Saturday, October 23, 2010

Targeting the inflammasome - new ventures for a hospitalist

When the undefined, unclear, obscure clinical presentation makes its appearance on the hospital stage, taking the patient as a hostage, the internist will always carry the flag of the best patient's advocate and passionately fight against the darkness of uncertainty.

In the classic case of the patients with fever of unknown origin we'll attempt to elaborate a list of the most common diagnosis, and once everything else has been ruled out, we'll leave to the end the strange and uncommon diseases, which in the case one of those is attributed and descifered as as the culprit of the patient's maladie, then not only a therapeutic opportunity can be offered to the patient, but of course, the internist's personal experience will broaden and solidify, as well as his/her ego boost up.

What is a similar challenge is when patients with an established rare diagnosis appear, with exacerbations of the disease that are uncontrolled with the usual medications. Then, the main issue will be whom to ask for help especially if the potential likelihood of not having an alternative therapy arises.

Well, we had in the teaching service a patient with Familial Mediterranean Fever (FMF). Yes. This is one of those diseases that everybody can just pop out in trivia and board questions without having ever seen one in their lives. This young patient had a very prominent abdominal pain as well as severe diarrhea - this last one, worsened with colchicine, which is by the way, the standard of care in this disease. Our question was whether this patient may be refractory to colchicine, and if this would be the case, what other alternative we would be able to offer her.

As a background, the FMF is a clinical entity manifested as recurrent attacks of serositis. Attacks can last sometime up to 5 days and the recurrence is variable - some patients have recurrence every few weeks to months to every few years. Stress (physical and emotional) has been linked as a trigger. Most commonly affects the peritoneum (90% of cases), the pleura (45% of cases), scrotum (5% of cases) and pericardium (1%). Patients can as well have acute monoarticular arthritis. Some patients can develop at long term complications such as amyloidosis.

The management is generally succesful with the use of colchicine. However, 5 to 10% of patients can have persistence of FMF's symptoms despite colchicine. Available choices are Interferon alpha and methylprednisolone. It has been described as well, that dietary changes with elimination of lactose as well as gluten in some patients, may help to avoid the colchicine intolerance.

Going back to our case, she has had intolerance to both IFN-alpha as well as methylprednisolone in the past, therefore creating a therapeutic challenge; as well, her diarrhea worsened with colchicine and did not improve despite the use of anti-diarrheal medications.

After expert discussion with the Rheumatologists, which by the way included the Pediatric Rheumatologist, we decided to use one of two drugs that blocks the Interelukin 1 action - either an IL-1 trap called Rilonacept or a soluble IL-1 receptor blocker called Anakinra.

Of note, as a hospitalist, my experience with either drug was only limited to some patients with Rheumatoid Arthritis treated with Anakinra. I looked in the literature which dates back to 2007 when this drug was suggested as a therapeutic alternative to colchicine in patients with FMF; I found as well some reported cases of its use as a salvage therapy in patients refractory to conventional treatment, such as this case and this other one.

More information about the pathogenesis of chronic inflammatory diseases which for ages its pathophysiology has been an enigma to clinicians is appearing. This article explains the role of IL-1 in this chronic inflammatory diseases as well as the role of the inflammasome which is a cytosolic multi-protein complex, which regulates the caspase-1 dependent processing of inflammatory cytokines IL-1β and IL-18.

The patient received anakinra with an impressive improvement in her clinical symptoms within 24 hours. Her pain subsided as well as her fever. The caveat is that the administration of this drug requires daily injections, which the patient is willing to take in order to avoid the devastating attacks. Further discussion with the insurance company will be needed to assess whether coverage for weekly rilonacept injections can be obtained.

This case brought to me several lessons. First, this was an opportunity to review the new pathophysiologic mechanisms of recurrent febrile and inflammatory diseases as well as understand based on this, the new pharmacologic approaches to these diseases. The use of IL-1 pathway antagonists has a very broad application; for me as a hospitalist, knowing about anakinra, canakinumab or rilonacept, permits me to manage a different language and be able to sustain a different level of conversation with our Rheumatology subspecialists, as well as share my fascination with my residents and medical students.

