Musings on the current COVID-19 pandemic

I want to share the perspective I have on the impressive enthusiasm to use unproven treatments for the SARS-CoV-2 infection (COVID-19).

In many countries, including the USA, lots of unproven therapies have been proposed as treatment for COVID-19; the lack of randomized clinical trials has been the constant. Many colleagues, medical centers and even national organizations in different countries have proposed treatment algoriths, with no evidence to support such.

The appeal as to being ethically questionnable "not to do anything" has spearheaded such behaviors. And time has proven the inefficacy and dangerous consequences of such treatments.

Doctors aim to offer the best for their patients. We are not used to a pandemic, and certainly is morally devastating to see the impressive mortality that this viral infection has brought along. Yet, when we reflect on the 1918 Influenza pandemic, the mortality rate was of millions of people worldwide. And the basic hygiene and isolation measures were key for its control. And nowadays it is no different than then.

I wrote along with a colleague from Mexico a perspective on the use of unproven treatments for COVID-19 in ACP Hospitalist (a publication from the American College of Physicians). We titled it "Primum non nocere: Two hospitalists muse on the current pandemic". I hope this reading provoke thought and reflection.

Basic supportive care is the cornerstone of our clinical success in our organization. Both in the regular nursing floor and the ICU. The medications are adjuncts to oxygen and good airway clearance.

In my search for the source of the coining of the phrase primum non nocere,  the esteemed professor and world renowned bronchologist Dr. Atul Mehta shared with me that it was Auguste Francois Chomel (1788-1858). Certainly Hippocrates work and philosophy is fundamental for this thought.

Clinical reasoning - the continuous reflection on our own decisions

Recently I had the privilage to write a blog post in OSLER, a fantastic academic and humanistic forum created by Johns Hopkins colleagues aiming to rescue Medicine from being purely technical into a more intellectual and clinically relevant field. It helps to reengage us as physicians end enhance our best qualities as humans.

One of the sections in CLOSLER is about Clinical Reasoning. This is very dear to our heart as clinician-educators; and to me personally, because as a Quality and Patient Safety Officer for a large academic institution, my responsibility it to promote a culture of safety and zero harm. I engage in a high reliability organization aiming to acknowledge that this is a complex system environment and we want to eliminate the chance of clinical and diagnostic errors.

In clinical reasoning we always step back - do not assume things; if a diagosis was made in the ED or the ICU before the patient arriving to our service, we must have a healthy skepticism; avoid anchoring, availability, recall, commission or omission, etc. We need to have awarenes of our cognitive process and bias. Understand whether we are appraising these bias and aim to mitigate them. You can read a further commentary based on a clinical case in my CLOSLER post.

As I always conclude my blog posts - physicians aim for the patients' best outcomes. First principle is do not harm.

Physicians as leaders - a reality

As physicians (especially Hospitalists) gain more clinical experience and maturity, a presumably inherent expectation is the engagement in leadership responsibilities within the heathcare system. However this also depends on the individual desire to do so. Althouh I believe that experience is very relevant, an inherent flaw of the system is the natural lack of mentorship and coaching in leadership.

The engagement in leadership roles with no formal training, "learning on the fly" - can be risky nowadays given the enormous complexity of the healthcare systems. However, the key to anything is the ability to communicate effectively, understand the situation, engage and inspire a team and find solutions that were not clearly outlined before tasking the problem. This is how a lot of physicians in leadership positions have gained experience.

Regardless of the individual level of experience, training in leadership is important; there are many styles and many publications on the topic - but the most relevant aspect is to engage this knowledge along with the real life solution of problems. Many colleagues are doing now MBA's, MMM's, MHA's, etc. Some becoming Fellows of healthcare administration societies, etc. And of course, the personal experience contributes to more meaningful engagement in these academic developments.

Along with other colleagues nationally, I have multiple discussions on their own leadership development and tasking unexpected complex challenges. We ended up discussing and outlining what we considered key aspects for leadership development. I want to invite you to read two blog posts that I wrote in Doximity with musings about this training, focusing on two national workshops that have been presented at the Society of Hospital Medicine 2018 and 2019 meetings. A third iteration of the leadership development series will be presented in Las Vegas in 2021 if we are allowed to travel and pending the pandemic behavior. 1) 3 Leadership Essentials for Success in Hospital Medicine: 2) What Does a Leader Need to Survive a Complex Environment?

