Physician, Heal Thyself!

An unwavering work ethic is a hallmark of many health professionals. But a new survey finds that when a doctor is sick, such dedication to duty can have serious consequences.

A poll of 150 attendees of an American College of Physicians meeting in 2010 revealed that more than half of resident physicians had worked with flu-like symptoms at least once in the last year and one in six reported working sick on three or more occasions during that time.

The survey conducted by researchers at the University of Chicago Medicine and Massachusetts General Hospital also asked the doctors whether they believed they’d ever directly transmitted an illness to a patient.  Shockingly, nearly 10 percent of respondents answered yes, and more than 20 percent believed other residents had passed on an illness to a patient. So much for the Hippocratic Oath and the promise to do no harm!

The results published in the Archives of Internal Medicine are further evidence of a culture of self-sacrifice long prevalent in medicine. Researchers say a physician’s sense of loyalty to already-overwhelmed peers, along with a commitment to patient care, often conflicts with an ethical stance against exposing patients and staff to an illness or compromised performance.

Resisting the pressure to work when ill can be particularly difficult for young doctors,” said study author Anupam B. Jena, MD, PhD,. “A work-first, self-second attitude is often seen as ideal among peers, superiors and even patients.”

In the first known account of the reasons for presenteeism among doctors-in-training, more than half of respondents cited obligation to colleagues who’d be forced to cover their duties or an obligation to patient care as the top reasons for not taking a sick day.

Far fewer, a mere 12%, indicated they’d worked when ill due to concerns their colleagues would think they were “weak” and 8% came to work sick because they felt pressured to repay colleagues for coverage.

Seniority appeared to be a factor in the results. Second-year residents were more likely than first-years to select responsibility to patient care as a reason for presenteeism. Gender differences were also brought to light with female residents more likely to work sick and cite patient care as the reason. Female residents were also more likely to report fear of being perceived as weak as a motive for not taking time off.

While time away from the office carries a similar stigma in other high-pressure professions, a business  executive showing up sick to the boardroom is significantly less worrisome than a doctor with flu treating patients. An otherwise healthy doctor can often recover quickly, but an infected patient with an already-compromised immune system may not.

Clearly it’s time for doctors to stop playing superheroes.  Presenteeism needs to be addressed and eliminated. Given the intellect of most doctors it shouldn’t be too difficult for them to understand that refraining from work while ill is the most professional way to ensure responsible and safe care for patients.

A word to my doctors – if  what you’ve got is contagious or makes you so sick that your judgment is clouded – STAY HOME!

Rogue Reporting

According to an article just published in the Journal of General Internal Medicine, results of drug studies published in medical journals may be misleading.

The UCLA-Harvard study says that the drug trials published in the most influential medical journals including the New England Journal of Medicine, the Journal of the American Medical AssociationThe Lancet, the Annals of Internal Medicine, the British Medical Journal and the Archives of Internal Medicine are frequently designed in a way that yields misleading or confusing results.

Investigators analyzed all the randomized drug trials published in the above journals between June 1, 2008, and Sept. 30, 2010, to determine the prevalence of outcome measures that make data interpretation difficult.  In addition, they reviewed each study’s abstract to determine the percentage that reported results using relative rather than absolute numbers, which can also be misleading.

They specifically looked at three outcome measures that have received increasing criticism from scientific experts: surrogate outcomes, composite outcomes and disease-specific mortality and found that :

  • 37% of the studies analyzed used surrogate outcomes – intermediate markers, such as a heart medication’s ability to lower blood pressure, but which may not be a good indicator of the medication’s impact on more important clinical outcomes, like heart attacks
  • 34% used composite outcomes which consist of multiple individual outcomes of unequal importance lumped together, such as hospitalizations and mortality, making it difficult to understand the effects on each outcome individually
  • 27% used disease-specific mortality, which measures deaths from a specific cause rather than from any cause. This may be a misleading measure because, even if a given treatment reduces one type of death, it could increase the risk of dying from another cause, to an equal or greater extent

Patients and doctors care less about whether a medication lowers blood pressure than they do about whether it prevents heart attacks and strokes or decreases the risk of premature death,” said the study’s lead author, Dr. Michael Hochman, a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at the David Geffen School of Medicine at UCLA’s division of general internal medicine and health services research, and at the U.S. Department of Veterans Affairs’ Los Angeles Medical Center.