I am very interested in following the long term outcome of this patients and hopefully the increased understanding of the mechanisms of disease may yield a really curative approach in the next 10-20 years.

Monday, September 27, 2010

An Academic Hospitalist

Well.  A lot of things have happened since my last post. I'm not precisely very happy with my scant productivity in this blog, and as frequent as I have ideas that I want to share, it is the same frequency I have other things to do.

I was busy in May, attending the ACP Leadership Day, advocating for Internal Medicine, attempting to minimize the Medicare cuts based on the obsolete Sustainable Growth Rate (SGR) formula; as well tried hard in advocating to ensure the perpetuation of a constant supply of Primary Care providers to ensure the future medical coverage of americans. It was exciting as well as intense and inspiring.

Then in June, I had a fantastic trip to the Far East, especifically, South Korea, where in addition to climbing the Halla-San in Jeju, we enjoyed the temples and cold water of the Sea of China in Busan, the jovial nature of the University in Gwanju, and the energetic life of Seoul. We appreciated the Korean food and hospitality, attempted to understand the Hangool symbols, and to learn some of their salutations and greetings ..."ani-aseei-yoh!, kansamnida!, etc...."as well as got inspired by their incredible and fast evolution within half a century. Understood a lot of their sentiments toward the japanese, whom essentially attempted to destroy their culture and heritage in a savage and brutal way. I'm impressed on the power of forgiveness and the intelligence of dialogue that both countries have nowadays; an example to follow in the rest of the world.

Then in July, the excitement of the new academic year brought winds of energy and passion; I attended in the Pediatric wards the first week of the month, and was happy with the new interns' performance.
Subsequently, got a sequential series of academic and curricular updates - got an accepted workshop at the 2011 Society of Hospital Medicine meeting, about Perioperative Management of the Pediatric Patient; got promoted to Full Staff; started my activity as a core faculty at the Internal Medicine residency; started a 4 weeks slam in the Internal Medicine teaching service (briefly interrupted by a family emergency that required switching my role from a physician to become a patient's relative).

Looking at the vertiginous last month, I realized how passionate I am about academic medicine, most importantly, Hospital Medicine. My accepted SHM workshop is in Pediatric Hospital Medicine and I'm giving tomorrow the Children's Hospital Grand Rounds on Pediatric Perioperative Medicine which will be a nice catalizer to find out which topics will be the best ones to present at the national meeting.

I was very fortunate, given my interest in academics, that there is an fantastic available course for thriving academic hospitalists, called the Academic Hospitalist Academy. It is sponsored by 2 of my favorite institutions, the Society of Hospital Medicine and the Society of General Internal Medicine. We flew last September 21 to Atlanta, GA. Then took a cab to the hotel in Peachtree, GA, 45 min away from downtown Atlanta, located in a picturesque town where people trasnport themselves carts! (they have more than 9000 golf carts in this town).

This course was given over three days, covering the most important aspects that will enhance any academic physician's career. I appreciated the innovative approach to teaching medicine, such as the Clinical Coaching, where rather than filling the students and residents with a bunch of facts, we teach them how to do clinical reasoning and think in a structured way. We had a fantastic approach to the Bayesian method for problem solving, and the use of a Socratic non-threatiening questionning technique for bedside teaching, as well as classroom teaching. In this very tenure, time management is a very important element, and the way to better administrate the time was taught in a masterful way.

We rediscovered the magic of the white board and color markers, with the idea of making didactic points clear and outstanding. We gave all mini-lectures, 6 minutes each in break groups, providing afterwards a feedback based upon the content and outline, as well as delivery of the talk. We used specific feedback with the idea of strongly improving  flaws such as "talking to the board", talking pace, shyness, etc. We discussed as well ways to give feedback to our students and residents, both on the fly and in a formal separate setting, with the notion that feedback is non-judgementa, targeting areas for improvement.

We discovered a new way of setting goals and expectations in a SMART way - Goals should be specific (but also systematic, synergistic and significant); measurable (and also meaningful and motivating); achievable; relevant (but also realistic, reasonable, rewarding, responsible, reliable, and remarkable); timely, tangible and thoughtful.

