 patients. Subsequent studies raise serious doubts as to the clinical utility of serum CTX to stratify ONJ risk.5 My patient’s CTX level is well over 150 pg/ml – a result that I suppose should be reassuring, but honestly, who knows? The evidence base and knowledge about bisphosphonate-induced ONJ will undoubtedly expand over the next few years. And, based on the best knowledge and evidence to date, it seems that my patient would be at very low risk for this problem. However, the Guidelines of the American Association of Oral and Maxillofacial Surgeons recommend that oral bisphosphonates be discontinued 3 months prior to and 3 months following invasive oral surgery in order to possibly reduce the risk of ONJ, despite their admission that there is no direct evidence to support this practice.6 So – if the surgery can be postponed, I will recommend that it be postponed. I’ll stop the alendronate. My gut tells me that this is unduly cautious. I look forward to guidelines that are based on clearer evidence. References 1. Marx RE, Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61 (9): 115-7. 2. Lewiecki EM, Long-term bisphosphonate therapy for the management of osteoporosis. Drugs 2011; 71 (6): 791-814. 3. Khosla S, Burr D, Cauley J et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2007; 22 (10): 1479-89. 4. Marx RE, Cillo JR JE, Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral MAxillofac Surg 2007; 65(12): 2397-2410. 5. Baim S, Miller PD. Assessing the clinical utility of serum CTX in postmenopausal osteoporosis and its use in predicting risk of osteonecrosis of the jaw. J Bone Miner Res 2009: 24(4): 561-574. 6. Ruggier SL, Dodson TB, Assael LA, et al. American Association of Oral and Maxillorfacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws: 2009 update. J Oral Maxillofac Surg 2009; 67 (5 Suppl): 2-12. Barbara R Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 29 Apr 2011 17:20:15 GMT http://community.modernmedicine.com/_Bisphosphanate-associated-osteonecrosis-of-the-jawRare-events-lots-of-worry-What-is-a-provider-to-do/blog/3544115/33379.html bgottlieb 2011-04-29T16:52:16Z Primary Care Modern Medicine Community Over the past few weeks, I have been dealing with a clinical situation that raises a lot of questions about data, medical “news” in the lay press, clinical judgment, and communication. Ms E is in her late 50’s. Her menopause came in her mid-forties, and she has a strong family history of osteoporosis.  She wanted to measure her bone density shortly after menopause and did, in fact, have osteopenia that reached the threshold for treatment. After reviewing the risks and benefits of bisphosphonates, she chose not to be treated for a number of years despite declining bone density. However, at the age of 56, when her bone density declined drastically and crossed the threshold for osteoporosis, she decided to begin alendronate. I try to educate patients about new medications, but have to admit that I took particular care with this patient who has the skepticism and critical mind of a scientist (which she is), and perhaps more than the typical overlay of anxiety and pessimism. She believes that if there are rare adverse side effects she will be the one in a million. We reviewed the potential risks and side effects. As I review my notes, I see that I actually documented the rare association with osteonecrosis of the jaw (ONJ), something that I had read about more in the newspaper than in the medical literature. At the time, ONJ was described in case reports and retrospective series in the medical literature, but bad publicity and threats of law suits loomed like a dark cloud in the lay press. We decided that her risk of serious fractures outweighed the potential risks of side effects. Fast forward to several weeks ago. She was taking alendronate as directed. Fortunately, she did not seem to have the relatively common GI side effects, nor the less common and more subtle bone pain and body aches.  However, she then developed a serious dental problem. Her oral surgeon was concerned about doing invasive oral surgery because of the alendronate. She wanted to know how long she needed to stop the medication before surgery. She wanted a serum C-telopeptide  test. She wanted my advice. What exactly is the story with bisphosphonates and ONJ? I learned that ONJ was first described as case reports in a letter to the editor in the Journal of Oral and Maxillofacial Surgery in 2003.1 Although alarmingly described as a “growing epidemic,” the report described 36 patients, all of whom had received high dose intravenous bisphosphonates, and 35 of whom were being treated for cancer-related conditions. There have been subsequent case reports and retrospective reviews. According to Lewiecki of the New Mexico Clinical Research and Osteoporosis Center in Albuquerque, accurate determination of incidence and prevalence of ONJ in the general population “has  been confounded by factors that include duplication of reported cases, variable terminology for describing the disorder, variable case definitions for ONJ and differences in study methodologies.”2 In order to address this problem, the American Society for Bone and Mineral Research convened a task force charged with developing a consensus definition of ONJ, and reviewing the existing literature and evidence. Bisphosphonate-associated ONJ is now defined as “exposed bone in the maxillofacial region with no healing within 8 weeks of identification by a healthcare provider, in a patient with exposure to a bisphosphonate and no history of radiation therapy to the cranio-facial area.”3 Then, based on the best available data,  the task force stratified the population and estimated the risk for patients being treated for osteoporosis as 1 in 10,000 or < 1 per 100,000 patient-treatment years. As in the initial reports, they noted that 95% of reported cases of ONJ were in cancer patients receiving high-dose intravenous bisphosphonates for prevention or treatment of cancer-related bone disease. Lewiecki then reviews the evidence for serum C-telopeptide (CTX) as a potential guide for assessing the risk of ONJ. He sites a study stratifying risk according to the level of CTX, recommending that invasive oral surgery be deferred in patients treated with bisphosphonates if the serum CTX is < 150 pg/ml, checking serial results until the level is > 150 pg/ml.4  However, these recommendations were made on the bases of an analysis of 30 patients. Subsequent studies raise serious doubts as to the clinical utility of serum CTX to stratify ONJ risk.5 My patient’s CTX level is well over 150 pg/ml – a result that I suppose should be reassuring, but honestly, who knows? The evidence base and knowledge about bisphosphonate-induced ONJ will undoubtedly expand over the next few years. And, based on the best knowledge and evidence to date, it seems that my patient would be at very low risk for this problem. However, the Guidelines of the American Association of Oral and Maxillofacial Surgeons recommend that oral bisphosphonates be discontinued 3 months prior to and 3 months following invasive oral surgery in order to possibly reduce the risk of ONJ, despite their admission that there is no direct evidence to support this practice.6 So – if the surgery can be postponed, I will recommend that it be postponed. I’ll stop the alendronate. My gut tells me that this is unduly cautious. I look forward to guidelines that are based on clearer evidence. References 1. Marx RE, Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61 (9): 115-7. 2. Lewiecki EM, Long-term bisphosphonate therapy for the management of osteoporosis. Drugs 2011; 71 (6): 791-814. 3. Khosla S, Burr D, Cauley J et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2007; 22 (10): 1479-89. 4. Marx RE, Cillo JR JE, Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral MAxillofac Surg 2007; 65(12): 2397-2410. 5. Baim S, Miller PD. Assessing the clinical utility of serum CTX in postmenopausal osteoporosis and its use in predicting risk of osteonecrosis of the jaw. J Bone Miner Res 2009: 24(4): 561-574. 6. Ruggier SL, Dodson TB, Assael LA, et al. American Association of Oral and Maxillorfacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws: 2009 update. J Oral Maxillofac Surg 2009; 67 (5 Suppl): 2-12. Barbara R Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] alendronate, bisphosphonates, onj, osteonecrosis, osteoporosis, primary care nonadult false Bisphosphanate-associated osteonecrosis of the jaw—Rare events, lots of worry. What is a provider to do? text blog alendronate,bisphosphonates,onj,osteonecrosis,osteoporosis,primary care 313 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 3544115 2771822 Member 0 http://community.modernmedicine.com/_When-Screening-Fails/blog/3368351/33379.html I know that everything we do as physicians and everything we say to patients is a question of odds. But sometimes I forget. The past week was one of those times. Mrs S is an 85-year old woman whom I have taken care of for the past 25 years.  Like many of my patients, she moved here from the Dominican Republic to live with her daughter (who is also my patient), to take care of her grandchildren, and to live in a place with a reliable health care system. She has been a model patient:  she has never smoked or drank, and has never been overweight. She walks every day, even when it is cold. Even before she was told, she restricted fats and red meat, ate lots of vegetables, and ate rice “like an American instead of a Dominican.”  She dutifully appeared for yearly physicals, blood work, mammograms and other screenings. Despite having only an elementary school education, she can name all of her medications, keeps track of refills so that she never runs out, and always comes to visits prepared with her brown bag of medications and a list of questions printed in careful capital letters on a small red pad. She has collected a few chronic conditions—hyperlipidemia, hypertension, hypothyroidism, and recently vitamin B12 deficiency. All of these conditions have been relatively easy to keep under control. Unlike many patients, I didn’t have to talk her into having colon cancer screening. She had her first colonoscopy at age 61, shortly after I met her, a second at age 71 and most recently, given her excellent state of health, at age 81. Each procedure yielded the same boring good news—satisfactory prep, small diverticula and no polyps. Not one, not ever. So why, less than 4 years after her most recent colonoscopy, did she have a bulky mass threatening to obstruct her sigmoid colon (adenocarcinoma), and widespread metastases to her liver and mesenteric lymph nodes and throughout the peritoneum?  Her family wanted to know, too. She has no family history of colon cancer. She has no known risk factors for colon cancer except for her age. In fact, if you look at protective factors, admittedly suggestive rather than certain—she has most of them: physically active, no smoking, no alcohol, not obese, no diabetes, low animal fat, high fiber diet, she takes an aspirin a day, calcium supplementation and a statin. As her physician, her diagnosis is particularly unexpected because in the past 6 months I have seen her often.  I diagnosed her with hypothyroidism and vitamin B12 deficiency. I have a series of weights—no weight loss, several hematocrits—no anemia, and even some recent transaminases—all normal. How was it that she came in for a routinely scheduled visit (a B12 injection!) one month after the previous, and everything was suddenly different? The first clue was that my usually happy, joyful, lighthearted patient was arguing with her daughter. They were arguing, it turns out, because Mrs S wasn’t eating. She just didn’t feel hungry. Everything made her feel full and heavy. Her daughter thought she was simply being difficult. She had, in fact, lost 5 lbs in 1 month. The first touch of her abdominal exam told me all I needed to know. Her liver filled her entire right side. The rest of the story unfolded like a bad dream—ultrasound confirmed that her liver was, in fact, enlarged, and filled with masses “concerning for metastatic disease.” A CT scan a few days later revealed a large mass in the sigmoid colon and multiple masses in the mesenteric lymph nodes. A flexible sigmoidscopy revealed a necrotic mass nearly obstructing the lumen. Both patients and physicians often confuse the terms screening and prevention. Patients often think that mammograms prevent breast cancer. I try to be clear that early detection can be important, but isn’t the same as prevention. However, as I try to convince patients to undergo colonoscopy, I try to win them over by explaining that colonoscopy is an opportunity to prevent. I seem to have gotten that point across to Mrs S’s family. Right now they feel betrayed. Why does she have this when she has done everything she was supposed to do? How did it get to be so advanced, when there wasn’t even a trace less than 4 years ago? There have certainly been times when a patient was found to have a preventable diagnosis when I wondered if I had done everything possible. That isn’t the case here. My self doubt is of a very different nature. Did I fail to explain that screening and prevention are always a matter of odds? Not 100%, never a certainty. I’m sure I did fail in this regard, although it will take me a while to think about how I will discuss colon cancer screening, something that I still believe in strongly, in the future, given this experience. How do I communicate uncertainty and not paralyze action…. Right now, however, I have other communication challenges to focus on. Once I saw the CT scan results I told her son that there would probably be a lot of bad news over the next few weeks. I have learned that it isn’t helpful to pretend that things aren’t bad when they are. They, like most people, have appreciated being prepared for bad news. The family seems to be in one-step-at-a time mode, taking in each incremental piece of news and focusing on the tasks at hand. But so far they have forbidden me from telling Mrs S that she has cancer. I’m confident that I will have that conversation with her, and that her joyful spirit, resilience and practical nature will provide her with the strength that she will need to face the future. Unfortunately, the odds for her right now are more certain than I would like them to be, and will probably be easier for her to grasp than the relative uncertainties of screening and prevention. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I know that everything we do as physicians and everything we say to patients is a question of odds. But sometimes I forget. The past week was one of those times. Mrs S is an 85-year old woman whom I have taken care of for the past 25 years.  Like many of my patients, she moved here from the Dominican Republic to live with her daughter (who is also my patient), to take care of her grandchildren, and to live in a place with a reliable health care system. She has been a model patient:  she has never smoked or drank, and has never been overweight. She walks every day, even when it is cold. Even before she was told, she restricted fats and red meat, ate lots of vegetables, and ate rice “like an American instead of a Dominican.”  She dutifully appeared for yearly physicals, blood work, mammograms and other screenings. Despite having only an elementary school education, she can name all of her medications, keeps track of refills so that she never runs out, and always comes to visits prepared with her brown bag of medications and a list of questions printed in careful capital letters on a small red pad. She has collected a few chronic conditions—hyperlipidemia, hypertension, hypothyroidism, and recently vitamin B12 deficiency. All of these conditions have been relatively easy to keep under control. Unlike many patients, I didn’t have to talk her into having colon cancer screening. She had her first colonoscopy at age 61, shortly after I met her, a second at age 71 and most recently, given her excellent state of health, at age 81. Each procedure yielded the same boring good news—satisfactory prep, small diverticula and no polyps. Not one, not ever. So why, less than 4 years after her most recent colonoscopy, did she have a bulky mass threatening to obstruct her sigmoid colon (adenocarcinoma), and widespread metastases to her liver and mesenteric lymph nodes and throughout the peritoneum?  Her family wanted to know, too. She has no family history of colon cancer. She has no known risk factors for colon cancer except for her age. In fact, if you look at protective factors, admittedly suggestive rather than certain—she has most of them: physically active, no smoking, no alcohol, not obese, no diabetes, low animal fat, high fiber diet, she takes an aspirin a day, calcium supplementation and a statin. As her physician, her diagnosis is particularly unexpected because in the past 6 months I have seen her often.  I diagnosed her with hypothyroidism and vitamin B12 deficiency. I have a series of weights—no weight loss, several hematocrits—no anemia, and even some recent transaminases—all normal. How was it that she came in for a routinely scheduled visit (a B12 injection!) one month after the previous, and everything was suddenly different? The first clue was that my usually happy, joyful, lighthearted patient was arguing with her daughter. They were arguing, it turns out, because Mrs S wasn’t eating. She just didn’t feel hungry. Everything made her feel full and heavy. Her daughter thought she was simply being difficult. She had, in fact, lost 5 lbs in 1 month. The first touch of her abdominal exam told me all I needed to know. Her liver filled her entire right side. The rest of the story unfolded like a bad dream—ultrasound confirmed that her liver was, in fact, enlarged, and filled with masses “concerning for metastatic disease.” A CT scan a few days later revealed a large mass in the sigmoid colon and multiple masses in the mesenteric lymph nodes. A flexible sigmoidscopy revealed a necrotic mass nearly obstructing the lumen. Both patients and physicians often confuse the terms screening and prevention. Patients often think that mammograms prevent breast cancer. I try to be clear that early detection can be important, but isn’t the same as prevention. However, as I try to convince patients to undergo colonoscopy, I try to win them over by explaining that colonoscopy is an opportunity to prevent. I seem to have gotten that point across to Mrs S’s family. Right now they feel betrayed. Why does she have this when she has done everything she was supposed to do? How did it get to be so advanced, when there wasn’t even a trace less than 4 years ago? There have certainly been times when a patient was found to have a preventable diagnosis when I wondered if I had done everything possible. That isn’t the case here. My self doubt is of a very different nature. Did I fail to explain that screening and prevention are always a matter of odds? Not 100%, never a certainty. I’m sure I did fail in this regard, although it will take me a while to think about how I will discuss colon cancer screening, something that I still believe in strongly, in the future, given this experience. How do I communicate uncertainty and not paralyze action…. Right now, however, I have other communication challenges to focus on. Once I saw the CT scan results I told her son that there would probably be a lot of bad news over the next few weeks. I have learned that it isn’t helpful to pretend that things aren’t bad when they are. They, like most people, have appreciated being prepared for bad news. The family seems to be in one-step-at-a time mode, taking in each incremental piece of news and focusing on the tasks at hand. But so far they have forbidden me from telling Mrs S that she has cancer. I’m confident that I will have that conversation with her, and that her joyful spirit, resilience and practical nature will provide her with the strength that she will need to face the future. Unfortunately, the odds for her right now are more certain than I would like them to be, and will probably be easier for her to grasp than the relative uncertainties of screening and prevention. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 04 Mar 2011 17:12:23 GMT http://community.modernmedicine.com/_When-Screening-Fails/blog/3368351/33379.html bgottlieb 2011-03-04T17:11:29Z Primary Care Modern Medicine Community I know that everything we do as physicians and everything we say to patients is a question of odds. But sometimes I forget. The past week was one of those times. Mrs S is an 85-year old woman whom I have taken care of for the past 25 years.  Like many of my patients, she moved here from the Dominican Republic to live with her daughter (who is also my patient), to take care of her grandchildren, and to live in a place with a reliable health care system. She has been a model patient:  she has never smoked or drank, and has never been overweight. She walks every day, even when it is cold. Even before she was told, she restricted fats and red meat, ate lots of vegetables, and ate rice “like an American instead of a Dominican.”  She dutifully appeared for yearly physicals, blood work, mammograms and other screenings. Despite having only an elementary school education, she can name all of her medications, keeps track of refills so that she never runs out, and always comes to visits prepared with her brown bag of medications and a list of questions printed in careful capital letters on a small red pad. She has collected a few chronic conditions—hyperlipidemia, hypertension, hypothyroidism, and recently vitamin B12 deficiency. All of these conditions have been relatively easy to keep under control. Unlike many patients, I didn’t have to talk her into having colon cancer screening. She had her first colonoscopy at age 61, shortly after I met her, a second at age 71 and most recently, given her excellent state of health, at age 81. Each procedure yielded the same boring good news—satisfactory prep, small diverticula and no polyps. Not one, not ever. So why, less than 4 years after her most recent colonoscopy, did she have a bulky mass threatening to obstruct her sigmoid colon (adenocarcinoma), and widespread metastases to her liver and mesenteric lymph nodes and throughout the peritoneum?  Her family wanted to know, too. She has no family history of colon cancer. She has no known risk factors for colon cancer except for her age. In fact, if you look at protective factors, admittedly suggestive rather than certain—she has most of them: physically active, no smoking, no alcohol, not obese, no diabetes, low animal fat, high fiber diet, she takes an aspirin a day, calcium supplementation and a statin. As her physician, her diagnosis is particularly unexpected because in the past 6 months I have seen her often.  I diagnosed her with hypothyroidism and vitamin B12 deficiency. I have a series of weights—no weight loss, several hematocrits—no anemia, and even some recent transaminases—all normal. How was it that she came in for a routinely scheduled visit (a B12 injection!) one month after the previous, and everything was suddenly different? The first clue was that my usually happy, joyful, lighthearted patient was arguing with her daughter. They were arguing, it turns out, because Mrs S wasn’t eating. She just didn’t feel hungry. Everything made her feel full and heavy. Her daughter thought she was simply being difficult. She had, in fact, lost 5 lbs in 1 month. The first touch of her abdominal exam told me all I needed to know. Her liver filled her entire right side. The rest of the story unfolded like a bad dream—ultrasound confirmed that her liver was, in fact, enlarged, and filled with masses “concerning for metastatic disease.” A CT scan a few days later revealed a large mass in the sigmoid colon and multiple masses in the mesenteric lymph nodes. A flexible sigmoidscopy revealed a necrotic mass nearly obstructing the lumen. Both patients and physicians often confuse the terms screening and prevention. Patients often think that mammograms prevent breast cancer. I try to be clear that early detection can be important, but isn’t the same as prevention. However, as I try to convince patients to undergo colonoscopy, I try to win them over by explaining that colonoscopy is an opportunity to prevent. I seem to have gotten that point across to Mrs S’s family. Right now they feel betrayed. Why does she have this when she has done everything she was supposed to do? How did it get to be so advanced, when there wasn’t even a trace less than 4 years ago? There have certainly been times when a patient was found to have a preventable diagnosis when I wondered if I had done everything possible. That isn’t the case here. My self doubt is of a very different nature. Did I fail to explain that screening and prevention are always a matter of odds? Not 100%, never a certainty. I’m sure I did fail in this regard, although it will take me a while to think about how I will discuss colon cancer screening, something that I still believe in strongly, in the future, given this experience. How do I communicate uncertainty and not paralyze action…. Right now, however, I have other communication challenges to focus on. Once I saw the CT scan results I told her son that there would probably be a lot of bad news over the next few weeks. I have learned that it isn’t helpful to pretend that things aren’t bad when they are. They, like most people, have appreciated being prepared for bad news. The family seems to be in one-step-at-a time mode, taking in each incremental piece of news and focusing on the tasks at hand. But so far they have forbidden me from telling Mrs S that she has cancer. I’m confident that I will have that conversation with her, and that her joyful spirit, resilience and practical nature will provide her with the strength that she will need to face the future. Unfortunately, the odds for her right now are more certain than I would like them to be, and will probably be easier for her to grasp than the relative uncertainties of screening and prevention. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] colon cancer, colonoscopy, primary care, screening nonadult false When Screening Fails text blog colon cancer,colonoscopy,primary care,screening 305 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 3368351 2771822 Member 0 http://community.modernmedicine.com/_What-Happens-Between-Visits/blog/3320237/33379.html I definitely judge books by their covers, or the cover may at least inspire me to take a second look. The same is true for articles in medical journals.  I'm inclined to skip over titles with lots of capital letters or numbers, or with words that have more than 12 letters.  I'm drawn to titles that speak to me, that use words that I can pronounce, spell, and use in a conversation. When I saw the title "What happens between visits?  Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes," I had to read on. My health center is in the process of developing a medical home model for delivering care. The medical home is built on the notion that the care that takes place in the office is only a fraction of the care that a patient needs in order to achieve the best outcomes in both disease management and overall well-being. This is particularly true for diabetes and other chronic diseases that require multiple complex decisions and interventions on the part of the patient every day. Sarkar and colleagues studied low income, ethnically diverse patients with poorly controlled type 2 diabetes—not fully representative of all diabetic patients, but certainly representative of my patients.   The study used subjects enrolled in the Automated Telephone Self-Management  (ATSM) arm of a larger project (Improving Diabetes Efforts Across Language and Literacy [IDEALL]). The ATSM intervention involved education and self-management support for patients through weekly interactive, automated telephone calls that were reviewed by a nurse care manager. The nurse case manager would then call patients back whose responses to the automated call met call-back criteria, such as failing to exercise at least once in the past week or a blood glucose reading of less than 60. Records were reviewed to identify adverse or potential adverse outcomes. The events were characterized according to self-management domain, including medication use, diet adherence, symptom recognition, glucose monitoring, diabetic foot care, and appointment adherence. Based on the characteristics of these outcomes, the events were categorized according to contributing causes: systems issues, impaired patient-clinician communication, patient contributions and primary care clinician contributions. A total of 264 events were confirmed, including 111 adverse events and 153 potential adverse events. Of the 111 patients in this arm, 96 (86%) experienced at least one event. The most common self-management domain involved medication use which accounted for 59% of the adverse events and 65% of the potential adverse events. Diet adherence, glucose monitoring and symptom recognition were also common. Only 20% of events had a single contributing cause. The majority of events involved multiple contributing causes: 40% had 2 contributing causes, 37% 3 or 4 causes, and in 3% of cases a cause could not be determined. Patient factors contributed to 77% of the events and systems to 69% of events. Of interest to me is that primary care clinician factors contributed to only 6% of events. Much of the patient safety literature focuses on in-patient care. While there are certain lessons and principles that can be applied to ambulatory settings, there are important differences. As complex as the in-patient setting is, patient contributions to safety and errors are more controllable than they are in the outpatient setting. Patients spend a brief time in the clinic and then return home to remember and interpret their instructions, administer their medications, prepare food, exercise (or not), go to the pharmacy which may make their own errors, and see other providers who may make conflicting recommendations or prescribe treatments that interfere with existing medications. Patients may experience symptoms which they fail to report or misinterpret. They may run out of medications, double up on some medications and decide to stop others. They may make self-management decisions based on unproven, untrustworthy information, fears, or unfounded beliefs. As their providers, we may or may not learn about any of these behaviors and choices. We may learn about them well after the fact, when harm has been done. Clearly, our 15-minute visits are too often centered on the provider's agenda and are not designed for optimal communication. There are particular communication challenges with patients such as those in the study who, like my patients, have low health literacy, are poorly educated, and speak little or no English. Accurate and effective communication of health information is problematic in any setting, and every patient group has its own challenges.  Management of chronic illnesses is complex, with multiple decision points and contingencies. Most people, even those who are highly educated, are anxious in a health care setting and thus are not taking in information clearly. And, like most of what you are taught, you don't really learn it, don't even really know what your questions are, until you try to do it and integrate it into your life. The authors call for "patient-level self-management support and patient-centered communication." Our medical home will have to incorporate multiple channels of communication and information flow. We need to know how our patients are taking their medications, what they are eating, and how they are implementing our sliding scales and dietary plans—in real time as much as possible. Beyond that, we need to have channels for coaching and encouraging physical activity, healthy eating, medication adherence, and other health-promoting behaviors. Physicians will likely play a critical, but small role in these on-going activities.  In this study, technology backed by medical personnel provided channels for a two-way flow of information. Computer and web-based technology can continue to be exploited to promote health and wellness, although it will be a while before my patients benefit from this. However, even my patients have cell phones and are savvy about their extended applications. Automated text messages, phone messages, phone alarms at medication times—all of this and more can support most of our patients' ability to manage their diabetes. References 1. Sarkar U, Handley M, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qual Saf Health Care. 2010;19:223-228. 2. Sarkar U, Handley M, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008; 23:459-65. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I definitely judge books by their covers, or the cover may at least inspire me to take a second look. The same is true for articles in medical journals.  I'm inclined to skip over titles with lots of capital letters or numbers, or with words that have more than 12 letters.  I'm drawn to titles that speak to me, that use words that I can pronounce, spell, and use in a conversation. When I saw the title "What happens between visits?  Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes," I had to read on. My health center is in the process of developing a medical home model for delivering care. The medical home is built on the notion that the care that takes place in the office is only a fraction of the care that a patient needs in order to achieve the best outcomes in both disease management and overall well-being. This is particularly true for diabetes and other chronic diseases that require multiple complex decisions and interventions on the part of the patient every day. Sarkar and colleagues studied low income, ethnically diverse patients with poorly controlled type 2 diabetes—not fully representative of all diabetic patients, but certainly representative of my patients.   The study used subjects enrolled in the Automated Telephone Self-Management  (ATSM) arm of a larger project (Improving Diabetes Efforts Across Language and Literacy [IDEALL]). The ATSM intervention involved education and self-management support for patients through weekly interactive, automated telephone calls that were reviewed by a nurse care manager. The nurse case manager would then call patients back whose responses to the automated call met call-back criteria, such as failing to exercise at least once in the past week or a blood glucose reading of less than 60. Records were reviewed to identify adverse or potential adverse outcomes. The events were characterized according to self-management domain, including medication use, diet adherence, symptom recognition, glucose monitoring, diabetic foot care, and appointment adherence. Based on the characteristics of these outcomes, the events were categorized according to contributing causes: systems issues, impaired patient-clinician communication, patient contributions and primary care clinician contributions. A total of 264 events were confirmed, including 111 adverse events and 153 potential adverse events. Of the 111 patients in this arm, 96 (86%) experienced at least one event. The most common self-management domain involved medication use which accounted for 59% of the adverse events and 65% of the potential adverse events. Diet adherence, glucose monitoring and symptom recognition were also common. Only 20% of events had a single contributing cause. The majority of events involved multiple contributing causes: 40% had 2 contributing causes, 37% 3 or 4 causes, and in 3% of cases a cause could not be determined. Patient factors contributed to 77% of the events and systems to 69% of events. Of interest to me is that primary care clinician factors contributed to only 6% of events. Much of the patient safety literature focuses on in-patient care. While there are certain lessons and principles that can be applied to ambulatory settings, there are important differences. As complex as the in-patient setting is, patient contributions to safety and errors are more controllable than they are in the outpatient setting. Patients spend a brief time in the clinic and then return home to remember and interpret their instructions, administer their medications, prepare food, exercise (or not), go to the pharmacy which may make their own errors, and see other providers who may make conflicting recommendations or prescribe treatments that interfere with existing medications. Patients may experience symptoms which they fail to report or misinterpret. They may run out of medications, double up on some medications and decide to stop others. They may make self-management decisions based on unproven, untrustworthy information, fears, or unfounded beliefs. As their providers, we may or may not learn about any of these behaviors and choices. We may learn about them well after the fact, when harm has been done. Clearly, our 15-minute visits are too often centered on the provider's agenda and are not designed for optimal communication. There are particular communication challenges with patients such as those in the study who, like my patients, have low health literacy, are poorly educated, and speak little or no English. Accurate and effective communication of health information is problematic in any setting, and every patient group has its own challenges.  Management of chronic illnesses is complex, with multiple decision points and contingencies. Most people, even those who are highly educated, are anxious in a health care setting and thus are not taking in information clearly. And, like most of what you are taught, you don't really learn it, don't even really know what your questions are, until you try to do it and integrate it into your life. The authors call for "patient-level self-management support and patient-centered communication." Our medical home will have to incorporate multiple channels of communication and information flow. We need to know how our patients are taking their medications, what they are eating, and how they are implementing our sliding scales and dietary plans—in real time as much as possible. Beyond that, we need to have channels for coaching and encouraging physical activity, healthy eating, medication adherence, and other health-promoting behaviors. Physicians will likely play a critical, but small role in these on-going activities.  In this study, technology backed by medical personnel provided channels for a two-way flow of information. Computer and web-based technology can continue to be exploited to promote health and wellness, although it will be a while before my patients benefit from this. However, even my patients have cell phones and are savvy about their extended applications. Automated text messages, phone messages, phone alarms at medication times—all of this and more can support most of our patients' ability to manage their diabetes. References 1. Sarkar U, Handley M, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qual Saf Health Care. 2010;19:223-228. 2. Sarkar U, Handley M, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008; 23:459-65. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 18 Feb 2011 02:38:39 GMT http://community.modernmedicine.com/_What-Happens-Between-Visits/blog/3320237/33379.html bgottlieb 2011-02-18T02:23:34Z Primary Care Modern Medicine Community I definitely judge books by their covers, or the cover may at least inspire me to take a second look. The same is true for articles in medical journals.  I'm inclined to skip over titles with lots of capital letters or numbers, or with words that have more than 12 letters.  I'm drawn to titles that speak to me, that use words that I can pronounce, spell, and use in a conversation. When I saw the title "What happens between visits?  Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes," I had to read on. My health center is in the process of developing a medical home model for delivering care. The medical home is built on the notion that the care that takes place in the office is only a fraction of the care that a patient needs in order to achieve the best outcomes in both disease management and overall well-being. This is particularly true for diabetes and other chronic diseases that require multiple complex decisions and interventions on the part of the patient every day. Sarkar and colleagues studied low income, ethnically diverse patients with poorly controlled type 2 diabetes—not fully representative of all diabetic patients, but certainly representative of my patients.   The study used subjects enrolled in the Automated Telephone Self-Management  (ATSM) arm of a larger project (Improving Diabetes Efforts Across Language and Literacy [IDEALL]). The ATSM intervention involved education and self-management support for patients through weekly interactive, automated telephone calls that were reviewed by a nurse care manager. The nurse case manager would then call patients back whose responses to the automated call met call-back criteria, such as failing to exercise at least once in the past week or a blood glucose reading of less than 60. Records were reviewed to identify adverse or potential adverse outcomes. The events were characterized according to self-management domain, including medication use, diet adherence, symptom recognition, glucose monitoring, diabetic foot care, and appointment adherence. Based on the characteristics of these outcomes, the events were categorized according to contributing causes: systems issues, impaired patient-clinician communication, patient contributions and primary care clinician contributions. A total of 264 events were confirmed, including 111 adverse events and 153 potential adverse events. Of the 111 patients in this arm, 96 (86%) experienced at least one event. The most common self-management domain involved medication use which accounted for 59% of the adverse events and 65% of the potential adverse events. Diet adherence, glucose monitoring and symptom recognition were also common. Only 20% of events had a single contributing cause. The majority of events involved multiple contributing causes: 40% had 2 contributing causes, 37% 3 or 4 causes, and in 3% of cases a cause could not be determined. Patient factors contributed to 77% of the events and systems to 69% of events. Of interest to me is that primary care clinician factors contributed to only 6% of events. Much of the patient safety literature focuses on in-patient care. While there are certain lessons and principles that can be applied to ambulatory settings, there are important differences. As complex as the in-patient setting is, patient contributions to safety and errors are more controllable than they are in the outpatient setting. Patients spend a brief time in the clinic and then return home to remember and interpret their instructions, administer their medications, prepare food, exercise (or not), go to the pharmacy which may make their own errors, and see other providers who may make conflicting recommendations or prescribe treatments that interfere with existing medications. Patients may experience symptoms which they fail to report or misinterpret. They may run out of medications, double up on some medications and decide to stop others. They may make self-management decisions based on unproven, untrustworthy information, fears, or unfounded beliefs. As their providers, we may or may not learn about any of these behaviors and choices. We may learn about them well after the fact, when harm has been done. Clearly, our 15-minute visits are too often centered on the provider's agenda and are not designed for optimal communication. There are particular communication challenges with patients such as those in the study who, like my patients, have low health literacy, are poorly educated, and speak little or no English. Accurate and effective communication of health information is problematic in any setting, and every patient group has its own challenges.  