Active Learning is Better Learning

As I work in academic medical center and spend a lot of time with students, residents and fellows, I read with interest an article on active learning on the wards published in Medical Education.

The investigators aimed to compare the educational effectiveness of ward rounds conducted with two different learning methodologies.  72 students in a pediatric rotation were first tested on 30 true/false questions to assess their initial degree of knowledge on pneumonia and diarrhea. Afterwards, they attended ward rounds conducted using an active and a traditional learning methodology. The participants were submitted to a second test 48 hours later in order to assess knowledge acquisition and were asked to answer two questions about self-directed learning and their opinions on the two learning methodologies used.

Reference: Medical Education 2011: 45: 273–279
Double Click image to enlarge

The active methodology proved to be statistically more effective for the three outcomes considered: knowledge acquisition, self-directed learning and student opinion on the methods.

I have always felt that active teaching in clinical setting leads to better knowledge acquisition and likely better clinical skills. This study provides some empiric evidence to that effect.

I struggle, however, with how to best implement this teaching method in our Internal Medicine Service. With heavy patient loads, mandatory teaching conferences, clinic sessions, days off and disposition/social work rounds, the day (and rounds) has become so fragmented that simply completing bedside assessments with a proper team has become nearly illusory.

I am open to any suggestions that you may have.

Separate and Unequeal

For those of you deluded that there are few disparities in health care in the USA,  and I am not referring to the gap between insured and uninsured, it is worth mentioning the regional differences in medical practice across the country for those that are insured.

A recent WSJ blog nicely highlights the differences in surgical treatment for back pain among Medicare recipients based on zip code. Regional differences in practice exists and these may be due to how area physicians were trained, number of specialists, and financial incentives.

More care may not necessarily translate into a better outcome. This topic is nicely explored in Shannon Brownlee's book, Overtreated, required reading in my Public Health Seminar.

Again, comparative effectiveness research is needed to best guide practice and treatment guidelines. 

Drug Marketing Undermines Patient Safety and Public Health

The American Journal of Public Health, a recently published a healthy policy and ethics article titled: The Inverse Benefit Law: How Drug Marketing Undermines Patient Safety and Public Health.

The authors critically review recent issue of pharmaceutical market withdrawals and postulate that these are not random events, but rather, part of a recurring theme. Under the 'inverse benefit law'  the ratio of benefits to harm varies inversely by how extensively the drugs are marketed.

Extensive and aggressive marketing is driven by primarily by profit motive and financial gain, not the public good.

6 basic marketing strategies are higlighted: 

• reducing thresholds for diagnosing disease 
• relying on surrogate endpoints 
• exaggerating safety claims 
• exaggerating efficacy claims 
• creating new diseases 
• encouraging unapproved use

By allowing a for-profit industry to heavily influence its practice, education, and research, the medical profession has compromised the integrity of medical science and public trust.

Comparative effectiveness research and reforms to improve evidence-based prescribing are urgently needed.

Affordable Health Care in Virginia

I recently read a thoughtful and well written perspective on health care reform and the Affordable Care Act. 

What was most striking was that the commentary was published in the Richmond Times Dispatch. 

Who would have predicted it?

The White Coat- Friend or Foe ?

The debate continues regarding ''bare below the elbows'' for inpatient care. At VCU medical center, this is an infection prevention recommendation and not a mandate.

A recent paper published in the Journal of Hospital Medicine failed to find a difference in bacterial and MRSA colonization between the white coats and uniforms. An excellent commentary was recently posted by my colleague Mike Edmond.

Photo: Mike Edmond

At the core of the ongoing argument is that garments can harbor pathogens. A bare below the elbows approach allows for hand hygiene to the forearms and limits the contact of colonized apparel (cuffs) with the patient. The intervention is simple, inexpensive (all you need is a short sleeve garment), biologically plausible and likely will not cause harm.

Larger studies are needed to definitively prove or refute this hypothesis.

Of note, ''bare below the elbows'' for inpatient care has been eagerly adopted, in our hospital, by young physicians (young defined as my age or younger). 

It seems that the old guard is resistant to shedding their symbolic white coats with some claiming that the lack of a shirt, tie and lab coat renders an unprofessional appearance. Others claim that coat pockets are needed for their instruments, papers, pens, etc.