Fantastic lectures and workshops on career building and paths for Promotion with specific 1- and 5-Year Planning were held, and this apparently threatening activity showed how important it is to efficiently organize the academic activities; some activities can occur simultaneously; some will occur at different stages; but the most important thing is not to lose track of  at what level of progress is each activity standing. The long term goal is the continuous career development and academic advancement. For instance, one of my goals is to be promoted to Associate Professor within the next 3 to 5 years.

The peer networking was fantastic, and I loved to meet so many young people from all the US, especially from the most important academic medical centers, all motivated with a single interest - become better academicians to improve medical education and patient care.

Other important skills were the Applied Principles of Quality Improvement (QI) and Change Management, as well as Patient safety and error analysis - hospitalists have a niche in QI. Most of the subspecialists will be busy enough to even attempt to stare at this. The hospitalists have become stewards of QI and patient safety, mainly through the use of IT, improved communication skills and efficient transitions of care. The systematic and critical analysis of errors, along with the proposal of corrective strategies to overcome these errors, are paramount in the establishement of QI initiatives to promote patient safety. We felt good about the importance hospitalists can achieve for their healthcare system.

Other fun activites included the teaching on how to develop a great Clinical Vignette - we had one on one teaching on pre-written Clinical Vignettes, and in a very rapid way were able to find significant flaws in the initial vignettes and correct them immediately. It was nice to see the before and after.

The creation and mainteinance of a teaching portfolio was one of the most important skills practiced, which will help find success in the academic career advancement. It was very clarifying to see the organization of the CV's according to each academic institution, which although seemed like a very though task, once accomplished, is a great stress reliever, as it is the tool required to apply for academic positions, awards, grants, etc.

Finally, the discussion of what the relationship among a mentor and a mentee should be was clarifying. I have changed my CV to my institution's characteristics and am now in search for an experienced but motivating and empowering mentor.

I found a lot of substance in this course - actually, I found that there is a lot of substance in our academic practice; a lot of raw energy and talent that appears as a brute diamond that needs to be polished. The energy needs to carefully be  focused and shifted toward constructive and highly achieving goals and profiles. I think the elements we obtained from this fantastic resource will be rewarding in the near future.

Tuesday, May 4, 2010

Ventures of a Young Physician in Narrative Medicine

I have multiple things to write about, especially from my experience in my second ABIM Foundation meeting, where we discussed the feelings elicited on all of us from the reading of an article written by a physician who died from ALS and had a terrible experience as a patient before her death. Her article was published after her death at Annals of Internal Medicine, and it is a true fountain of inspiration to recall and rescue our most intimate values as physicians and human beings. We are not health-care technicians. We are doctors and should act up as advocates of our patient's wellbeing in all spheres - bio-psycho-social. We should always ensure a warm and compassionate environment.
In the article, the doctor recalls how much she suffered when she had an EMG (electromyography) done; this is a study where needles are inserted in the muscles with electrical stimulation in order to record the nerve action potential. It is quite painful and a torture in itself. The author writes how the attending physician, who was a presumed recognized neurophysiologist, was cold and detached. He was teaching the residents while performing the EMG, and in a fascinated mood described "the typical and pathognomonic electrophysiological characteristics of ALS". ALS or Amyotrophic Lateral Sclerosis is one of the most devastating diseases the human being can face. It is one of the most frustrating diseases for any physician, given the lack of cure even in 2010. It is famously known as "Lou Gehrig's disease" as the famous ballplayer died from it. It affects both your upper and lower motor neurons, and cause a steadily progressive and devastating neurologic damage.
I was wondering how the academic environment and fascination for teaching should not detach from acknowledging the patient's suffering itself. I wonder how the physician could have been more toughttful and perhaps hold on making any "academic" comments in front of a colleague who simply suffered the invisible "saber stabs" in her soul by hearing the veredict of an unavoidable destiny.
I enjoy involving the patients in the academic discussions. Teaching them and improving their health literacy is satisfying. This week, for example, I treated a patient with severe pulmonary hypertension coming for a pre-operative evaluation; his chest roentgenogram (fancy word for chest X-ray), revealed an unsuspected pneumothorax. In the setting of pulmonary hypertension this is quite worrisome as if untreated can be fatal. The patient was upset of requiring a confirmatory chest CT-scan, as the image was not categorical at all; as well as if confirmed, may need to be admitted. By that time, I have already discussed the case with his primary pulmonologist. He couldn't understand what was the meaning of the pneumothorax. I draw in a blank piece of paper the chest anatomy, the virtual pleural cavity and the lungs, and explained how the lung compression by the pneumothorax would yield in an dramatic increase in the pulmonary hypertension in addition to the worsening of hypoxemia by the collapsed lung with a VQ mismatch. His anger faded (slightly); he accepted to be transferred to the Emergency Room and get the CT scan.
My point is that we need to understand the patient's frustration; sometimes their frustration is due to their lack of understanding and our lack of explanation. Once they are able to acquaint the rationale of our medical decision making, they can accept it in a smoother and less painful way.
We as physicians and teachers need to strive in rescuing humanism in Medicine and teach our students the value of the individual as a human being an as a member of society; the medical students should learn from early stages in their career to interact with suffering. We should not train health care technicians who will be skillful exam takers, get into fancy surgical residency programs aiming to make a lot of money from a given specialty. They should aim to be compassionate doctors who want to help their patients to achieve wellness, and a sense of well-being from all the standpoints - bio-psycho-social. They should aim to be pillars of the society and more than being recognized as doctors, be recognized as humanistic and compassionate human-beings because at the very end we aim to provide care, comfort, healing and mitigate suffering as much as we can.