Management of chronic illnesses is complex, with multiple decision points and contingencies. Most people, even those who are highly educated, are anxious in a health care setting and thus are not taking in information clearly. And, like most of what you are taught, you don't really learn it, don't even really know what your questions are, until you try to do it and integrate it into your life. The authors call for "patient-level self-management support and patient-centered communication." Our medical home will have to incorporate multiple channels of communication and information flow. We need to know how our patients are taking their medications, what they are eating, and how they are implementing our sliding scales and dietary plans—in real time as much as possible. Beyond that, we need to have channels for coaching and encouraging physical activity, healthy eating, medication adherence, and other health-promoting behaviors. Physicians will likely play a critical, but small role in these on-going activities.  In this study, technology backed by medical personnel provided channels for a two-way flow of information. Computer and web-based technology can continue to be exploited to promote health and wellness, although it will be a while before my patients benefit from this. However, even my patients have cell phones and are savvy about their extended applications. Automated text messages, phone messages, phone alarms at medication times—all of this and more can support most of our patients' ability to manage their diabetes. References 1. Sarkar U, Handley M, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. Qual Saf Health Care. 2010;19:223-228. 2. Sarkar U, Handley M, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. J Gen Intern Med 2008; 23:459-65. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] adverse, diabetes, endocrinology, home, ideall, medical, primary care, reactions nonadult false What Happens Between Visits? text blog adverse,diabetes,endocrinology,home,ideall,medical,primary care,reactions 373 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 3320237 2771822 Member 0 http://community.modernmedicine.com/_3-Lessons-from-the-In-patient-Experience/blog/3130082/33379.html Each year, I spend 2 weeks as attending physician on the general medical service of my hospital. Each year on day one, I am struck by how different in-patient care is now compared to my experience as a resident (and even compared to last year on the wards!); I am intimidated by how much I have forgotten, and how incredibly smart the residents seem to be; and I worry that I will have little to add to the teaching – or at least little that the residents have learned to value. But then I begin to settle into my role. I remember that I have actually seen many more sick people than the residents have, and that my perspective, clinical skills and “instincts”--if I can put them into packages that fit into the frenetic pace of in-patient rounding and patient care--are actually valuable and valued. And each year, as the 2 weeks come to a close, I am reminded that this system, crazy as it is, is a great way to learn. This year 3 lessons stand out: FallsAs a primary care physician, I need to do a better job of evaluating my patients’ gait and their risk for falling. I need to anticipate--ask about lighting, loose rugs, and other safety hazards. I need to educate my patients about choice of shoes, exercise for strength and balance. And I need to intervene aggressively when I identify a medical condition that can add to my patients’ risk for falling. The simple Get Up and Go test is probably more worthwhile than many things that I spend 30 seconds on in the course of a visit with a patient 65 and older, but honestly, on what percent of my patients to I actually do this test?Many patients were hospitalized either directly or indirectly because of falls. They had hip fractures, complications of hip fractures, complications of complications of hip fractures…. While I found the residents’ questions interesting: “Why did this patient have a bleed while taking Coumadin?”  “Why did this patient have a second clot with therapeutic INRs on Coumadin?” my own questions were much more mundane: “Why did this patient fall?” “Could this fall have been prevented?”HypertensionAs a primary care physician, it is my job to keep people from developing end-stage renal disease and becoming dependent on dialysis. Blood pressure and weight are among the most frequent measurements in medical care. It is only recently at my health center that we have done quality improvement and staff education projects focused on the correct measurement of hypertension in adults, and monitored how aggressively we manage hypertension in order to achieve target levels. It is even more recently that we have identified the target levels in children and adolescents and implemented aggressive follow-up and intervention at these young ages. At times, the majority of our patients were on chronic hemodialysis. They were admitted for sepsis from lines and other sources, severe hypertension, orthostatic hypotension, and congestive heart failure. Most were admitted every few weeks with one or another of these complications and associated conditions. And most of these admissions were extended by additional complications. I wondered if any of the patients had been told what to expect of their lives as dialysis patients, and how much time they would end up spending in the hospital. The amount of human suffering by patients and families is immense. And the societal cost of this care, completely apart from the direct costs of dialysis, is staggering. Hypertension, of course, is not the only cause of end-stage renal disease, but it is a major contributor. To the extent that data on blood pressure is available in nearly every medical encounter, aggressive control of hypertension should be foremost in our minds.Think. Be curious. Ask why. One of the greatest contrasts between inpatient and outpatient medicine is the way in which each is practiced. Inpatient medicine is a team effort. Multiple people interview and examine the patient separately and then together. Nurses, nutritionists, and physical therapists are gathered for rounds. Consultants may be brought in. You all think together to develop the best diagnostic and therapeutic plans. Outpatient care--particularly primary care--is a much more individual endeavor. It is you and the patient.  Even if others are brought in, a team is rarely assembled in one place. There may be communication, but back-and-forth dialogue is rare. The questions that are asked on inpatient rounds are intended to encourage curiosity, to dig deeper. “What is this?” “Why do you think that?” “What else could this be?” “What is the mechanism?’ “What are we missing?”Granted, there is a difference between acute and chronic illnesses. And there is something to be said for the kind of systematic approach that primary care providers are so good at--so that we can be thorough and efficient, even with patients who have multiple complicated conditions. Checklists and consistency are strategies for insuring that important steps are not overlooked. Probably from the patients’ perspective there is something comforting about the predictability of a return visit to a primary care provider. But our consistency can be a trap, confining us to blind alleys of diagnosis and treatment. Perhaps we could infuse an element of curiosity into our approach to patient care without losing the strengths of what we have to offer. “Why is the patient on each of these medications?” “Is there a better way of handling this condition?” “Could some of the patient’s symptoms be a result of a medication?” “Could there be a relationship between condition X and Y that I hadn’t seen before?” With the advent of hospitalists, many of my colleagues have chosen not to do inpatient care, including inpatient teaching, at all. That is not an unreasonable choice, given the intensity, acuity, and pressure of inpatient care as it is currently structured. Perhaps at some point I will make the same choice. But for now, a periodic infusion of inpatient medicine is an important part of my own continuing education, from which I draw valuable lessons about the continuum of prevention and chronic and acute illness and re-invigorate my critical thinking skills.Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Each year, I spend 2 weeks as attending physician on the general medical service of my hospital. Each year on day one, I am struck by how different in-patient care is now compared to my experience as a resident (and even compared to last year on the wards!); I am intimidated by how much I have forgotten, and how incredibly smart the residents seem to be; and I worry that I will have little to add to the teaching – or at least little that the residents have learned to value. But then I begin to settle into my role. I remember that I have actually seen many more sick people than the residents have, and that my perspective, clinical skills and “instincts”--if I can put them into packages that fit into the frenetic pace of in-patient rounding and patient care--are actually valuable and valued. And each year, as the 2 weeks come to a close, I am reminded that this system, crazy as it is, is a great way to learn. This year 3 lessons stand out: FallsAs a primary care physician, I need to do a better job of evaluating my patients’ gait and their risk for falling. I need to anticipate--ask about lighting, loose rugs, and other safety hazards. I need to educate my patients about choice of shoes, exercise for strength and balance. And I need to intervene aggressively when I identify a medical condition that can add to my patients’ risk for falling. The simple Get Up and Go test is probably more worthwhile than many things that I spend 30 seconds on in the course of a visit with a patient 65 and older, but honestly, on what percent of my patients to I actually do this test?Many patients were hospitalized either directly or indirectly because of falls. They had hip fractures, complications of hip fractures, complications of complications of hip fractures…. While I found the residents’ questions interesting: “Why did this patient have a bleed while taking Coumadin?”  “Why did this patient have a second clot with therapeutic INRs on Coumadin?” my own questions were much more mundane: “Why did this patient fall?” “Could this fall have been prevented?”HypertensionAs a primary care physician, it is my job to keep people from developing end-stage renal disease and becoming dependent on dialysis. Blood pressure and weight are among the most frequent measurements in medical care. It is only recently at my health center that we have done quality improvement and staff education projects focused on the correct measurement of hypertension in adults, and monitored how aggressively we manage hypertension in order to achieve target levels. It is even more recently that we have identified the target levels in children and adolescents and implemented aggressive follow-up and intervention at these young ages. At times, the majority of our patients were on chronic hemodialysis. They were admitted for sepsis from lines and other sources, severe hypertension, orthostatic hypotension, and congestive heart failure. Most were admitted every few weeks with one or another of these complications and associated conditions. And most of these admissions were extended by additional complications. I wondered if any of the patients had been told what to expect of their lives as dialysis patients, and how much time they would end up spending in the hospital. The amount of human suffering by patients and families is immense. And the societal cost of this care, completely apart from the direct costs of dialysis, is staggering. Hypertension, of course, is not the only cause of end-stage renal disease, but it is a major contributor. To the extent that data on blood pressure is available in nearly every medical encounter, aggressive control of hypertension should be foremost in our minds.Think. Be curious. Ask why. One of the greatest contrasts between inpatient and outpatient medicine is the way in which each is practiced. Inpatient medicine is a team effort. Multiple people interview and examine the patient separately and then together. Nurses, nutritionists, and physical therapists are gathered for rounds. Consultants may be brought in. You all think together to develop the best diagnostic and therapeutic plans. Outpatient care--particularly primary care--is a much more individual endeavor. It is you and the patient.  Even if others are brought in, a team is rarely assembled in one place. There may be communication, but back-and-forth dialogue is rare. The questions that are asked on inpatient rounds are intended to encourage curiosity, to dig deeper. “What is this?” “Why do you think that?” “What else could this be?” “What is the mechanism?’ “What are we missing?”Granted, there is a difference between acute and chronic illnesses. And there is something to be said for the kind of systematic approach that primary care providers are so good at--so that we can be thorough and efficient, even with patients who have multiple complicated conditions. Checklists and consistency are strategies for insuring that important steps are not overlooked. Probably from the patients’ perspective there is something comforting about the predictability of a return visit to a primary care provider. But our consistency can be a trap, confining us to blind alleys of diagnosis and treatment. Perhaps we could infuse an element of curiosity into our approach to patient care without losing the strengths of what we have to offer. “Why is the patient on each of these medications?” “Is there a better way of handling this condition?” “Could some of the patient’s symptoms be a result of a medication?” “Could there be a relationship between condition X and Y that I hadn’t seen before?” With the advent of hospitalists, many of my colleagues have chosen not to do inpatient care, including inpatient teaching, at all. That is not an unreasonable choice, given the intensity, acuity, and pressure of inpatient care as it is currently structured. Perhaps at some point I will make the same choice. But for now, a periodic infusion of inpatient medicine is an important part of my own continuing education, from which I draw valuable lessons about the continuum of prevention and chronic and acute illness and re-invigorate my critical thinking skills.Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Mon, 20 Dec 2010 20:40:30 GMT http://community.modernmedicine.com/_3-Lessons-from-the-In-patient-Experience/blog/3130082/33379.html bgottlieb 2010-12-20T20:37:24Z Primary Care Modern Medicine Community Each year, I spend 2 weeks as attending physician on the general medical service of my hospital. Each year on day one, I am struck by how different in-patient care is now compared to my experience as a resident (and even compared to last year on the wards!); I am intimidated by how much I have forgotten, and how incredibly smart the residents seem to be; and I worry that I will have little to add to the teaching – or at least little that the residents have learned to value. But then I begin to settle into my role. I remember that I have actually seen many more sick people than the residents have, and that my perspective, clinical skills and “instincts”--if I can put them into packages that fit into the frenetic pace of in-patient rounding and patient care--are actually valuable and valued. And each year, as the 2 weeks come to a close, I am reminded that this system, crazy as it is, is a great way to learn. This year 3 lessons stand out: FallsAs a primary care physician, I need to do a better job of evaluating my patients’ gait and their risk for falling. I need to anticipate--ask about lighting, loose rugs, and other safety hazards. I need to educate my patients about choice of shoes, exercise for strength and balance. And I need to intervene aggressively when I identify a medical condition that can add to my patients’ risk for falling. The simple Get Up and Go test is probably more worthwhile than many things that I spend 30 seconds on in the course of a visit with a patient 65 and older, but honestly, on what percent of my patients to I actually do this test?Many patients were hospitalized either directly or indirectly because of falls. They had hip fractures, complications of hip fractures, complications of complications of hip fractures…. While I found the residents’ questions interesting: “Why did this patient have a bleed while taking Coumadin?”  “Why did this patient have a second clot with therapeutic INRs on Coumadin?” my own questions were much more mundane: “Why did this patient fall?” “Could this fall have been prevented?”HypertensionAs a primary care physician, it is my job to keep people from developing end-stage renal disease and becoming dependent on dialysis. Blood pressure and weight are among the most frequent measurements in medical care. It is only recently at my health center that we have done quality improvement and staff education projects focused on the correct measurement of hypertension in adults, and monitored how aggressively we manage hypertension in order to achieve target levels. It is even more recently that we have identified the target levels in children and adolescents and implemented aggressive follow-up and intervention at these young ages. At times, the majority of our patients were on chronic hemodialysis. They were admitted for sepsis from lines and other sources, severe hypertension, orthostatic hypotension, and congestive heart failure. Most were admitted every few weeks with one or another of these complications and associated conditions. And most of these admissions were extended by additional complications. I wondered if any of the patients had been told what to expect of their lives as dialysis patients, and how much time they would end up spending in the hospital. The amount of human suffering by patients and families is immense. And the societal cost of this care, completely apart from the direct costs of dialysis, is staggering. Hypertension, of course, is not the only cause of end-stage renal disease, but it is a major contributor. To the extent that data on blood pressure is available in nearly every medical encounter, aggressive control of hypertension should be foremost in our minds.Think. Be curious. Ask why. One of the greatest contrasts between inpatient and outpatient medicine is the way in which each is practiced. Inpatient medicine is a team effort. Multiple people interview and examine the patient separately and then together. Nurses, nutritionists, and physical therapists are gathered for rounds. Consultants may be brought in. You all think together to develop the best diagnostic and therapeutic plans. Outpatient care--particularly primary care--is a much more individual endeavor. It is you and the patient.  Even if others are brought in, a team is rarely assembled in one place. There may be communication, but back-and-forth dialogue is rare. The questions that are asked on inpatient rounds are intended to encourage curiosity, to dig deeper. “What is this?” “Why do you think that?” “What else could this be?” “What is the mechanism?’ “What are we missing?”Granted, there is a difference between acute and chronic illnesses. And there is something to be said for the kind of systematic approach that primary care providers are so good at--so that we can be thorough and efficient, even with patients who have multiple complicated conditions. Checklists and consistency are strategies for insuring that important steps are not overlooked. Probably from the patients’ perspective there is something comforting about the predictability of a return visit to a primary care provider. But our consistency can be a trap, confining us to blind alleys of diagnosis and treatment. Perhaps we could infuse an element of curiosity into our approach to patient care without losing the strengths of what we have to offer. “Why is the patient on each of these medications?” “Is there a better way of handling this condition?” “Could some of the patient’s symptoms be a result of a medication?” “Could there be a relationship between condition X and Y that I hadn’t seen before?” With the advent of hospitalists, many of my colleagues have chosen not to do inpatient care, including inpatient teaching, at all. That is not an unreasonable choice, given the intensity, acuity, and pressure of inpatient care as it is currently structured. Perhaps at some point I will make the same choice. But for now, a periodic infusion of inpatient medicine is an important part of my own continuing education, from which I draw valuable lessons about the continuum of prevention and chronic and acute illness and re-invigorate my critical thinking skills.Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] cardiology, dialysis, disease”, falls, geriatrics, hypertension, inpatient, outpatient, primary care, “cardiovascular nonadult false 3 Lessons from the In-patient Experience text blog cardiology,dialysis,disease”,falls,geriatrics,hypertension,inpatient,outpatient,primary care,“cardiovascular 371 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 3130082 2771822 Member 0 http://community.modernmedicine.com/_Bariatric-Surgery-and-Suicide/blog/3070305/33379.html Over the years I have had between 50 and 100 patients undergo bariatric surgery. For the most part, these patients initiated the process themselves and were highly motivated to explore all possible surgical options. They seemed to be typical of many obese patients in that they had tried a variety of strategies to lose weight, with commitment and consistency ranging from half-hearted to moderately self-disciplined.  And, like many obese patients, they had been unsuccessful at meeting and/or maintaining their weight loss goals.  The availability of minimally invasive techniques, the rise in the obesity epidemic, and, perhaps publicity and direct-to-consumer advertising campaigns by surgical centers have increased demand for bariatric surgery.  I’m sure that my practice is not different from most:  I have seen a steep rise in the number of bariatric procedures among my patients—from a scattered few to many each year. I can understand the appeal of surgical approaches to obesity. I have watched initially motivated patients become disheartened and defeated by the slow process of weight loss through behavioral change. Surgical methods provide a jump start on weight loss and allow patients to bypass that initial struggle—thus reinforcing motivation and building confidence and a sense of efficacy. Beyond that, I’m not surprised that surgical treatments to obesity are appealing to many of my patients who tend to take a concrete approach to their bodies, health, and wellness. Without intending to stereotype, many of my patients would prefer a quick injection to a longer treatment with pills; my female patients have higher than average rates of cosmetic surgeries (breast augmentation, elevation, reduction, abdominoplasty, liposuction) as a strategy for achieving an iconic hourglass body shape. Permanent or long-lasting forms of contraception have greater appeal compared to methods that involve action on a daily basis or with each act of intercourse. While behavioral change is certainly required in order to reap maximum benefit, bariatric surgery is concrete, imposes restrictions that are to some extent independent of day-to-day personal motivation and discipline, and brings about results more quickly than most nonsurgical approaches to weight loss. While not surprised by its appeal to my patients, I have wondered—and in some cases worried—about the long-term physical and particularly psychological effects of rapid weight loss.  Because of this, a recent study of suicide in patients who have undergone bariatric surgery caught my eye.1 The authors obtained suicide data from the Pennsylvania Department of Health Division of Vital Records from 1996-2006 and compared rates among those who had bariatric surgery to age and sex-matched rates in the general United States population.  Among patients who had bariatric surgery, the overall rate of suicide was 6.6/10,000—13.7 for men and 5.2 for women. These rates are significantly greater than for the general population (ages 35-64 years) which were 2.4/10,0000 for men and 0.7/10,000 for women.  Suicide rates in Pennsylvania in 2005 (ages 35-64) were similar at 2.5/10,000 for men and 0.6/10,000 for women. Data were not presented by race or ethnicity because nonwhite rates were very low.  Stratified by gender and age, rates among men were higher than women in all categories. Men aged 45 to 54 years had the highest rates (21.7/10,000). The highest rates for women were for those younger than 35 (14.0/10,000). Ten percent of suicides took place in the first year following surgery, an additional 19% in the second year and an additional 39% in the third year—a total of 68% within the first 3 years. The study resonates with fears I have had about bariatric surgery in certain patients. None of my patients who have undergone bariatric surgery has committed suicide. However, suicide is often the tip of a much larger iceberg of mental health morbidity. I have seen enough patients demonstrate a worsening of their baseline anxiety and depression that I have wondered about the impact of a drastic change in their body on self-image, self-concept, identity, and overall well-being. Most of my patients who have undergone bariatric surgery are women.  This is not surprising since I have more female than male patients, and obesity is more common among women.  While I have not studied this systematically, I know that many of my morbidly obese female patients have a history of childhood sexual abuse, and I know that this tracks with studies that connect obesity with abuse.2,3 Obesity, like many bodily states, can signify a great deal more than simply extra weight.  Obesity may have symbolic meaning that is related to emotional states—a so-called embodied emotion. And being obese (read: large, cushioned, protected, imposing, powerful, unapproachable) may have positive meaning to the patient.  For most people, weight loss has an explicit positive meaning—“I did it!” “I am more healthy!” “ I am more consistent with society’s standards of beauty!” However, the change may also be threatening and carry an unexpected negative meaning—“I am vulnerable.” “I am unprotected.” I have seen many patients become extremely anxious as their bodies “melt” and watched helplessly as they felt compelled to eat their way back to their pre-surgical (or greater) weights. Many surgical weight loss programs are comprehensive and require patients to demonstrate the capacity to change behaviors, undergo psychological evaluation, and wait for their procedure—presumably in order to allow them to process the full impact of bariatric surgery and to demonstrate an enduring commitment to the lifestyle and anticipated body-image changes. However, wishful thinking can cloud a patient’s judgment and create an unrealistic appearance of motivation and optimism. In addition, a multitude of factors, not all pure evidence- based medicine, may influence surgeons and surgical centers (both for-profit and not-for-profit) in their patient selection process.  So far, only one of my patients was disqualified for bariatric surgery for psychological reasons (there was no subtlety in this case!).  I have had many who made the decision impulsively, who were emotionally unstable prior to surgery, and quickly unraveled following the surgery. The authors recognize the limitations of the study: There are no comparable data for suicide rates among obese individuals who did not undergo bariatric surgery. There are no longitudinal studies to date to examine presurgical characteristics, including emotional state, and their relationship to postsurgical emotional states. The authors are clear that the reasons for excess suicides among these patients are not known. The data set did not provide information about characteristics of the surgical programs such as medical and surgical follow-up, weight-loss outcomes, nor characteristics of the patients involved.  The authors recommend additional studies, and perhaps mandatory registries that would allow tracking of key program and patient characteristics, short- and long-term outcomes in order to fill in some of the gaps in understanding. Suicides among this group of patients are another example of a phenomenon that has been described in other contexts—that people who commit suicide have often had extensive contact with the medical system in the period of time preceding the suicide. While not all suicides can be prevented, the medical system cannot ignore the opportunities that it has to prevent at least some. It is well-known that morbidly obese individuals have a high degree of depression and other mental comorbidities.4,5 Bariatric surgery programs must enhance their presurgery screening and assessment processes for depression and other serious mental illnesses and monitor patients post-surgically physically and mentally. I believe that qualitative studies are needed to understand the deeper meanings and symbolism of weight and weight loss. These studies can then inform the types of presurgical screenings that might identify individuals who are vulnerable to poor mental health outcomes, as well as the types of interventions that might prevent morbidity postsurgically. As a primary care physician, I have the privilege of knowing my patients well and the opportunity to accompany them through many chapters of their lives.  It is incumbent on me to explore their motivations, hopes, and expectations for considering elective surgery of this nature and to closely monitor them following surgery as they live with the consequences of their choices. References 1. Tindle HA, Omalu B, Courcoulas A, et al. Risk of suicide after long-term follow-up from bariatric surgery. Am J of Med. 2010;123:1036-1042. 2. Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: A prospective study. Pediatrics. 2007;120:e61-67. 3. Coker AL, Williams C, Ferguson JE, et al. Intimate or childhood sexual abuse and obesity in Kentucky. Fam Violence Prev Health Pract. 2006. http://endabuse.org/health/ejournal/archive/1-7/abuse_and_obesity.php.  Accessed November 26, 2010. 4. Luppino FS, de Wit LM, Bouvy PF, et al.Overweight, obesity and depression: A systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010:67(3):220-229. 5. Mather AA, Cox BJ, Enns MW, Sareen J. Association of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample. J Psychosom Res. 2009; 66:277-285. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Over the years I have had between 50 and 100 patients undergo bariatric surgery. For the most part, these patients initiated the process themselves and were highly motivated to explore all possible surgical options. They seemed to be typical of many obese patients in that they had tried a variety of strategies to lose weight, with commitment and consistency ranging from half-hearted to moderately self-disciplined.  And, like many obese patients, they had been unsuccessful at meeting and/or maintaining their weight loss goals.  The availability of minimally invasive techniques, the rise in the obesity epidemic, and, perhaps publicity and direct-to-consumer advertising campaigns by surgical centers have increased demand for bariatric surgery.  I’m sure that my practice is not different from most:  I have seen a steep rise in the number of bariatric procedures among my patients—from a scattered few to many each year. I can understand the appeal of surgical approaches to obesity. I have watched initially motivated patients become disheartened and defeated by the slow process of weight loss through behavioral change. Surgical methods provide a jump start on weight loss and allow patients to bypass that initial struggle—thus reinforcing motivation and building confidence and a sense of efficacy. Beyond that, I’m not surprised that surgical treatments to obesity are appealing to many of my patients who tend to take a concrete approach to their bodies, health, and wellness. Without intending to stereotype, many of my patients would prefer a quick injection to a longer treatment with pills; my female patients have higher than average rates of cosmetic surgeries (breast augmentation, elevation, reduction, abdominoplasty, liposuction) as a strategy for achieving an iconic hourglass body shape. Permanent or long-lasting forms of contraception have greater appeal compared to methods that involve action on a daily basis or with each act of intercourse. While behavioral change is certainly required in order to reap maximum benefit, bariatric surgery is concrete, imposes restrictions that are to some extent independent of day-to-day personal motivation and discipline, and brings about results more quickly than most nonsurgical approaches to weight loss. While not surprised by its appeal to my patients, I have wondered—and in some cases worried—about the long-term physical and particularly psychological effects of rapid weight loss.  Because of this, a recent study of suicide in patients who have undergone bariatric surgery caught my eye.1 The authors obtained suicide data from the Pennsylvania Department of Health Division of Vital Records from 1996-2006 and compared rates among those who had bariatric surgery to age and sex-matched rates in the general United States population.  Among patients who had bariatric surgery, the overall rate of suicide was 6.6/10,000—13.7 for men and 5.2 for women. These rates are significantly greater than for the general population (ages 35-64 years) which were 2.4/10,0000 for men and 0.7/10,000 for women.  Suicide rates in Pennsylvania in 2005 (ages 35-64) were similar at 2.5/10,000 for men and 0.6/10,000 for women. Data were not presented by race or ethnicity because nonwhite rates were very low.  Stratified by gender and age, rates among men were higher than women in all categories. Men aged 45 to 54 years had the highest rates (21.7/10,000). The highest rates for women were for those younger than 35 (14.0/10,000). Ten percent of suicides took place in the first year following surgery, an additional 19% in the second year and an additional 39% in the third year—a total of 68% within the first 3 years. The study resonates with fears I have had about bariatric surgery in certain patients. None of my patients who have undergone bariatric surgery has committed suicide. However, suicide is often the tip of a much larger iceberg of mental health morbidity. I have seen enough patients demonstrate a worsening of their baseline anxiety and depression that I have wondered about the impact of a drastic change in their body on self-image, self-concept, identity, and overall well-being. Most of my patients who have undergone bariatric surgery are women.  This is not surprising since I have more female than male patients, and obesity is more common among women.  While I have not studied this systematically, I know that many of my morbidly obese female patients have a history of childhood sexual abuse, and I know that this tracks with studies that connect obesity with abuse.2,3 Obesity, like many bodily states, can signify a great deal more than simply extra weight.  Obesity may have symbolic meaning that is related to emotional states—a so-called embodied emotion. And being obese (read: large, cushioned, protected, imposing, powerful, unapproachable) may have positive meaning to the patient.  For most people, weight loss has an explicit positive meaning—“I did it!” “I am more healthy!” “ I am more consistent with society’s standards of beauty!” However, the change may also be threatening and carry an unexpected negative meaning—“I am vulnerable.” “I am unprotected.” I have seen many patients become extremely anxious as their bodies “melt” and watched helplessly as they felt compelled to eat their way back to their pre-surgical (or greater) weights. Many surgical weight loss programs are comprehensive and require patients to demonstrate the capacity to change behaviors, undergo psychological evaluation, and wait for their procedure—presumably in order to allow them to process the full impact of bariatric surgery and to demonstrate an enduring commitment to the lifestyle and anticipated body-image changes. However, wishful thinking can cloud a patient’s judgment and create an unrealistic appearance of motivation and optimism. In addition, a multitude of factors, not all pure evidence- based medicine, may influence surgeons and surgical centers (both for-profit and not-for-profit) in their patient selection process.  So far, only one of my patients was disqualified for bariatric surgery for psychological reasons (there was no subtlety in this case!).  I have had many who made the decision impulsively, who were emotionally unstable prior to surgery, and quickly unraveled following the surgery. The authors recognize the limitations of the study: There are no comparable data for suicide rates among obese individuals who did not undergo bariatric surgery. There are no longitudinal studies to date to examine presurgical characteristics, including emotional state, and their relationship to postsurgical emotional states. The authors are clear that the reasons for excess suicides among these patients are not known. The data set did not provide information about characteristics of the surgical programs such as medical and surgical follow-up, weight-loss outcomes, nor characteristics of the patients involved.  The authors recommend additional studies, and perhaps mandatory registries that would allow tracking of key program and patient characteristics, short- and long-term outcomes in order to fill in some of the gaps in understanding. Suicides among this group of patients are another example of a phenomenon that has been described in other contexts—that people who commit suicide have often had extensive contact with the medical system in the period of time preceding the suicide. While not all suicides can be prevented, the medical system cannot ignore the opportunities that it has to prevent at least some. It is well-known that morbidly obese individuals have a high degree of depression and other mental comorbidities.4,5 Bariatric surgery programs must enhance their presurgery screening and assessment processes for depression and other serious mental illnesses and monitor patients post-surgically physically and mentally. I believe that qualitative studies are needed to understand the deeper meanings and symbolism of weight and weight loss. These studies can then inform the types of presurgical screenings that might identify individuals who are vulnerable to poor mental health outcomes, as well as the types of interventions that might prevent morbidity postsurgically. As a primary care physician, I have the privilege of knowing my patients well and the opportunity to accompany them through many chapters of their lives.  It is incumbent on me to explore their motivations, hopes, and expectations for considering elective surgery of this nature and to closely monitor them following surgery as they live with the consequences of their choices. References 1. Tindle HA, Omalu B, Courcoulas A, et al. Risk of suicide after long-term follow-up from bariatric surgery. Am J of Med. 2010;123:1036-1042. 2. Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: A prospective study. Pediatrics. 2007;120:e61-67. 3. Coker AL, Williams C, Ferguson JE, et al. Intimate or childhood sexual abuse and obesity in Kentucky. Fam Violence Prev Health Pract. 2006. http://endabuse.org/health/ejournal/archive/1-7/abuse_and_obesity.php.  Accessed November 26, 2010. 4. Luppino FS, de Wit LM, Bouvy PF, et al.Overweight, obesity and depression: A systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010:67(3):220-229. 5. Mather AA, Cox BJ, Enns MW, Sareen J. Association of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample. J Psychosom Res. 2009; 66:277-285. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Tue, 07 Dec 2010 20:08:08 GMT http://community.modernmedicine.com/_Bariatric-Surgery-and-Suicide/blog/3070305/33379.html bgottlieb 2010-12-07T20:06:46Z Primary Care Modern Medicine Community Over the years I have had between 50 and 100 patients undergo bariatric surgery. For the most part, these patients initiated the process themselves and were highly motivated to explore all possible surgical options. They seemed to be typical of many obese patients in that they had tried a variety of strategies to lose weight, with commitment and consistency ranging from half-hearted to moderately self-disciplined.  And, like many obese patients, they had been unsuccessful at meeting and/or maintaining their weight loss goals.  The availability of minimally invasive techniques, the rise in the obesity epidemic, and, perhaps publicity and direct-to-consumer advertising campaigns by surgical centers have increased demand for bariatric surgery.  