For this last group, perhaps they could resolve the insufficient pockets issue by carrying a man purse !

TB Screening of Healthcare Workers: From Simple to Complicated

Tuberculin Skin Test (PPD) -Photo: CDC

As an infectious diseases physician and hospital epidemiologist, I have heard over and over how difficult it is for the hospital’s employee health to TB screen our employees yearly with a PPD skin test.

Enter a new tuberculosis screening strategy for healthcare workers recently published in the Journal of Hospital Infection.

Japanese investigators integrated chest CT scans and the QuantiFERON^®-TB Gold (QFT-G) test into their healthcare worker TB screening program. First, contacts were tested using the QFT-G test. Those positive for the QFT-G test were investigated by CT and classified as having active, latent, or old TB.  A total of 512 healthcare workers with close or high risk contacts were identified, and underwent screening. Out of those, 34 (6.64%) were QFT-G positive, whereas 478 (93.36%) were negative. Of the 34 QFT-G-positive HCWs, four had CT findings compatible with active TB and received multidrug treatment; 24 showed no findings of active TB and received isoniazid for six months. All completed their regimens without any adverse effects.

Sounds excellent, however, several questions remain.

• How many healthcare workers with latent TB would have been missed by the traditional PPD skin testing?
• How many cases of active TB would have been missed by PPD testing, chest X-ray and symptom review?
• What is the cost/benefit of this new approach?
• Perhaps the Japanese are more disciplined and compliant with mandated employee screening. We cannot even get many of our healthcare workers to receive an influenza vaccine or have a PPD placed and read. How are we going to convince them to have serum drawn and undergo a CT scan?

I am by no means a big fan of the PPD skin testing. As a screening test, the PPD is insensitive and unreliable.

This new approach may be much more sensitive yet not feasible.

  

Oxygen Bar: Where the Party is Up Your Nose

Earlier in the week I came across an oxygen bar in a North American ski resort town.

An oxygen bar is an establishment that sells oxygen for recreational-medicinal use. Individual flavored scents may be added to enhance the experience. Oxygen is fashionably sold and delivered via a nasal cannula device as an alternative medicine that is meant to correct oxygen deprivation, remove toxins, cure hangovers, alleviate headaches, stress and enhance relaxation.

So there I was, in a rather fashionable bar-lounge, with leather sofas, slick music and the patrons hooked up to individual nasal cannula devices, breathing in the scented oxygen, relaxing and rejuvenating.

The party in this bar was literally up your nose.

After 30 minutes I felt no different and my wife still had her migraine headache. I need to investigate the medical literature on this further.

Until then, I will take my oxygen the old fashioned way.

Dry Hands from Hand Washing? Well, Here is Some Data for You.

Okay, I may have a one track mind lately. Here I go again, focusing on hand hygiene.

For those hand hygiene laggards, specifically, those who resist the use of alcohol based hand santizers, a recent prospective study compared the effects of traditional hand washing vs. alcohol based hand hygiene rubs. The results of 1932 assessments show that traditional handwashing is a risk factor for dryness and irritation, whereas the use of an alcohol based hand rub causes no skin deterioration and might have a protective effect on skin health.

Alcohol based sanitizers are effective and cause less skin irritation, so why hold back?  Get with the times.

On a different note, I have been skiing this week. Below is a photo I snapped of the medical ski patrol gurney-sleds, nicely lined up, awaiting a call to action. I hope not to experience them in the first hand.

Deviants for a Good Cause: Hand Hygiene

Who said that being deviant is a bad thing?

Dr. Alex Marra, a former trainee of ours, recently published a paper on positive deviance and hand hygiene.

Photo: CDC

Positive deviance is a social and behavioral change process based on the premise that in most organizations and communities there are people or groups of people who solve problems better than colleagues with the exact same resources.

 

With respect to hand hygiene, positive deviants are healthcare workers who want to change and develop new ideas for improving hand hygiene and who stimulate other healthcare workers to wash their hands. In essence, the positive deviants of a hospital are empowered to promote hand hygiene in creative, collaborative and non-threatening ways. They are hand hygiene ‘champions’.