Saturday, March 13, 2010

Narrative Medicine, the Charter and the battle to preserve professionalism

Last week I became engaged in one of the most educational programs I've ever been before - it is a project sponsored by the ABIM (American Board of Internal Medicine) Foundation to promote the use of Narrative in Medicine (reflective writing) as a vehicle to increase self-awareness, with the intention of improving empathy among physicians. Multiple institutions are participating in this project and have different goals.

We started by reviewing a classic document that I read many years ago, the Physician Charter, published in Annals of Internal Medicine as well as The Lancet. This document was created by internists worldwide with the intention of rescue professionalism in medicine which is being threatened by the new "values" in industrialized world which has prompted to changes in healthcare delivery. This document supports physicians' committment to patient welfare and social justice, which by itself is just a confirmation of the principles by which we as a profession have always abided to for ages.

I liked the document, and I think that most of my colleagues by reading it just confirm what they are already practicing, however, I do agree that in the current world - especially non-academic medical centers and practices - physicians need to reconsider whether the circumstances of practice are interfering with these principles of care.

It is interesting as I participated last week in the session of the Healthcare and Public Policy committee of my local ACP chapter and I heard interesting stories from colleagues working in non-academic practices, where the medical insurance companies essentially block them from practicing medicine, and decide in an arbitrary manner whether "the customer" (that is how insurance companies see patients) needs a study or not - for example they deny a stress test to a patient "because he can walk, so doesn't need a stress test", or a CT scan "because they should do a pelvic US first"....of course, my colleagues cry their inmense frustration as can't practice Medicine anymore without hurdles put in place by unscrupulous non-physicians. So, their internal battle arises from their frustration as they try to practice Medicine with the highest regards and respect for patient's welfare, but totally external influences - the "industry"-really threatens professionalism.

My dilemma surges from the fact that I am privileged to work in an institution that promotes an academic and humanistic environment that promotes the patient's welfare as its principle - our motto is "Patient's First" - for instance, we get the opportunity to participate in this ABIM Foundation activity - however, I feel terrified for my colleagues in non-academic environments, where they need to fight for every space they deserve in order to preserve their principles as physicians.

So, moving along the way, the Charter starts by defining Professionalism, which is "placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health." They then discuss how the role of the physician as a "healer" is being threatened by the current changes in healthcare, advancement in technology, etc.
Then they state the three Fundamental Principles of the Charter - which should not be put under pressure from the industry needs- are:

1. Principle of primacy of patient welfare:  Altruism and the best interest of the patient is the driving force in medical practice.