I’m sure that my practice is not different from most:  I have seen a steep rise in the number of bariatric procedures among my patients—from a scattered few to many each year. I can understand the appeal of surgical approaches to obesity. I have watched initially motivated patients become disheartened and defeated by the slow process of weight loss through behavioral change. Surgical methods provide a jump start on weight loss and allow patients to bypass that initial struggle—thus reinforcing motivation and building confidence and a sense of efficacy. Beyond that, I’m not surprised that surgical treatments to obesity are appealing to many of my patients who tend to take a concrete approach to their bodies, health, and wellness. Without intending to stereotype, many of my patients would prefer a quick injection to a longer treatment with pills; my female patients have higher than average rates of cosmetic surgeries (breast augmentation, elevation, reduction, abdominoplasty, liposuction) as a strategy for achieving an iconic hourglass body shape. Permanent or long-lasting forms of contraception have greater appeal compared to methods that involve action on a daily basis or with each act of intercourse. While behavioral change is certainly required in order to reap maximum benefit, bariatric surgery is concrete, imposes restrictions that are to some extent independent of day-to-day personal motivation and discipline, and brings about results more quickly than most nonsurgical approaches to weight loss. While not surprised by its appeal to my patients, I have wondered—and in some cases worried—about the long-term physical and particularly psychological effects of rapid weight loss.  Because of this, a recent study of suicide in patients who have undergone bariatric surgery caught my eye.1 The authors obtained suicide data from the Pennsylvania Department of Health Division of Vital Records from 1996-2006 and compared rates among those who had bariatric surgery to age and sex-matched rates in the general United States population.  Among patients who had bariatric surgery, the overall rate of suicide was 6.6/10,000—13.7 for men and 5.2 for women. These rates are significantly greater than for the general population (ages 35-64 years) which were 2.4/10,0000 for men and 0.7/10,000 for women.  Suicide rates in Pennsylvania in 2005 (ages 35-64) were similar at 2.5/10,000 for men and 0.6/10,000 for women. Data were not presented by race or ethnicity because nonwhite rates were very low.  Stratified by gender and age, rates among men were higher than women in all categories. Men aged 45 to 54 years had the highest rates (21.7/10,000). The highest rates for women were for those younger than 35 (14.0/10,000). Ten percent of suicides took place in the first year following surgery, an additional 19% in the second year and an additional 39% in the third year—a total of 68% within the first 3 years. The study resonates with fears I have had about bariatric surgery in certain patients. None of my patients who have undergone bariatric surgery has committed suicide. However, suicide is often the tip of a much larger iceberg of mental health morbidity. I have seen enough patients demonstrate a worsening of their baseline anxiety and depression that I have wondered about the impact of a drastic change in their body on self-image, self-concept, identity, and overall well-being. Most of my patients who have undergone bariatric surgery are women.  This is not surprising since I have more female than male patients, and obesity is more common among women.  While I have not studied this systematically, I know that many of my morbidly obese female patients have a history of childhood sexual abuse, and I know that this tracks with studies that connect obesity with abuse.2,3 Obesity, like many bodily states, can signify a great deal more than simply extra weight.  Obesity may have symbolic meaning that is related to emotional states—a so-called embodied emotion. And being obese (read: large, cushioned, protected, imposing, powerful, unapproachable) may have positive meaning to the patient.  For most people, weight loss has an explicit positive meaning—“I did it!” “I am more healthy!” “ I am more consistent with society’s standards of beauty!” However, the change may also be threatening and carry an unexpected negative meaning—“I am vulnerable.” “I am unprotected.” I have seen many patients become extremely anxious as their bodies “melt” and watched helplessly as they felt compelled to eat their way back to their pre-surgical (or greater) weights. Many surgical weight loss programs are comprehensive and require patients to demonstrate the capacity to change behaviors, undergo psychological evaluation, and wait for their procedure—presumably in order to allow them to process the full impact of bariatric surgery and to demonstrate an enduring commitment to the lifestyle and anticipated body-image changes. However, wishful thinking can cloud a patient’s judgment and create an unrealistic appearance of motivation and optimism. In addition, a multitude of factors, not all pure evidence- based medicine, may influence surgeons and surgical centers (both for-profit and not-for-profit) in their patient selection process.  So far, only one of my patients was disqualified for bariatric surgery for psychological reasons (there was no subtlety in this case!).  I have had many who made the decision impulsively, who were emotionally unstable prior to surgery, and quickly unraveled following the surgery. The authors recognize the limitations of the study: There are no comparable data for suicide rates among obese individuals who did not undergo bariatric surgery. There are no longitudinal studies to date to examine presurgical characteristics, including emotional state, and their relationship to postsurgical emotional states. The authors are clear that the reasons for excess suicides among these patients are not known. The data set did not provide information about characteristics of the surgical programs such as medical and surgical follow-up, weight-loss outcomes, nor characteristics of the patients involved.  The authors recommend additional studies, and perhaps mandatory registries that would allow tracking of key program and patient characteristics, short- and long-term outcomes in order to fill in some of the gaps in understanding. Suicides among this group of patients are another example of a phenomenon that has been described in other contexts—that people who commit suicide have often had extensive contact with the medical system in the period of time preceding the suicide. While not all suicides can be prevented, the medical system cannot ignore the opportunities that it has to prevent at least some. It is well-known that morbidly obese individuals have a high degree of depression and other mental comorbidities.4,5 Bariatric surgery programs must enhance their presurgery screening and assessment processes for depression and other serious mental illnesses and monitor patients post-surgically physically and mentally. I believe that qualitative studies are needed to understand the deeper meanings and symbolism of weight and weight loss. These studies can then inform the types of presurgical screenings that might identify individuals who are vulnerable to poor mental health outcomes, as well as the types of interventions that might prevent morbidity postsurgically. As a primary care physician, I have the privilege of knowing my patients well and the opportunity to accompany them through many chapters of their lives.  It is incumbent on me to explore their motivations, hopes, and expectations for considering elective surgery of this nature and to closely monitor them following surgery as they live with the consequences of their choices. References 1. Tindle HA, Omalu B, Courcoulas A, et al. Risk of suicide after long-term follow-up from bariatric surgery. Am J of Med. 2010;123:1036-1042. 2. Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: A prospective study. Pediatrics. 2007;120:e61-67. 3. Coker AL, Williams C, Ferguson JE, et al. Intimate or childhood sexual abuse and obesity in Kentucky. Fam Violence Prev Health Pract. 2006. http://endabuse.org/health/ejournal/archive/1-7/abuse_and_obesity.php.  Accessed November 26, 2010. 4. Luppino FS, de Wit LM, Bouvy PF, et al.Overweight, obesity and depression: A systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010:67(3):220-229. 5. Mather AA, Cox BJ, Enns MW, Sareen J. Association of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample. J Psychosom Res. 2009; 66:277-285. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] bariatric surgery, depression, obesity, overweight, primary care, psychiatric disorders, suicide, weight loss nonadult false Bariatric Surgery and Suicide text blog bariatric surgery,depression,obesity,overweight,primary care,psychiatric disorders,suicide,weight loss 387 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 3070305 2771822 Member 0 http://community.modernmedicine.com/_Doing-a-Lot-with-a-Little/blog/2949020/33379.html I just returned from a month in Eastern Congo. Among other things, I worked in a small clinic that is part of a program for orphans.1 I was charged with assessing the health of these children—primarily their nutritional status and the burden of infectious disease. I also made recommendations to the program leaders to help plan the clinic’s next steps, including its role in healing and recovery from the community’s wide scale trauma. The project’s leader is an energetic Congolese woman in her mid-30’s with advanced degrees in education and community organizing. In a few short years, she has developed a multifaceted program for 600 orphans that includes a school (pre-school or “maternelle,” primary and secondary schools), an education and micro-credit program for the children’s host families, a farm that will ultimately yield the food to feed the children and support teachers’ salaries, and now a small clinic. Despite its limited resources, the school has set high standards and succeeded in achieving such impressive scores on national tests that families, including local officials, now pay to send their children to study and learn alongside the orphans of war and maternal death. The ultimate vision is for the school to be self-sustaining. The vision goes on to imagine post-secondary education—to train the nurses, teachers, agronomists, and technicians who will become the future of Congo. A key ingredient of the program’s success is its close collaboration with a visionary and brilliant Australian psychologist who has developed a model for working with large scale trauma.2 This model builds on the intrinsic strengths of individuals and the society as a whole and provides them with the tools to become active agents in their own healing.3 Because I returned just a few days ago, I am still in the cultural, linguistic, time-zone mist of re-entry. It will take me much longer to digest my experiences, my own personal lessons, much less the broader lessons of Congo’s painful history. And I would not pretend to capture the impressive work and accomplishments of my new Congolese and Australian colleagues, even after many days or weeks of careful reflection. But I would like to share a few vignettes that illustrate the scarcity of resources, the need to use one’s wits—because, frankly, there isn’t much else to use—and the capacity to solve problems and move forward that leaves me with a sense of optimism, despite the challenges. GlovesSince this was my first trip to Congo I didn’t have a clear idea of the work or the needs. Therefore, I didn’t bring very much in the way of equipment or supplies. I did, however, bring gloves. Lots of gloves. It turned out that these were the only gloves that we had. The nurses—very intelligent, kind, and committed individuals—started IVs, examined patients, dressed wounds, gathered specimens in their bare hands. They were aware of the risks but had no choice. If there are no gloves, there are no gloves. I became aware of how often I reached for gloves, and how rarely they did. I also became aware of how often I reached for gloves for nonglove purposes. Sprains and strains? In the absence of ACE bandages, you can make a nice elasticized bandage for a child’s wrist or ankle by cutting and reshaping a glove. Pressure dressing? Once again, a reconfigured glove and a bit of tape can be used to tamp a pulsing arterial bleed. I know this because I had to stabilize a man who injured himself in a motorbike accident. I’m told that the dressing over his neck wound held until he got to the local hospital. And I’m sure its tensile strength was tested, because his “ambulance” was a “taxi,” which was, in fact, a motorbike that carried him across town on Bunia’s bumpy and rutted roads. I cut gloves to make tourniquets, bands to hold IV’s in place, and on my last day in clinic, when I had compiled records and data into various piles, one of the nurses made transverse cuts along the wrists of the gloves—rubber bands! Technology I brought a few thermometers, an otoscope/ophthalmoscope, a measuring tape, blood pressure cuffs, and my trusty stethoscope. They had a scale, blood pressure cuff, thermometer and otoscope without batteries, and an old monocular microscope. You learn quickly to make diagnoses with minimal diagnostic technology. You learn that if you listen long and hard, you can find the fetal heartbeat with a regular stethoscope. You learn that if you’re patient and know what you’re looking for, you can diagnose malaria, giardia and any number of parasites with a sun-light powered clunky microscope. Luckily, there are a finite number of immediate threats—malaria being the greatest and typhoid fever another—and these are usually straightforward to diagnose and treat. Luckily many intestinal parasites are killed by the same treatment—so you can mistake one worm for another and usually get away with it. Of all of the technology available to us, it was the tape measure and the scale that probably provided the most important data. In this way we documented the degree of calorie malnutrition in babies, children and adults (crisis level), protein-calorie malnutrition (crisis level in babies and children with improvement in middle childhood), growth curves (slightly better in adolescent girls than boys) that will help to define program needs that will have huge impact on health, education, and ultimately economic performance of these children and adults. While your mantra becomes, by necessity, that you won’t let the perfect become the enemy of the good—you still try to maintain the best possible standards under the circumstances and try to do as good a job as possible. Vital signs! When I was an intern, a very smart resident gave me helpful advice for my first nights on call. He told me to always ask for the patient’s vital signs when I was called and to think carefully about what those vital signs could tell me about how sick the patient was and how quickly I had to act. In primary care, you can get pretty far from vital signs. Yes—we pay attention to blood pressure, but most of the time the temperature, pulse and respiratory rate are normal. And most of the time someone else takes these measurements. But when you have very little data, every piece of data becomes important. I re-learned to carefully count respiratory rate and to factor this into my clinical assessment. Is this pneumonia? Bronchitis?.... I re-learned the use of pulse characteristics as an adjunct to the cardiac exam in determining the significance of a murmur. You learn to appreciate and use what you have. As I process my experiences from the past month, I expect that I will focus on the lessons learned as a citizen of the world more than as a health professional. As a physician, the threats to health and well being in Congo are quite different than the threats here in the United States. However, my relatively brief exposure to the challenges of delivering medical care in a sparse environment has provided me with valuable reminders of universal principles of patient care: The importance of being careful and systematic, of extracting the fullest possible meaning from any and all available data, however limited, and using the available resources to their fullest advantage in the interest of the patient. References 1. The Baraka Academy/ Bunia Children’s Hope Center http://africanhopecenters.org/BuniaVol5Issue1.pdf 2. Research into the healing power of community. The Macquarie Globe Edition 6.  2010 11 Feb. http://www.international.mq.edu.au/globe/default.aspx?id=244&EditionID=291 3. Traum Aid International.  http://www.traumaid.org/ Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I just returned from a month in Eastern Congo. Among other things, I worked in a small clinic that is part of a program for orphans.1 I was charged with assessing the health of these children—primarily their nutritional status and the burden of infectious disease. I also made recommendations to the program leaders to help plan the clinic’s next steps, including its role in healing and recovery from the community’s wide scale trauma. The project’s leader is an energetic Congolese woman in her mid-30’s with advanced degrees in education and community organizing. In a few short years, she has developed a multifaceted program for 600 orphans that includes a school (pre-school or “maternelle,” primary and secondary schools), an education and micro-credit program for the children’s host families, a farm that will ultimately yield the food to feed the children and support teachers’ salaries, and now a small clinic. Despite its limited resources, the school has set high standards and succeeded in achieving such impressive scores on national tests that families, including local officials, now pay to send their children to study and learn alongside the orphans of war and maternal death. The ultimate vision is for the school to be self-sustaining. The vision goes on to imagine post-secondary education—to train the nurses, teachers, agronomists, and technicians who will become the future of Congo. A key ingredient of the program’s success is its close collaboration with a visionary and brilliant Australian psychologist who has developed a model for working with large scale trauma.2 This model builds on the intrinsic strengths of individuals and the society as a whole and provides them with the tools to become active agents in their own healing.3 Because I returned just a few days ago, I am still in the cultural, linguistic, time-zone mist of re-entry. It will take me much longer to digest my experiences, my own personal lessons, much less the broader lessons of Congo’s painful history. And I would not pretend to capture the impressive work and accomplishments of my new Congolese and Australian colleagues, even after many days or weeks of careful reflection. But I would like to share a few vignettes that illustrate the scarcity of resources, the need to use one’s wits—because, frankly, there isn’t much else to use—and the capacity to solve problems and move forward that leaves me with a sense of optimism, despite the challenges. GlovesSince this was my first trip to Congo I didn’t have a clear idea of the work or the needs. Therefore, I didn’t bring very much in the way of equipment or supplies. I did, however, bring gloves. Lots of gloves. It turned out that these were the only gloves that we had. The nurses—very intelligent, kind, and committed individuals—started IVs, examined patients, dressed wounds, gathered specimens in their bare hands. They were aware of the risks but had no choice. If there are no gloves, there are no gloves. I became aware of how often I reached for gloves, and how rarely they did. I also became aware of how often I reached for gloves for nonglove purposes. Sprains and strains? In the absence of ACE bandages, you can make a nice elasticized bandage for a child’s wrist or ankle by cutting and reshaping a glove. Pressure dressing? Once again, a reconfigured glove and a bit of tape can be used to tamp a pulsing arterial bleed. I know this because I had to stabilize a man who injured himself in a motorbike accident. I’m told that the dressing over his neck wound held until he got to the local hospital. And I’m sure its tensile strength was tested, because his “ambulance” was a “taxi,” which was, in fact, a motorbike that carried him across town on Bunia’s bumpy and rutted roads. I cut gloves to make tourniquets, bands to hold IV’s in place, and on my last day in clinic, when I had compiled records and data into various piles, one of the nurses made transverse cuts along the wrists of the gloves—rubber bands! Technology I brought a few thermometers, an otoscope/ophthalmoscope, a measuring tape, blood pressure cuffs, and my trusty stethoscope. They had a scale, blood pressure cuff, thermometer and otoscope without batteries, and an old monocular microscope. You learn quickly to make diagnoses with minimal diagnostic technology. You learn that if you listen long and hard, you can find the fetal heartbeat with a regular stethoscope. You learn that if you’re patient and know what you’re looking for, you can diagnose malaria, giardia and any number of parasites with a sun-light powered clunky microscope. Luckily, there are a finite number of immediate threats—malaria being the greatest and typhoid fever another—and these are usually straightforward to diagnose and treat. Luckily many intestinal parasites are killed by the same treatment—so you can mistake one worm for another and usually get away with it. Of all of the technology available to us, it was the tape measure and the scale that probably provided the most important data. In this way we documented the degree of calorie malnutrition in babies, children and adults (crisis level), protein-calorie malnutrition (crisis level in babies and children with improvement in middle childhood), growth curves (slightly better in adolescent girls than boys) that will help to define program needs that will have huge impact on health, education, and ultimately economic performance of these children and adults. While your mantra becomes, by necessity, that you won’t let the perfect become the enemy of the good—you still try to maintain the best possible standards under the circumstances and try to do as good a job as possible. Vital signs! When I was an intern, a very smart resident gave me helpful advice for my first nights on call. He told me to always ask for the patient’s vital signs when I was called and to think carefully about what those vital signs could tell me about how sick the patient was and how quickly I had to act. In primary care, you can get pretty far from vital signs. Yes—we pay attention to blood pressure, but most of the time the temperature, pulse and respiratory rate are normal. And most of the time someone else takes these measurements. But when you have very little data, every piece of data becomes important. I re-learned to carefully count respiratory rate and to factor this into my clinical assessment. Is this pneumonia? Bronchitis?.... I re-learned the use of pulse characteristics as an adjunct to the cardiac exam in determining the significance of a murmur. You learn to appreciate and use what you have. As I process my experiences from the past month, I expect that I will focus on the lessons learned as a citizen of the world more than as a health professional. As a physician, the threats to health and well being in Congo are quite different than the threats here in the United States. However, my relatively brief exposure to the challenges of delivering medical care in a sparse environment has provided me with valuable reminders of universal principles of patient care: The importance of being careful and systematic, of extracting the fullest possible meaning from any and all available data, however limited, and using the available resources to their fullest advantage in the interest of the patient. References 1. The Baraka Academy/ Bunia Children’s Hope Center http://africanhopecenters.org/BuniaVol5Issue1.pdf 2. Research into the healing power of community. The Macquarie Globe Edition 6.  2010 11 Feb. http://www.international.mq.edu.au/globe/default.aspx?id=244&EditionID=291 3. Traum Aid International.  http://www.traumaid.org/ Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Tue, 09 Nov 2010 20:39:27 GMT http://community.modernmedicine.com/_Doing-a-Lot-with-a-Little/blog/2949020/33379.html bgottlieb 2010-11-09T20:36:33Z Primary Care Modern Medicine Community I just returned from a month in Eastern Congo. Among other things, I worked in a small clinic that is part of a program for orphans.1 I was charged with assessing the health of these children—primarily their nutritional status and the burden of infectious disease. I also made recommendations to the program leaders to help plan the clinic’s next steps, including its role in healing and recovery from the community’s wide scale trauma. The project’s leader is an energetic Congolese woman in her mid-30’s with advanced degrees in education and community organizing. In a few short years, she has developed a multifaceted program for 600 orphans that includes a school (pre-school or “maternelle,” primary and secondary schools), an education and micro-credit program for the children’s host families, a farm that will ultimately yield the food to feed the children and support teachers’ salaries, and now a small clinic. Despite its limited resources, the school has set high standards and succeeded in achieving such impressive scores on national tests that families, including local officials, now pay to send their children to study and learn alongside the orphans of war and maternal death. The ultimate vision is for the school to be self-sustaining. The vision goes on to imagine post-secondary education—to train the nurses, teachers, agronomists, and technicians who will become the future of Congo. A key ingredient of the program’s success is its close collaboration with a visionary and brilliant Australian psychologist who has developed a model for working with large scale trauma.2 This model builds on the intrinsic strengths of individuals and the society as a whole and provides them with the tools to become active agents in their own healing.3 Because I returned just a few days ago, I am still in the cultural, linguistic, time-zone mist of re-entry. It will take me much longer to digest my experiences, my own personal lessons, much less the broader lessons of Congo’s painful history. And I would not pretend to capture the impressive work and accomplishments of my new Congolese and Australian colleagues, even after many days or weeks of careful reflection. But I would like to share a few vignettes that illustrate the scarcity of resources, the need to use one’s wits—because, frankly, there isn’t much else to use—and the capacity to solve problems and move forward that leaves me with a sense of optimism, despite the challenges. GlovesSince this was my first trip to Congo I didn’t have a clear idea of the work or the needs. Therefore, I didn’t bring very much in the way of equipment or supplies. I did, however, bring gloves. Lots of gloves. It turned out that these were the only gloves that we had. The nurses—very intelligent, kind, and committed individuals—started IVs, examined patients, dressed wounds, gathered specimens in their bare hands. They were aware of the risks but had no choice. If there are no gloves, there are no gloves. I became aware of how often I reached for gloves, and how rarely they did. I also became aware of how often I reached for gloves for nonglove purposes. Sprains and strains? In the absence of ACE bandages, you can make a nice elasticized bandage for a child’s wrist or ankle by cutting and reshaping a glove. Pressure dressing? Once again, a reconfigured glove and a bit of tape can be used to tamp a pulsing arterial bleed. I know this because I had to stabilize a man who injured himself in a motorbike accident. I’m told that the dressing over his neck wound held until he got to the local hospital. And I’m sure its tensile strength was tested, because his “ambulance” was a “taxi,” which was, in fact, a motorbike that carried him across town on Bunia’s bumpy and rutted roads. I cut gloves to make tourniquets, bands to hold IV’s in place, and on my last day in clinic, when I had compiled records and data into various piles, one of the nurses made transverse cuts along the wrists of the gloves—rubber bands! Technology I brought a few thermometers, an otoscope/ophthalmoscope, a measuring tape, blood pressure cuffs, and my trusty stethoscope. They had a scale, blood pressure cuff, thermometer and otoscope without batteries, and an old monocular microscope. You learn quickly to make diagnoses with minimal diagnostic technology. You learn that if you listen long and hard, you can find the fetal heartbeat with a regular stethoscope. You learn that if you’re patient and know what you’re looking for, you can diagnose malaria, giardia and any number of parasites with a sun-light powered clunky microscope. Luckily, there are a finite number of immediate threats—malaria being the greatest and typhoid fever another—and these are usually straightforward to diagnose and treat. Luckily many intestinal parasites are killed by the same treatment—so you can mistake one worm for another and usually get away with it. Of all of the technology available to us, it was the tape measure and the scale that probably provided the most important data. In this way we documented the degree of calorie malnutrition in babies, children and adults (crisis level), protein-calorie malnutrition (crisis level in babies and children with improvement in middle childhood), growth curves (slightly better in adolescent girls than boys) that will help to define program needs that will have huge impact on health, education, and ultimately economic performance of these children and adults. While your mantra becomes, by necessity, that you won’t let the perfect become the enemy of the good—you still try to maintain the best possible standards under the circumstances and try to do as good a job as possible. Vital signs! When I was an intern, a very smart resident gave me helpful advice for my first nights on call. He told me to always ask for the patient’s vital signs when I was called and to think carefully about what those vital signs could tell me about how sick the patient was and how quickly I had to act. In primary care, you can get pretty far from vital signs. Yes—we pay attention to blood pressure, but most of the time the temperature, pulse and respiratory rate are normal. And most of the time someone else takes these measurements. But when you have very little data, every piece of data becomes important. I re-learned to carefully count respiratory rate and to factor this into my clinical assessment. Is this pneumonia? Bronchitis?.... I re-learned the use of pulse characteristics as an adjunct to the cardiac exam in determining the significance of a murmur. You learn to appreciate and use what you have. As I process my experiences from the past month, I expect that I will focus on the lessons learned as a citizen of the world more than as a health professional. As a physician, the threats to health and well being in Congo are quite different than the threats here in the United States. However, my relatively brief exposure to the challenges of delivering medical care in a sparse environment has provided me with valuable reminders of universal principles of patient care: The importance of being careful and systematic, of extracting the fullest possible meaning from any and all available data, however limited, and using the available resources to their fullest advantage in the interest of the patient. References 1. The Baraka Academy/ Bunia Children’s Hope Center http://africanhopecenters.org/BuniaVol5Issue1.pdf 2. Research into the healing power of community. The Macquarie Globe Edition 6.  2010 11 Feb. http://www.international.mq.edu.au/globe/default.aspx?id=244&EditionID=291 3. Traum Aid International.  http://www.traumaid.org/ Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] adolescents, children, congo, glove, infectious disease, malnutrition, parasites, primary care, technology, trauma, vital signs nonadult false Doing a Lot with a Little text blog adolescents,children,congo,glove,infectious disease,malnutrition,parasites,primary care,technology,trauma,vital signs 378 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 2949020 2771822 Member 0 http://community.modernmedicine.com/_Falls-What-Is-Happening/blog/2837962/33379.html In the past week, I have had 3 patients (that I know of) fall and require further medical attention. The fact that the first patient fell is not a surprise. She is very debilitated and has every chronic illness you can name. She has been hospitalized 4 times in as many months and had recently returned home following a cholecystectomy. Her Foley catheter had been removed a few days before, and she was a little slow to pick up on the signals that she had a full bladder. So she stood up quickly, started rushing to the bathroom, and the next thing she knew she was on the floor. Back to the emergency room, 4 fractured ribs, more pain medications, and yet another set-back. The next 2 patients were not people I would have expected to fall. One is a man in his mid 60’s. He is relatively fit and active, despite what seems to be my patients’ standard triad: diabetes, hypertension, and asthma. But he was feeling fine. Fine enough to climb on a chair to reach something. Next thing he knew he was on the floor. Also went to the emergency room—x-rays, including brain imaging (maybe he was a little dizzy before he fell—well, just in case), labs, EKG…in the end just some bruised ribs and an aching back. The third patient is a 78-year-old woman. But she is a “young” 78—active, healthy, “walks everywhere.” She wanted to get just a few more days out of her sandals before retiring them until next summer. She caught the open part of her sandal on the curb, slipped, and landed on the sidewalk. She broke the fall with her left hand and fractured her wrist. Emergency room, x-rays, luckily no surgery. But she’s in a cast, refuses pain medications, needs therapy, and will definitely miss out on some of her usual activities. With great foresight, I had torn a page out of the May 26, 2010 JAMA about screening elders to prevent falls.1 This page, by now slightly coffee-stained, was sitting on my remember-to-read-some-day articles. The author refers to recently updated guidelines from the American and British Geriatrics Societies encouraging primary care physicians to screen all older patients for risk factors that can lead to falls. I do, dutifully, ask every patient over 50 if they have fallen in the past year at their annual visit. Most haven’t. In fact, none of the 3 patients who fell this past week had ever reported a fall to me. However, clearly each of them had risk factors that I had failed to identify. The guidelines are straightforward: According to the American Geriatrics Society, patients who have had recurrent falls in the past year, who seek medical attention because of a fall, or who report problems with gait and/or balance should undergo a multi-factorial risk assessment.2 Anyone who has had 1 fall should receive further testing of gait and balance and be referred for further testing if abnormalities are detected. At minimum, you can observe the patient’s gait, ideally when he or she is unaware. Then ask the patient to walk toward you on his/her heels, and away from you on his/her toes. Finally, have the patient walk in tandem along a straight line. In each of these exercises, observe for signs of weakness, asymmetry, and strides of differing lengths. Provocative tests can include: Get up and go – in which the patient is asked to stand from a sitting position, walk a fixed distance across the room, turn around, return to the seat and sit back down. Fluidity, balance, and strength are rated on a 5-point scale. There is some question about the validity of this test and its ability to predict falls, but it can be a quick tool in a clinical setting—particularly if the patient seems to have difficulty with these simple actions. Berg Balance test.3 This test takes longer, but seems to have a better track record for predicting unsuspected risk for falls. The patient is asked to carry out a variety of actions, including sitting unsupported, rising from a sitting position, standing with feet close together, standing with eyes closed, reaching forward, bending down to pick up an object and others. The observer rates the patients’ ability using a clearly described scale. The multi-factorial evaluation is yet more complicated and should be carried out by someone who has been appropriately trained. This includes a focused history, review of medications, physical examination focusing on cardiovascular and neuromuscular systems, visual acuity, shoes, use of assistive devices, assessment of function, and an environmental assessment. This evaluation should yield recommendations that can be implemented in order to reduce risk of falling. What can I realistically do in order to do a better job? Many of the features of the general physical exam are things I do anyway. But, I have to admit that I don’t always connect the dots. I don’t always think of the ways in which specific findings can put someone at risk for falling. Observing the gait is easy enough, and slipping in a few provocative maneuvers wouldn’t be too difficult or time consuming. I do notice my patients’ shoes, but I can be clearer with my admonitions. I can also take some lessons from my own life and move upstream a bit in my patient education and anticipatory guidance. When I reached the golden age of 60, I told myself that while I am still fit and agile, still able to climb on chairs, wear flimsy sandals and clunky shoes, shower without a mat without hurting myself, now is the time to make changes. It will be a lot harder physically and psychologically to admit that I have to make changes  when I am also trying to come to terms with being OLDER, MORE FRAIL, LESS AGILE. It is less threatening to my sense of myself to get the step stool, use the bath mat, get the sensible shoes now—when I don’t really need them. So—I am beginning to share my personal revelations with my patients, and ask, “Do you use a shower mat?” “Do you have a step stool?” “Is there someone else who can change the light bulbs?” And—not to be too corny, but, just like Valentine’s Day has become a time when people in medicine and public health talk about the cardiovascular system (the actual heart), maybe come September, October, November, I can remind myself to think about…well…falls. References 1. Kuehn BM. Primary care screening and intervention helps prevent falls among elderly. JAMA. 2010;303(20):2019-2020. 2. Prevention of Falls in Older Persons. AGS/BGS clinical Practice Guideline. Available at: http://www.medcats.com/FALLS/frameset.htm 3. Berg Balance Scale. Available at: http://www.fallssa.com.au/documents/hp/Berg_Balance_Scale.pdf Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] In the past week, I have had 3 patients (that I know of) fall and require further medical attention. The fact that the first patient fell is not a surprise. She is very debilitated and has every chronic illness you can name. She has been hospitalized 4 times in as many months and had recently returned home following a cholecystectomy. Her Foley catheter had been removed a few days before, and she was a little slow to pick up on the signals that she had a full bladder. So she stood up quickly, started rushing to the bathroom, and the next thing she knew she was on the floor. Back to the emergency room, 4 fractured ribs, more pain medications, and yet another set-back. The next 2 patients were not people I would have expected to fall. One is a man in his mid 60’s. He is relatively fit and active, despite what seems to be my patients’ standard triad: diabetes, hypertension, and asthma. But he was feeling fine. Fine enough to climb on a chair to reach something. Next thing he knew he was on the floor. Also went to the emergency room—x-rays, including brain imaging (maybe he was a little dizzy before he fell—well, just in case), labs, EKG…in the end just some bruised ribs and an aching back. The third patient is a 78-year-old woman. But she is a “young” 78—active, healthy, “walks everywhere.” She wanted to get just a few more days out of her sandals before retiring them until next summer. She caught the open part of her sandal on the curb, slipped, and landed on the sidewalk. She broke the fall with her left hand and fractured her wrist. Emergency room, x-rays, luckily no surgery. But she’s in a cast, refuses pain medications, needs therapy, and will definitely miss out on some of her usual activities. With great foresight, I had torn a page out of the May 26, 2010 JAMA about screening elders to prevent falls.1 This page, by now slightly coffee-stained, was sitting on my remember-to-read-some-day articles. The author refers to recently updated guidelines from the American and British Geriatrics Societies encouraging primary care physicians to screen all older patients for risk factors that can lead to falls. I do, dutifully, ask every patient over 50 if they have fallen in the past year at their annual visit. Most haven’t. In fact, none of the 3 patients who fell this past week had ever reported a fall to me. However, clearly each of them had risk factors that I had failed to identify. The guidelines are straightforward: According to the American Geriatrics Society, patients who have had recurrent falls in the past year, who seek medical attention because of a fall, or who report problems with gait and/or balance should undergo a multi-factorial risk assessment.2 Anyone who has had 1 fall should receive further testing of gait and balance and be referred for further testing if abnormalities are detected. At minimum, you can observe the patient’s gait, ideally when he or she is unaware. Then ask the patient to walk toward you on his/her heels, and away from you on his/her toes. Finally, have the patient walk in tandem along a straight line. In each of these exercises, observe for signs of weakness, asymmetry, and strides of differing lengths. Provocative tests can include: Get up and go – in which the patient is asked to stand from a sitting position, walk a fixed distance across the room, turn around, return to the seat and sit back down. Fluidity, balance, and strength are rated on a 5-point scale. There is some question about the validity of this test and its ability to predict falls, but it can be a quick tool in a clinical setting—particularly if the patient seems to have difficulty with these simple actions. Berg Balance test.3 This test takes longer, but seems to have a better track record for predicting unsuspected risk for falls. The patient is asked to carry out a variety of actions, including sitting unsupported, rising from a sitting position, standing with feet close together, standing with eyes closed, reaching forward, bending down to pick up an object and others. The observer rates the patients’ ability using a clearly described scale. The multi-factorial evaluation is yet more complicated and should be carried out by someone who has been appropriately trained. This includes a focused history, review of medications, physical examination focusing on cardiovascular and neuromuscular systems, visual acuity, shoes, use of assistive devices, assessment of function, and an environmental assessment. This evaluation should yield recommendations that can be implemented in order to reduce risk of falling. What can I realistically do in order to do a better job? Many of the features of the general physical exam are things I do anyway. But, I have to admit that I don’t always connect the dots. I don’t always think of the ways in which specific findings can put someone at risk for falling. Observing the gait is easy enough, and slipping in a few provocative maneuvers wouldn’t be too difficult or time consuming. I do notice my patients’ shoes, but I can be clearer with my admonitions. I can also take some lessons from my own life and move upstream a bit in my patient education and anticipatory guidance. When I reached the golden age of 60, I told myself that while I am still fit and agile, still able to climb on chairs, wear flimsy sandals and clunky shoes, shower without a mat without hurting myself, now is the time to make changes. It will be a lot harder physically and psychologically to admit that I have to make changes  when I am also trying to come to terms with being OLDER, MORE FRAIL, LESS AGILE. It is less threatening to my sense of myself to get the step stool, use the bath mat, get the sensible shoes now—when I don’t really need them. So—I am beginning to share my personal revelations with my patients, and ask, “Do you use a shower mat?” “Do you have a step stool?” “Is there someone else who can change the light bulbs?” And—not to be too corny, but, just like Valentine’s Day has become a time when people in medicine and public health talk about the cardiovascular system (the actual heart), maybe come September, October, November, I can remind myself to think about…well…falls. References 1. Kuehn BM. Primary care screening and intervention helps prevent falls among elderly. JAMA. 2010;303(20):2019-2020. 