Leadership development is fundamental but also is the development of a culture based on values of respect, teamwork, excellence and tolerance. I have recently enjoyed a book that actually emphasizes on these topics and focuses on 7 virtues – trust, compassion, courage, justice, wisdom, temperance and hope. This is the book "Exception to the Rule" written by Drs. Peter Rhea, Jamie Stoller and Alan Kolp. A terrific resource which along with emotional intelligence development, provides tremendous assets for a compassionate and effective servant leadership.

I would also like to share a reflection; in leadership in healthcare, the ultimate focus is enhancing clinical outcomes for our patients as well as to promote enhanced population health. A robust healthcare system can have tremendous impact on the financial success and the health of the community it serves to. And this starts with each individual leader. Having the vision of best patient and community outcomes help to outline and support the engagement in personal and professional development to serve in a more effective way.

Reinforcing a parsimonious approach toward blood transfusion

Blood transfusion as a treatment modality became a prominent resource throughout the last century. However, in the late 1980’s an analysis of the high volume of blood transfusions associated with its inherent cost and risks, raised concern and skepticism regarding the arbitrary hemoglobin and hematocrit cut-offs of “10/30” which were followed since the 1940 following the recommendations by Adams and Lundy. ¹ The NIH consensus statement on blood transfusions published in 1988 brought into question the previous practice and propose more parsimonious thresholds of transfusion (Hb 7 g/dL).²

The evidence that supports the safety of parsimonious approach to blood utilization was built over the decades of 1990 and 2000 with very robust and compelling results. The hemodilution studies demonstrated that the human body could tolerate lower hemoglobin values, and subsequently, clinical comparison of restrictive versus liberal transfusional approaches demonstrated the safety of restrictive transfusional approach in different clinical scenarios such as critical care, high cardiovascular risk surgical patients, sepsis, etc. ³  

In this decade, the AABB has published 2 guidelines (2012 and 2016) which are robustly supported by evidence with recommendations for consideration (not an immediately actionable item) of blood transfusion when the hemoglobin reaches a value of less than 7 g/dL in non-cardiac patients, or 8 g/dL in cardiac patients.⁴ More importantly, the guideline also demystified a current practice that has increased the costs of blood management - which was avoiding the use of blood older than 14 days; the evidence that “old” blood is not associated with worse outcomes is extremely compelling. ⁴

The current practices of Medicine are substantially different from 10 years ago - at least from blood utilization - not only it is a lower transfusional threshold being utilized, but also there is a decrease in the number of units of blood transfused at a given time. In addition, the clinicians are increasingly mindful of addressing the primary etiology of anemia with focus on hematinic replacement. Also, the behavior has gradually shifted toward mitigating the risk of iatrogenic blood loss by means of decreasing the routine ancillary diagnostic blood tests, which may not necessarily change management.

There are multiple venues which have adopted the recommendations of parsimonious approach to blood utilization such as the ABIM Foundation Choosing Wisely. And it is highly likely that newer organizations aimed to pursue high value and low cost medical care, will adopt the recommendations of restrictive transfusional thresholds to mitigate excess blood use with its associated inherent risks. 

Less is more - the increased focus on enhancing patient outcomes and minimizing the risk associated with excessive diagnostic and therapeutic approaches, will yield in a safer, more effective and less costly practice of Medicine, pursuing the most elemental principle of medicine...primum non nocere.

References

1. Adams RC, Lundy JS. Anesthesia in cases of poor surgical risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet.1942;74:1011-1119.

2. Consensus Conference. Perioperative red blood cell transfusion. JAMA, 1988; 260: 2700-2703.

3. Auron M, Duran-Castillo MY, Kumar A. Parsimonious blood utilization and transfusion triggers. Clev Clin J Med. 2017;84(1):43-51.

4. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-35.

Readmissions, quality and medical education

Finding the way through understanding quality improvement, and most importantly to hardwire the concepts and best practices can appear difficult and cumbersome to the novice. 

But it is not. 

Quality improvement is, as a matter of fact, a fascinating field where you can gain insight and perspective on your own performance and opportunities to improve. In addition, this has been the reason behind the expansion and growth of all the industrial and technological movement in the past century. 

From Taylor to Deming to the creation of the IHI, and now with well established quality health research institutions like Intermountain, Dartmouth, Harvard, etc. we now have formal training and education of a whole generation of health care scientist and providers. This has rapidly changed the culture, and all new trainees and students are intensely getting exposed to terminologies and practices that I barely had any during medical school and my first residency.

I had the honor an privilege to write this guest blog post  at the SHM Blog "The Hospital Leader". I had the opportunity of having direct mentorship from Dr. Brad Flansbaum who helped me tremendously to put the ideas together to obtain the final published piece. 