2. Principle of patient autonomy:  The patients should receive honest and clear information about their health, and should be empowered to make their very own informed decisions about their treatment. Of course, these decisions should be honored only if they are supportive of ethical practice and permits appropriate care. Essentially, respect the patient's medical decision making if they are able to acquaint and express an understanding the risks and benefits they are getting involved into.

3. Principle of social justice:  All individuals belonging to society, regardless of their religious or political beliefs, gender, ethnic backroung, socioeconomic status, etc. have the same rights to healthcare.
Then they discuss the Professional Responsibilities, to which all physicians are commited to:

1. Professional competence. Physicians should be knowledgeable up-to-date. This basically supports the use of mainteinance of certification process, CME, etc. This is why physicians who don't keep their CME can be expelled from the State Medical Boards.

2. Honesty with patients. The truth is fundamental. We need to let patients know all risks and benefits of the medical care. But if we commit a mistake, we should be open about it. Is all about transparence.

3. Patient confidentiality.  This is why HIPPA exists. However, if welfare of others is compromised, then this can be overruled.

4. Maintaining appropriate relations with patients. Relationship with patients are exclusively professional.
5. Improving quality of care. Will sound redundant - this is what supports all measures of quality improvement; these protocols in the medical system are designed to minimize human error with increase in patient safety, and promoting an optimal utilization of resources. All this leads to improved outcomes.

6. Improving access to care. This basically entails that we should identify and minimize all barriers to adequate health care. These barriers can be based on patient educational level, laws, economic status, geographic location, as well as social discrimination.

7. Fair distribution of finite resources. Cost-effective care should be sought at all times as this will render in enough resources for everybody.
8. Adequate scientific knowledge. Essentially - we are commited to lifelong learning and up-to-date knowledge.

9. Maintaining trust by managing conflicts of interest. Physicians should disclose their relationships with industry and pharmaceutical companies.
10. Professional responsibilities. We need to ensure that our colleagues practice within the medical and ethical standards of care as well as that they are updated in their medical knowledge. This supports the sanctioning by State Medical Boards to unethical physicians.

In summary, this Charter is a document that reinstates and brings back the principles that rules an ethical medical practice with the intention of respecting the patient's welfare to the most.

On that day, we reviewed the principles in the charter, as well as some terminologies that we need to be aware such as the difference between patient vs. customer, physician vs. provider, the hospital as a healthcare site vs. corporation, etc, etc, etc. We reviewed as well some bibliographic basis for narrative writing such as this small article by Dr. Charon, as well as other articles that discuss the conflict that physicians suffer when adapting to the new changes in healthcare after introduction of technology, cost-saving industry behaviors, etc.

Then afterwards we sit down in several groups to write down a specific time when our empathy was challenged. We all spent a good 30 minutes of writing and then heard out stories. The beauty of reflective writing, is that the patient's identity can be very well concealed and some components could be fictional. In reflective writing it is encouraged to do so freely without caring for grammatical details or vocabulary changes, as it will permit more freedom to express the physician's feelings. The fictional components won't take away the substance and power from the document; the beauty of it is that we open up to our colleagues some of the hardest and most challenging times we've had as human beings and as physicians, and we all learn from these stories. We all become better, we get to understand our colleagues in a better way. I truly admire my colleagues by the way the see life and medicine and really feel honored of being able to share my experience with them.

In my travel along the discovery of Narrative Medicine I found several excellent reources:
Literature, Arts and Medicine Blog.
Medical Humanities Blog.
Medical Humanities.
Narrative Medicine Program at Columbia University.
Master of Science in Narrative Medicine.

I have always been interested in writing besides scientific writing; essentially writing essays and my own thoughts and feelings. Did it all the time in medical school, but never thought it was so useful and so powerful. Now I have rediscovered this great resource and will encourage my young colleagues, medical students and residents to pursue it. We may add a session on reflective writing in future meetings (such as our local chapter meeting) to provide more resources to promote empathy and professionalism.

I think that this is one of the best ways of pursuing the principle of primum non nocere...

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