Dr. Danny McCormick, the study’s senior author and a physician at the Cambridge Health Alliance and Harvard Medical School, added: “Patients also want to know, in as much detail as possible, what the effects of a treatment are, and this can be difficult when multiple outcomes of unequal importance are lumped together.”

The authors also found that 45% of exclusively commercially funded trials used surrogate endpoints, whereas only 29% of trials receiving non-commercial funding did. Furthermore, while 39% of exclusively commercially funded trials used disease-specific mortality, only 16% of trials receiving non-commercial funding did.

The study also showed that 44% of abstracts reported results in relative rather than absolute numbers, which can be misleading.  “The way in which study results are presented is critical,” McCormick said. “It’s one thing to say a medication lowers your risk of heart attacks from two-in-a-million to one-in-a-million, and something completely different to say a medication lowers your risk of heart attacks by 50 percent. Both ways of presenting the data are technically correct, but the second way, using relative numbers, could be misleading.”

To remedy the problems identified by their analysis, Hochman and McCormick believe that studies should report results in absolute numbers, either instead of, or in addition to, relative numbers, and that committees overseeing research studies should closely scrutinize study outcomes to ensure that lower-quality outcomes, like surrogate makers, are only used in appropriate circumstances.

So who’s to blame?  The pharma companies for using outcomes that are most likely to indicate favorable results for their products, the study authors for writing them up that way or the journals for accepting the manuscripts?  Let us know what you think.

Infectious Disease Guidelines: A Matter of Opinion!

In recent years, a deluge of publications addressing nearly every aspect of patient care has enhanced clinical decision making, However, some feel it may also have encumbered it, owing to the tremendous volume of new and often conflicting information.

Clinical practice guidelines were developed to aid clinicians in improving patient outcomes and streamlining health care delivery by analyzing and summarizing data from all relevant publications. Lately, these guidelines have also been used as tools for educational purposes, performance measures and policy making. They are also meant to assist in the delivery of patient care. Not surprising then, that both physicians and patients assume that following such guidelines means practicing evidence-based medicine.

However, according to a new study published in the Archives of Internal Medicine, more than half of recommendations included in infectious disease guidelines rely on low-quality evidence.

Researchers examined 41 guidelines published by the Infectious Diseases Society of America (IDSA) since 1994. Of the 4200 recommendations in those guidelines, only 14% were guided by randomized controlled trials (level I evidence) while 55% were supported by expert opinions only (level III evidence).

Five guidelines were updated during the study period. In these updates, the number of recommendations increased between 20% and 400%, but only two updates saw an increase in the number of recommendations based on high-quality evidence.

An accompanying editorial advises physicians to be wary of falling into the trap of ‘cookbook medicine.’ “Guidelines may provide a starting point for searching for information, but they are not the finish line.” said John H. Powers, MD of the National Institute of Allergy and Infectious Diseases.

Ultimately, the existence of guidelines is probably better than no guidelines, but clearly guidelines should never replace critical thinking in patient care and physicians should avoid  using guidelines as their only source when making clinical decisions.

For better critical thinking or to discuss the development of true evidence based guidelines for your brand, contact SRxA today. Learn how our teams of expert Advisors in Allergy, Pulmonology, ENT, Ocular Medicine and Surgery, Aesthetics, Reproductive Medicine and Behavioral Health can help you and your brand.

One test too many?

How’s this for a dichotomy?  During the same week we learned that America is $13 trillion in debt, a new study reported that over 90% of US doctors knowingly order more tests and procedures than are medically necessary.

No surprise then that the United States spends more than any other industrialized country on healthcare expenses.  A staggering $2 trillion annually to be exact.

The new survey by Mount Sinai School of Medicine, published in Archives of Internal Medicine questioned 2,416 physicians. 91% of respondents believe that concerns over malpractice lawsuits result in them practicing “defensive medicine.”

About $60 billion is spent annually on defensive medicine and many physicians feel they are vulnerable to malpractice lawsuits even when they practice competently within the standard of care,” said Tara Bishop, MD, co-author of the study.

The majority of physicians (90.7%) also stated that for them to decrease the ordering of unnecessary medical tests, better protections against unwarranted malpractice suits are needed.

Word on Health could not agree more.  At a time when the healthcare system is in such crisis that hospitals nationwide are reporting major drug shortages, we should not be forcing physicians to waste money to protect themselves from malpractice concerns. Not only are we exposing patients to unnecessary, and often invasive, procedures, this crippling fear of litigation is surely impacting health care reform efforts.

Time for tort reform?  Let us know what you think .