I hope you are able to read the guest post and more importantly that it yields into motivating curiosity to explore the fascinating world of quality improvement and patient safety. Remember, primum non nocere...

Musings of a Medical Educator - Reflections of the Philosophy of Teaching

I love medical education and teaching in general. Now that I've been a father for 2.5 years, I have appreciated the incredible beauty of curiosity, of the genuine motivation to know and learn - witnessing it on my son. This has been very refreshing - and has made me a better person and professional. 

I was appointed as an Associate Professor in July 2014. Yet I submit my application in 2012. I had now a recent conversation with a colleague about applying for academic promotion. He asked me for the statement I wrote. 

Reflecting on this - the request from my friend, and the everyday fascination I feel from seeing my son growing and learning, I decided to delve into my archives and search for the statement I wrote for my academic advancement regarding my philosophy of teaching. I wrote and signed in August, 2012. Here it is and I'm happy to share:

PHILOSOPHY OF TEACHING / PERSONAL DEVELOPMENT

As an adult learner myself, involved in the complex world of medical education, I have a strong awareness of the different ways of learning that people use.  People use the senses in different ways: some individuals require a persistent memorization effort and may appear bright in terms of factual information recall yet may be unable to develop a critical and analytical perspective of things. Others may have a more practical way of learning by solving problems and putting analysis and reflection into practice yet may not have the ability to retain factual data.  Yet others may need to visually appreciate a concept or idea in order to create a visuospatial relationship with previous concepts.  And finally, some individuals achieve better understanding by listening on a repetitive basis.

The most important consideration is that the educator be aware of the different methods of learning people have and is creative enough to be able to deliver the information or ideas in an efficient way to each individual learner. Creating an environment that fosters learning is essential so that the learner feels motivated – this is done by matching the teaching technique with the learner’s own best learning style.

First of all, I’m a clinician – a hospitalist – I work in the inpatient wards, where seeing acute patients is the norm. Patients are very sick, families are distressed, and most health-caregivers are under significant emotional and professional pressure. My teaching scenario is the patient bedside. I need to teach medical students, residents and fellows. Each of them has a different level of training in addition to their own learning style.  Although the most experienced learners have had more exposure, may not necessarily have more plasticity toward different learning methodologies.

My responsibility as an educator is to ensure all my trainees feel motivated, inspired, and committed to provide excellent patient care. They must come every morning with a great desire to be here. This is done by fostering a team spirit – we all together as a team see all the patients, and the patients belong to all of us.  We all know about each patient, we all discuss about and learn from each individual patient, we all enjoy taking care of patients. The second thing I do is to have the learners acknowledge their own knowledge gap – they shall not feel embarrassed about it, but rather feel a compelling need to close the gap – I make them read about it and give the team a concise and brief presentation usually accompanied by a handout and /or a journal article. This allows me to understand: 1) the ability of the learner to review and synthesize the literature, 2) the ability to frame and write his/her ideas in the handout, 3) the ability to orally deliver a presentation (clarity, structure, length, sequence, etc.), 4) the creativity involved in putting ideas together (presenting the information in a test format, in a clinical vignette format, in a slide presentation, etc.), 5) the interaction with the other learners answering their questions and delivering the information.

My particular method is to teach while rounding and seeing patients – make them observe carefully the patient at the bedside, and first of all, understand that the patient is in a delicate situation and maybe be suffering – have them empathize and be compassionate; know to talk to the patient, provide comfort and hope. This is perhaps the single best teaching we can do at the bedside: good bedside manners. Everything else follows naturally.  The next thing while providing comfort is to enhance the awareness of clinical signs and symptoms: have the trainees to use their senses and enhance their observation and auscultatory skills; then we discuss a differential diagnosis. I put in play the Bayesian approach using pre-test probability of disease and we define a diagnostic and therapeutic approach based on the likelihood of a given pathology.  I use the electronic health record as a teaching tool as well.  We review the bloodwork and analyze the abnormalities with immediate “on the fly” teaching, associating given laboratory values with the patient’s clinical diagnosis or physiologic condition.  This allows the visual learner to make a visuospatial relationship; my explanation allows the auditory learner to understand the process; the whole clinical experience (seeing the patient, reviewing the labwork and imaging, discussing the case) allows the analytical learner to understand the process of disease. In addition, we have the fortune of being in a technology rich environment – this allows me to do literature searches in PubMed at the bedside and look at the literature in the point of care to help facilitate the medical decision making. I show them how to download podcasts especially for the auditory learners.

Once my trainees have written their clinical documentation, another opportunity arises to help them further reflect into the process of disease as well as medical decision making by reviewing their “Assessment and Plans” and discussing with them about the reason for adjusting or changing it allows them to obtain further feedback and reinforce previously taught concepts or as well identify new teaching opportunities.