2. Prevention of Falls in Older Persons. AGS/BGS clinical Practice Guideline. Available at: http://www.medcats.com/FALLS/frameset.htm 3. Berg Balance Scale. Available at: http://www.fallssa.com.au/documents/hp/Berg_Balance_Scale.pdf Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Mon, 25 Oct 2010 14:41:16 GMT http://community.modernmedicine.com/_Falls-What-Is-Happening/blog/2837962/33379.html bgottlieb 2010-10-25T14:38:17Z Primary Care Modern Medicine Community In the past week, I have had 3 patients (that I know of) fall and require further medical attention. The fact that the first patient fell is not a surprise. She is very debilitated and has every chronic illness you can name. She has been hospitalized 4 times in as many months and had recently returned home following a cholecystectomy. Her Foley catheter had been removed a few days before, and she was a little slow to pick up on the signals that she had a full bladder. So she stood up quickly, started rushing to the bathroom, and the next thing she knew she was on the floor. Back to the emergency room, 4 fractured ribs, more pain medications, and yet another set-back. The next 2 patients were not people I would have expected to fall. One is a man in his mid 60’s. He is relatively fit and active, despite what seems to be my patients’ standard triad: diabetes, hypertension, and asthma. But he was feeling fine. Fine enough to climb on a chair to reach something. Next thing he knew he was on the floor. Also went to the emergency room—x-rays, including brain imaging (maybe he was a little dizzy before he fell—well, just in case), labs, EKG…in the end just some bruised ribs and an aching back. The third patient is a 78-year-old woman. But she is a “young” 78—active, healthy, “walks everywhere.” She wanted to get just a few more days out of her sandals before retiring them until next summer. She caught the open part of her sandal on the curb, slipped, and landed on the sidewalk. She broke the fall with her left hand and fractured her wrist. Emergency room, x-rays, luckily no surgery. But she’s in a cast, refuses pain medications, needs therapy, and will definitely miss out on some of her usual activities. With great foresight, I had torn a page out of the May 26, 2010 JAMA about screening elders to prevent falls.1 This page, by now slightly coffee-stained, was sitting on my remember-to-read-some-day articles. The author refers to recently updated guidelines from the American and British Geriatrics Societies encouraging primary care physicians to screen all older patients for risk factors that can lead to falls. I do, dutifully, ask every patient over 50 if they have fallen in the past year at their annual visit. Most haven’t. In fact, none of the 3 patients who fell this past week had ever reported a fall to me. However, clearly each of them had risk factors that I had failed to identify. The guidelines are straightforward: According to the American Geriatrics Society, patients who have had recurrent falls in the past year, who seek medical attention because of a fall, or who report problems with gait and/or balance should undergo a multi-factorial risk assessment.2 Anyone who has had 1 fall should receive further testing of gait and balance and be referred for further testing if abnormalities are detected. At minimum, you can observe the patient’s gait, ideally when he or she is unaware. Then ask the patient to walk toward you on his/her heels, and away from you on his/her toes. Finally, have the patient walk in tandem along a straight line. In each of these exercises, observe for signs of weakness, asymmetry, and strides of differing lengths. Provocative tests can include: Get up and go – in which the patient is asked to stand from a sitting position, walk a fixed distance across the room, turn around, return to the seat and sit back down. Fluidity, balance, and strength are rated on a 5-point scale. There is some question about the validity of this test and its ability to predict falls, but it can be a quick tool in a clinical setting—particularly if the patient seems to have difficulty with these simple actions. Berg Balance test.3 This test takes longer, but seems to have a better track record for predicting unsuspected risk for falls. The patient is asked to carry out a variety of actions, including sitting unsupported, rising from a sitting position, standing with feet close together, standing with eyes closed, reaching forward, bending down to pick up an object and others. The observer rates the patients’ ability using a clearly described scale. The multi-factorial evaluation is yet more complicated and should be carried out by someone who has been appropriately trained. This includes a focused history, review of medications, physical examination focusing on cardiovascular and neuromuscular systems, visual acuity, shoes, use of assistive devices, assessment of function, and an environmental assessment. This evaluation should yield recommendations that can be implemented in order to reduce risk of falling. What can I realistically do in order to do a better job? Many of the features of the general physical exam are things I do anyway. But, I have to admit that I don’t always connect the dots. I don’t always think of the ways in which specific findings can put someone at risk for falling. Observing the gait is easy enough, and slipping in a few provocative maneuvers wouldn’t be too difficult or time consuming. I do notice my patients’ shoes, but I can be clearer with my admonitions. I can also take some lessons from my own life and move upstream a bit in my patient education and anticipatory guidance. When I reached the golden age of 60, I told myself that while I am still fit and agile, still able to climb on chairs, wear flimsy sandals and clunky shoes, shower without a mat without hurting myself, now is the time to make changes. It will be a lot harder physically and psychologically to admit that I have to make changes  when I am also trying to come to terms with being OLDER, MORE FRAIL, LESS AGILE. It is less threatening to my sense of myself to get the step stool, use the bath mat, get the sensible shoes now—when I don’t really need them. So—I am beginning to share my personal revelations with my patients, and ask, “Do you use a shower mat?” “Do you have a step stool?” “Is there someone else who can change the light bulbs?” And—not to be too corny, but, just like Valentine’s Day has become a time when people in medicine and public health talk about the cardiovascular system (the actual heart), maybe come September, October, November, I can remind myself to think about…well…falls. References 1. Kuehn BM. Primary care screening and intervention helps prevent falls among elderly. JAMA. 2010;303(20):2019-2020. 2. Prevention of Falls in Older Persons. AGS/BGS clinical Practice Guideline. Available at: http://www.medcats.com/FALLS/frameset.htm 3. Berg Balance Scale. Available at: http://www.fallssa.com.au/documents/hp/Berg_Balance_Scale.pdf Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] falls, geriatrics, primary care, safety nonadult false Fall(s): What Is Happening? text blog falls,geriatrics,primary care,safety 345 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Primary Care 0 2837962 2771822 Member 0 http://community.modernmedicine.com/_4-Key-Lessons-from-a-Minority-Health-Project/blog/2601417/33379.html I don’t do a lot of research these days. However, for the past 2 years I have had the privilege to serve as the evaluator for a project to integrate mental health services and complementary health practices such as yoga, acupuncture, and relaxation techniques into primary care. The research “question” is whether this integration will result in better care for Latina women who have chronic diseases such as diabetes, asthma, and hypertension. The project is funded by the Federal Office of Minority Health and is located at 2 community health centers (not my own) that care for large numbers of Latino patients. In my role as evaluator, I periodically interview program participants (patients), mental health and medical providers. While not specifically focused on practice re-design, I am gaining insight that could help shape this process to better serve both patients and providers. Briefly, the project consists of placing a Case Manager in the adult primary care clinic of each health center. Each female Latina patient (meaning pretty much all of the women) is screened by the Case Manager for depression, other behavioral risks, and variety of potential concrete needs such as transportation, housing and food. Concrete needs are addressed by the Case Manager, and women who screen positive in any of the domains are assisted with mental health referrals, and informed about yoga classes, acupuncture, and stress-reduction groups. The Case Manager keeps track of the referrals and makes sure that the patients get to their appointments. She also does outreach to encourage them to participate in the various services offered by the program. It is a relatively simple intervention that seems to fit into the flow of primary care and relieves the providers of some of their most time-consuming tasks. We will eventually measure some clinically relevant endpoints—improvement in disease-specific measurements such as HgA1c levels, improvement in depression scores, systems improvements such as appointments kept, emergency room use, and patient and provider satisfaction. But for now, I am focusing on “softer” measures. What about this intervention “works?” What does this add to patient care that patients and providers feel has been missing? “I want to feel like a person, not a diagnosis.” For the most part, patients speak positively of their medical providers. However, they describe their visits as too short, too rushed, and too focused on the 1 or 2 issues that the providers choose to focus on. Patients do not feel invited to discuss their own questions, and often feel that if they raise questions that were not on their providers’ agenda, their questions are ignored. While the patients in the program each have a long list of problems, they tend to feel either bad or good in general, rather than disease-specific ways. They feel that doctors are focused on issues that have a specific answer—a medicine, a test, rather than the more undifferentiated ways in which patients experience their illnesses. In short, they feel like a problem list, a diagnosis. Providers feel the same. They are not satisfied with the way that reimbursement and other systemic factors shape their interactions with patients. They are aware of spending inadequate time listening to their patients and are frustrated by their inability to focus on prevention. Attempts to change the structure, including group visits, disease-specific programs such as diabetes groups, while providing some opportunities that are missing in the individual patient encounter, often replicate the same diagnosis-driven agenda that constrains standard patient visits. In contrast, the Case Manager truly delivers patient-centered care. Her agenda is entirely driven by the patient. She calls to remind patients of their appointments and group meetings. If they miss, she calls to find out why. Patients notice that. “I feel valued as a person.” While patients are aware that their doctors’ time is limited, they feel that the Case Manager can “take the time” to listen. She is “approachable,” “more like a friend.” The Case Manager conducts a variety of “stress reduction,” support groups. Unlike previous attempts to establish patient groups that failed due to lack of participation, these groups have been going for more than a year with very consistent and growing attendance. Previous groups included healthy snacks, a patient education topic, a talk by a provider, as do the current groups. What is different about these groups? What accounts for their success? Clearly the patients value the tools and services they gain from the groups—relaxation techniques, access to massage, yoga, and acupuncture. (What’s not to like??) Even though the groups do have educational and chronic disease-specific objectives (stress reduction, promotion of healthy eating, and physical activity), participants primarily perceive the groups as an opportunity to socialize with others, to learn that they are neither unique nor alone in their suffering. The lessons, the learning come as a natural by-product of the positive group process. In contrast to health center visits “for my heart” or “for my diabetes,” these groups are “for me.” While there is no specific agenda to promote self-confidence and efficacy, participants note that they understand more about their health and their illnesses and are less afraid to ask questions of their providers. Providers comment on their patients’ self-confidence and assertiveness. They perceive that patients’ participation in the group has provided positive opportunities for social contact for their patients, and forged positive bonds with the health center. They also note that many patients who initially seemed to require formal mental health services in fact get their needs met by the Case Manager and the support groups. Any program that reduces the demand for scarce mental health services and cuts down on waste by reducing missed appointments is appreciated. What are the lessons so far? Patients and providers are frustrated by many of the same problems and have many of the same hopes for their encounters and relationship While it may be unrealistic for patients to get everything they need from their physician, their “medical home” can provide for a broad range of needs to improve their health and well-being by developing other roles and programs The role of Case Managers and other personnel may be more ideally suited to meet certain patient care needs than the physician role. This is fine if patients perceive that the roles are linked, and if the providers perceived that they are being unburdened of important, yet time-consuming tasks. Patients appreciate and benefit from groups. However, before proceeding into this new model of providing care, it would behoove practices to ask patients what they might want from groups. There are undoubtedly demographic differences that must be accounted for, but in any case, group visits should open new doors to enhance patient experience and outcomes and not replicate the problems that constrain individual patient visits. As I step back from my evaluator role into my more familiar role of primary care physician, I reflect upon my own practice and interactions with patients. I try to be approachable, non-intimidating. How many physicians can say that a patient gave them pajamas for Christmas? Over the years I have been called a variety of nicknames and diminutives, (just last week—doctorita…little doctor??) My patients must feel comfortable with me. But, if I am honest, I know that for the most part I set the agenda. If that weren’t the case, I wouldn’t be hearing from the diabetes educator or our diabetes community outreach worker that my patients don’t actually take their medications as prescribed. I am reminded that while I spend most of my time talking with patients, I may not spend quite enough of it actually listening. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I don’t do a lot of research these days. However, for the past 2 years I have had the privilege to serve as the evaluator for a project to integrate mental health services and complementary health practices such as yoga, acupuncture, and relaxation techniques into primary care. The research “question” is whether this integration will result in better care for Latina women who have chronic diseases such as diabetes, asthma, and hypertension. The project is funded by the Federal Office of Minority Health and is located at 2 community health centers (not my own) that care for large numbers of Latino patients. In my role as evaluator, I periodically interview program participants (patients), mental health and medical providers. While not specifically focused on practice re-design, I am gaining insight that could help shape this process to better serve both patients and providers. Briefly, the project consists of placing a Case Manager in the adult primary care clinic of each health center. Each female Latina patient (meaning pretty much all of the women) is screened by the Case Manager for depression, other behavioral risks, and variety of potential concrete needs such as transportation, housing and food. Concrete needs are addressed by the Case Manager, and women who screen positive in any of the domains are assisted with mental health referrals, and informed about yoga classes, acupuncture, and stress-reduction groups. The Case Manager keeps track of the referrals and makes sure that the patients get to their appointments. She also does outreach to encourage them to participate in the various services offered by the program. It is a relatively simple intervention that seems to fit into the flow of primary care and relieves the providers of some of their most time-consuming tasks. We will eventually measure some clinically relevant endpoints—improvement in disease-specific measurements such as HgA1c levels, improvement in depression scores, systems improvements such as appointments kept, emergency room use, and patient and provider satisfaction. But for now, I am focusing on “softer” measures. What about this intervention “works?” What does this add to patient care that patients and providers feel has been missing? “I want to feel like a person, not a diagnosis.” For the most part, patients speak positively of their medical providers. However, they describe their visits as too short, too rushed, and too focused on the 1 or 2 issues that the providers choose to focus on. Patients do not feel invited to discuss their own questions, and often feel that if they raise questions that were not on their providers’ agenda, their questions are ignored. While the patients in the program each have a long list of problems, they tend to feel either bad or good in general, rather than disease-specific ways. They feel that doctors are focused on issues that have a specific answer—a medicine, a test, rather than the more undifferentiated ways in which patients experience their illnesses. In short, they feel like a problem list, a diagnosis. Providers feel the same. They are not satisfied with the way that reimbursement and other systemic factors shape their interactions with patients. They are aware of spending inadequate time listening to their patients and are frustrated by their inability to focus on prevention. Attempts to change the structure, including group visits, disease-specific programs such as diabetes groups, while providing some opportunities that are missing in the individual patient encounter, often replicate the same diagnosis-driven agenda that constrains standard patient visits. In contrast, the Case Manager truly delivers patient-centered care. Her agenda is entirely driven by the patient. She calls to remind patients of their appointments and group meetings. If they miss, she calls to find out why. Patients notice that. “I feel valued as a person.” While patients are aware that their doctors’ time is limited, they feel that the Case Manager can “take the time” to listen. She is “approachable,” “more like a friend.” The Case Manager conducts a variety of “stress reduction,” support groups. Unlike previous attempts to establish patient groups that failed due to lack of participation, these groups have been going for more than a year with very consistent and growing attendance. Previous groups included healthy snacks, a patient education topic, a talk by a provider, as do the current groups. What is different about these groups? What accounts for their success? Clearly the patients value the tools and services they gain from the groups—relaxation techniques, access to massage, yoga, and acupuncture. (What’s not to like??) Even though the groups do have educational and chronic disease-specific objectives (stress reduction, promotion of healthy eating, and physical activity), participants primarily perceive the groups as an opportunity to socialize with others, to learn that they are neither unique nor alone in their suffering. The lessons, the learning come as a natural by-product of the positive group process. In contrast to health center visits “for my heart” or “for my diabetes,” these groups are “for me.” While there is no specific agenda to promote self-confidence and efficacy, participants note that they understand more about their health and their illnesses and are less afraid to ask questions of their providers. Providers comment on their patients’ self-confidence and assertiveness. They perceive that patients’ participation in the group has provided positive opportunities for social contact for their patients, and forged positive bonds with the health center. They also note that many patients who initially seemed to require formal mental health services in fact get their needs met by the Case Manager and the support groups. Any program that reduces the demand for scarce mental health services and cuts down on waste by reducing missed appointments is appreciated. What are the lessons so far? Patients and providers are frustrated by many of the same problems and have many of the same hopes for their encounters and relationship While it may be unrealistic for patients to get everything they need from their physician, their “medical home” can provide for a broad range of needs to improve their health and well-being by developing other roles and programs The role of Case Managers and other personnel may be more ideally suited to meet certain patient care needs than the physician role. This is fine if patients perceive that the roles are linked, and if the providers perceived that they are being unburdened of important, yet time-consuming tasks. Patients appreciate and benefit from groups. However, before proceeding into this new model of providing care, it would behoove practices to ask patients what they might want from groups. There are undoubtedly demographic differences that must be accounted for, but in any case, group visits should open new doors to enhance patient experience and outcomes and not replicate the problems that constrain individual patient visits. As I step back from my evaluator role into my more familiar role of primary care physician, I reflect upon my own practice and interactions with patients. I try to be approachable, non-intimidating. How many physicians can say that a patient gave them pajamas for Christmas? Over the years I have been called a variety of nicknames and diminutives, (just last week—doctorita…little doctor??) My patients must feel comfortable with me. But, if I am honest, I know that for the most part I set the agenda. If that weren’t the case, I wouldn’t be hearing from the diabetes educator or our diabetes community outreach worker that my patients don’t actually take their medications as prescribed. I am reminded that while I spend most of my time talking with patients, I may not spend quite enough of it actually listening. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Tue, 31 Aug 2010 15:45:40 GMT http://community.modernmedicine.com/_4-Key-Lessons-from-a-Minority-Health-Project/blog/2601417/33379.html bgottlieb 2010-08-31T15:40:30Z Primary Care Modern Medicine Community I don’t do a lot of research these days. However, for the past 2 years I have had the privilege to serve as the evaluator for a project to integrate mental health services and complementary health practices such as yoga, acupuncture, and relaxation techniques into primary care. The research “question” is whether this integration will result in better care for Latina women who have chronic diseases such as diabetes, asthma, and hypertension. The project is funded by the Federal Office of Minority Health and is located at 2 community health centers (not my own) that care for large numbers of Latino patients. In my role as evaluator, I periodically interview program participants (patients), mental health and medical providers. While not specifically focused on practice re-design, I am gaining insight that could help shape this process to better serve both patients and providers. Briefly, the project consists of placing a Case Manager in the adult primary care clinic of each health center. Each female Latina patient (meaning pretty much all of the women) is screened by the Case Manager for depression, other behavioral risks, and variety of potential concrete needs such as transportation, housing and food. Concrete needs are addressed by the Case Manager, and women who screen positive in any of the domains are assisted with mental health referrals, and informed about yoga classes, acupuncture, and stress-reduction groups. The Case Manager keeps track of the referrals and makes sure that the patients get to their appointments. She also does outreach to encourage them to participate in the various services offered by the program. It is a relatively simple intervention that seems to fit into the flow of primary care and relieves the providers of some of their most time-consuming tasks. We will eventually measure some clinically relevant endpoints—improvement in disease-specific measurements such as HgA1c levels, improvement in depression scores, systems improvements such as appointments kept, emergency room use, and patient and provider satisfaction. But for now, I am focusing on “softer” measures. What about this intervention “works?” What does this add to patient care that patients and providers feel has been missing? “I want to feel like a person, not a diagnosis.” For the most part, patients speak positively of their medical providers. However, they describe their visits as too short, too rushed, and too focused on the 1 or 2 issues that the providers choose to focus on. Patients do not feel invited to discuss their own questions, and often feel that if they raise questions that were not on their providers’ agenda, their questions are ignored. While the patients in the program each have a long list of problems, they tend to feel either bad or good in general, rather than disease-specific ways. They feel that doctors are focused on issues that have a specific answer—a medicine, a test, rather than the more undifferentiated ways in which patients experience their illnesses. In short, they feel like a problem list, a diagnosis. Providers feel the same. They are not satisfied with the way that reimbursement and other systemic factors shape their interactions with patients. They are aware of spending inadequate time listening to their patients and are frustrated by their inability to focus on prevention. Attempts to change the structure, including group visits, disease-specific programs such as diabetes groups, while providing some opportunities that are missing in the individual patient encounter, often replicate the same diagnosis-driven agenda that constrains standard patient visits. In contrast, the Case Manager truly delivers patient-centered care. Her agenda is entirely driven by the patient. She calls to remind patients of their appointments and group meetings. If they miss, she calls to find out why. Patients notice that. “I feel valued as a person.” While patients are aware that their doctors’ time is limited, they feel that the Case Manager can “take the time” to listen. She is “approachable,” “more like a friend.” The Case Manager conducts a variety of “stress reduction,” support groups. Unlike previous attempts to establish patient groups that failed due to lack of participation, these groups have been going for more than a year with very consistent and growing attendance. Previous groups included healthy snacks, a patient education topic, a talk by a provider, as do the current groups. What is different about these groups? What accounts for their success? Clearly the patients value the tools and services they gain from the groups—relaxation techniques, access to massage, yoga, and acupuncture. (What’s not to like??) Even though the groups do have educational and chronic disease-specific objectives (stress reduction, promotion of healthy eating, and physical activity), participants primarily perceive the groups as an opportunity to socialize with others, to learn that they are neither unique nor alone in their suffering. The lessons, the learning come as a natural by-product of the positive group process. In contrast to health center visits “for my heart” or “for my diabetes,” these groups are “for me.” While there is no specific agenda to promote self-confidence and efficacy, participants note that they understand more about their health and their illnesses and are less afraid to ask questions of their providers. Providers comment on their patients’ self-confidence and assertiveness. They perceive that patients’ participation in the group has provided positive opportunities for social contact for their patients, and forged positive bonds with the health center. They also note that many patients who initially seemed to require formal mental health services in fact get their needs met by the Case Manager and the support groups. Any program that reduces the demand for scarce mental health services and cuts down on waste by reducing missed appointments is appreciated. What are the lessons so far? Patients and providers are frustrated by many of the same problems and have many of the same hopes for their encounters and relationship While it may be unrealistic for patients to get everything they need from their physician, their “medical home” can provide for a broad range of needs to improve their health and well-being by developing other roles and programs The role of Case Managers and other personnel may be more ideally suited to meet certain patient care needs than the physician role. This is fine if patients perceive that the roles are linked, and if the providers perceived that they are being unburdened of important, yet time-consuming tasks. Patients appreciate and benefit from groups. However, before proceeding into this new model of providing care, it would behoove practices to ask patients what they might want from groups. There are undoubtedly demographic differences that must be accounted for, but in any case, group visits should open new doors to enhance patient experience and outcomes and not replicate the problems that constrain individual patient visits. As I step back from my evaluator role into my more familiar role of primary care physician, I reflect upon my own practice and interactions with patients. I try to be approachable, non-intimidating. How many physicians can say that a patient gave them pajamas for Christmas? Over the years I have been called a variety of nicknames and diminutives, (just last week—doctorita…little doctor??) My patients must feel comfortable with me. But, if I am honest, I know that for the most part I set the agenda. If that weren’t the case, I wouldn’t be hearing from the diabetes educator or our diabetes community outreach worker that my patients don’t actually take their medications as prescribed. I am reminded that while I spend most of my time talking with patients, I may not spend quite enough of it actually listening. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] complementary medicine, medical home, minority health, primary care nonadult false 4 Key Lessons from a Minority Health Project text blog complementary medicine,medical home,minority health,primary care 372 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 2601417 2771822 Member 0 http://community.modernmedicine.com/_Cancer-and-Diabetes/blog/2535306/33379.html Since the beginning of the year I have diagnosed 8 new cases of breast cancer. All of these women have diabetes except for the 34-year-old, although even she has a related state of insulin resistance -polycystic ovarian syndrome. Clearly, since I work in a health center that serves large numbers of minorities, I can expect to have a high prevalence of diabetes in my patient population…not to mention working almost anywhere in the 21st century, in an epidemic of obesity. Are there simply independently high rates of both diabetes and cancer? Or, is there a relationship between cancer and diabetes? Sitting at the top of my neglected must-read pile was an article that posed this question in a more rigorous manner and provided me with some food for thought.1 In December 2009 the American Diabetes Association (ADA) and the American Cancer Society (ACS) convened a consensus development conference to address this relationship. The writing group was charged with developing a consensus report to address the following questions: Is there a meaningful association between diabetes and cancer incidence or prognosis? What risk factors are common to both diabetes and cancer? What are possible biologic links between diabetes and cancer risk? Do diabetes treatments influence the risk of cancer or cancer prognosis? While the report does not represent the official position of either the ADA or the ACS, it is based on a series of presentations by experts during the December 2009 gathering, as well as a review of the evidence. It is a useful synthesis of what is known and what questions remain. As for the association between diabetes and cancer, the authors point out that after several decades of conflicting evidence, it appears that “cancer and diabetes are diagnosed within the same individual more frequently than would be expected by chance, even after adjusting for age.” The relative risk of cancer associated with diabetes, primarily type 2, varies by site from > 2-fold for liver, pancreas, and endometrium, to 1.2-1.5-fold for colorectal, breast, and bladder. There is no apparent association between type 2 diabetes and lung cancer; for kidney cancer and non-Hodgkin’s lymphoma, the data is inconclusive.  The association between type 1 diabetes and cancer has not been well-studied, and it appears that diabetes is associated with a lower risk of only prostate cancer. The effect of diabetes on cancer mortality is difficult to establish, since diabetes is associated with excess age-adjusted mortality with or without a cancer diagnosis. Of relevance to my patients, the authors refer to a study that indicates that 5-year mortality from breast cancer was increased among those with co-existing diabetes compared to those without (hazard ratio 1.39).2 Cancer and diabetes share many risk factors: age, race/ethnicity, obesity, diet, physical activity, and tobacco. Apart from childhood cancers, the incidence of the majority of cancers increases with age, with highest rates among those aged 55 and older. Although increasingly prevalent among children and adolescents, the incidence of type 2 diabetes also increases with age, with highest rates among those aged 60 and older. In the United States, cancer incidence and mortality are greater among African Americans compared to all other groups. In the United States, type 2 diabetes incidence, morbidity, and mortality are greatest among all non-white groups compared to non-Hispanic whites. In both cancer and diabetes, race and ethnicity likely reflect a combination of socially determined risks, including environmental, socioeconomic, and behavioral factors in combination genetic factors. Overweight and obesity are both associated with multiple cancers compared to body mass index less than 25—including postmenopausal breast cancer, colorectal, endometrial, pancreatic, and adenocarcinoma of the esophagus, kidney, gallbladder, and liver. Obesity seems to increase mortality for some cancers, including prostate. An intriguing phenomenon is the association of weight gain during adulthood with the development of certain cancers such as breast cancer. This is relevant to my patients, since Latina women tend to gain and retain weight with each pregnancy. If weight loss was associated with reduced risk, the causal relationship between obesity and disease incidence and outcome would be strengthened. The association between weight loss and reduced incidence of and morbidity from type 2 diabetes is clear. The impact of weight loss on cancer is difficult to establish because a large amount of weight loss is needed to observe an effect, and large weight loss can also be a result of cancer.  Several studies demonstrate that women who underwent bariatric surgery had lower rates of cancer, primarily because of substantially reduced risk of breast and endometrial cancer. To date, comparable studies in men do not demonstrate an effect in lowering cancer risk.3 There is overlap in the type of diet that seems to be associated with lower risk for cancer and lower risk for diabetes, including those that are low in red and processed meat, high in vegetables, fruits, whole grains. However, like most of what we believe about nutrition, the evidence is largely based on observational studies, with relatively few randomized, controlled clinical trials to support the claims. Both observational and randomized clinical trials support the role of physical activity in preventing and controlling type 2 diabetes. Observational studies support the role of physical activity in preventing certain cancers, namely colon, and postmenopausal breast and endometrial cancers, but clinical trials are lacking. The association between tobacco exposure and cancers is well-established, including trachea, bronchus, lung, larynx, upper digestive tract, bladder, kidney, pancreas, leukemia, liver, stomach, and cervix. Tobacco is also a risk factor for the development of type 2 diabetes and for accelerating its adverse consequences. Even moderate alcohol increases the risk of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon, rectum, and breast. Similarly, excess consumption is a risk factor for diabetes. However moderate consumption may be protective. The authors explore several potential links between diabetes and cancer, including hyperinsulinemia, hyperglycemia, and chronic inflammation. Insulin may stimulate all cell growth and proliferation, including that of neoplastic cells, and hyperinsulinemia may promote carcinogenesis through several pathways. In vitro and human studies suggest a role for insulin and insulin receptors in breast cancer risk and outcome. Insulin receptors have been identified in various cancers, including breast cancer cells, and may be a marker for specific cell phenotypes. However, as with inflammatory cytokines and circulating hyperglycemia, the relationship between circulating insulin, the density of insulin receptors at the cellular level, and other growth factors is complex and not yet clarified. What about diabetes treatments? There is intriguing evidence that metformin inhibits cell proliferation, including tumor cells. The authors cite in vivo and human studies that suggest that metformin may be associated with a reduced risk for cancer as well as reduced cancer mortality. On the other hand, there is some evidence that exogenous insulin and insulin analogs may be associated with an increased risk of cancer. However, the evidence is inconclusive and requires further study. Observational studies have had multiple confounders, and RCTs were designed to look at cardiovascular outcomes and were not powered to evaluate the more rare cancer outcomes. What did I learn from this review? It does seem that there are plausible links between type 2 diabetes and certain cancers, and that the two broad categories of disease may share multiple risk factors. There are intriguing, plausible but inconclusive studies that define the potential causal pathways between diabetes and neoplastic processes, as well as between specific diabetes medications and neoplasia. The authors conclude, and I agree, that “many research questions remain.” In the United States and worldwide, cancer follows cardiovascular disease as the second leading cause of death. For Latinos, diabetes is a major contributor to cardiovascular morbidity and mortality. However, at least among my patients, emotional truth trumps epidemiologic truth. My patients fear cancer. Especially breast cancer.  The good news and the bad news is that there is considerable overlap among the major risk factors for cancer as well as cardiovascular disease and diabetes. The bad news first: Since obesity and physical inactivity are epidemic, and tobacco and alcohol use are prevalent, I will probably see a lot of cancer and diabetes, separately and together, disproportionately so among my socio-economically vulnerable patients.  Now the good news: The majority of these risk factors are modifiable, even if the evidence base for how to do so is less solid. I can use my patients’ intrinsic motivation to prevent cancer—not a bad motivation, after all—to reduce their risk for a whole group of killers. References 1. Giovannucci E, Harlan DM, Acher MC, et al, Diabetes and cancer: A consensus report. CA Cancer J Clin. 2010; 60:207-221. 2. Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin KR, Hux JE. The impact of diabetes on survival following breast cancer. Breast Cancer Res Treat. 2008;109: 389-395. 