In this paper, the positive deviance approach was responsible for a sustained improvement in hand hygiene and was associated with a decrease in the incidence of device-associated hospital acquired infections.

I am not sure if positive deviance is sustainable, especially if it does not lead to policy and expectation change in a hospital. What happens if the driving force, the deviant, changes employment, loses interests or simply quits? Will practice revert back to the norm? Must a successor to the deviant be identified?

At the very least, the concept of positive deviance appears beneficial in the short term.

So, go ahead, be (positively) deviant.

No smoking, Ever!

As a doctor, I am fully in support of hospitals banning smoking on the premises.

Photo: WSJ

There is recent blog in the WSJ about hospitals in New York not only banning smoking, but prohibiting smoking by their employees at all times. If you are a smoker, you will not be hired.


Libertarians, of course, must be in full disagreement. The decision is based on the concept of negative externalities, that is, although one makes a free and supposedly informed choice,the decision can have a negative impact on others (society). The most commonly quantified negative impact is cost. This argument has been used before, such as with helmet laws and seat belts. By limiting injury, morbidity and mortality, helmets and seat belts limit societal cost.


Back to the hospital. Healthcare workers who smoke cost the employer more on insurance premiums, hence the ban.


This is controversial and may lead to a slippery slope. Should obese people not be hired on similar grounds?

Random Observations: My Weekend in the Hospital

Antimicrobial stethoscope cover - Internal Medicine.

Not sure about the nature of supporting data on this but it seems cool.

I need to get one, use it.....then culture it.

Well, it has been another long and not so glamorous weekend seeing patients in the hospital.


Here are a few observations that I made during the course of the last several days, while going from unit to unit, doing infectious diseases consults.


Pardon the low quality photos, but they were taken with a mobile phone.

Box Full O' Goggles - Internal Medicine

Leadership has been promoting goggle use. 

They certainly are not 'unavailable' so use them!

Although the mask is more effective on your face,

this NIOSH N95 mask is worn cleverly on the back of the shoulder!

Protective AND Portable.

Humanism, Literature and Medicine

I think that no one can argue that humanism is an integral part of medicine.  Unlike medical science, based in biology, biochemistry, physiology and pharmacology, humanism is difficult to teach, and even more challenging to quantify and evaluate.

This should not necessarily be a deterrent to promoting humanism in medical education. I came across this report and perspective from the University of Michigan.

At Virginia Commonwealth University School of Medicine, I teach a 4th year elective titled Exploring the Human Condition;Medicine in Literature. The aim is to stimulate thought and reflection on humanism through great works of literature. Of course, these courses self select students who are likely self described readers and thinkers, so in many ways, it may be a case of 'preaching to the choir.'

Whether classes such as these can have any impact on the alleviation of pain and suffering is largely unknown and essentially unquantifiable.

Although this is a small measure of progress,  last year I had one student, this year, 18 are enrolled.

Who would have guessed?

Food: Keeping it Real

Mark Bitman, writer on food and all things related, published an interesting viewpoint on eating 'real food'.

Veggies- as photographed by the blogger, somewhere in rural Virginia

At the heart of the matter is the ongoing, increasing obesity epidemic in the USA.  Dietary patterns in much of the developed world is characterized by energy rich, nutrient poor, high fat, processed foods. There is a tremendous marketing and lobbying by agribusiness to ensure that their products are consumed and profitable. As such, it is no surprise, per Bitman, that the 2010 USDA Dietary Guidelines for Americans are a watered down version of nutritional best advice.

Although there is a message to eat more refined grains and fewer solid fats and added sugars (SOFAS), there is the implication that eating manufactured, processed food that is low in SOFAS is a healthy alternative. The reason, the agency's mission as nutrition experts is at odds with its other mission: to promote agriculture and food manufacturing.

Bitman's nutritional message can be partly simplified as follows: eat fresh food, as close from the source as possible, and prepare it at home.

Perhaps another way to approach individual food choices is to follow Michael Pollan's mantra: 'Eat food, not too much, mostly plants'

.......I am going to eat breakfast now.


