medical research confusion

Sunday, April 23, 2017

The importance of science was highlighted by the worldwide marches of physicists, chemists, biologists and other scientists whose discoveries have made a difference in how lives are lived. From the houses where we live, to that water that we drink, the food that we eat and the electricity that powers our cellphone networks, each eureka moment is supported by thousands of smaller innovations that transform theory into something that actually works. In medicine, research in the lab needs to be translated into real world situations and interpreted by doctors and nurses at the bedside. The application of that research isn’t always neat and tidy.

Prostate Screening

This month, the US Preventive Services Task Force reversed its previous 2012 position on screening men for prostate cancer using the PSA (prostate specific antigen) blood test. The Task Force now recommends that primary care clinicians routinely discuss the potential benefits and harms of testing screening in men aged 55-69 and screen those men who desire the blood test. This change of heart relied on new research from Europe that suggested that there may be a moderate benefit in survival and life expectancy gained by testing, but that had to balance against the increased rate of potentially unnecessary operations and complications that would arise.  The American Cancer Society and the American Urological Association (urologists treat and operate on prostate cancer) agree with the revised guidelines and urge patients to be screened. The American Academy of Family Physicians and the American College of Preventive Medicine disagree and recommend against PSA testing. What should the poor patient do? and does the decision depend upon what office the poor guy walked into? Welcome to the uncertainty of medical research.

While controversies might exist in preventive medicine, the hope would be that doctors and researchers could agree on how to treat the sickest of patients. One would hope, wouldn’t one.

Septic Shock

When it comes to treating patients in septic shock, a situation where infection has spread throughout the body and overwhelmed its ability to respond, the standard of care for the past 15 years is being challenged and up for debate. Early goal directed therapy (EGDT) protocols use intravenous fluids, vasopressor and inotropic drugs to support blood pressure, as well as red blood cell transfusions to treat the septic patient and there is a time crunch to get it all done. The goal is to get everything possible started within 6 hours. The target goals aimed to meet arterial blood pressure, central venous pressure, central venous oxidation, and hemoglobin level goals. Lots of physiology needed to be measured and require invasive procedures to put intravenous catheters into the veins located within the chest near the heart and other catheters into arteries either in the arm or leg. The protocols were widely established for patient care after research was published in 2001 suggesting that by meeting these EGDT goals, patient survival increased by about 50%.

Not all doctors were convinced and controversy continued throughout the years, especially fueled by other research published in 2014 and 2015 that did not reproduce the initial success rates. And in March 2017, a major study published in the New England Journal of Medicine found no evidence that EGDT resulted in lower mortality than usual care.

This is may not be the end of the controversy. Perhaps the best summary about the treatment of patients with septic shock patients comes from Dr. Derek Angus of the University of Pittsburgh, a researcher whose research with the National Institutes of Health found no benefit to early goal directed therapy.  In an interview with MedPage Today he was quoted as follows:

It’s a little like American politics today. Everyone has an opinion. You won’t find many people who are ambivalent about President Trump. And there is really no one [in emergency medicine] who is ambivalent about early goal-directed therapy.”

Isn’t it nice to know that the medical care you and your family receive at the bedside is backed by science and research, or at least the science and research your doctor believes in. Perhaps it is another reason to ask questions to understand what your doctor is thinking. The idea of shared decision making is difficult. In times of crisis, it may be impossible to teach the patient everything they need to know to make an informed decision, but the bedside skill of nurse and doctor is sometimes measured by how well they can take confusion and make it understandable…and that presumes that they can understand the confusion that sometimes is medical research.

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the mess in akron

Sunday, April 9, 2017

The road to the Final Four culminates in a national holiday and it is also an opportunity for many to consider the plight of the student athlete. While their skill allows coaches and colleges to make millions, the players do not share in the bounty and very few will go on to play professionally. A student athlete is bound by the many rules and regulations of the NCAA and often has little recourse should the coach leave, the school be placed on probation or any myriad other issue that might arise.

But it’s not only college athletes who may fall victim to arbitrary rules that are more about money than equity. Consider the situation of emergency medicine residents training at the Summa Health System in Akron, Ohio. Their training program has been placed on probation by the Accreditation Council for Graduate Medical Education (ACGME) and may lose its accreditation on July 1. The residents in the program could transfer to another hospital or university program but unless they are granted their released by Summa, their new employer won’t get paid to teach them and likely would not open up a spot on their “roster.”

Some background about how medical education works. After graduating from medical school, newly minted doctors continue their postgraduate training as residents at teaching hospitals. Depending upon the specialty, that training can last three to seven years or more. Like an apprenticeship, as the doctors gather more experience in caring for patient, they are given more responsibility and less supervision until at the end of their training, they can care for patients independently. In addition to seeing patients, the hospitals are required to have teaching physicians who are responsible for lectures and research to expand the new docs’ knowledge base beyond what was taught in medical school. Medicare funds those residency teaching programs, including resident salaries and hospital expenses associated with their teaching, from the professors to the office support staff. And to be funded, a teaching program needs to be accredited by the ACGME.

The Mess in Akron

In Akron, Summa, a major teaching hospital, underwent an unusual change in their emergency department on January 1. The incumbent group of emergency doctors who had practiced there for 40 years was replaced by another. It wasn’t about the quality of patient care; it was about a contract coming due, a dispute over money and who would be paid what. The hospital announced a hastily arranged bidding process to find a new group of ER doctors, with a request for proposal due on December 29. The incumbent local group was not chosen and a new national company was awarded the contract that began on January 1. Normally, there is a transition period that lasts 3-4 months so that there is minimal disruption to patient care. In Akron, Summa arranged for a new set of docs to start 48 hours after the contract was awarded. Unfortunately for the emergency residents who were caught in the crossfire, the new group did not hit the ground running when it came to teaching and providing academic structure and supervision. On February 8, the ACGME placed the residency program on probation.

In the world of the NCAA, players have little option when a coach leaves or the college changes its promise to a student athlete. The education opportunity may remain, but the opportunity to play or compete may be lost. Perhaps a worse situation now exists for the emergency medicine resident trainees in Akron. There is no guarantee that their program will regain accreditation and if that accreditation does not occur, those same doctors will not be able to take their board exams so that they can call themselves specialists. Training has to occur in an approved, accredited program to count. And yet, if they try to find another place to train, there may not be funds to allow that to happen, because the hospital can, in effect, block the transfer. It sounds a lot like a student athlete wanting to transfer to another college but can’t because they were being blocked by their coach.

Medical students often begin their journey filled with optimism. As they progress through four years of medical school and then more years of postgrad training, it takes a lot of work and emotional capital to maintain a level minimum level of altruism. For those caught in the Akron mess, it is a sad reminder that too often money takes precedence over common sense, and while it’s hard to consider physician as victim, perhaps this might be one time when it is true.

Reference:Annals of Emergency Medicine April 2017

 

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