Today at morning report, we discussed the resources available to a general internist when deciding which imaging study to order. Besides a phone call to your friendly radiology colleague, one of the most helpful resources is the American College of Radiology’s Appropriateness Criteria. These evidence-based guidelines were developed and are periodically updated by a panel of expert radiologists (last update November 2015). The guidelines include numerical “appropriateness” scores (1-3 usually not appropriate, 4-6 may be appropriate, 7-9 usually appropriate) for individual modalities in specific clinical settings. They also include literature review and suggestions for clinical variations (i.e. pregnancy, contrast allergy). A useful resource when deciding whether or not to send your patient through the tube of truth!
Example appropriateness criteria for jaundice with acute abdominal pain:
American College of Radiology. ACR Appropriateness Criteria®. Available at https://acsearch.acr.org/list. Accessed 11/23/2015.
Classic manifestation of Wernicke’s Syndrome is isolated abducens nerve (CN XI) palsy.
Today at morning report we discussed high value care and professionalism/managerial skills. We specifically noted a recent article published in JAMA by oncologist Dr. Ezekiel Emanuel from the University of Pennsylvania and an article in NEJM by Dr. Michael Porter of the Harvard Business School published in 2010. Click on the links below to read the articles!
“Higher income, higher educational attainment, and a cleaner environment are actually more important in determining patients’ well-being than health care services.” Dr. Ezekiel Emanuel
What is Value in Health Care
Enhancing Professionalism Through Management
This past April, two podcasts were released by Freakonomics that took a closer look at randomized controlled trials and taking the approach of “less is more” in taking care of patients. The first podcast interviews Amy Finkelstein, an economist from M.I.T, who has been looking at the utility of conducting randomized controlled trials in studying health care delivery and uses the Oregon Medicaid Health Experiment as an example. In the second podcast, Dr. Anupam Jena (assistant professor at Harvard Medical School) is interviewed regarding a study he led that looked at outcomes in Medicare patients when specialists are away at a conference. Click on the links below to be directed to the podcast from the Freaknonomics website. Thanks to resident Sean Townsend for the reference!
How Do We Know What Really Works in Healthcare
How Many Doctors Does It Take to Start a Healthcare Revolution?
This past December in JAMA, Dr. Jeffrey Chi and Dr. Abraham Varghese from Stanford University published an op-ed article in the Viewpoint section titled “The Flipped Patient”. They discuss how electronic health records (EHR) have provided many advantages in care of patients but point out some unintended consequences to training of physicians. Has EHR moved us away from the patient’s bedside? Do we bypass asking about the family history and past medical history because it already auto-populates on the note template? Has the question, “What brings you to the hospital?”, become obsolete with the abundance of information provided in the EHR before you even see the patient? Click on the link below to read the rest the article! Thanks to Dr. Croft and Dr. Kazi for the article reference.
“Ultimately, however, the nature of medicine is the interaction of a vulnerable human being in distress with a caring empathetic team represented by other humans.”
The Flipped Patient
Congratulations to Dr. Ishak Mansi from the division of General Internal Medicine at UT Southwestern for his recently published article, “Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults” in the Journal of General Internal Medicine. Dr. Mansi’s findings were featured on the frontpage of Medscape this past week and has gained a lot of attention. According to Dr. Mansi and the authors, this is one of the first studies to show a connection between statin use and risk of diabetes in a generally healthy group. Click on the links below to read the summary of the article’s findings as well as the abstract!
Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults
Statins Linked to Diabetes and Complications in Healthy Adults (Medscape)
Recently the NY Times had an article commenting on the unforeseen consequences of cost-sharing among patients with chronic illnesses like diabetes, hypertension, and heart disease. This is based on a recent study from The National Bureau of Economic Research that observed patients with higher cost-sharing for medications tend to cut back on them which can have deleterious consequences – more ER visits, hospitalizations, and complications from their chronic illnesses. This would then lead to more healthcare spending which is what cost-sharing was meant to decrease. Check out the article below and click on the link above to the study!
With Sickest Patients, Cost Sharing Comes At A Price
“Shared decision making” is a term we often hear and referred to in health care as patients have become more educated about their health and want to be informed when making medical decisions. With recent spotlight in the media and medical literature on utility of tests and treatments, patients have even more questions for their providers. There is a resource for patients who want to know more about tests and treatments from the Informed Medical Decisions Foundation. This website provides links and articles that help guide a patient through clinic visits and what questions they may want to ask their provider. Also, there are links to online tools such as the cardiovascular disease risk calculator that patients can use. Thanks to Dr. Ethan Halm from the division of General Internal Medicine at UT Southwestern for the reference!
Informed Medical Decisions Foundation – Patient Resources
STRAIGHT FROM THE HOUSESTAFF – the April 2015 UT Southwestern Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from alcoholic hepatitis to which medications to use for stroke prevention in afib. Make sure to take the EKG challenge at the end! You will have to view this post on our website to access the PDF. There is a quick run down of the topics below:
- Extended report: Prediction of cardiovascular risk in rheumatoid arthritis: performance of original and adapted SCORE algorithms. Dr. Brian Skaug reviewing Arts, et al. Ann Rheum Dis. 2015 Feb 17. pii: annrheumdis-2014-206879. doi: 10.1136/annrheumdis-2014-206879
- Trial of Early, Goal-Directed Resuscitation for Septic Shock [The Protocolised Management in Sepsis (ProMISe) Trial]. Dr. James Galloway reviewing Mouncey PR et al. N Engl J Med. 2015;372(14):1301-11.
- A Randomized Trial of Icatibant in ACE-Inhibitor-Induced Angioedema. Dr. James Galloway reviewing Bas M, et al. N Engl J Med. 2015;372(5):418-25.
All of the work above comes from the IMJW Editorial Board: Jan Petrasek, Brian Skaug, Ben Galloway, Natalia Rocha, Doug Darden, and Jeanney Lew!
Today Dr. Bethany Agusala from the division of General Internal Medicine at UT Southwestern gave a lecture today on women’s health, focusing on cervical and breast cancer screening and post-menopausal management. Check out her slides below!