In addition, at the end of the day, it is important for them to realize how much they need to know and how much they have already learned but perhaps not been quite aware of it. I send them links to articles based on our patient’s diagnosis, diagnostic pathway or treatment, then ask them to choose one article each to present later on the week.  I send these emails on a routine basis – almost daily throughout the rotation – to foster the need to read and appraise the literature in order to provide the best patient care; in addition motivates them to search for the literature on their own sharing their readings with the rest of the team. The advantage of this is that at the end of the day, the learners not only get “live” teaching during rounds, and close their knowledge gaps on their own, but they learn to become self sufficient to search the literature and start building their core of knowledge.

My main satisfaction comes at the end of a rotation when I witness an impressive learning curve, as well as an enhanced level of comfort and ease for medical decision making. My patients express satisfaction with the degree of thoroughness my learners put in every morning during rounds for both assessing the patients as well as explaining to them the results of the diagnostic pathways. I enjoy seeing the degree of satisfaction that my learners show when we are able to successfully discharge a patient who came very ill and is able to look into the future with hope, renewed strengths and desire for recovery. Most importantly I enjoy when my learners actively demonstrate that critical directive, primum, non nocere.

M.A.

Cleveland, OH, August 2012.

Choosing wisely - the saga continues

Today, the ABIM Foundation published a nice blog post on the choosing Wisely campaign - which they launched several years ago. It can be read here. 

This week, this was the topic of my institution Department of Hospital Medicine Grand Rounds. We reviewed the current state of healthcare in USA - and the disproportionate ratio between healthcare expenditure and outcomes. Then we discussed the 5 SHM recommendations. 1) Don't use routine antacid prophylaxis out of ICU, 2) Don't place routinely urinary catheters, 3) Don't get daily labs in the setting of clinical stability, 4) Don't routinely transfuse unless clinically unstable and Hb < 7 (and we emphasized the word "consider" transfusion instead of "just go ahead and transfuse"), 5) Don't use telemetry routinely.

Interestingly, there was a lot of controversy around each topics - why so far, we still have gaps in performance? - why so far is so difficult to hardwire change?.

Let's just focus on the urine catheter use.

Regarding urinary catheters, we have an overall low DUR (Device Utilization Ratio) - meaning the number of "Foley-days" divided by the total number of patient days. We have a low rate of CA-UTI - still it is not zero. Why? 

In most cases, the CA-UTI was linked to urine cultures obtained by trainees at the middle of the night in patients with fever as part of a pan-culture approach. Yet, these patients were: 1) not neutropenic, 2) didn't have urinary malformations, 3) didn't have a renal transplant, 4) did not have any clinical evidence of cystitis or pyelonephritis, 5) were not hemodynamically stable. Still - it is very difficult for a trainee to simply withhold a urine culture in a patient with a Foley catheter. In addition, these positive cultures had no translation whatsoever into any kind of clinical meaning. They become a statistic without clinical relevance, yet with impact in the overall institutional quality metrics.

The question needs to go further and beyond - does the patient still needs the Foley catheter? 

My question to my trainees is - instead of just performing a urine culture in this patient, which most likely will have no real clinical meaning, why don't we just consider having the urine catheter removed?

We reviewed the other organizations Choosing Wisely recommendations - and the ACEP also recommends against routine placement of urinary catheters - therefore, hopefully, the story of "the patient already came with a Foley when admitted from the ED" will be a goner.

We had implemented in 2013-2014 an enterprise-wide Nursing driven protocol for Foley removal - which has impacted in a 30% decrease in CA-UTI rate. The current utilization of the protocol ranges in the 80%. Interestingly is that in quality improvement, it is not only the implementation of a new protocol or change which creates impact, but also the adherence and compliance with it. 

Nowadays an interesting phenomenon, is the engagement of patients in the decision making process, which by the way is a principle objective of Choosing Wisely. When a catheter is placed - for instance to "monitor diuresis in a patient who is getting IV diuretics" - I have now patients asking if the catheter is strictly necessary, as they can use a urinal for quantification of urinary output. Still, I've witnessed resistance from providers regarding the "need for an accurate output measurement" and accepting not placing the catheter in a "lost battle mood". And this is because we were hardwired to use catheters in an indiscriminate way - and now are swinging the balance to the opposite side.

The times are changing and we all need to ensure there is engagement, especially from our young trainees. We need to hardwire best practices early enough. Teach them the words of Henry Ford "Quality is doing the right thing when nobody is watching".