PS: for additional reading, here are few titles off my bookshelf:

Food Matters by Mark Bitman
The Omnivore's Dilemma by Michael Pollan
Food Rules, an Eater's Manual by Michael Pollan
Fast Food Nation by Eric Schlosser
Food Fight by Kelly Brownell

Aggressive Care in the Hospital- is More Better?

There is a very interesting article in the New York Times exploring the notion of 'aggressive' hospitals, with the suggestion that aggressive care, particularly following surgical complications, may lead to improved outcomes.

Photo: New York Times

The American health care system is historically well known for it's aggressive care, much of which has been criticized for it's role in spiraling costs. 

I am by no means attempting to debunk some of the studies referenced in the article, however, I must question the thought that aggressive care will guarantee a better outcome. It appears to me that aggressive, life saving interventions may serve best in the event of an acute injury or a post-operative complication. In the event of a chronic, advanced or terminal medical illness, such measures may simply delay the inevitable, cause more suffering, and yes, increase costs. 

Having recently lost a family member to a terminal, chronic disease, it was obvious to us that treatment beyond comfort measures would have been futile. 

The benefits of aggressiveness care in medicine is situational and the challenge is how to recognize and best apply it. 

MRSA and Healthcare Workers. Perhaps it is best not to know?

Should healthcare workers (HCWs) be routinely screened for MRSA carriage?


This remains an unresolved and contentious issue. Although reports exists about HCWs have been implicated in MRSA outbreaks, most MRSA hospital acquired outbreaks do not involve a HCW as the point source. The endemic rate of MRSA carriage by HCWs is estimated at 0-15%.


There is a recent review of the literature on routine MRSA screening of HCWs in the Journal of Hospital Infection.


It seems like many answers remain to questions such as:


1. What is the best measure of endemic MRSA carriage by HCWs? Is this estimate valid in acute care settings, ambulatory settings and in long term care facilities?
2. What evidence based protocols exist for HCW MRSA decolonization?
3. How long will decolonization be effective?
4. How should HCWs be decolonized in the event of recolonization?
5. Should a colonized HCW be removed from clinical responsibilities while undergoing decolonization?
6. Should this leave be with or without pay?


Clearly, further research is needed before routinely seeking out MRSA colonized HCWs.


Perhaps it is best not to know?

Mysterious Maladies: When the Diagnosis is Elusive

There is an interesting persepective published in yesterday's New York Times by medical writer Gina Kolata. The focus is on the Undiagnosed Diseases Program at NIH, a consult of last resort for patients with symptoms and syndromes of poor diagnostic categorization.  

For some, there mere characterization and diagnosis of a disease is of great comfort, even if little can be done therapeutically to alter it's course.

Despite modern day sophistication, medical science simply cannot neatly categorize and define all maladies. Even recognized diagnoses such as fibromyalgia and chronic fatigue syndrome, lack a clear underlying pathophysiology, unlike diabetes mellitus or sickle cell disease.

The limitations to both our diagnostic and therapeutic abilities can be humbling.

Antriretrovirals Before Sex- Part Deux

Last year I posted a comment on preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. 

The CDC / MMWR has just released an interim guidance statement on the matter. The PDF is available via this link.

I still have lingering doubts whether this is a feasible and sustainable public health intervention.

Winter Scenes/Imágenes de Invierno: New York

Oneida Hospital

I have spent the last 4 days in Central New York partially snowed in, with a cancelled flight back to Virginia. 

A storm followed by a chilly walk and a  beautiful winter day.

I thought that I would share a few images. Apologies for the low quality of the pics, but I took all of these with my mobile phone.

Los ultimos cuatro días los pasé en Central New York, parcialmente bajo la nieve, y con el vuelo de vuelta a Virginia cancelado.  

Oneida, NY

Una tormenta seguida por una caminata

fría y un hermoso día de invierno.  

Acá comparto unos imágenes de los últimos días. 

Siento la baja calidad de las fotos, pero las saqué con mi teléfono celular.

Oneida, NY

Oneida, NY- Alex Bearman

Oneida, NY

Oneida, NY

Oneida, NY

Fayetteville, NY

Fayetteville, NY

Fayetteville, NY

Fayetteville, NY

Fayetteville, NY