Interviewing 100 patients or their surrogates in the ICU, 85% of whom were “full code,” Gehlbach et al found 16% of patients’ code status in the chart did not correlate with their expressed preferences during the interview (10 wanted less care, 6 wanted more). Respondents’ average prediction for their survival should they have a cardiac [… read more]
Remember when you were a third year medical student? Me neither. But that’s when you first started to build that tough & isolating carapace to protect you from all the overwhelming emotions flying through the hospital, & you, this essay suggests. A seasoned clinical educator and a third-year med student have a conversation about our [… read more]
Psychiatrist Aaron Lazare from U-Mass has been writing and thinking about humiliation in medical education and practice for years. This engrossing article exposes the destructiveness and persistence of this toxic emotion that he argues is sadly endemic in our profession. CHEST 2011;139:746-751.
An excess amount of the chaos and stress endemic to ICUs is due to poor systems engineering (think alarm fatigue); a rational, integrated approach to design & technology selection is needed to make ICUs more effective and safer for patients, argue Mathews & Pronovost. Academic health systems should fill the leadership vacuum, organize stakeholders and [… read more]
Arthur Kleinman, physician and ethnographer, challenges you to abandon comforting but simplistic value constructions and look unblinkingly at your divided medical soul, if you dare. Lancet 2011;377:804-805.
Efficient private systems like Geisinger and Kaiser outperform academic institutions on accepted measures of quality . Dhalla & Detsky say that’s because academic docs aren’t trying, because thanks to misguided incentives, their careers suffer if they do. They encourage hospitals and payers to take the lead to reward quality improvement, since universities are unlikely to. [… read more]
Drospirenone is the new progesterone analog in heavily marketed new oral contraceptive pills (trade names Yaz, Yasmin, Angelique). Using a large insurance claims database, Jick et al identified 186 cases of DVT or PE in women aged 15-44 taking oral contraceptives and compared them to controls. Those taking drospirenone-containing OCPs had a nonfatal DVT/PE incidence [… read more]
Autonomy and beneficence, a historical perspective. Will JF, CHEST 2011;139:669-673. ICU ethics review.
As Andy Rooney might say, “With all the diagnoses doctors like to make these days, didjever wonder if anyone is actually healthy anymore?” When it comes to heart health, according to Bambs et al, the answer is yes: one person is. Circulation 2011;123:850-857.
MedPAC wants the next generation of MDs to be cost-conscious, evidence-minded, and amenable to standardization of care. To prod GME programs to train young MDs thusly, the influential government advisory body recommends allocating $3.5B of the $9.5B annual GME outlay as at-risk incentive payments. A proposed committee would have 3 years to design metrics for [… read more]
DeMets & Califf give a historical play-by-play, lament the current state of affairs, and issue a call to arms for academics to leverage the current political climate favoring comparative-effectiveness and translational research, in order to build a new clinical trials edifice that favors the public’s health over profits. JAMA 2011;305:713-714.
Moses & Martin see an impending crisis of public trust in the entire enterprise. They call for an epic shift in national priorities, policy, and funding of research, envisioning a more collaborative, value-based system– while acknowledging that such a sea change would take decades. NEJM 2011;364:567-571. FREE FULL TEXT
ICU patients have a 5-10% risk of deep venous thrombosis, even with appropriate prophylaxis. Ultrasound screening can detect many of these asymptomatic and clinically unsuspected DVTs. However, since many DVTs disappear without incident, and complications can result from additional testing and treatment with anticoagulation, and all of this costs money, the best approach to prevention [… read more]
Ultrasound in the ICU: Case 1 Discussion Go Back to Ultrasound Case 1 Ultrasound Case 1 Answer: Hypovolemia. Hypotension may be caused by diverse pathophysiologic states that are hard to differentiate by clinical exam. Bedside ultrasound can provide immediate visual information that can help to rapidly make diagnoses of life-threatening conditions, without dependence on radiology [… read more]