3. Renehan AG. Bariatric surgery, weight reduction and cancer prevention. Lancet Oncol. 2009;10:640-641. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Since the beginning of the year I have diagnosed 8 new cases of breast cancer. All of these women have diabetes except for the 34-year-old, although even she has a related state of insulin resistance -polycystic ovarian syndrome. Clearly, since I work in a health center that serves large numbers of minorities, I can expect to have a high prevalence of diabetes in my patient population…not to mention working almost anywhere in the 21st century, in an epidemic of obesity. Are there simply independently high rates of both diabetes and cancer? Or, is there a relationship between cancer and diabetes? Sitting at the top of my neglected must-read pile was an article that posed this question in a more rigorous manner and provided me with some food for thought.1 In December 2009 the American Diabetes Association (ADA) and the American Cancer Society (ACS) convened a consensus development conference to address this relationship. The writing group was charged with developing a consensus report to address the following questions: Is there a meaningful association between diabetes and cancer incidence or prognosis? What risk factors are common to both diabetes and cancer? What are possible biologic links between diabetes and cancer risk? Do diabetes treatments influence the risk of cancer or cancer prognosis? While the report does not represent the official position of either the ADA or the ACS, it is based on a series of presentations by experts during the December 2009 gathering, as well as a review of the evidence. It is a useful synthesis of what is known and what questions remain. As for the association between diabetes and cancer, the authors point out that after several decades of conflicting evidence, it appears that “cancer and diabetes are diagnosed within the same individual more frequently than would be expected by chance, even after adjusting for age.” The relative risk of cancer associated with diabetes, primarily type 2, varies by site from > 2-fold for liver, pancreas, and endometrium, to 1.2-1.5-fold for colorectal, breast, and bladder. There is no apparent association between type 2 diabetes and lung cancer; for kidney cancer and non-Hodgkin’s lymphoma, the data is inconclusive.  The association between type 1 diabetes and cancer has not been well-studied, and it appears that diabetes is associated with a lower risk of only prostate cancer. The effect of diabetes on cancer mortality is difficult to establish, since diabetes is associated with excess age-adjusted mortality with or without a cancer diagnosis. Of relevance to my patients, the authors refer to a study that indicates that 5-year mortality from breast cancer was increased among those with co-existing diabetes compared to those without (hazard ratio 1.39).2 Cancer and diabetes share many risk factors: age, race/ethnicity, obesity, diet, physical activity, and tobacco. Apart from childhood cancers, the incidence of the majority of cancers increases with age, with highest rates among those aged 55 and older. Although increasingly prevalent among children and adolescents, the incidence of type 2 diabetes also increases with age, with highest rates among those aged 60 and older. In the United States, cancer incidence and mortality are greater among African Americans compared to all other groups. In the United States, type 2 diabetes incidence, morbidity, and mortality are greatest among all non-white groups compared to non-Hispanic whites. In both cancer and diabetes, race and ethnicity likely reflect a combination of socially determined risks, including environmental, socioeconomic, and behavioral factors in combination genetic factors. Overweight and obesity are both associated with multiple cancers compared to body mass index less than 25—including postmenopausal breast cancer, colorectal, endometrial, pancreatic, and adenocarcinoma of the esophagus, kidney, gallbladder, and liver. Obesity seems to increase mortality for some cancers, including prostate. An intriguing phenomenon is the association of weight gain during adulthood with the development of certain cancers such as breast cancer. This is relevant to my patients, since Latina women tend to gain and retain weight with each pregnancy. If weight loss was associated with reduced risk, the causal relationship between obesity and disease incidence and outcome would be strengthened. The association between weight loss and reduced incidence of and morbidity from type 2 diabetes is clear. The impact of weight loss on cancer is difficult to establish because a large amount of weight loss is needed to observe an effect, and large weight loss can also be a result of cancer.  Several studies demonstrate that women who underwent bariatric surgery had lower rates of cancer, primarily because of substantially reduced risk of breast and endometrial cancer. To date, comparable studies in men do not demonstrate an effect in lowering cancer risk.3 There is overlap in the type of diet that seems to be associated with lower risk for cancer and lower risk for diabetes, including those that are low in red and processed meat, high in vegetables, fruits, whole grains. However, like most of what we believe about nutrition, the evidence is largely based on observational studies, with relatively few randomized, controlled clinical trials to support the claims. Both observational and randomized clinical trials support the role of physical activity in preventing and controlling type 2 diabetes. Observational studies support the role of physical activity in preventing certain cancers, namely colon, and postmenopausal breast and endometrial cancers, but clinical trials are lacking. The association between tobacco exposure and cancers is well-established, including trachea, bronchus, lung, larynx, upper digestive tract, bladder, kidney, pancreas, leukemia, liver, stomach, and cervix. Tobacco is also a risk factor for the development of type 2 diabetes and for accelerating its adverse consequences. Even moderate alcohol increases the risk of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon, rectum, and breast. Similarly, excess consumption is a risk factor for diabetes. However moderate consumption may be protective. The authors explore several potential links between diabetes and cancer, including hyperinsulinemia, hyperglycemia, and chronic inflammation. Insulin may stimulate all cell growth and proliferation, including that of neoplastic cells, and hyperinsulinemia may promote carcinogenesis through several pathways. In vitro and human studies suggest a role for insulin and insulin receptors in breast cancer risk and outcome. Insulin receptors have been identified in various cancers, including breast cancer cells, and may be a marker for specific cell phenotypes. However, as with inflammatory cytokines and circulating hyperglycemia, the relationship between circulating insulin, the density of insulin receptors at the cellular level, and other growth factors is complex and not yet clarified. What about diabetes treatments? There is intriguing evidence that metformin inhibits cell proliferation, including tumor cells. The authors cite in vivo and human studies that suggest that metformin may be associated with a reduced risk for cancer as well as reduced cancer mortality. On the other hand, there is some evidence that exogenous insulin and insulin analogs may be associated with an increased risk of cancer. However, the evidence is inconclusive and requires further study. Observational studies have had multiple confounders, and RCTs were designed to look at cardiovascular outcomes and were not powered to evaluate the more rare cancer outcomes. What did I learn from this review? It does seem that there are plausible links between type 2 diabetes and certain cancers, and that the two broad categories of disease may share multiple risk factors. There are intriguing, plausible but inconclusive studies that define the potential causal pathways between diabetes and neoplastic processes, as well as between specific diabetes medications and neoplasia. The authors conclude, and I agree, that “many research questions remain.” In the United States and worldwide, cancer follows cardiovascular disease as the second leading cause of death. For Latinos, diabetes is a major contributor to cardiovascular morbidity and mortality. However, at least among my patients, emotional truth trumps epidemiologic truth. My patients fear cancer. Especially breast cancer.  The good news and the bad news is that there is considerable overlap among the major risk factors for cancer as well as cardiovascular disease and diabetes. The bad news first: Since obesity and physical inactivity are epidemic, and tobacco and alcohol use are prevalent, I will probably see a lot of cancer and diabetes, separately and together, disproportionately so among my socio-economically vulnerable patients.  Now the good news: The majority of these risk factors are modifiable, even if the evidence base for how to do so is less solid. I can use my patients’ intrinsic motivation to prevent cancer—not a bad motivation, after all—to reduce their risk for a whole group of killers. References 1. Giovannucci E, Harlan DM, Acher MC, et al, Diabetes and cancer: A consensus report. CA Cancer J Clin. 2010; 60:207-221. 2. Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin KR, Hux JE. The impact of diabetes on survival following breast cancer. Breast Cancer Res Treat. 2008;109: 389-395. 3. Renehan AG. Bariatric surgery, weight reduction and cancer prevention. Lancet Oncol. 2009;10:640-641. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 06 Aug 2010 16:47:54 GMT http://community.modernmedicine.com/_Cancer-and-Diabetes/blog/2535306/33379.html bgottlieb 2010-08-06T16:46:08Z Oncology Modern Medicine Community Since the beginning of the year I have diagnosed 8 new cases of breast cancer. All of these women have diabetes except for the 34-year-old, although even she has a related state of insulin resistance -polycystic ovarian syndrome. Clearly, since I work in a health center that serves large numbers of minorities, I can expect to have a high prevalence of diabetes in my patient population…not to mention working almost anywhere in the 21st century, in an epidemic of obesity. Are there simply independently high rates of both diabetes and cancer? Or, is there a relationship between cancer and diabetes? Sitting at the top of my neglected must-read pile was an article that posed this question in a more rigorous manner and provided me with some food for thought.1 In December 2009 the American Diabetes Association (ADA) and the American Cancer Society (ACS) convened a consensus development conference to address this relationship. The writing group was charged with developing a consensus report to address the following questions: Is there a meaningful association between diabetes and cancer incidence or prognosis? What risk factors are common to both diabetes and cancer? What are possible biologic links between diabetes and cancer risk? Do diabetes treatments influence the risk of cancer or cancer prognosis? While the report does not represent the official position of either the ADA or the ACS, it is based on a series of presentations by experts during the December 2009 gathering, as well as a review of the evidence. It is a useful synthesis of what is known and what questions remain. As for the association between diabetes and cancer, the authors point out that after several decades of conflicting evidence, it appears that “cancer and diabetes are diagnosed within the same individual more frequently than would be expected by chance, even after adjusting for age.” The relative risk of cancer associated with diabetes, primarily type 2, varies by site from > 2-fold for liver, pancreas, and endometrium, to 1.2-1.5-fold for colorectal, breast, and bladder. There is no apparent association between type 2 diabetes and lung cancer; for kidney cancer and non-Hodgkin’s lymphoma, the data is inconclusive.  The association between type 1 diabetes and cancer has not been well-studied, and it appears that diabetes is associated with a lower risk of only prostate cancer. The effect of diabetes on cancer mortality is difficult to establish, since diabetes is associated with excess age-adjusted mortality with or without a cancer diagnosis. Of relevance to my patients, the authors refer to a study that indicates that 5-year mortality from breast cancer was increased among those with co-existing diabetes compared to those without (hazard ratio 1.39).2 Cancer and diabetes share many risk factors: age, race/ethnicity, obesity, diet, physical activity, and tobacco. Apart from childhood cancers, the incidence of the majority of cancers increases with age, with highest rates among those aged 55 and older. Although increasingly prevalent among children and adolescents, the incidence of type 2 diabetes also increases with age, with highest rates among those aged 60 and older. In the United States, cancer incidence and mortality are greater among African Americans compared to all other groups. In the United States, type 2 diabetes incidence, morbidity, and mortality are greatest among all non-white groups compared to non-Hispanic whites. In both cancer and diabetes, race and ethnicity likely reflect a combination of socially determined risks, including environmental, socioeconomic, and behavioral factors in combination genetic factors. Overweight and obesity are both associated with multiple cancers compared to body mass index less than 25—including postmenopausal breast cancer, colorectal, endometrial, pancreatic, and adenocarcinoma of the esophagus, kidney, gallbladder, and liver. Obesity seems to increase mortality for some cancers, including prostate. An intriguing phenomenon is the association of weight gain during adulthood with the development of certain cancers such as breast cancer. This is relevant to my patients, since Latina women tend to gain and retain weight with each pregnancy. If weight loss was associated with reduced risk, the causal relationship between obesity and disease incidence and outcome would be strengthened. The association between weight loss and reduced incidence of and morbidity from type 2 diabetes is clear. The impact of weight loss on cancer is difficult to establish because a large amount of weight loss is needed to observe an effect, and large weight loss can also be a result of cancer.  Several studies demonstrate that women who underwent bariatric surgery had lower rates of cancer, primarily because of substantially reduced risk of breast and endometrial cancer. To date, comparable studies in men do not demonstrate an effect in lowering cancer risk.3 There is overlap in the type of diet that seems to be associated with lower risk for cancer and lower risk for diabetes, including those that are low in red and processed meat, high in vegetables, fruits, whole grains. However, like most of what we believe about nutrition, the evidence is largely based on observational studies, with relatively few randomized, controlled clinical trials to support the claims. Both observational and randomized clinical trials support the role of physical activity in preventing and controlling type 2 diabetes. Observational studies support the role of physical activity in preventing certain cancers, namely colon, and postmenopausal breast and endometrial cancers, but clinical trials are lacking. The association between tobacco exposure and cancers is well-established, including trachea, bronchus, lung, larynx, upper digestive tract, bladder, kidney, pancreas, leukemia, liver, stomach, and cervix. Tobacco is also a risk factor for the development of type 2 diabetes and for accelerating its adverse consequences. Even moderate alcohol increases the risk of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon, rectum, and breast. Similarly, excess consumption is a risk factor for diabetes. However moderate consumption may be protective. The authors explore several potential links between diabetes and cancer, including hyperinsulinemia, hyperglycemia, and chronic inflammation. Insulin may stimulate all cell growth and proliferation, including that of neoplastic cells, and hyperinsulinemia may promote carcinogenesis through several pathways. In vitro and human studies suggest a role for insulin and insulin receptors in breast cancer risk and outcome. Insulin receptors have been identified in various cancers, including breast cancer cells, and may be a marker for specific cell phenotypes. However, as with inflammatory cytokines and circulating hyperglycemia, the relationship between circulating insulin, the density of insulin receptors at the cellular level, and other growth factors is complex and not yet clarified. What about diabetes treatments? There is intriguing evidence that metformin inhibits cell proliferation, including tumor cells. The authors cite in vivo and human studies that suggest that metformin may be associated with a reduced risk for cancer as well as reduced cancer mortality. On the other hand, there is some evidence that exogenous insulin and insulin analogs may be associated with an increased risk of cancer. However, the evidence is inconclusive and requires further study. Observational studies have had multiple confounders, and RCTs were designed to look at cardiovascular outcomes and were not powered to evaluate the more rare cancer outcomes. What did I learn from this review? It does seem that there are plausible links between type 2 diabetes and certain cancers, and that the two broad categories of disease may share multiple risk factors. There are intriguing, plausible but inconclusive studies that define the potential causal pathways between diabetes and neoplastic processes, as well as between specific diabetes medications and neoplasia. The authors conclude, and I agree, that “many research questions remain.” In the United States and worldwide, cancer follows cardiovascular disease as the second leading cause of death. For Latinos, diabetes is a major contributor to cardiovascular morbidity and mortality. However, at least among my patients, emotional truth trumps epidemiologic truth. My patients fear cancer. Especially breast cancer.  The good news and the bad news is that there is considerable overlap among the major risk factors for cancer as well as cardiovascular disease and diabetes. The bad news first: Since obesity and physical inactivity are epidemic, and tobacco and alcohol use are prevalent, I will probably see a lot of cancer and diabetes, separately and together, disproportionately so among my socio-economically vulnerable patients.  Now the good news: The majority of these risk factors are modifiable, even if the evidence base for how to do so is less solid. I can use my patients’ intrinsic motivation to prevent cancer—not a bad motivation, after all—to reduce their risk for a whole group of killers. References 1. Giovannucci E, Harlan DM, Acher MC, et al, Diabetes and cancer: A consensus report. CA Cancer J Clin. 2010; 60:207-221. 2. Lipscombe LL, Goodwin PJ, Zinman B, McLaughlin KR, Hux JE. The impact of diabetes on survival following breast cancer. Breast Cancer Res Treat. 2008;109: 389-395. 3. Renehan AG. Bariatric surgery, weight reduction and cancer prevention. Lancet Oncol. 2009;10:640-641. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] bariatric, cancer, diabetes, loss, obesity, oncology, surgery, weight nonadult false Cancer and Diabetes text blog bariatric,cancer,diabetes,loss,obesity,oncology,surgery,weight 360 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Oncology 0 2535306 2771822 Member 0 http://community.modernmedicine.com/_Water/blog/2425358/33379.html I have been going to the same community in rural Guatemala every year since 2000. I had always wanted to do work in an international setting. In 2000 I felt that my kids were old enough for me to be able to leave them for a few weeks. A colleague enticed me to visit San Lucas Toliman, a place that he had visited for the previous 15 years. He warned me: “Guatemala, it gets into your blood.” He meant that in the best possible way. He was right. And now, 10 years later, I have made friends in a small community on the shores of Lake Atitlan, in Guatemala’s western highlands, where the majority of the population is Maya and speaks Spanish as a second language. Over the years I have provided a lot of direct care during the weeks I am there and raised funds for basic medications and supplies. In recent years I have concentrated on building the skills of a dedicated group of health promoters who, unlike the short term visiting doctors are in their communities 52 weeks a year, year after year. I have prepared trainings on tuberculosis (a small but quite serious problem in the area), maternal health (Guatemala has among the highest rates of maternal and infant mortality in this hemisphere), and mental health (40 years of civil war, abductions, torture and mass slayings have a lasting impact on the mental health of a population.) My visits are usually in February. Okay, I’m not a saint. I take vacation time to make these trips, so I do want to be sure to go when the weather is nicer than it is in Boston. But this past trip was different. Hurricane Agatha hit Guatemala hard. A giant sink hole opened up in Guatemala City. Floods ravaged rural and urban areas throughout the country. At the same time, a large volcano 25 miles south of Guatemala City, Pacaya, erupted and spewed rocks and volcanic ash, grounding planes for many days and leaving a thick layer of soot in Guatemala City and surrounding communities. Many rural communities including San Lucas were hit hard by the storm. Mudslides and landslides followed. One small rural community I knew well, fortunately, one whose residents had been moved to a less geographically vulnerable area several years ago, was completely covered by mud, rocks the size of cars and trucks, huge tree trunks suddenly sprung loose from their roots. Within minutes the community was gone. An elderly couple who had refused to leave with their neighbors several years ago, again refused to leave when the storm hit. They were buried alive in their home. Only a church is left standing. In contrast to the rubble and debris, connected at odd angles, the church’s pale yellow walls stand vertical, stunted, mud up to its window ledges. In San Lucas proper, residents of a low-lying neighborhood at the base of a volcano heard the rains beating on their laminated metal roofs. Soon they heard the sounds of rushing water as small gullies swelled and became small rivers, overflowing their banks and flooding into their homes. Most knew that it was time to get out, and grabbed a few possessions and fled to the main streets, the large church, school buildings. A few didn’t leave and were swept into the rubble. The homes of hundreds were damaged or destroyed. Several residents who didn’t believe in banks lost their life savings--stashed somewhere in their homes, now buried in the mud? Floated off into Lake Atitlan? Miraculously fallen into the hands of looters? I knew I would have only a limited time to spend, but when I heard the news I knew I wanted to be there now. I felt that if I waited until my trip next February I would fail to understand something important about my friends’ lives. I knew that there would be a lot of physical illness, and I assumed that the loss of life, devastation of communities, farms, livelihood, and the legitimate fear of further destruction--this is only the beginning of this year’s rainy season--would have a huge emotional impact. Making the time to visit now, during the crisis, felt like I would be making a deeper pact of friendship than I have so far, by visiting only on my own schedule. Pricking my own finger and placing it against theirs. Sixteen small communities surround San Lucas proper. Most communities had no safe water for the days of the heaviest rains from Agatha. Four communities are still, one month later, without safe water. The mudslides and landslides cut through precious water lines. Infrastructure is sparse; there are no back-up lines. The main road was damaged by the storm: bridges sank, rivers flooded, boulders shifted and rolled onto the pavement. The roads were not passable during the week following the storm – thus cutting the communities off from necessities. On any given day the road might be shut down, depending on how heavy the rains are. After weeks of drinking boiled rainwater, unfiltered run off from swollen rivers, water collected from roof tops and drains, adults and children have diarrhea. How quickly I begin to catch the nuances as patients describe symptoms in their expressive Kaqchiquel, punctuated by grand flourishes of hands and dramatic facial expressions: This must be Giardia, this bacteria, could this be typhoid? During previous visits, I found it challenging to ask about symptoms of mental distress. People were typically more comfortable reporting physical symptoms, including headaches, body pain, and occasionally certain specific “culture-bound” symptoms of distress--severe fright, panic, temporary paralysis of parts of their bodies, sudden weakness, fits of screaming. I wondered if it would be difficult to ask people about their mental health in the context of the mudslides. Would I have to use some sort of clinical tool to assess posttraumatic stress symptoms? As it turns out, the opposite was true. It was as if they had memorized a checklist and were reciting it back to me: nightmares, intrusive thoughts, difficulty concentrating, feeling of doom, panic; loss of faith, anger, and irritability…the list goes on. PTSD is widespread, even among the health promoters, who have experienced their own trauma directly, and indirectly the trauma of their neighbors and friends for whom they are the caretakers. Water. So many times during my week in Guatemala I thought of that word. Water: your best friend; your worst nightmare. The rains come. Water hits the fine volcanic soil that covers the volcanoes, the soil no longer held down by tree roots, because the trees have long ago been cut down for fuel, mixes with the water as it runs down – first in a fine trickle, then becoming streams of mud that gather into rivers. The sides of the volcanoes are scarred by deep gouges of mud that carried off trees and rocks. The rivers foam and roil; their colors do not reflect the sky, rather the gouges on the volcanoes – deep grey, brown, ochre. Water. R, a health promoter in one of the communities without water, has had diarrhea and cramping abdominal pain for days. She drinks orange soda because there is no bottled water. She doesn’t trust the water that has been boiled – that is probably what made her sick in the first place. She has already dispensed the medication in her small medical kit to her sick neighbors. There is none left for her. Water. A group of women and girls clambered onto the pick-up truck with large bundles of clothing. The bundles are heavy, and leave wet marks on the floor of the truck. They jump off the truck at the next community and head almost straight up the volcano to their homes – another community without water – not even enough for laundry, so they traveled with the week’s clothes to the river below. The water isn’t clean, but as it rushes through the rocks it dislodges some of the clothing’s’ accumulated dirt. Water. Just 3 weeks postpartum, febrile, short of breath, S seems to have pneumonia in the upper and lower lobes of her right lung. Her legs are swollen. Her pulse is thin and thready. Her blood pressure is low, her lips are parched. Dehydrated and edematous. Water: Her best friend, her worst enemy. I saw some very sick people, and, hopefully, helped steer their care in a good direction. I comforted a few people, and, I hope, left the health promoters with greater confidence in their ability to in turn provide support and comfort to their neighbors and communities. Beyond my own modest contributions, I witnessed the strength and resilience of people who have endured greater hardships than I can imagine. Although I arrived with 2 suitcases and left with one, as is always the case, I left with more than I came with. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I have been going to the same community in rural Guatemala every year since 2000. I had always wanted to do work in an international setting. In 2000 I felt that my kids were old enough for me to be able to leave them for a few weeks. A colleague enticed me to visit San Lucas Toliman, a place that he had visited for the previous 15 years. He warned me: “Guatemala, it gets into your blood.” He meant that in the best possible way. He was right. And now, 10 years later, I have made friends in a small community on the shores of Lake Atitlan, in Guatemala’s western highlands, where the majority of the population is Maya and speaks Spanish as a second language. Over the years I have provided a lot of direct care during the weeks I am there and raised funds for basic medications and supplies. In recent years I have concentrated on building the skills of a dedicated group of health promoters who, unlike the short term visiting doctors are in their communities 52 weeks a year, year after year. I have prepared trainings on tuberculosis (a small but quite serious problem in the area), maternal health (Guatemala has among the highest rates of maternal and infant mortality in this hemisphere), and mental health (40 years of civil war, abductions, torture and mass slayings have a lasting impact on the mental health of a population.) My visits are usually in February. Okay, I’m not a saint. I take vacation time to make these trips, so I do want to be sure to go when the weather is nicer than it is in Boston. But this past trip was different. Hurricane Agatha hit Guatemala hard. A giant sink hole opened up in Guatemala City. Floods ravaged rural and urban areas throughout the country. At the same time, a large volcano 25 miles south of Guatemala City, Pacaya, erupted and spewed rocks and volcanic ash, grounding planes for many days and leaving a thick layer of soot in Guatemala City and surrounding communities. Many rural communities including San Lucas were hit hard by the storm. Mudslides and landslides followed. One small rural community I knew well, fortunately, one whose residents had been moved to a less geographically vulnerable area several years ago, was completely covered by mud, rocks the size of cars and trucks, huge tree trunks suddenly sprung loose from their roots. Within minutes the community was gone. An elderly couple who had refused to leave with their neighbors several years ago, again refused to leave when the storm hit. They were buried alive in their home. Only a church is left standing. In contrast to the rubble and debris, connected at odd angles, the church’s pale yellow walls stand vertical, stunted, mud up to its window ledges. In San Lucas proper, residents of a low-lying neighborhood at the base of a volcano heard the rains beating on their laminated metal roofs. Soon they heard the sounds of rushing water as small gullies swelled and became small rivers, overflowing their banks and flooding into their homes. Most knew that it was time to get out, and grabbed a few possessions and fled to the main streets, the large church, school buildings. A few didn’t leave and were swept into the rubble. The homes of hundreds were damaged or destroyed. Several residents who didn’t believe in banks lost their life savings--stashed somewhere in their homes, now buried in the mud? Floated off into Lake Atitlan? Miraculously fallen into the hands of looters? I knew I would have only a limited time to spend, but when I heard the news I knew I wanted to be there now. I felt that if I waited until my trip next February I would fail to understand something important about my friends’ lives. I knew that there would be a lot of physical illness, and I assumed that the loss of life, devastation of communities, farms, livelihood, and the legitimate fear of further destruction--this is only the beginning of this year’s rainy season--would have a huge emotional impact. Making the time to visit now, during the crisis, felt like I would be making a deeper pact of friendship than I have so far, by visiting only on my own schedule. Pricking my own finger and placing it against theirs. Sixteen small communities surround San Lucas proper. Most communities had no safe water for the days of the heaviest rains from Agatha. Four communities are still, one month later, without safe water. The mudslides and landslides cut through precious water lines. Infrastructure is sparse; there are no back-up lines. The main road was damaged by the storm: bridges sank, rivers flooded, boulders shifted and rolled onto the pavement. The roads were not passable during the week following the storm – thus cutting the communities off from necessities. On any given day the road might be shut down, depending on how heavy the rains are. After weeks of drinking boiled rainwater, unfiltered run off from swollen rivers, water collected from roof tops and drains, adults and children have diarrhea. How quickly I begin to catch the nuances as patients describe symptoms in their expressive Kaqchiquel, punctuated by grand flourishes of hands and dramatic facial expressions: This must be Giardia, this bacteria, could this be typhoid? During previous visits, I found it challenging to ask about symptoms of mental distress. People were typically more comfortable reporting physical symptoms, including headaches, body pain, and occasionally certain specific “culture-bound” symptoms of distress--severe fright, panic, temporary paralysis of parts of their bodies, sudden weakness, fits of screaming. I wondered if it would be difficult to ask people about their mental health in the context of the mudslides. Would I have to use some sort of clinical tool to assess posttraumatic stress symptoms? As it turns out, the opposite was true. It was as if they had memorized a checklist and were reciting it back to me: nightmares, intrusive thoughts, difficulty concentrating, feeling of doom, panic; loss of faith, anger, and irritability…the list goes on. PTSD is widespread, even among the health promoters, who have experienced their own trauma directly, and indirectly the trauma of their neighbors and friends for whom they are the caretakers. Water. So many times during my week in Guatemala I thought of that word. Water: your best friend; your worst nightmare. The rains come. Water hits the fine volcanic soil that covers the volcanoes, the soil no longer held down by tree roots, because the trees have long ago been cut down for fuel, mixes with the water as it runs down – first in a fine trickle, then becoming streams of mud that gather into rivers. The sides of the volcanoes are scarred by deep gouges of mud that carried off trees and rocks. The rivers foam and roil; their colors do not reflect the sky, rather the gouges on the volcanoes – deep grey, brown, ochre. Water. R, a health promoter in one of the communities without water, has had diarrhea and cramping abdominal pain for days. She drinks orange soda because there is no bottled water. She doesn’t trust the water that has been boiled – that is probably what made her sick in the first place. She has already dispensed the medication in her small medical kit to her sick neighbors. There is none left for her. Water. A group of women and girls clambered onto the pick-up truck with large bundles of clothing. The bundles are heavy, and leave wet marks on the floor of the truck. They jump off the truck at the next community and head almost straight up the volcano to their homes – another community without water – not even enough for laundry, so they traveled with the week’s clothes to the river below. The water isn’t clean, but as it rushes through the rocks it dislodges some of the clothing’s’ accumulated dirt. Water. Just 3 weeks postpartum, febrile, short of breath, S seems to have pneumonia in the upper and lower lobes of her right lung. Her legs are swollen. Her pulse is thin and thready. Her blood pressure is low, her lips are parched. Dehydrated and edematous. Water: Her best friend, her worst enemy. I saw some very sick people, and, hopefully, helped steer their care in a good direction. I comforted a few people, and, I hope, left the health promoters with greater confidence in their ability to in turn provide support and comfort to their neighbors and communities. Beyond my own modest contributions, I witnessed the strength and resilience of people who have endured greater hardships than I can imagine. Although I arrived with 2 suitcases and left with one, as is always the case, I left with more than I came with. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Fri, 02 Jul 2010 14:27:18 GMT http://community.modernmedicine.com/_Water/blog/2425358/33379.html bgottlieb 2010-07-02T14:19:20Z Primary Care Modern Medicine Community I have been going to the same community in rural Guatemala every year since 2000. I had always wanted to do work in an international setting. In 2000 I felt that my kids were old enough for me to be able to leave them for a few weeks. A colleague enticed me to visit San Lucas Toliman, a place that he had visited for the previous 15 years. He warned me: “Guatemala, it gets into your blood.” He meant that in the best possible way. He was right. And now, 10 years later, I have made friends in a small community on the shores of Lake Atitlan, in Guatemala’s western highlands, where the majority of the population is Maya and speaks Spanish as a second language. Over the years I have provided a lot of direct care during the weeks I am there and raised funds for basic medications and supplies. In recent years I have concentrated on building the skills of a dedicated group of health promoters who, unlike the short term visiting doctors are in their communities 52 weeks a year, year after year. I have prepared trainings on tuberculosis (a small but quite serious problem in the area), maternal health (Guatemala has among the highest rates of maternal and infant mortality in this hemisphere), and mental health (40 years of civil war, abductions, torture and mass slayings have a lasting impact on the mental health of a population.) My visits are usually in February. Okay, I’m not a saint. I take vacation time to make these trips, so I do want to be sure to go when the weather is nicer than it is in Boston. But this past trip was different. Hurricane Agatha hit Guatemala hard. A giant sink hole opened up in Guatemala City. Floods ravaged rural and urban areas throughout the country. At the same time, a large volcano 25 miles south of Guatemala City, Pacaya, erupted and spewed rocks and volcanic ash, grounding planes for many days and leaving a thick layer of soot in Guatemala City and surrounding communities. Many rural communities including San Lucas were hit hard by the storm. Mudslides and landslides followed. One small rural community I knew well, fortunately, one whose residents had been moved to a less geographically vulnerable area several years ago, was completely covered by mud, rocks the size of cars and trucks, huge tree trunks suddenly sprung loose from their roots. Within minutes the community was gone. An elderly couple who had refused to leave with their neighbors several years ago, again refused to leave when the storm hit. They were buried alive in their home. Only a church is left standing. In contrast to the rubble and debris, connected at odd angles, the church’s pale yellow walls stand vertical, stunted, mud up to its window ledges. In San Lucas proper, residents of a low-lying neighborhood at the base of a volcano heard the rains beating on their laminated metal roofs. Soon they heard the sounds of rushing water as small gullies swelled and became small rivers, overflowing their banks and flooding into their homes. Most knew that it was time to get out, and grabbed a few possessions and fled to the main streets, the large church, school buildings. A few didn’t leave and were swept into the rubble. The homes of hundreds were damaged or destroyed. Several residents who didn’t believe in banks lost their life savings--stashed somewhere in their homes, now buried in the mud? Floated off into Lake Atitlan? Miraculously fallen into the hands of looters? I knew I would have only a limited time to spend, but when I heard the news I knew I wanted to be there now. I felt that if I waited until my trip next February I would fail to understand something important about my friends’ lives. I knew that there would be a lot of physical illness, and I assumed that the loss of life, devastation of communities, farms, livelihood, and the legitimate fear of further destruction--this is only the beginning of this year’s rainy season--would have a huge emotional impact. Making the time to visit now, during the crisis, felt like I would be making a deeper pact of friendship than I have so far, by visiting only on my own schedule. Pricking my own finger and placing it against theirs. Sixteen small communities surround San Lucas proper. Most communities had no safe water for the days of the heaviest rains from Agatha. Four communities are still, one month later, without safe water. The mudslides and landslides cut through precious water lines. Infrastructure is sparse; there are no back-up lines. The main road was damaged by the storm: bridges sank, rivers flooded, boulders shifted and rolled onto the pavement. The roads were not passable during the week following the storm – thus cutting the communities off from necessities. On any given day the road might be shut down, depending on how heavy the rains are. After weeks of drinking boiled rainwater, unfiltered run off from swollen rivers, water collected from roof tops and drains, adults and children have diarrhea. How quickly I begin to catch the nuances as patients describe symptoms in their expressive Kaqchiquel, punctuated by grand flourishes of hands and dramatic facial expressions: This must be Giardia, this bacteria, could this be typhoid? During previous visits, I found it challenging to ask about symptoms of mental distress. People were typically more comfortable reporting physical symptoms, including headaches, body pain, and occasionally certain specific “culture-bound” symptoms of distress--severe fright, panic, temporary paralysis of parts of their bodies, sudden weakness, fits of screaming. I wondered if it would be difficult to ask people about their mental health in the context of the mudslides. Would I have to use some sort of clinical tool to assess posttraumatic stress symptoms? As it turns out, the opposite was true. It was as if they had memorized a checklist and were reciting it back to me: nightmares, intrusive thoughts, difficulty concentrating, feeling of doom, panic; loss of faith, anger, and irritability…the list goes on. PTSD is widespread, even among the health promoters, who have experienced their own trauma directly, and indirectly the trauma of their neighbors and friends for whom they are the caretakers. Water. So many times during my week in Guatemala I thought of that word. Water: your best friend; your worst nightmare. The rains come. Water hits the fine volcanic soil that covers the volcanoes, the soil no longer held down by tree roots, because the trees have long ago been cut down for fuel, mixes with the water as it runs down – first in a fine trickle, then becoming streams of mud that gather into rivers. The sides of the volcanoes are scarred by deep gouges of mud that carried off trees and rocks. The rivers foam and roil; their colors do not reflect the sky, rather the gouges on the volcanoes – deep grey, brown, ochre. Water. R, a health promoter in one of the communities without water, has had diarrhea and cramping abdominal pain for days. She drinks orange soda because there is no bottled water. She doesn’t trust the water that has been boiled – that is probably what made her sick in the first place. She has already dispensed the medication in her small medical kit to her sick neighbors. There is none left for her. Water. A group of women and girls clambered onto the pick-up truck with large bundles of clothing. The bundles are heavy, and leave wet marks on the floor of the truck. They jump off the truck at the next community and head almost straight up the volcano to their homes – another community without water – not even enough for laundry, so they traveled with the week’s clothes to the river below. The water isn’t clean, but as it rushes through the rocks it dislodges some of the clothing’s’ accumulated dirt. Water. Just 3 weeks postpartum, febrile, short of breath, S seems to have pneumonia in the upper and lower lobes of her right lung. Her legs are swollen. Her pulse is thin and thready. Her blood pressure is low, her lips are parched. Dehydrated and edematous. Water: Her best friend, her worst enemy. I saw some very sick people, and, hopefully, helped steer their care in a good direction. I comforted a few people, and, I hope, left the health promoters with greater confidence in their ability to in turn provide support and comfort to their neighbors and communities. Beyond my own modest contributions, I witnessed the strength and resilience of people who have endured greater hardships than I can imagine. Although I arrived with 2 suitcases and left with one, as is always the case, I left with more than I came with. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] guatemala, infections disease, maternal health, mental health, primary care nonadult false Water text blog guatemala,infections disease,maternal health,mental health,primary care 369 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 2425358 2771822 Member 0 http://community.modernmedicine.com/_Why-Is-There-So-Much-Vitamin-B12-Deficiency/blog/2408502/33379.html Is it my imagination, or does it seem like every other patient has vitamin B12 deficiency? Is it because my patients, unlike myself, are getting older? Are there other factors to consider?As humans age the risk of developing a vitamin B12 deficiency increases. Andres et al, report that more than 20% of adults 65 and older are deficient in this nutrient.1 I have been taught to attribute this to poor absorption due to factors in the stomach, the small intestine, or both. We are all familiar with the consequences of B12 deficiency to the hematologic and neurologic systems; every medical student memorizes the pathways that lead to macrocytosis, neuropathies, and spinal cord degeneration. There is increasing evidence that B12 is a key piece of other common pathophysiologic puzzles including atherosclerosis and dementia.2 Vitamin B12 deficiency contributes to common psychiatric disorders including PTSD, panic disorder, depression, and obsessive compulsive disorders.3,4 Vitamin B12 is involved in the humoral immune response, and low levels have been associated with an impaired response to pneumococcal vaccine.5 It does seem that B12 deficiency is at least in part a phenomenon of “normal aging.” There are age-related changes in the stomach that reduce the availability of intrinsic factor. One might also argue that age alone can change the motility of the intestines, thereby altering the microflora, leading to poor absorption through the intestinal wall. However, the high prevalence of this nutritional deficiency among younger individuals suggests that there are other factors. For example, Mclean et al found high rates of vitamin B12 deficiency among Kenyan school children6; others have documented high rates of vitamin B12 deficiency throughout Africa and Asia, and among immigrant and refugee populations in the developed world who come from areas where this deficiency is endemic.7-9 Clearly diets that are deficient in animal-based foods--either because of religious or cultural beliefs or poverty--are known to be associated with vitamin B12 deficiency. Worldwide, several common infections are also associated with vitamin B12 deficiency. Chronic infection with Helicobacter pylori can lead to gastric atrophy, reduction of parietal cells and intrinsic factor, and impaired absorption of vitamin B12.10 Intestinal parasites, including Giardia lamblia can lead to chronic malabsorption of many nutrients, including vitamin B12.7 These infections are unfortunately more common in parts of the developing world where diets are marginal in animal-based foods, thus increasing the vulnerability of these populations to vitamin B12 deficiency. Some of the things we do as physicians contribute to the problem. There has been recent attention to the association between vitamin B12 deficiency and commonly prescribed medications, including H2 antagonists, proton pump inhibitors (PPIs), and now metformin.11-15 When I think about how many prescriptions I write in a day for H2-blockers and PPIs, and the epidemic of obesity and diabetes, I have to reckon with the likelihood that I will be responsible for vitamin B12 deficiency (or already have been) for a significant number of patients. Sturtzel et al call attention to a more obscure possibility in their compelling, although small study, of frail elderly patients in a geriatric home.16 Patients were randomized to an intervention group that received 5.2 g/d of oat bran mixed into their food, and a control group. Both groups were fed the standard diet of the facility, were followed clinically for constipation, and treated with laxatives as indicated. Baseline laxative use and serum vitamin B12 and B6, and folic acid were the same. After 12 weeks, vitamin B6 and folic acid levels were unchanged. However, laxative use was reduced by 59% in the intervention group and only 8% in the control group, a difference that was statistically significant (P<.001). Vitamin B12 levels decreased significantly in the control group (P<.05), but showed no significant decrease in the intervention group (P<.05). The authors point out that physicians often treat constipation in the elderly without regard to potential consequences to the microflora of the intestines. Selecting a regimen for preventing constipation, or a treatment that does not alter the microflora, may preserve normal levels of vitamin B12 in this vulnerable population.   Although the consequences of B12 deficiency can be permanent, in many cases they are reversible over time. Many of the medication-induced causes of B12 deficiency are also reversible over time. It is up to us to have a heightened awareness of the possibility of B12 deficiency--to identify it early and treat before consequences develop. Equally important is to prevent its development in the first place. Here is my “note to self”: •    Ask a good dietary history. This is especially true of vulnerable groups--the elderly, immigrants, and refugees, the poor. (Also women of childbearing age, which is a whole discussion unto itself.) •    Test for H pylori—particularly among patients who come from areas of the world where this infection is endemic. Think about H pylori when a patient has vitamin B12 deficiency. •    Think about intestinal parasites, and test when appropriate. If a patient seems to have been infected chronically, consider checking a B12 level. •    Monitor B12 levels regularly when patients take H2 antagonists, PPIs, and metformin for extended periods of time. •    Since short term use of H2 antagonists and PPIs does not seem to cause B12 deficiency, use these medications carefully and for the shortest amount of time. •    Remember that preventing constipation is better than treating it once it develops.•    Remember that all medications can have consequences, particularly if they are used on a regular basis. Consider the mechanism of action of commonly used medications such as laxatives. Choose medications that are least likely to alter the body’s fragile microsystems, especially among the frail elderly. •    Finally, review all medications regularly, and discontinue them when they are no longer indicated. References 1. Andres E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption  in elderly patients: clinical manifestations and treatment. Am J Med. 2005; 118:1154-1159. 2. Seshadri S, Beiser A, Selhub C,  et al. Plasma homocysteine as a risk factor for dementia and Alzheimer’s disease. N Engl J Med. 2002;346:476-483. 3. Guzelcan Y, van Loon P. Vitamin B12 status in patients of Turkish and Dutch descent with depression: a comparative cross-sectional study. Ann Gen Psychiatry. 2009; 8:18. 4. Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharmacol. 2005;19:59-65. 5. Fata F, Herzlich B, Shiffman G, et al. Impaired antibody responses to pneumococcal polysaccharide in elderly patients with low serum vitamin B12 levels. Ann Intern Med. 1996;124:299-304. 6. McLean E, Allen L, Neumann C, et al. Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods. J Nutr. 2007; 137:676-682. 7. Stabler S, Allen R. Vitamin B12 deficiency as a world-wide problem. Annu Rev Nutr. 2004;24:299-326. 8. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010;29(1):87-99. 9. Benson J, Maldari T, Turnbull T. Vitamin B12 deficiency: why refugee patients are at high risk. Australian Family Physician. 2010;39(4): 215-217. 10. Kaptan K, Beyan C, Ural A, et al. Helicobacter pylori: is it a novel causative agent in vitamin B12 deficiency? Arch Int Med. 2000;160:1349-1353. 11. Ruscin JM, Page RL, Valuck RJ. Vitamin B (12) deficiency associated with histamine (2)-receptor antagonists and a proton-pump inhibitor. Ann Pharmacother. 2002:36(5):812-816. 12. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010; 29(1):87-99. 13. Valuck RJ, Tuscin JM. A case-control study on adverse effects: H-2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol. 2004;57(4):422-428. 14. Ting R, Sceto C, Chan M, et al. Risk factor of vitamin B12 deficiency in patients receiving metformin. Arch Int Med. 2006;166:1975-1979. 15. deJager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ. 2010;340:c 2181. 16. Sturtzel B, Dietrich A, Wagner K-H et al. The status of vitamins B6, B12, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber. The Journal of Health, Nutrition & Aging. 2010;14:219-223. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.[Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]   Is it my imagination, or does it seem like every other patient has vitamin B12 deficiency? Is it because my patients, unlike myself, are getting older? Are there other factors to consider?As humans age the risk of developing a vitamin B12 deficiency increases. Andres et al, report that more than 20% of adults 65 and older are deficient in this nutrient.1 I have been taught to attribute this to poor absorption due to factors in the stomach, the small intestine, or both. We are all familiar with the consequences of B12 deficiency to the hematologic and neurologic systems; every medical student memorizes the pathways that lead to macrocytosis, neuropathies, and spinal cord degeneration. There is increasing evidence that B12 is a key piece of other common pathophysiologic puzzles including atherosclerosis and dementia.2 Vitamin B12 deficiency contributes to common psychiatric disorders including PTSD, panic disorder, depression, and obsessive compulsive disorders.3,4 Vitamin B12 is involved in the humoral immune response, and low levels have been associated with an impaired response to pneumococcal vaccine.5 It does seem that B12 deficiency is at least in part a phenomenon of “normal aging.” There are age-related changes in the stomach that reduce the availability of intrinsic factor. One might also argue that age alone can change the motility of the intestines, thereby altering the microflora, leading to poor absorption through the intestinal wall. However, the high prevalence of this nutritional deficiency among younger individuals suggests that there are other factors. For example, Mclean et al found high rates of vitamin B12 deficiency among Kenyan school children6; others have documented high rates of vitamin B12 deficiency throughout Africa and Asia, and among immigrant and refugee populations in the developed world who come from areas where this deficiency is endemic.7-9 Clearly diets that are deficient in animal-based foods--either because of religious or cultural beliefs or poverty--are known to be associated with vitamin B12 deficiency. Worldwide, several common infections are also associated with vitamin B12 deficiency. Chronic infection with Helicobacter pylori can lead to gastric atrophy, reduction of parietal cells and intrinsic factor, and impaired absorption of vitamin B12.10 Intestinal parasites, including Giardia lamblia can lead to chronic malabsorption of many nutrients, including vitamin B12.7 These infections are unfortunately more common in parts of the developing world where diets are marginal in animal-based foods, thus increasing the vulnerability of these populations to vitamin B12 deficiency. Some of the things we do as physicians contribute to the problem. There has been recent attention to the association between vitamin B12 deficiency and commonly prescribed medications, including H2 antagonists, proton pump inhibitors (PPIs), and now metformin.11-15 When I think about how many prescriptions I write in a day for H2-blockers and PPIs, and the epidemic of obesity and diabetes, I have to reckon with the likelihood that I will be responsible for vitamin B12 deficiency (or already have been) for a significant number of patients. Sturtzel et al call attention to a more obscure possibility in their compelling, although small study, of frail elderly patients in a geriatric home.16 Patients were randomized to an intervention group that received 5.2 g/d of oat bran mixed into their food, and a control group. Both groups were fed the standard diet of the facility, were followed clinically for constipation, and treated with laxatives as indicated. Baseline laxative use and serum vitamin B12 and B6, and folic acid were the same. After 12 weeks, vitamin B6 and folic acid levels were unchanged. However, laxative use was reduced by 59% in the intervention group and only 8% in the control group, a difference that was statistically significant (P<.001). Vitamin B12 levels decreased significantly in the control group (P<.05), but showed no significant decrease in the intervention group (P<.05). The authors point out that physicians often treat constipation in the elderly without regard to potential consequences to the microflora of the intestines. Selecting a regimen for preventing constipation, or a treatment that does not alter the microflora, may preserve normal levels of vitamin B12 in this vulnerable population.   Although the consequences of B12 deficiency can be permanent, in many cases they are reversible over time. Many of the medication-induced causes of B12 deficiency are also reversible over time. It is up to us to have a heightened awareness of the possibility of B12 deficiency--to identify it early and treat before consequences develop. Equally important is to prevent its development in the first place. Here is my “note to self”: •    Ask a good dietary history. This is especially true of vulnerable groups--the elderly, immigrants, and refugees, the poor. (Also women of childbearing age, which is a whole discussion unto itself.) •    Test for H pylori—particularly among patients who come from areas of the world where this infection is endemic. Think about H pylori when a patient has vitamin B12 deficiency. •    Think about intestinal parasites, and test when appropriate. If a patient seems to have been infected chronically, consider checking a B12 level. •    Monitor B12 levels regularly when patients take H2 antagonists, PPIs, and metformin for extended periods of time. •    Since short term use of H2 antagonists and PPIs does not seem to cause B12 deficiency, use these medications carefully and for the shortest amount of time. •    Remember that preventing constipation is better than treating it once it develops.•    Remember that all medications can have consequences, particularly if they are used on a regular basis. Consider the mechanism of action of commonly used medications such as laxatives. Choose medications that are least likely to alter the body’s fragile microsystems, especially among the frail elderly. •    Finally, review all medications regularly, and discontinue them when they are no longer indicated. References 1. Andres E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption  in elderly patients: clinical manifestations and treatment. Am J Med. 2005; 118:1154-1159. 2. Seshadri S, Beiser A, Selhub C,  et al. Plasma homocysteine as a risk factor for dementia and Alzheimer’s disease. N Engl J Med. 2002;346:476-483. 3. Guzelcan Y, van Loon P. Vitamin B12 status in patients of Turkish and Dutch descent with depression: a comparative cross-sectional study. Ann Gen Psychiatry. 2009; 8:18. 4. Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharmacol. 2005;19:59-65. 5. Fata F, Herzlich B, Shiffman G, et al. Impaired antibody responses to pneumococcal polysaccharide in elderly patients with low serum vitamin B12 levels. Ann Intern Med. 1996;124:299-304. 6. McLean E, Allen L, Neumann C, et al. Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods. J Nutr. 2007; 137:676-682. 7. Stabler S, Allen R. Vitamin B12 deficiency as a world-wide problem. Annu Rev Nutr. 2004;24:299-326. 8. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010;29(1):87-99. 9. Benson J, Maldari T, Turnbull T. Vitamin B12 deficiency: why refugee patients are at high risk. Australian Family Physician. 2010;39(4): 215-217. 10. Kaptan K, Beyan C, Ural A, et al. Helicobacter pylori: is it a novel causative agent in vitamin B12 deficiency? Arch Int Med. 2000;160:1349-1353. 11. Ruscin JM, Page RL, Valuck RJ. Vitamin B (12) deficiency associated with histamine (2)-receptor antagonists and a proton-pump inhibitor. Ann Pharmacother. 2002:36(5):812-816. 12. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010; 29(1):87-99. 13. Valuck RJ, Tuscin JM. A case-control study on adverse effects: H-2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol. 2004;57(4):422-428. 14. Ting R, Sceto C, Chan M, et al. Risk factor of vitamin B12 deficiency in patients receiving metformin. Arch Int Med. 2006;166:1975-1979. 15. deJager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ. 2010;340:c 2181. 16. Sturtzel B, Dietrich A, Wagner K-H et al. The status of vitamins B6, B12, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber. The Journal of Health, Nutrition & Aging. 2010;14:219-223. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.[Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]   Wed, 23 Jun 2010 21:16:37 GMT http://community.modernmedicine.com/_Why-Is-There-So-Much-Vitamin-B12-Deficiency/blog/2408502/33379.html bgottlieb 2010-06-23T21:04:59Z Primary Care Modern Medicine Community Is it my imagination, or does it seem like every other patient has vitamin B12 deficiency? Is it because my patients, unlike myself, are getting older? Are there other factors to consider?As humans age the risk of developing a vitamin B12 deficiency increases. Andres et al, report that more than 20% of adults 65 and older are deficient in this nutrient.1 I have been taught to attribute this to poor absorption due to factors in the stomach, the small intestine, or both. We are all familiar with the consequences of B12 deficiency to the hematologic and neurologic systems; every medical student memorizes the pathways that lead to macrocytosis, neuropathies, and spinal cord degeneration. There is increasing evidence that B12 is a key piece of other common pathophysiologic puzzles including atherosclerosis and dementia.2 Vitamin B12 deficiency contributes to common psychiatric disorders including PTSD, panic disorder, depression, and obsessive compulsive disorders.3,4 Vitamin B12 is involved in the humoral immune response, and low levels have been associated with an impaired response to pneumococcal vaccine.5 It does seem that B12 deficiency is at least in part a phenomenon of “normal aging.” There are age-related changes in the stomach that reduce the availability of intrinsic factor. One might also argue that age alone can change the motility of the intestines, thereby altering the microflora, leading to poor absorption through the intestinal wall. However, the high prevalence of this nutritional deficiency among younger individuals suggests that there are other factors. For example, Mclean et al found high rates of vitamin B12 deficiency among Kenyan school children6; others have documented high rates of vitamin B12 deficiency throughout Africa and Asia, and among immigrant and refugee populations in the developed world who come from areas where this deficiency is endemic.7-9 Clearly diets that are deficient in animal-based foods--either because of religious or cultural beliefs or poverty--are known to be associated with vitamin B12 deficiency. Worldwide, several common infections are also associated with vitamin B12 deficiency. Chronic infection with Helicobacter pylori can lead to gastric atrophy, reduction of parietal cells and intrinsic factor, and impaired absorption of vitamin B12.10 Intestinal parasites, including Giardia lamblia can lead to chronic malabsorption of many nutrients, including vitamin B12.7 These infections are unfortunately more common in parts of the developing world where diets are marginal in animal-based foods, thus increasing the vulnerability of these populations to vitamin B12 deficiency. Some of the things we do as physicians contribute to the problem. There has been recent attention to the association between vitamin B12 deficiency and commonly prescribed medications, including H2 antagonists, proton pump inhibitors (PPIs), and now metformin.11-15 When I think about how many prescriptions I write in a day for H2-blockers and PPIs, and the epidemic of obesity and diabetes, I have to reckon with the likelihood that I will be responsible for vitamin B12 deficiency (or already have been) for a significant number of patients. Sturtzel et al call attention to a more obscure possibility in their compelling, although small study, of frail elderly patients in a geriatric home.16 Patients were randomized to an intervention group that received 5.2 g/d of oat bran mixed into their food, and a control group. Both groups were fed the standard diet of the facility, were followed clinically for constipation, and treated with laxatives as indicated. Baseline laxative use and serum vitamin B12 and B6, and folic acid were the same. After 12 weeks, vitamin B6 and folic acid levels were unchanged. However, laxative use was reduced by 59% in the intervention group and only 8% in the control group, a difference that was statistically significant (P<.001). Vitamin B12 levels decreased significantly in the control group (P<.05), but showed no significant decrease in the intervention group (P<.05). The authors point out that physicians often treat constipation in the elderly without regard to potential consequences to the microflora of the intestines. Selecting a regimen for preventing constipation, or a treatment that does not alter the microflora, may preserve normal levels of vitamin B12 in this vulnerable population.   Although the consequences of B12 deficiency can be permanent, in many cases they are reversible over time. Many of the medication-induced causes of B12 deficiency are also reversible over time. It is up to us to have a heightened awareness of the possibility of B12 deficiency--to identify it early and treat before consequences develop. Equally important is to prevent its development in the first place. Here is my “note to self”: •    Ask a good dietary history. This is especially true of vulnerable groups--the elderly, immigrants, and refugees, the poor. (Also women of childbearing age, which is a whole discussion unto itself.) •    Test for H pylori—particularly among patients who come from areas of the world where this infection is endemic. Think about H pylori when a patient has vitamin B12 deficiency. •    Think about intestinal parasites, and test when appropriate. If a patient seems to have been infected chronically, consider checking a B12 level. •    Monitor B12 levels regularly when patients take H2 antagonists, PPIs, and metformin for extended periods of time. •    Since short term use of H2 antagonists and PPIs does not seem to cause B12 deficiency, use these medications carefully and for the shortest amount of time. •    Remember that preventing constipation is better than treating it once it develops.•    Remember that all medications can have consequences, particularly if they are used on a regular basis. Consider the mechanism of action of commonly used medications such as laxatives. Choose medications that are least likely to alter the body’s fragile microsystems, especially among the frail elderly. •    Finally, review all medications regularly, and discontinue them when they are no longer indicated. References 1. Andres E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption  in elderly patients: clinical manifestations and treatment. Am J Med. 2005; 118:1154-1159. 2. Seshadri S, Beiser A, Selhub C,  et al. Plasma homocysteine as a risk factor for dementia and Alzheimer’s disease. N Engl J Med. 2002;346:476-483. 3. Guzelcan Y, van Loon P. Vitamin B12 status in patients of Turkish and Dutch descent with depression: a comparative cross-sectional study. Ann Gen Psychiatry. 2009; 8:18. 4. Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharmacol. 2005;19:59-65. 5. Fata F, Herzlich B, Shiffman G, et al. Impaired antibody responses to pneumococcal polysaccharide in elderly patients with low serum vitamin B12 levels. Ann Intern Med. 1996;124:299-304. 6. McLean E, Allen L, Neumann C, et al. Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods. J Nutr. 2007; 137:676-682. 7. Stabler S, Allen R. Vitamin B12 deficiency as a world-wide problem. Annu Rev Nutr. 2004;24:299-326. 8. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010;29(1):87-99. 9. Benson J, Maldari T, Turnbull T. Vitamin B12 deficiency: why refugee patients are at high risk. Australian Family Physician. 2010;39(4): 215-217. 10. Kaptan K, Beyan C, Ural A, et al. Helicobacter pylori: is it a novel causative agent in vitamin B12 deficiency? Arch Int Med. 2000;160:1349-1353. 11. Ruscin JM, Page RL, Valuck RJ. Vitamin B (12) deficiency associated with histamine (2)-receptor antagonists and a proton-pump inhibitor. Ann Pharmacother. 2002:36(5):812-816. 12. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010; 29(1):87-99. 13. Valuck RJ, Tuscin JM. A case-control study on adverse effects: H-2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol. 2004;57(4):422-428. 14. Ting R, Sceto C, Chan M, et al. Risk factor of vitamin B12 deficiency in patients receiving metformin. Arch Int Med. 2006;166:1975-1979. 15. deJager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ. 2010;340:c 2181. 16. Sturtzel B, Dietrich A, Wagner K-H et al. The status of vitamins B6, B12, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber. The Journal of Health, Nutrition & Aging. 2010;14:219-223. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.[Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]   deficiency”, geriatrics, infections”, metformin, nutrition, primary care, “intestinal, “vitamin nonadult false Why Is There So Much Vitamin B12 Deficiency? text blog deficiency”,geriatrics,infections”,metformin,nutrition,primary care,“intestinal,“vitamin 991 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 1 2408502 2771822 Member 0 http://community.modernmedicine.com/_Suboxone-A-Bad-Few-Weeks/blog/2335600/33379.html I have only a handful of patients who take Suboxone (naloxone HCl/buprenorphine HCl). I never intended this to become a large part of my practice, and it hasn’t. I did the special training required to prescribe this type of medication because I believe that the scope of primary care practice, especially for those of us who practice in “safety net” settings, should be as broad as possible in order to serve our patients and community. Substance abuse is a huge problem in all communities. Even the wealthy and well-insured do not get the best of services. Certainly the patients in my community suffer disproportionately from poor quality and lack of integration of services, and because the supply falls so far short of the demand. Plus, honestly, after more than a quarter of a century of practice, I wanted to feel like I, too, could learn something entirely new. My first patients have been stars. They had been in methadone maintenance programs, several of them for a number of years. They had done well in terms of their substance use – stopped using, stopped craving, but hated the way they felt. The lethargy, constipation, swelling were bad enough. What was worse was the feeling that they were still drugged. They still didn’t feel like themselves. Their transition to Suboxone was easy. Thankfully. They were my first patients, and I was geared up for something dramatic to happen in the office. No drama. I just followed the instructions for transitioning from methadone to Suboxone in my training, and my patients were all set within a few days. They felt better almost instantly. Of these first patients, all have been able to continue to work. Their family lives have improved, and they remain, after several years, substance free. Those who had chronic diseases (diabetes, primarily) have shown improvement. I believe that this is largely because their lethargy has lifted. They are more motivated. They experienced breakthroughs in those all important and seemingly recalcitrant behaviors—they exercise more, eat better, smoke less, take their medications more consistently, and approach life with a more positive outlook. Maybe it is just more years of sobriety. Perhaps. I think it is the change of drugs as well. Here is my favorite story. Mr X was 51 when he began to use Suboxone. He had heard that people felt better taking this medication and was tired of the fatigue and drugged feeling he experienced with methadone. His weight didn’t go below 426 lb, and having diabetes (HbA1c in the double digits) didn’t help. But he could not motivate himself to do much about these problems except take the medications he was prescribed. Once he began taking Suboxone and stopped methadone, his transformation was amazing. He started walking—at first in his neighborhood, and then after losing about 25 lb, he joined a gym. Despite chronic knee, hip, and back pain, he began to walk on the treadmill for 2 to 3 h/d. The pain decreased! He lost more weight. And more weight. After the first year, he had lost 80 lb. After 2 years, 110 lb, and as of now, after 3 ½ years he has lost an astonishing 150 lb. We celebrated when he could be weighed on a regular office scale. We have eliminated some medications for diabetes, BP, pain, and depression. Svelte he is not. But he has achieved what few people can, even with bariatric surgery, and he is so proud of himself. However, this has been a bad few weeks for Suboxone. Despite the contracts we have in place, the monitoring, the urine tests, the requirement that patients attend drug treatment programs and mental health counseling, I have had a run of unexpected events: Several patients relapsed on heroin and required higher levels of care than we can provide in our health center; several relapsed on other substances—found in the urine but not admitted to in our visits; information from reliable family sources that the patient has been using on the side; patients hiding “clean” urines on their bodies and providing those during our random toxic screens. Like many primary care sites, we do not have supervised urine checks. I can accept relapse. I accept the axiom that relapse is part of the disease of addiction. It is the dishonesty that wears me down. I do realize that dishonesty, in this sense, is also part of the disease of addiction. The craving, the drugs, for some people, under some circumstances, simply cannot be resisted, and they will resort to behaviors that involve lying, distortion, manipulation… and worse. Why is my reaction to this different than, for example, when an obese patient who has gained another 10 lb since his visit a month ago tells me that he “really doesn’t eat a thing, Dr. Gottlieb”? Or an asthmatic patient who hasn’t asked for a refill for her chronic medications in over a year insists that she is doing exactly what I tell her?… or any number of scenarios in which the patient’s report does not match observable reality? Is it because of the illegality of substances? Is it because my DEA and special license are involved in the case of drug addiction, whereas the DEA would not take note if I prescribed one albuterol inhaler more or less? Perhaps my frustration is that the overall program we have for treating drug addicted patients in outpatient settings is simply not enough. I realize that what we have at my health center is exceptional: right down the hall, within the same system of care, connected through a common electronic record and care giver meetings, is a mental health department with counselors, psychiatrists, psychologists, social workers, specialists in addictions. Not only that, they are bilingual (English and Spanish-speaking), and, for the most part, bicultural as well. But we don’t have the personnel to supervise urine toxic screens. We don’t have outreach workers, people who can help patients with their many concrete social service needs, which, if met, might reduce some of the stress in their lives. And because demand for all mental health services, including addictions, exceeds supply, we cannot quickly and seamlessly step up care as our patients experience the inevitable ups and downs in their sobriety. In that sense, it is not parallel to the asthmatic patient who has not taken her medications. I can simply see her today, tomorrow, and the next day to get her back on track or send her to the emergency room if that is what is needed. So—I have to take a deep breath. I have to take an honest look and review and sharpen my own clinical skills, instincts, and practices. I have to look at the policies and systems our health center has in place to make sure they are adequate and appropriate to care for people for whom sobriety is not well established. And I have to remind myself why I wanted to expand my skills to treat patients with addictions as part of my self-definition as a primary care physician. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.  [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I have only a handful of patients who take Suboxone (naloxone HCl/buprenorphine HCl). I never intended this to become a large part of my practice, and it hasn’t. I did the special training required to prescribe this type of medication because I believe that the scope of primary care practice, especially for those of us who practice in “safety net” settings, should be as broad as possible in order to serve our patients and community. Substance abuse is a huge problem in all communities. Even the wealthy and well-insured do not get the best of services. Certainly the patients in my community suffer disproportionately from poor quality and lack of integration of services, and because the supply falls so far short of the demand. Plus, honestly, after more than a quarter of a century of practice, I wanted to feel like I, too, could learn something entirely new. My first patients have been stars. They had been in methadone maintenance programs, several of them for a number of years. They had done well in terms of their substance use – stopped using, stopped craving, but hated the way they felt. The lethargy, constipation, swelling were bad enough. What was worse was the feeling that they were still drugged. They still didn’t feel like themselves. Their transition to Suboxone was easy. Thankfully. They were my first patients, and I was geared up for something dramatic to happen in the office. No drama. I just followed the instructions for transitioning from methadone to Suboxone in my training, and my patients were all set within a few days. They felt better almost instantly. Of these first patients, all have been able to continue to work. Their family lives have improved, and they remain, after several years, substance free. Those who had chronic diseases (diabetes, primarily) have shown improvement. I believe that this is largely because their lethargy has lifted. They are more motivated. They experienced breakthroughs in those all important and seemingly recalcitrant behaviors—they exercise more, eat better, smoke less, take their medications more consistently, and approach life with a more positive outlook. Maybe it is just more years of sobriety. Perhaps. I think it is the change of drugs as well. Here is my favorite story. Mr X was 51 when he began to use Suboxone. He had heard that people felt better taking this medication and was tired of the fatigue and drugged feeling he experienced with methadone. His weight didn’t go below 426 lb, and having diabetes (HbA1c in the double digits) didn’t help. But he could not motivate himself to do much about these problems except take the medications he was prescribed. Once he began taking Suboxone and stopped methadone, his transformation was amazing. He started walking—at first in his neighborhood, and then after losing about 25 lb, he joined a gym. Despite chronic knee, hip, and back pain, he began to walk on the treadmill for 2 to 3 h/d. The pain decreased! He lost more weight. And more weight. After the first year, he had lost 80 lb. After 2 years, 110 lb, and as of now, after 3 ½ years he has lost an astonishing 150 lb. We celebrated when he could be weighed on a regular office scale. We have eliminated some medications for diabetes, BP, pain, and depression. Svelte he is not. But he has achieved what few people can, even with bariatric surgery, and he is so proud of himself. However, this has been a bad few weeks for Suboxone. Despite the contracts we have in place, the monitoring, the urine tests, the requirement that patients attend drug treatment programs and mental health counseling, I have had a run of unexpected events: Several patients relapsed on heroin and required higher levels of care than we can provide in our health center; several relapsed on other substances—found in the urine but not admitted to in our visits; information from reliable family sources that the patient has been using on the side; patients hiding “clean” urines on their bodies and providing those during our random toxic screens. Like many primary care sites, we do not have supervised urine checks. I can accept relapse. I accept the axiom that relapse is part of the disease of addiction. It is the dishonesty that wears me down. I do realize that dishonesty, in this sense, is also part of the disease of addiction. The craving, the drugs, for some people, under some circumstances, simply cannot be resisted, and they will resort to behaviors that involve lying, distortion, manipulation… and worse. Why is my reaction to this different than, for example, when an obese patient who has gained another 10 lb since his visit a month ago tells me that he “really doesn’t eat a thing, Dr. Gottlieb”? Or an asthmatic patient who hasn’t asked for a refill for her chronic medications in over a year insists that she is doing exactly what I tell her?… or any number of scenarios in which the patient’s report does not match observable reality? Is it because of the illegality of substances? Is it because my DEA and special license are involved in the case of drug addiction, whereas the DEA would not take note if I prescribed one albuterol inhaler more or less? Perhaps my frustration is that the overall program we have for treating drug addicted patients in outpatient settings is simply not enough. I realize that what we have at my health center is exceptional: right down the hall, within the same system of care, connected through a common electronic record and care giver meetings, is a mental health department with counselors, psychiatrists, psychologists, social workers, specialists in addictions. Not only that, they are bilingual (English and Spanish-speaking), and, for the most part, bicultural as well. But we don’t have the personnel to supervise urine toxic screens. We don’t have outreach workers, people who can help patients with their many concrete social service needs, which, if met, might reduce some of the stress in their lives. And because demand for all mental health services, including addictions, exceeds supply, we cannot quickly and seamlessly step up care as our patients experience the inevitable ups and downs in their sobriety. In that sense, it is not parallel to the asthmatic patient who has not taken her medications. I can simply see her today, tomorrow, and the next day to get her back on track or send her to the emergency room if that is what is needed. So—I have to take a deep breath. I have to take an honest look and review and sharpen my own clinical skills, instincts, and practices. I have to look at the policies and systems our health center has in place to make sure they are adequate and appropriate to care for people for whom sobriety is not well established. And I have to remind myself why I wanted to expand my skills to treat patients with addictions as part of my self-definition as a primary care physician. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.  [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Thu, 13 May 2010 03:10:19 GMT http://community.modernmedicine.com/_Suboxone-A-Bad-Few-Weeks/blog/2335600/33379.html bgottlieb 2010-05-13T03:02:58Z Patient Care Modern Medicine Community I have only a handful of patients who take Suboxone (naloxone HCl/buprenorphine HCl). I never intended this to become a large part of my practice, and it hasn’t. I did the special training required to prescribe this type of medication because I believe that the scope of primary care practice, especially for those of us who practice in “safety net” settings, should be as broad as possible in order to serve our patients and community. Substance abuse is a huge problem in all communities. Even the wealthy and well-insured do not get the best of services. Certainly the patients in my community suffer disproportionately from poor quality and lack of integration of services, and because the supply falls so far short of the demand. Plus, honestly, after more than a quarter of a century of practice, I wanted to feel like I, too, could learn something entirely new. My first patients have been stars. They had been in methadone maintenance programs, several of them for a number of years. They had done well in terms of their substance use – stopped using, stopped craving, but hated the way they felt. The lethargy, constipation, swelling were bad enough. What was worse was the feeling that they were still drugged. They still didn’t feel like themselves. Their transition to Suboxone was easy. Thankfully. They were my first patients, and I was geared up for something dramatic to happen in the office. No drama. I just followed the instructions for transitioning from methadone to Suboxone in my training, and my patients were all set within a few days. They felt better almost instantly. Of these first patients, all have been able to continue to work. Their family lives have improved, and they remain, after several years, substance free. Those who had chronic diseases (diabetes, primarily) have shown improvement. I believe that this is largely because their lethargy has lifted. They are more motivated. They experienced breakthroughs in those all important and seemingly recalcitrant behaviors—they exercise more, eat better, smoke less, take their medications more consistently, and approach life with a more positive outlook. Maybe it is just more years of sobriety. Perhaps. I think it is the change of drugs as well. Here is my favorite story. Mr X was 51 when he began to use Suboxone. He had heard that people felt better taking this medication and was tired of the fatigue and drugged feeling he experienced with methadone. His weight didn’t go below 426 lb, and having diabetes (HbA1c in the double digits) didn’t help. But he could not motivate himself to do much about these problems except take the medications he was prescribed. Once he began taking Suboxone and stopped methadone, his transformation was amazing. He started walking—at first in his neighborhood, and then after losing about 25 lb, he joined a gym. Despite chronic knee, hip, and back pain, he began to walk on the treadmill for 2 to 3 h/d. The pain decreased! He lost more weight. And more weight. After the first year, he had lost 80 lb. After 2 years, 110 lb, and as of now, after 3 ½ years he has lost an astonishing 150 lb. We celebrated when he could be weighed on a regular office scale. We have eliminated some medications for diabetes, BP, pain, and depression. Svelte he is not. But he has achieved what few people can, even with bariatric surgery, and he is so proud of himself. However, this has been a bad few weeks for Suboxone. Despite the contracts we have in place, the monitoring, the urine tests, the requirement that patients attend drug treatment programs and mental health counseling, I have had a run of unexpected events: Several patients relapsed on heroin and required higher levels of care than we can provide in our health center; several relapsed on other substances—found in the urine but not admitted to in our visits; information from reliable family sources that the patient has been using on the side; patients hiding “clean” urines on their bodies and providing those during our random toxic screens. Like many primary care sites, we do not have supervised urine checks. I can accept relapse. I accept the axiom that relapse is part of the disease of addiction. It is the dishonesty that wears me down. I do realize that dishonesty, in this sense, is also part of the disease of addiction. The craving, the drugs, for some people, under some circumstances, simply cannot be resisted, and they will resort to behaviors that involve lying, distortion, manipulation… and worse. Why is my reaction to this different than, for example, when an obese patient who has gained another 10 lb since his visit a month ago tells me that he “really doesn’t eat a thing, Dr. Gottlieb”? Or an asthmatic patient who hasn’t asked for a refill for her chronic medications in over a year insists that she is doing exactly what I tell her?… or any number of scenarios in which the patient’s report does not match observable reality? Is it because of the illegality of substances? Is it because my DEA and special license are involved in the case of drug addiction, whereas the DEA would not take note if I prescribed one albuterol inhaler more or less? Perhaps my frustration is that the overall program we have for treating drug addicted patients in outpatient settings is simply not enough. I realize that what we have at my health center is exceptional: right down the hall, within the same system of care, connected through a common electronic record and care giver meetings, is a mental health department with counselors, psychiatrists, psychologists, social workers, specialists in addictions. Not only that, they are bilingual (English and Spanish-speaking), and, for the most part, bicultural as well. But we don’t have the personnel to supervise urine toxic screens. We don’t have outreach workers, people who can help patients with their many concrete social service needs, which, if met, might reduce some of the stress in their lives. And because demand for all mental health services, including addictions, exceeds supply, we cannot quickly and seamlessly step up care as our patients experience the inevitable ups and downs in their sobriety. In that sense, it is not parallel to the asthmatic patient who has not taken her medications. I can simply see her today, tomorrow, and the next day to get her back on track or send her to the emergency room if that is what is needed. So—I have to take a deep breath. I have to take an honest look and review and sharpen my own clinical skills, instincts, and practices. I have to look at the policies and systems our health center has in place to make sure they are adequate and appropriate to care for people for whom sobriety is not well established. And I have to remind myself why I wanted to expand my skills to treat patients with addictions as part of my self-definition as a primary care physician. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.  [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] diabetes, drug addiction, mental health, methadone, patient care, suboxone, substance abuse nonadult false Suboxone: A Bad Few Weeks text blog diabetes,drug addiction,mental health,methadone,patient care,suboxone,substance abuse 461 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Patient Care 0 2335600 2771822 Member 0 http://community.modernmedicine.com/_Communicating-Test-Results-Swimming-in-the-Quality-Chasm/blog/2277643/33379.html I recently missed about 3 weeks of work for personal reasons. And my health center uses an electronic medical record (EMR) system to which, for better or worse (better for patients, worse for me), I have access 24-7. However, I was instructed to “REALLY TAKE TIME OFF. Someone will take care of your patients, review your results… anyway, when you’re distracted you’re liable to make important errors.” I am not indispensable. For the most part, my patients were taken care of and were fine during my absence. And it really was good to be freed up from patient care responsibilities. But when I returned, I realized that not everything was taken care of. The really urgent abnormal results were addressed—at least the first steps were taken. But in fact, many of the nonurgent abnormals were left behind, not to mention the normal results. I had to swim extra fast in order to catch up and keep up with the fast current of my resumed patient care responsibilities. In its landmark report, “Crossing the Quality Chasm, A New Health System for the 21st Century,” the Institute of Medicine established 6 aims for improving health care systems. The authors called for health care systems to be safe, effective, patient-centered, timely, efficient, and equitable.1 If the IOM were to give me a report card for my communication of test results to patients in the past few weeks, I wouldn’t have received a passing grade; my personal quality chasm was very wide. I don’t have to be convinced that a physician’s handling of test results has major implications for patient safety, patient satisfaction, and avoidance of diagnostic errors. While many factors contribute to diagnostic error, it turns out that systems factors surpass cognitive errors on the part of physicians as well as so-called “no-fault” errors in which medical knowledge was insufficient to prevent the error.2 Some sort of problem in handling test results is the most common systems problem contributing to diagnostic error. So lacking a clear system to handle test results in my absence was probably more dangerous than my presence might have been—even if I were very distracted. This is not good news. Luckily, most of my abnormal test results were handled appropriately, and in a relatively timely manner. Within a few days I caught up with some of the loose ends. No major harm seems to have occurred. However, my normal results were untouched. Pap tests, mammograms, glycosylated hemoglobins, lipid panels. How much does it matter that they get communicated? According to Boohaker, it is important to communicate patients’ normal as well as abnormal results.3 Those who don’t receive test results are less “activated,” less adherent, and, not surprisingly, have poorer outcomes. The IOM cautions strongly against the “no news is good news” approach to test results and encourages communication of all results as the standard. Electronic medical records have certainly made it easier to manage test results. However, Wahls and others warn that high rates of missed or delayed review and reporting of test results occur even when EMRs have advanced systems for flagging results to physicians and organizing results according to degree of abnormality.4,5 So, what does this mean for me? I typically spend more than an hour a day reviewing test results, communicating them to patients, and arranging the next diagnostic and therapeutic steps. It turns out that I am not unique. Poon, et al surveyed 168 internists about their practices for reviewing test results.6 Physicians with EMRs spend an average of 37 minutes per half day spent seeing patients reviewing and managing test results. Our EMR has the capacity to generate letters to patients. However, I rarely make use of this feature. Even though the letters can be written in both English and Spanish, many of my patients read at a third-grade level or lower, and their health literacy is also quite low. Often when they receive a letter announcing normal results they schedule an appointment—panicked that something is terribly wrong. They fear any letter that looks “official” because in their experience, official means bad news. So, for the most part, I call my patients. I have to say that they love it. LOVE IT. They are surprised and honored that I call them. If they have any questions, I can answer them right away. If there are misunderstandings, I can clear them up without generating unnecessary visits and phone calls. Activating patients? I never called it that, but when my patients say “Oh—my cholesterol is normal, so I can stop the medicine,” I can encourage them to keep on taking their medication because it is working. Or when I report a normal Pap test, I can remind them when their next one is due. To me, this is the meaning of the IOM’s 6th aim—that health care must be equitable, specifically, that quality “doesn’t vary because of personal characteristics such as ethnicity, geographic location or socio-economic status.” This letter-generating enhancement of our EMR doesn’t provide equity. I have to do that on my own. However—doing this is very time-consuming. And, one might argue, not the best use of my expensive time. I agree. But I haven’t found an alternative strategy, and even if I did, it would likely require a person in addition to information-systems changes. Maybe that person will eventually be part of the Medical Home team, but right now that person is me. Yet, even with my system, who is to say that I don’t miss important results or cause medically-significant delays in reviewing and acting on results? In Poon’s study, 83% of respondents reported at least 1 test result in the previous 2 months that they wished they had known about earlier. Eighteen percent of respondents had 5 or more such delays. Wahls points out that the handling of test results is complex and likely requires innovations on multiple levels, including information technology, clear policies and procedures to address predictable gaps such as absences, and activating patients’ expectations of receiving test results as a fail-safe. One of the strategies for “activating” patients is to provide direct access to their own test results through the electronic record. This is not new—but it is new for my health center. There is no doubt that EMRs have improved patient care in countless ways. However, I am a bit wary: So far, each enhancement to our EMR (including the EMR itself) has added to my work. Patient access to parts of the electronic record raises particular challenges when the patient population has low literacy and limited access to computers. So, with any new enhancement, I ask: Will this enhancement be a good thing or a bad thing for my patients? Will they acquire the skills and access that this enhancement requires, or is it one more thing that will bypass them? Is this enhancement guided by the goal of equity, or does this strategy preclude other potential strategies that might have been more equitable, but have been put aside in favor of this? Or will I, and others who care for poor and low literacy patients continue to have to find our own ways of ensuring equity and closing the quality chasm? References 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. 2. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005:165:1493-1499. 3. Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996:156:327-331. 4. Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage. 2007;30:338-343. 5. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244. 6. Poon EG, Gandhi TK, Sequist TD, et al. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] I recently missed about 3 weeks of work for personal reasons. And my health center uses an electronic medical record (EMR) system to which, for better or worse (better for patients, worse for me), I have access 24-7. However, I was instructed to “REALLY TAKE TIME OFF. Someone will take care of your patients, review your results… anyway, when you’re distracted you’re liable to make important errors.” I am not indispensable. For the most part, my patients were taken care of and were fine during my absence. And it really was good to be freed up from patient care responsibilities. But when I returned, I realized that not everything was taken care of. The really urgent abnormal results were addressed—at least the first steps were taken. But in fact, many of the nonurgent abnormals were left behind, not to mention the normal results. I had to swim extra fast in order to catch up and keep up with the fast current of my resumed patient care responsibilities. In its landmark report, “Crossing the Quality Chasm, A New Health System for the 21st Century,” the Institute of Medicine established 6 aims for improving health care systems. The authors called for health care systems to be safe, effective, patient-centered, timely, efficient, and equitable.1 If the IOM were to give me a report card for my communication of test results to patients in the past few weeks, I wouldn’t have received a passing grade; my personal quality chasm was very wide. I don’t have to be convinced that a physician’s handling of test results has major implications for patient safety, patient satisfaction, and avoidance of diagnostic errors. While many factors contribute to diagnostic error, it turns out that systems factors surpass cognitive errors on the part of physicians as well as so-called “no-fault” errors in which medical knowledge was insufficient to prevent the error.2 Some sort of problem in handling test results is the most common systems problem contributing to diagnostic error. So lacking a clear system to handle test results in my absence was probably more dangerous than my presence might have been—even if I were very distracted. This is not good news. Luckily, most of my abnormal test results were handled appropriately, and in a relatively timely manner. Within a few days I caught up with some of the loose ends. No major harm seems to have occurred. However, my normal results were untouched. Pap tests, mammograms, glycosylated hemoglobins, lipid panels. How much does it matter that they get communicated? According to Boohaker, it is important to communicate patients’ normal as well as abnormal results.3 Those who don’t receive test results are less “activated,” less adherent, and, not surprisingly, have poorer outcomes. The IOM cautions strongly against the “no news is good news” approach to test results and encourages communication of all results as the standard. Electronic medical records have certainly made it easier to manage test results. However, Wahls and others warn that high rates of missed or delayed review and reporting of test results occur even when EMRs have advanced systems for flagging results to physicians and organizing results according to degree of abnormality.4,5 So, what does this mean for me? I typically spend more than an hour a day reviewing test results, communicating them to patients, and arranging the next diagnostic and therapeutic steps. It turns out that I am not unique. Poon, et al surveyed 168 internists about their practices for reviewing test results.6 Physicians with EMRs spend an average of 37 minutes per half day spent seeing patients reviewing and managing test results. Our EMR has the capacity to generate letters to patients. However, I rarely make use of this feature. Even though the letters can be written in both English and Spanish, many of my patients read at a third-grade level or lower, and their health literacy is also quite low. Often when they receive a letter announcing normal results they schedule an appointment—panicked that something is terribly wrong. They fear any letter that looks “official” because in their experience, official means bad news. So, for the most part, I call my patients. I have to say that they love it. LOVE IT. They are surprised and honored that I call them. If they have any questions, I can answer them right away. If there are misunderstandings, I can clear them up without generating unnecessary visits and phone calls. Activating patients? I never called it that, but when my patients say “Oh—my cholesterol is normal, so I can stop the medicine,” I can encourage them to keep on taking their medication because it is working. Or when I report a normal Pap test, I can remind them when their next one is due. To me, this is the meaning of the IOM’s 6th aim—that health care must be equitable, specifically, that quality “doesn’t vary because of personal characteristics such as ethnicity, geographic location or socio-economic status.” This letter-generating enhancement of our EMR doesn’t provide equity. I have to do that on my own. However—doing this is very time-consuming. And, one might argue, not the best use of my expensive time. I agree. But I haven’t found an alternative strategy, and even if I did, it would likely require a person in addition to information-systems changes. Maybe that person will eventually be part of the Medical Home team, but right now that person is me. Yet, even with my system, who is to say that I don’t miss important results or cause medically-significant delays in reviewing and acting on results? In Poon’s study, 83% of respondents reported at least 1 test result in the previous 2 months that they wished they had known about earlier. Eighteen percent of respondents had 5 or more such delays. Wahls points out that the handling of test results is complex and likely requires innovations on multiple levels, including information technology, clear policies and procedures to address predictable gaps such as absences, and activating patients’ expectations of receiving test results as a fail-safe. One of the strategies for “activating” patients is to provide direct access to their own test results through the electronic record. This is not new—but it is new for my health center. There is no doubt that EMRs have improved patient care in countless ways. However, I am a bit wary: So far, each enhancement to our EMR (including the EMR itself) has added to my work. Patient access to parts of the electronic record raises particular challenges when the patient population has low literacy and limited access to computers. So, with any new enhancement, I ask: Will this enhancement be a good thing or a bad thing for my patients? Will they acquire the skills and access that this enhancement requires, or is it one more thing that will bypass them? Is this enhancement guided by the goal of equity, or does this strategy preclude other potential strategies that might have been more equitable, but have been put aside in favor of this? Or will I, and others who care for poor and low literacy patients continue to have to find our own ways of ensuring equity and closing the quality chasm? References 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. 2. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005:165:1493-1499. 3. Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996:156:327-331. 4. Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage. 2007;30:338-343. 5. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244. 6. Poon EG, Gandhi TK, Sequist TD, et al. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] Thu, 01 Apr 2010 20:02:53 GMT http://community.modernmedicine.com/_Communicating-Test-Results-Swimming-in-the-Quality-Chasm/blog/2277643/33379.html bgottlieb 2010-04-01T20:00:07Z Managing Your Practice Modern Medicine Community I recently missed about 3 weeks of work for personal reasons. And my health center uses an electronic medical record (EMR) system to which, for better or worse (better for patients, worse for me), I have access 24-7. However, I was instructed to “REALLY TAKE TIME OFF. Someone will take care of your patients, review your results… anyway, when you’re distracted you’re liable to make important errors.” I am not indispensable. For the most part, my patients were taken care of and were fine during my absence. And it really was good to be freed up from patient care responsibilities. But when I returned, I realized that not everything was taken care of. The really urgent abnormal results were addressed—at least the first steps were taken. But in fact, many of the nonurgent abnormals were left behind, not to mention the normal results. I had to swim extra fast in order to catch up and keep up with the fast current of my resumed patient care responsibilities. In its landmark report, “Crossing the Quality Chasm, A New Health System for the 21st Century,” the Institute of Medicine established 6 aims for improving health care systems. The authors called for health care systems to be safe, effective, patient-centered, timely, efficient, and equitable.1 If the IOM were to give me a report card for my communication of test results to patients in the past few weeks, I wouldn’t have received a passing grade; my personal quality chasm was very wide. I don’t have to be convinced that a physician’s handling of test results has major implications for patient safety, patient satisfaction, and avoidance of diagnostic errors. While many factors contribute to diagnostic error, it turns out that systems factors surpass cognitive errors on the part of physicians as well as so-called “no-fault” errors in which medical knowledge was insufficient to prevent the error.2 Some sort of problem in handling test results is the most common systems problem contributing to diagnostic error. So lacking a clear system to handle test results in my absence was probably more dangerous than my presence might have been—even if I were very distracted. This is not good news. Luckily, most of my abnormal test results were handled appropriately, and in a relatively timely manner. Within a few days I caught up with some of the loose ends. No major harm seems to have occurred. However, my normal results were untouched. Pap tests, mammograms, glycosylated hemoglobins, lipid panels. How much does it matter that they get communicated? According to Boohaker, it is important to communicate patients’ normal as well as abnormal results.3 Those who don’t receive test results are less “activated,” less adherent, and, not surprisingly, have poorer outcomes. The IOM cautions strongly against the “no news is good news” approach to test results and encourages communication of all results as the standard. Electronic medical records have certainly made it easier to manage test results. However, Wahls and others warn that high rates of missed or delayed review and reporting of test results occur even when EMRs have advanced systems for flagging results to physicians and organizing results according to degree of abnormality.4,5 So, what does this mean for me? I typically spend more than an hour a day reviewing test results, communicating them to patients, and arranging the next diagnostic and therapeutic steps. It turns out that I am not unique. Poon, et al surveyed 168 internists about their practices for reviewing test results.6 Physicians with EMRs spend an average of 37 minutes per half day spent seeing patients reviewing and managing test results. Our EMR has the capacity to generate letters to patients. However, I rarely make use of this feature. Even though the letters can be written in both English and Spanish, many of my patients read at a third-grade level or lower, and their health literacy is also quite low. Often when they receive a letter announcing normal results they schedule an appointment—panicked that something is terribly wrong. They fear any letter that looks “official” because in their experience, official means bad news. So, for the most part, I call my patients. I have to say that they love it. LOVE IT. They are surprised and honored that I call them. If they have any questions, I can answer them right away. If there are misunderstandings, I can clear them up without generating unnecessary visits and phone calls. Activating patients? I never called it that, but when my patients say “Oh—my cholesterol is normal, so I can stop the medicine,” I can encourage them to keep on taking their medication because it is working. Or when I report a normal Pap test, I can remind them when their next one is due. To me, this is the meaning of the IOM’s 6th aim—that health care must be equitable, specifically, that quality “doesn’t vary because of personal characteristics such as ethnicity, geographic location or socio-economic status.” This letter-generating enhancement of our EMR doesn’t provide equity. I have to do that on my own. However—doing this is very time-consuming. And, one might argue, not the best use of my expensive time. I agree. But I haven’t found an alternative strategy, and even if I did, it would likely require a person in addition to information-systems changes. Maybe that person will eventually be part of the Medical Home team, but right now that person is me. Yet, even with my system, who is to say that I don’t miss important results or cause medically-significant delays in reviewing and acting on results? In Poon’s study, 83% of respondents reported at least 1 test result in the previous 2 months that they wished they had known about earlier. Eighteen percent of respondents had 5 or more such delays. Wahls points out that the handling of test results is complex and likely requires innovations on multiple levels, including information technology, clear policies and procedures to address predictable gaps such as absences, and activating patients’ expectations of receiving test results as a fail-safe. One of the strategies for “activating” patients is to provide direct access to their own test results through the electronic record. This is not new—but it is new for my health center. There is no doubt that EMRs have improved patient care in countless ways. However, I am a bit wary: So far, each enhancement to our EMR (including the EMR itself) has added to my work. Patient access to parts of the electronic record raises particular challenges when the patient population has low literacy and limited access to computers. So, with any new enhancement, I ask: Will this enhancement be a good thing or a bad thing for my patients? Will they acquire the skills and access that this enhancement requires, or is it one more thing that will bypass them? Is this enhancement guided by the goal of equity, or does this strategy preclude other potential strategies that might have been more equitable, but have been put aside in favor of this? Or will I, and others who care for poor and low literacy patients continue to have to find our own ways of ensuring equity and closing the quality chasm? References 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. 2. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005:165:1493-1499. 3. Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996:156:327-331. 4. Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage. 2007;30:338-343. 5. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244. 6. Poon EG, Gandhi TK, Sequist TD, et al. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.] electronic medical record, emr, health care systems, managing your practice, mmglobal nonadult false Communicating Test Results (Swimming in the Quality Chasm) text blog electronic medical record,emr,health care systems,managing your practice,mmglobal 812 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 4 Managing Your Practice 1 2277643 2771822 Member 0 http://community.modernmedicine.com/_Everything-I-Didnt-Know-about-Elder-Care-The-Postscript/blog/1929220/33379.html Disclaimer: I never intended to use this blog/column as an opportunity to discuss my personal life, except in-so-far as my own clinical experiences, reflections on medically relevant current events, and literature might provide jumping off points for a discussion that resonates with the experiences of my colleagues, known and unknown. However, in the past few months, my life at home, caring for my mother, has dominated my thoughts. So please bear with me for one more entry. My mother died last week. She died quietly, peacefully, as far as I can ever know, at home. Last month I described the nonsystem of elder care. My comments and critiques stand. But it feels important and fair to add that in the end, really at the end, the pieces came together, and my mother’s death was as she would have wished. She was in her own room, cats at her feet. The hospice music therapist had come just hours before and played her signature song (“Slow Boat to China” – my lullaby, but that is another story); a social worker, to whom my mother had confided her fear of death many times, and who had responded with a Reiki maneuver meant to be calming in the face of fear, performed that familiar maneuver as she passed; the nurse, aides, and others who had come to love my mother in her last weeks and months were there to hold her hand.  She seemed to choose a moment when I had stepped away…perhaps her opportunity to leave, without family pulling her back into this world. But she was not alone, as we had promised many times.  In the end these caretakers were the skilled and compassionate midwifes of this final passage. So—what did I learn? What do I want to share from this experience? In the midst of my frenzy to get all of the pieces of her care in place and keep them more or less connected, I didn’t notice the difference between my mother’s experience and my own. For my mother, her care was a system.  She didn’t experience the seams, the disconnections. While that isn’t everything, it is something. I can appreciate this now, but it might have been reassuring if I had realized this during those unsettling months. We did a few things right. We were able to celebrate her 95th birthday just days before she died.  Friends and family came or phoned and paid tribute to her. Although she was weak, she was aware and appreciative of their words, and, I like to believe, at least a little bit proud of the wide circle of people whose lives she had touched. We will have a memorial gathering, but her birthday gave us the opportunity to honor her while she was still alive. My mother’s death was about as good as it gets:  95 years old; 92+ good/great years; anticipated (to the extent that you can truly anticipate and prepare for such a loss); in her home; ample opportunities to honor her and say good bye. And yet the void is huge. Our house, so recently filled with caregivers, my mother a constant presence, suddenly empty. Quiet. All of the equipment accumulated over months now still, useless, almost grotesque. Her few possessions provide little comfort. I wander aimlessly, forgetful, unraveled.  How do people cope with unnatural losses such as the loss of a child, the loss of a loved one by violence, losses on the scale of the recent earthquake in Haiti? Nursing colleagues at my health center lost multiple family members, young and old, all at once, without warning, buried in mass graves, no goodbyes…. How do you reconfigure your life following such losses? During the past months, the lessons of my personal life have become the key lessons of my professional life: what you need to die well is not that different from what you need to live well: to be embraced by a community of friends and family, physical comfort, safety, to be released from your fears, appreciated for yourself and your contributions small or large, and gentle, loving care through all transitions and passages. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: The Modern Medicine staff extends our sympathy and our heartfelt thanks to Dr Gottlieb for sharing her experiences in the hopes that it may benefit another.] Disclaimer: I never intended to use this blog/column as an opportunity to discuss my personal life, except in-so-far as my own clinical experiences, reflections on medically relevant current events, and literature might provide jumping off points for a discussion that resonates with the experiences of my colleagues, known and unknown. However, in the past few months, my life at home, caring for my mother, has dominated my thoughts. So please bear with me for one more entry. My mother died last week. She died quietly, peacefully, as far as I can ever know, at home. Last month I described the nonsystem of elder care. My comments and critiques stand. But it feels important and fair to add that in the end, really at the end, the pieces came together, and my mother’s death was as she would have wished. She was in her own room, cats at her feet. The hospice music therapist had come just hours before and played her signature song (“Slow Boat to China” – my lullaby, but that is another story); a social worker, to whom my mother had confided her fear of death many times, and who had responded with a Reiki maneuver meant to be calming in the face of fear, performed that familiar maneuver as she passed; the nurse, aides, and others who had come to love my mother in her last weeks and months were there to hold her hand.  She seemed to choose a moment when I had stepped away…perhaps her opportunity to leave, without family pulling her back into this world. But she was not alone, as we had promised many times.  In the end these caretakers were the skilled and compassionate midwifes of this final passage. So—what did I learn? What do I want to share from this experience? In the midst of my frenzy to get all of the pieces of her care in place and keep them more or less connected, I didn’t notice the difference between my mother’s experience and my own. For my mother, her care was a system.  She didn’t experience the seams, the disconnections. While that isn’t everything, it is something. I can appreciate this now, but it might have been reassuring if I had realized this during those unsettling months. We did a few things right. We were able to celebrate her 95th birthday just days before she died.  Friends and family came or phoned and paid tribute to her. Although she was weak, she was aware and appreciative of their words, and, I like to believe, at least a little bit proud of the wide circle of people whose lives she had touched. We will have a memorial gathering, but her birthday gave us the opportunity to honor her while she was still alive. My mother’s death was about as good as it gets:  95 years old; 92+ good/great years; anticipated (to the extent that you can truly anticipate and prepare for such a loss); in her home; ample opportunities to honor her and say good bye. And yet the void is huge. Our house, so recently filled with caregivers, my mother a constant presence, suddenly empty. Quiet. All of the equipment accumulated over months now still, useless, almost grotesque. Her few possessions provide little comfort. I wander aimlessly, forgetful, unraveled.  How do people cope with unnatural losses such as the loss of a child, the loss of a loved one by violence, losses on the scale of the recent earthquake in Haiti? Nursing colleagues at my health center lost multiple family members, young and old, all at once, without warning, buried in mass graves, no goodbyes…. How do you reconfigure your life following such losses? During the past months, the lessons of my personal life have become the key lessons of my professional life: what you need to die well is not that different from what you need to live well: to be embraced by a community of friends and family, physical comfort, safety, to be released from your fears, appreciated for yourself and your contributions small or large, and gentle, loving care through all transitions and passages. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: The Modern Medicine staff extends our sympathy and our heartfelt thanks to Dr Gottlieb for sharing her experiences in the hopes that it may benefit another.] Tue, 09 Mar 2010 18:35:29 GMT http://community.modernmedicine.com/_Everything-I-Didnt-Know-about-Elder-Care-The-Postscript/blog/1929220/33379.html bgottlieb 2010-03-03T15:08:50Z Primary Care Modern Medicine Community Disclaimer: I never intended to use this blog/column as an opportunity to discuss my personal life, except in-so-far as my own clinical experiences, reflections on medically relevant current events, and literature might provide jumping off points for a discussion that resonates with the experiences of my colleagues, known and unknown. However, in the past few months, my life at home, caring for my mother, has dominated my thoughts. So please bear with me for one more entry. My mother died last week. She died quietly, peacefully, as far as I can ever know, at home. Last month I described the nonsystem of elder care. My comments and critiques stand. But it feels important and fair to add that in the end, really at the end, the pieces came together, and my mother’s death was as she would have wished. She was in her own room, cats at her feet. The hospice music therapist had come just hours before and played her signature song (“Slow Boat to China” – my lullaby, but that is another story); a social worker, to whom my mother had confided her fear of death many times, and who had responded with a Reiki maneuver meant to be calming in the face of fear, performed that familiar maneuver as she passed; the nurse, aides, and others who had come to love my mother in her last weeks and months were there to hold her hand.  She seemed to choose a moment when I had stepped away…perhaps her opportunity to leave, without family pulling her back into this world. But she was not alone, as we had promised many times.  In the end these caretakers were the skilled and compassionate midwifes of this final passage. So—what did I learn? What do I want to share from this experience? In the midst of my frenzy to get all of the pieces of her care in place and keep them more or less connected, I didn’t notice the difference between my mother’s experience and my own. For my mother, her care was a system.  She didn’t experience the seams, the disconnections. While that isn’t everything, it is something. I can appreciate this now, but it might have been reassuring if I had realized this during those unsettling months. We did a few things right. We were able to celebrate her 95th birthday just days before she died.  Friends and family came or phoned and paid tribute to her. Although she was weak, she was aware and appreciative of their words, and, I like to believe, at least a little bit proud of the wide circle of people whose lives she had touched. We will have a memorial gathering, but her birthday gave us the opportunity to honor her while she was still alive. My mother’s death was about as good as it gets:  95 years old; 92+ good/great years; anticipated (to the extent that you can truly anticipate and prepare for such a loss); in her home; ample opportunities to honor her and say good bye. And yet the void is huge. Our house, so recently filled with caregivers, my mother a constant presence, suddenly empty. Quiet. All of the equipment accumulated over months now still, useless, almost grotesque. Her few possessions provide little comfort. I wander aimlessly, forgetful, unraveled.  How do people cope with unnatural losses such as the loss of a child, the loss of a loved one by violence, losses on the scale of the recent earthquake in Haiti? Nursing colleagues at my health center lost multiple family members, young and old, all at once, without warning, buried in mass graves, no goodbyes…. How do you reconfigure your life following such losses? During the past months, the lessons of my personal life have become the key lessons of my professional life: what you need to die well is not that different from what you need to live well: to be embraced by a community of friends and family, physical comfort, safety, to be released from your fears, appreciated for yourself and your contributions small or large, and gentle, loving care through all transitions and passages. Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health. [Editor’s Note: The Modern Medicine staff extends our sympathy and our heartfelt thanks to Dr Gottlieb for sharing her experiences in the hopes that it may benefit another.] elder care, end-of-life care, geriatrics, primary care nonadult false Everything I Didn’t Know about Elder Care: The Postscript text blog elder care,end-of-life care,geriatrics,primary care 460 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 1 Primary Care 0 1929220 2771822 Member 0 http://community.modernmedicine.com/_Everything-I-Never-Knew-About-Elder-Care/blog/1778191/33379.html Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] Fri, 29 Jan 2010 16:39:14 GMT http://community.modernmedicine.com/_Everything-I-Never-Knew-About-Elder-Care/blog/1778191/33379.html bgottlieb 2010-01-29T16:35:38Z Primary Care Modern Medicine Community Many years ago, when my children were little, I remember my pediatrician saying that he never knew how hollow and meaningless much of his advice to parents was until he had his own children. I now make a similar claim. Except in my case, it is about elder care. My mother has had extraordinary health. Until age 92—2 years ago—she volunteered at my health center. For more than 10 years, she sat at the child-sized table and chairs in the dental department’s waiting room (she is not much taller than a fifth grader herself), coloring, doing word games, and making puzzles with children from the school dental program who would otherwise run wild as they waited for their appointments. She lived in an in-law apartment on the third floor of our house until one year ago, and until recently filled her days with knitting, reading, listening to her divas Ella Fitzgerald and Billie Holiday. Just after Labor Day, 2009, my mother was hospitalized for about a month. Between the hospitalization and a stint in a highly recommended rehabilitation facility, I received an education on the state of elder care, and on the state of the health care “system” in general that my 29 years of practice had not yet provided. Questions about hospital care: Where are the nurses? What used to be nursing care has been divided up according to discrete tasks: one nurse’s aide does the vital signs; another aide changes the bed; yet another shows up for bathroom calls; the dietary aide picks up the next day’s menu. Patient care as piece work. As far as I can tell, the nurses mainly focus on medications—tracking, administering, and an enormous amount of documentation. My mother had no idea who her primary nurse was. Although the nurse’s name was dutifully written on the whiteboard across from my mother’s bed, this person was a phantom. No one knew very much about my mother. No one could really answer simple questions, like when a test that required fasting would be done so she would know when she could expect to eat. At the rehabilitation facility, there simply was no one minding the store. How do patients eat? For most of the time during her hospitalization, my mother had an IV line in her right hand. Being right handed, this presented some challenges in eating. If a family member wasn’t there at mealtime, her tray would sit too far for her to reach, and even if she could reach it, she wouldn’t have been able to open the various packages, remove the lids and actually get the food from the plate to her mouth. At rehab it was even worse. Many days we arrived at dinner time, only to find the lunch tray next to the door, cold, untouched, and completely unappealing. The degree of neglect at the rehab facility was such that my mother, who entered fully continent, left 10 days later in diapers that she has not been able to shed. She entered rehab walking unassisted from her bed to the bathroom. She left barely able to walk, fully assisted by another person, fully dependent on a walker. Re-hab? No. De-hab. Not funny. She has never regained her independence. My mother has had a lifelong fear of nursing homes. We had promised to honor her wish to be cared for at home. After considering her needs, wants, wishes, values and options, my mother chose to be cared for by a home hospice agency. We were so happy to get her home, where we could keep an eye on things and have some choice about who would care for her and how she would be cared for. We soon learned that choice was really another word for responsibility—way more responsibility than we expected. If I have so many case managers, why am I managing everything? In the week following my mother’s discharge, I met with nurse case managers, social work case managers, chaplains, nurses’ aides. There was a long list of services that I needed to get in place and an even longer list of equipment and supplies. Thankfully, hospice is great about the latter. You want a hospital bed—you get one within a few hours. I know because I needed one that quickly. I called late Sunday morning. By sundown the bed was in place, assembled and our 2 cats had adjusted to this strange new mechanical device. Arranging the actual services and personnel is a bit trickier. My husband and I both work full time plus. We knew we needed to arrange for full-time care for my mother. But in retrospect I admit that I didn’t really know what that meant. Luckily, we could fill in some of the hours with a student who took my mother’s former apartment in exchange for some hours of care. But waking hours are a lot of hours to fill. We learned quickly that hospice doesn’t provide actual care. Nursing visits, therapists, chaplains, a little bit of personal care, yes. But not care that filled in any of the unfilled long hours of the day. They provided us with a list of agencies, but we were on our own to arrange this. We then learned that Medicare doesn’t pay for home health care. The hourly wages plus the agency fees would all be out-of-pocket expenses. Although we have excellent salaries, the dollars add up fast. We tried to be practical and realistic in the schedule we drew up. We quickly covered the hours from when we left for work until we returned. But as my mother has become weaker and more needy, we quickly needed more hours. And more. And more. And then the tasks. Keeping track of medications. Keeping track of supplies. Laundry. Emails to each of the care providers. Some days require up to 15 emails to keep things on track. Is it because I am a physician that I am in the middle of all of these details? Within a few weeks I felt I was so consumed by all of these tasks that I had no time to spend enjoying my mother’s last days. I found myself looking longingly back at the weeks she spent in the hospital and at rehab. What did I expect? It seems so naïve now. I am embarrassed to even write what I expected. I thought there was a system of care. No. There isn’t. There are pieces of care that you, the consumer, you, the family must string together. You provide the glue—the coordination, the communication hub. I thought that hospice focused on the quality of life—for the patient at the end of life, for the family and friends. There are, indeed components of such a vision. Each individual person is lovely, hard working and devoted. But the components are just that—discrete pieces of a badly engineered plan. I thought that someone who was an expert and experienced in end-of-life care could help me anticipate the things we would need to put in place. While it is helpful for someone to remind me of the stages of grief, it would have been more useful for someone to point out that if a person is this weak now, it is likely that she will be this much weaker in XX amount of time, and would consequently require XXX additional care. My mother has been home for nearly 4 months. I feel like I am still chasing her needs—still barely keeping up with the moving target that end of life is. Don’t the nurses and social workers who see this all the time know this? I feel that they are generous with generic advice and insight (sitting in my living room, my resplendent Steinway with my current Mozart sonata on the stand in full view, the social worker asked if I had ever thought about bringing music into the home because it can be so helpful to the dying patient) but no one helped me think ahead to the need for a hospital bed with side rails until it threatened to became a crisis. I am not a geriatrician, but I have taken care of many elderly patients. I even care for them at home as they become unable to come into the health center. If you had asked me 5 months ago if I knew what it was like to take care of your failing elder at home, I would have said that I had some idea. But I would have been wrong. I now encourage my students and residents to consider geriatrics. And for nonphysicians who are looking for a promising career—how about a career in elder services planning. The demographics are with you. And if health care continues in its current poorly engineered state, there will be great demand for people who can plan and coordinate care for this vulnerable group. [Editor’s Note: Do you have thoughts on this topic? Please Log in and Comment in the box that will appear below this blog.] elder care, geriatrics, primary care nonadult false Everything I Never Knew About Elder Care… text blog elder care,geriatrics,primary care 566 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 4 Primary Care 0 1778191 2771822 Member 0 http://community.modernmedicine.com/_The-Crisis-in-Primary-Care/blog/1694851/33379.html I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. Wed, 06 Jan 2010 17:20:05 GMT http://community.modernmedicine.com/_The-Crisis-in-Primary-Care/blog/1694851/33379.html bgottlieb 2010-01-06T16:32:47Z Primary Care Modern Medicine Community I spend most of my time working in the outpatient setting. However, each year for 2 weeks I dust off my inpatient skills and attend on the general medical service of my busy academic teaching hospital. I’m never sure how much I have to teach, but I know that I learn a lot each year—about acute/inpatient medicine and about the state of health care. As it turned out, these were 2 interesting weeks to be on-service. As the Senate debated the language of the health care bill and health reform was the on the minds of all Americans, I witnessed a critical dimension of our nation’s challenge in health care each time I rounded in the hospital—the crisis in primary care. At least one third of the patients were admitted with problems that could have been (should have been) prevented by reasonably well-coordinated primary care: CHF, hypertension, diabetes, asthma out of control due to misunderstanding of medications; several cases of herpes zoster in patients who had never been vaccinated—adding to the cost and complexity of hospital care; patients who had not been treated and/or retested for their MRSA or VERS following previous hospitalizations, also adding to the cost and complexity of their subsequent admissions. One patient with cardiomyopathy was admitted because she could not afford the copayments on her medications. The residents and I were struck by the irony that it would be easier to get her a heart transplant than to ensure that she received her Lasix every year. Patients were sick because they had not received influenza vaccines, pneumococcal vaccines, and on and on. Many of our patients actually had primary care providers but all reported difficulty getting an appointment. “She is so busy; I can never get an appointment.” “He never has a chance to call me back when I have a question.” None of this is new, although it seemed a little worse this year. What was new was the plea I began to hear on a daily basis. “Would you be my doctor?” Many patients have no primary care provider. Others hadn’t seen theirs in a very long time. On several occasions, while rounding in a double room, my patient asked if I would be her doctor, and her roommate chimed in, “Can I come and see you, too?” One morning the woman cleaning the floors asked if I would mind seeing her. She has qualified for insurance for the first time and needs a doctor. Another day it was the phlebotomist--insured for several years, but still unable to find a doctor with an open practice. "Please let me come to your practice." The most remarkable request came while I was Christmas shopping. I had run out of the hospital for an hour to do some frenetic gift-hunting. As I was checking out, the clerk asked what kind of doctor I was. For a moment I wondered how she had guessed. Then I realized that I had forgotten to remove my stethoscope. I told her that I was a primary care internist. When she asked where I practiced. I assumed she was just making conversation until she, too, joined the chorus. “Could I become your patient?” It turned out that she had been treated for breast cancer, was up-to-date with all of her cancer follow-up and doing well, but has no primary care doctor. “So I’m behind on ‘the regular things that people get.’ ” Complicated and incomplete as the bills before Congress may be, it is exciting that the country is beginning to see health care as a basic right. However, there is a lot more to resolve than who will have insurance and how that insurance will be paid for. We need well-run systems that link inpatient to outpatient care; that constantly seek to improve outpatient care for people with complex chronic conditions such as CHF, hypertension, diabetes and asthma. We need to provide preventive care and surveillance and to maintain optimum health and well-being for all people. We need to avoid unnecessary suffering and the use of scarce resources for complications that are preventable. In my view, primary care would, of course, be at the center of such a well-designed system. However, primary care will not be able to deliver on its potential to provide high quality care, insure rational use of resources, and foster the best and most equitable outcomes possible if it is overwhelmed by the onslaught of increased demand. Health care reform efforts must be tied to plausible short- and long-term strategies to address the shortage in primary care providers. health care resources, primary care, quality medical care nonadult false The Crisis in Primary Care— text blog health care resources,primary care,quality medical care 1533 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 9 Primary Care 0 1694851 2771822 Member 0 http://community.modernmedicine.com/_Diabetes-medications-and-the-doughnut-hole/blog/1549354/33379.html Several years ago, our health center was lucky enough to be able to put together funding to support a diabetes nurse educator. The benefits were apparent almost immediately. HbA1c tests plummeted; LDLs went down; BP readings improved. The majority of these improvements occurred without any change in medications or doses. What made the biggest difference? According to the nurse, medication adherence was the greatest factor. First of all, it seemed that patients were more willing to tell her that they weren’t taking their medications than us, their primary care physicians. Second, even when patients were not forthcoming, she had the time to check their medication records and see if they were requesting refills at the expected intervals. She worked closely with local pharmacists to get a better picture of our patients’ medication use. Armed with this knowledge and insight, as providers, we were then able to address the issue of medication adherence more directly and with greater clarity than previously. In these difficult economic times, and, ironically, at times as a result of efforts to expand insurance benefits, we are seeing new problems in medication adherence among patients who are insured but whose coverage requires substantial out of pocket expenses. Anecdotally, our nurse is seeing a few patterns: One is of patients who take 6 to 10 medications each day who cannot afford monthly co-payments on all prescriptions—so they get some of their medications some months and others another month. This may explain why medications that I thought I renewed on the same day seem to be running out on different days. It may also explain why, suddenly, my diabetic patients who had previously met all targets are not doing as well as they had been. Their LDL is 20 points higher after being below target for several years; their HbA1c is climbing above 7 without any apparent reason. Another pattern is one that has been identified among Medicare Part D beneficiaries. Medicare Part D is designed in such a way that enrollees have a potential coverage gap, commonly known as “the doughnut hole.” In 2006, the year of the study, enrollees received partial coverage for the first $2250 of drug costs, followed by a period during which they paid out of pocket to a total of $3600 in out-of-pocket payments, at which point catastrophic coverage kicks in. At that point, patients pay 5% of drug costs or a predetermined co-payment from that time forward. Schmittdiel and colleagues performed a recent study of people age 65 and older in California who were identified as having diabetes and were beneficiaries of a Medicare Advantage Prescription Drug (MADP) plan.1 The authors chose to study diabetic patients because of their vulnerability to “cost related nonadherence.” Diabetics typically have a long list of daily medications specifically for their diabetes, for their many associated co-morbidities, as well as for prevention of cardiac and renal complications. When the Medicare Part D program began, many predicted that large numbers of diabetic patients would fall into the “doughnut hole.”2 In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap. This number was fewer than expected. However, relatively speaking, more diabetics reached the coverage gap than seniors as a whole. However, only 2% of beneficiaries reached the $3600 level in out-of-pocket expenses that would qualify them for catastrophic benefits. They found that beneficiaries had $2182 in total drug costs, with a mean of $807 in out-of-pocket drug costs. For senior citizens living on a fixed income, this is not a trivial expense and can often require a trade-off between medications and other necessary expenses such as food or heat. Indeed, the authors noted that total drug costs were decreasing in the latter part of the year as out-of pocket costs were rising. Their interpretation is that medication use by diabetic patients could be decreasing once they hit the “doughnut hole.” The authors cite other studies of Medicare Part D in which there is decreased drug adherence based on cost, especially among patients with worse health status such as diabetes.3 Indeed, my Medicare Part D patients admit to making trade-offs. “I have a headache, so I’ll fill my blood pressure medication this month.” “My blood sugar has been good, so I can hold off on these diabetes pills for a few months.” It shouldn’t be surprising that medication nonadherence has significant adverse consequences. As a provider, I need to be aware of the forces that have an impact on my patients’ health, including economic forces. Rather than blindly increasing doses of medications when disease marker outcomes are getting worse, I need to discuss medication and treatment costs and carefully and respectfully assess medication adherence. [Editor's Note: How are your patients managing to comply with their medication regimens in this recession? Log in and Comment in the box below.] References 1. Schmittdiel JA, Ettner SL, Fung V, et al. Medicare Part D coverage gap and diabetes beneficiaries. Am J Manag Care. 2009;15(3):189-193.2. Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among elderly and disabled Medicare beneficiaries: a national survey 1 year before the Medicare drug benefit. Arch Intern Med. 2006;166(17):1829-1835.3. Jackson JE, Doescher MP, Saver BG, et al. Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions. Med Care. 2004:42(11):1056-1065. Several years ago, our health center was lucky enough to be able to put together funding to support a diabetes nurse educator. The benefits were apparent almost immediately. HbA1c tests plummeted; LDLs went down; BP readings improved. The majority of these improvements occurred without any change in medications or doses. What made the biggest difference? According to the nurse, medication adherence was the greatest factor. First of all, it seemed that patients were more willing to tell her that they weren’t taking their medications than us, their primary care physicians. Second, even when patients were not forthcoming, she had the time to check their medication records and see if they were requesting refills at the expected intervals. She worked closely with local pharmacists to get a better picture of our patients’ medication use. Armed with this knowledge and insight, as providers, we were then able to address the issue of medication adherence more directly and with greater clarity than previously. In these difficult economic times, and, ironically, at times as a result of efforts to expand insurance benefits, we are seeing new problems in medication adherence among patients who are insured but whose coverage requires substantial out of pocket expenses. Anecdotally, our nurse is seeing a few patterns: One is of patients who take 6 to 10 medications each day who cannot afford monthly co-payments on all prescriptions—so they get some of their medications some months and others another month. This may explain why medications that I thought I renewed on the same day seem to be running out on different days. It may also explain why, suddenly, my diabetic patients who had previously met all targets are not doing as well as they had been. Their LDL is 20 points higher after being below target for several years; their HbA1c is climbing above 7 without any apparent reason. Another pattern is one that has been identified among Medicare Part D beneficiaries. Medicare Part D is designed in such a way that enrollees have a potential coverage gap, commonly known as “the doughnut hole.” In 2006, the year of the study, enrollees received partial coverage for the first $2250 of drug costs, followed by a period during which they paid out of pocket to a total of $3600 in out-of-pocket payments, at which point catastrophic coverage kicks in. At that point, patients pay 5% of drug costs or a predetermined co-payment from that time forward. Schmittdiel and colleagues performed a recent study of people age 65 and older in California who were identified as having diabetes and were beneficiaries of a Medicare Advantage Prescription Drug (MADP) plan.1 The authors chose to study diabetic patients because of their vulnerability to “cost related nonadherence.” Diabetics typically have a long list of daily medications specifically for their diabetes, for their many associated co-morbidities, as well as for prevention of cardiac and renal complications. When the Medicare Part D program began, many predicted that large numbers of diabetic patients would fall into the “doughnut hole.”2 In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap. This number was fewer than expected. However, relatively speaking, more diabetics reached the coverage gap than seniors as a whole. However, only 2% of beneficiaries reached the $3600 level in out-of-pocket expenses that would qualify them for catastrophic benefits. They found that beneficiaries had $2182 in total drug costs, with a mean of $807 in out-of-pocket drug costs. For senior citizens living on a fixed income, this is not a trivial expense and can often require a trade-off between medications and other necessary expenses such as food or heat. Indeed, the authors noted that total drug costs were decreasing in the latter part of the year as out-of pocket costs were rising. Their interpretation is that medication use by diabetic patients could be decreasing once they hit the “doughnut hole.” The authors cite other studies of Medicare Part D in which there is decreased drug adherence based on cost, especially among patients with worse health status such as diabetes.3 Indeed, my Medicare Part D patients admit to making trade-offs. “I have a headache, so I’ll fill my blood pressure medication this month.” “My blood sugar has been good, so I can hold off on these diabetes pills for a few months.” It shouldn’t be surprising that medication nonadherence has significant adverse consequences. As a provider, I need to be aware of the forces that have an impact on my patients’ health, including economic forces. Rather than blindly increasing doses of medications when disease marker outcomes are getting worse, I need to discuss medication and treatment costs and carefully and respectfully assess medication adherence. [Editor's Note: How are your patients managing to comply with their medication regimens in this recession? Log in and Comment in the box below.] References 1. Schmittdiel JA, Ettner SL, Fung V, et al. Medicare Part D coverage gap and diabetes beneficiaries. Am J Manag Care. 2009;15(3):189-193.2. Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among elderly and disabled Medicare beneficiaries: a national survey 1 year before the Medicare drug benefit. Arch Intern Med. 2006;166(17):1829-1835.3. Jackson JE, Doescher MP, Saver BG, et al. Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions. Med Care. 2004:42(11):1056-1065. Thu, 10 Dec 2009 15:07:10 GMT http://community.modernmedicine.com/_Diabetes-medications-and-the-doughnut-hole/blog/1549354/33379.html bgottlieb 2009-12-08T15:42:25Z Endocrinology Modern Medicine Community Several years ago, our health center was lucky enough to be able to put together funding to support a diabetes nurse educator. The benefits were apparent almost immediately. HbA1c tests plummeted; LDLs went down; BP readings improved. The majority of these improvements occurred without any change in medications or doses. What made the biggest difference? According to the nurse, medication adherence was the greatest factor. First of all, it seemed that patients were more willing to tell her that they weren’t taking their medications than us, their primary care physicians. Second, even when patients were not forthcoming, she had the time to check their medication records and see if they were requesting refills at the expected intervals. She worked closely with local pharmacists to get a better picture of our patients’ medication use. Armed with this knowledge and insight, as providers, we were then able to address the issue of medication adherence more directly and with greater clarity than previously. In these difficult economic times, and, ironically, at times as a result of efforts to expand insurance benefits, we are seeing new problems in medication adherence among patients who are insured but whose coverage requires substantial out of pocket expenses. Anecdotally, our nurse is seeing a few patterns: One is of patients who take 6 to 10 medications each day who cannot afford monthly co-payments on all prescriptions—so they get some of their medications some months and others another month. This may explain why medications that I thought I renewed on the same day seem to be running out on different days. It may also explain why, suddenly, my diabetic patients who had previously met all targets are not doing as well as they had been. Their LDL is 20 points higher after being below target for several years; their HbA1c is climbing above 7 without any apparent reason. Another pattern is one that has been identified among Medicare Part D beneficiaries. Medicare Part D is designed in such a way that enrollees have a potential coverage gap, commonly known as “the doughnut hole.” In 2006, the year of the study, enrollees received partial coverage for the first $2250 of drug costs, followed by a period during which they paid out of pocket to a total of $3600 in out-of-pocket payments, at which point catastrophic coverage kicks in. At that point, patients pay 5% of drug costs or a predetermined co-payment from that time forward. Schmittdiel and colleagues performed a recent study of people age 65 and older in California who were identified as having diabetes and were beneficiaries of a Medicare Advantage Prescription Drug (MADP) plan.1 The authors chose to study diabetic patients because of their vulnerability to “cost related nonadherence.” Diabetics typically have a long list of daily medications specifically for their diabetes, for their many associated co-morbidities, as well as for prevention of cardiac and renal complications. When the Medicare Part D program began, many predicted that large numbers of diabetic patients would fall into the “doughnut hole.”2 In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap. This number was fewer than expected. However, relatively speaking, more diabetics reached the coverage gap than seniors as a whole. However, only 2% of beneficiaries reached the $3600 level in out-of-pocket expenses that would qualify them for catastrophic benefits. They found that beneficiaries had $2182 in total drug costs, with a mean of $807 in out-of-pocket drug costs. For senior citizens living on a fixed income, this is not a trivial expense and can often require a trade-off between medications and other necessary expenses such as food or heat. Indeed, the authors noted that total drug costs were decreasing in the latter part of the year as out-of pocket costs were rising. Their interpretation is that medication use by diabetic patients could be decreasing once they hit the “doughnut hole.” The authors cite other studies of Medicare Part D in which there is decreased drug adherence based on cost, especially among patients with worse health status such as diabetes.3 Indeed, my Medicare Part D patients admit to making trade-offs. “I have a headache, so I’ll fill my blood pressure medication this month.” “My blood sugar has been good, so I can hold off on these diabetes pills for a few months.” It shouldn’t be surprising that medication nonadherence has significant adverse consequences. As a provider, I need to be aware of the forces that have an impact on my patients’ health, including economic forces. Rather than blindly increasing doses of medications when disease marker outcomes are getting worse, I need to discuss medication and treatment costs and carefully and respectfully assess medication adherence. [Editor's Note: How are your patients managing to comply with their medication regimens in this recession? Log in and Comment in the box below.] References 1. Schmittdiel JA, Ettner SL, Fung V, et al. Medicare Part D coverage gap and diabetes beneficiaries. Am J Manag Care. 2009;15(3):189-193.2. Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among elderly and disabled Medicare beneficiaries: a national survey 1 year before the Medicare drug benefit. Arch Intern Med. 2006;166(17):1829-1835.3. Jackson JE, Doescher MP, Saver BG, et al. Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions. Med Care. 2004:42(11):1056-1065. diabetes, endocrinology, medicare part d, medication adherence, prescription drug coverage nonadult false Diabetes, medications, and the doughnut hole text blog diabetes,endocrinology,medicare part d,medication adherence,prescription drug coverage 408 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Endocrinology 0 1549354 2771822 Member 0 http://community.modernmedicine.com/_AACEACE-Consensus-Statement-on-Diabetes-Treatment-One-practitioners-gratitude/blog/1479647/33379.html This will be a simple expression of gratitude. I have never been so happy to read a medical document as I was to read the recent AACE/ACE Consensus Statement on the treatment and control of type 2 diabetes.1 [abstract] This 19-page document provides solid, practical, and simple guidelines for the evaluation and treatment of type 2 diabetes--a no-frills approach to this complex and prevalent disease. The panel consists of experts in the management of diabetes. They reviewed the available literature and established underlying principles for their recommendations and target levels for treatment endpoints. However, given the relative lack of randomized controlled clinical trials that evaluate combinations of medications, they also based recommendations on their extensive clinical experience, attempting to achieve consensus as much as possible. The authors make their underlying principles transparent and remain true to these principles: Avoid hypoglycemia (the key guiding principle) Lifestyle (diet and exercise) activities are the cornerstone of all treatment programs and should be encouraged at every opportunity Fasting and postprandial control are treatment endpoints Maximize safety and efficacy (safety and efficacy are valued over cost, since cost of medications is only a small part of the cost of care of type 2 diabetes) Minimize weight gain Consider all FDA-approved medication classes Maximize simplicity of treatment regimens as much as possible Anticipate the degree of patient adherence, and modify treatments appropriately Consider cost of treatment to the individual and society (medications, monitoring, and the cost of complications) The treatment algorithm provides a useful guide to both the expert and the generalist. By focusing on the level of HbA1c and the expected lowering by particular drug classes, the provider knows what to expect and can provide realistic guidance to the patient as well. The recommendations include an aggressive, yet safe pace for lowering the HbA1c by monitoring every 2 to 3 months and stepping up treatment as indicated. The report is comprehensive. The provider is reminded to reinforce lifestyle changes at sentinel moments of treatment, such as when a new drug class is introduced. Similarly, the provider is reminded to reinforce the full range of risk reduction interventions: tobacco cessation, use of aspirin, ACE inhibitors or angiotensin receptor blockers, and statins. In addition, there is a brief review of the pharmacology of each class of drug and a practical guide to drug-drug interactions. Why am I so grateful? Not a clinical session goes by that I don’t have to face some sort of decision about diabetes treatment. However, the decision, the circumstances, the nuances are different for each patient. While the authors caution the practitioner to individualize treatment, this document provides a solid jumping-off point. I always tell my students that diabetes is a low-tech disease. What I mean by this is that diabetes is related to the most basic activities of life--what you eat and how much you eat, your exercise and physical activity, and the many social and economic factors that have an impact on these basic activities. Therefore, sadly, even with 8 major categories of medications and research and development seeking new and better pharmacologic pathways to exploit, the solutions to diabetes are, ultimately, low-tech solutions: lifestyle changes and treatment that is safe, effective, and sustainable. I now feel that I have a handle on how to achieve that low-tech objective with my diabetic patients. Reference 1. Rodbard HW, Jellinger PS, Davidson JA et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocrine Practice. 2009;14:540-559. This will be a simple expression of gratitude. I have never been so happy to read a medical document as I was to read the recent AACE/ACE Consensus Statement on the treatment and control of type 2 diabetes.1 [abstract] This 19-page document provides solid, practical, and simple guidelines for the evaluation and treatment of type 2 diabetes--a no-frills approach to this complex and prevalent disease. The panel consists of experts in the management of diabetes. They reviewed the available literature and established underlying principles for their recommendations and target levels for treatment endpoints. However, given the relative lack of randomized controlled clinical trials that evaluate combinations of medications, they also based recommendations on their extensive clinical experience, attempting to achieve consensus as much as possible. The authors make their underlying principles transparent and remain true to these principles: Avoid hypoglycemia (the key guiding principle) Lifestyle (diet and exercise) activities are the cornerstone of all treatment programs and should be encouraged at every opportunity Fasting and postprandial control are treatment endpoints Maximize safety and efficacy (safety and efficacy are valued over cost, since cost of medications is only a small part of the cost of care of type 2 diabetes) Minimize weight gain Consider all FDA-approved medication classes Maximize simplicity of treatment regimens as much as possible Anticipate the degree of patient adherence, and modify treatments appropriately Consider cost of treatment to the individual and society (medications, monitoring, and the cost of complications) The treatment algorithm provides a useful guide to both the expert and the generalist. By focusing on the level of HbA1c and the expected lowering by particular drug classes, the provider knows what to expect and can provide realistic guidance to the patient as well. The recommendations include an aggressive, yet safe pace for lowering the HbA1c by monitoring every 2 to 3 months and stepping up treatment as indicated. The report is comprehensive. The provider is reminded to reinforce lifestyle changes at sentinel moments of treatment, such as when a new drug class is introduced. Similarly, the provider is reminded to reinforce the full range of risk reduction interventions: tobacco cessation, use of aspirin, ACE inhibitors or angiotensin receptor blockers, and statins. In addition, there is a brief review of the pharmacology of each class of drug and a practical guide to drug-drug interactions. Why am I so grateful? Not a clinical session goes by that I don’t have to face some sort of decision about diabetes treatment. However, the decision, the circumstances, the nuances are different for each patient. While the authors caution the practitioner to individualize treatment, this document provides a solid jumping-off point. I always tell my students that diabetes is a low-tech disease. What I mean by this is that diabetes is related to the most basic activities of life--what you eat and how much you eat, your exercise and physical activity, and the many social and economic factors that have an impact on these basic activities. Therefore, sadly, even with 8 major categories of medications and research and development seeking new and better pharmacologic pathways to exploit, the solutions to diabetes are, ultimately, low-tech solutions: lifestyle changes and treatment that is safe, effective, and sustainable. I now feel that I have a handle on how to achieve that low-tech objective with my diabetic patients. Reference 1. Rodbard HW, Jellinger PS, Davidson JA et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocrine Practice. 2009;14:540-559. Thu, 12 Nov 2009 18:01:31 GMT http://community.modernmedicine.com/_AACEACE-Consensus-Statement-on-Diabetes-Treatment-One-practitioners-gratitude/blog/1479647/33379.html bgottlieb 2009-11-09T21:02:03Z Endocrinology Modern Medicine Community This will be a simple expression of gratitude. I have never been so happy to read a medical document as I was to read the recent AACE/ACE Consensus Statement on the treatment and control of type 2 diabetes.1 [abstract] This 19-page document provides solid, practical, and simple guidelines for the evaluation and treatment of type 2 diabetes--a no-frills approach to this complex and prevalent disease. The panel consists of experts in the management of diabetes. They reviewed the available literature and established underlying principles for their recommendations and target levels for treatment endpoints. However, given the relative lack of randomized controlled clinical trials that evaluate combinations of medications, they also based recommendations on their extensive clinical experience, attempting to achieve consensus as much as possible. The authors make their underlying principles transparent and remain true to these principles: Avoid hypoglycemia (the key guiding principle) Lifestyle (diet and exercise) activities are the cornerstone of all treatment programs and should be encouraged at every opportunity Fasting and postprandial control are treatment endpoints Maximize safety and efficacy (safety and efficacy are valued over cost, since cost of medications is only a small part of the cost of care of type 2 diabetes) Minimize weight gain Consider all FDA-approved medication classes Maximize simplicity of treatment regimens as much as possible Anticipate the degree of patient adherence, and modify treatments appropriately Consider cost of treatment to the individual and society (medications, monitoring, and the cost of complications) The treatment algorithm provides a useful guide to both the expert and the generalist. By focusing on the level of HbA1c and the expected lowering by particular drug classes, the provider knows what to expect and can provide realistic guidance to the patient as well. The recommendations include an aggressive, yet safe pace for lowering the HbA1c by monitoring every 2 to 3 months and stepping up treatment as indicated. The report is comprehensive. The provider is reminded to reinforce lifestyle changes at sentinel moments of treatment, such as when a new drug class is introduced. Similarly, the provider is reminded to reinforce the full range of risk reduction interventions: tobacco cessation, use of aspirin, ACE inhibitors or angiotensin receptor blockers, and statins. In addition, there is a brief review of the pharmacology of each class of drug and a practical guide to drug-drug interactions. Why am I so grateful? Not a clinical session goes by that I don’t have to face some sort of decision about diabetes treatment. However, the decision, the circumstances, the nuances are different for each patient. While the authors caution the practitioner to individualize treatment, this document provides a solid jumping-off point. I always tell my students that diabetes is a low-tech disease. What I mean by this is that diabetes is related to the most basic activities of life--what you eat and how much you eat, your exercise and physical activity, and the many social and economic factors that have an impact on these basic activities. Therefore, sadly, even with 8 major categories of medications and research and development seeking new and better pharmacologic pathways to exploit, the solutions to diabetes are, ultimately, low-tech solutions: lifestyle changes and treatment that is safe, effective, and sustainable. I now feel that I have a handle on how to achieve that low-tech objective with my diabetic patients. Reference 1. Rodbard HW, Jellinger PS, Davidson JA et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocrine Practice. 2009;14:540-559. diabetes guidelines, endocrinology nonadult false AACE/ACE Consensus Statement on Diabetes Treatment: One practitioner’s gratitude text blog diabetes guidelines,endocrinology 1034 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771822&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1388043_33379_2771822_ap_160X120.jpg false 0 Endocrinology 0 1479647 2771822 Member 0