Observing medical students: how will they learn if we don’t watch them with patients?

December 5, 2010  |  General  |  No Comments

I went off to medical school thirty-seven years ago. For the era, I went to what folks regarded as a very progressive place. It had a curriculum that was quite revolutionary for the time. Among other things, we started having interactions with actual patients during our first year, rather than the third year, as was traditional then. These days many, probably most, medical schools get their students seeing real patients sooner. That’s good. But do these students get any sort of planned, structured assessments with how they’re doing with those real patients? Does anybody watch them, encourage what they’re doing right and correct what they’re doing wrong?

A recent editorial in the journal Pediatrics, the official journal of the American Academy of Pediatrics, has an enlightening title: “Oh, what you can see: the role of observation in medical student education.” It turns out that students often don’t get what they need to learn how to do things right. (The full article at the link is behind a pay wall — if anybody wants the full editorial, let me know.)

It turns out that during their pediatric rotation only 57% of students have a faculty member observe them throughout the entire process of meeting a child and family, taking a medical history, and doing a physical examination. In my day I think it was worse than that: I can’t even recall having a teacher watch me go through the entire process; generally, the students would watch the teacher, then go off and try things on their own. Of course we weren’t allowed to do anything involving needles and such without training and supervision (at least at first), but thinking back it is surprising that we were mostly left to ourselves.

The rationale for direct observation is straightforward and obvious. In the words of the authors:

“The aim of direct clinical observation is clear — to help preceptors gather accurate information about students’ actual performance in real-life clinical settings rather than inferring performance. Preceptors can then provide effective, timely, and specific feedback on observed skills that can be incorporated into subsequent clinical encounters. With better supervision of learners, both student skills and clinical care improve.”

It seems obvious. Our colleagues in internal medicine are doing even worse they we are in pediatrics, though: the survey found that only 22% of students had an in-depth patient encounter observed by one of their teachers. Teachers of surgery, too, evaluated students “primarily on the basis of their own interactions with students rather than on observed clinical interactions with patients.”

The authors’ conclusion is self-evident, but at times somebody needs to point out the obvious:

“Focused, direct observation of medical students in clinical settings provides valuable information about learners’ skills in history-taking, communication, physical examination, and providing information to children and parents. Observing students’ encounters with patients improves teaching, evaluation, preceptor satisfaction, student satisfaction, and, ultimately, patient care. For the great clinical teacher, direct observation is worth the effort.”

Removing infant cold medicines from the market has reduced untoward events from them

December 1, 2010  |  General  |  No Comments

No pediatrician I know has ever liked any of the many over-the-counter cough and cold remedies very much, especially for very young children. There never has been any evidence that they help cold symptoms, and what’s in them (typically a decongestant and an antihistamine) can cause actual harm to children. Risking harm for dubious benefit is never a good trade-off in medical practice. I’ve seen more than a few kids over the years need to be admitted to the PICU because they have overdosed on these medications, either because they got into the meds and took them themselves or because their parents miscalculated the dose and gave too much.

Recognizing the problem, the makers of these products agreed voluntarily three years ago to take the ones intended for children less than two years of age off the market. These were usually various kinds of drops. Did this new policy have any effect? A recent study in the journal Pediatrics, the official journal of the American Academy of Pediatrics, suggests that it did.

The authors looked at emergency room visits before and after the product withdrawal went into effect. They sampled sixty-three representative pediatric emergency rooms across the country. What they found is that the number of trips to the ER for untoward effects from these medications — overdoses or just funny reactions — dropped by half. Such ER visits for children older than two did not change. Of course, as we say, correlation doesn’t prove causation, so it may have been a coincidence. But I don’t think so — I think the new policy helped.

It’s good that ER visits from the ill effects of over-the-counter cold remedies dropped for young children, but there still were too many of them — 1,248 in the sample hospitals. That’s a lot of risk for no benefit at all. For children over two years of age, there were nearly ten thousand ER visits for this problems. That concerns me just as much. Roughly two-thirds of the cases were ones in which unsupervised children took the medicine themselves, but fully a third of them were because parents gave the children the medication. My advice — don’t use these agents unless your doctor suggests them, and never in children less than four.

Every parent should know where to find the number of their local poison control center — it’s generally in the front pages of the telephone book. Call them if you have any questions about drug effects — they are always very helpful and you might save yourself and your child a trip to the emergency department.

Influenza vaccine is for everybody

November 26, 2010  |  General  |  1 Comment

Influenza, the flu virus, has arrived. It can be a serious infection, and it’s too soon to tell if this year’s epidemic will be as severe as last year’s was.

When I first started in medicine, influenza vaccine was generally only recommended for the elderly or those with some serious underlying condition involving their hearts or their lungs. That’s changed now, and for good reason: the higher the rate of vaccination in the population, the better the degree of herd immunity. For some infections, such as pertussis, a key to reducing the rate of infection is to stop its transmission among those who may only get mild cases, because that interrupts the chain of infection. Influenza is like that. The recommendation now is that nearly everybody should be vaccinated against it.

We also discovered last winter that the new so-called H1N1 strain of influenza could cause severe disease in otherwise normal people. For example, I cared for several children who required several weeks in the PICU on a mechanical ventilator before they improved.

The influenza vaccine is far from an ideal one. This is largely because the virus changes every year and the vaccine mixture needs to be tweaked annually to account for this. We have two types of vaccine — a shot in the arm and a mist blown up the nose. Depending upon you (or your child’s) age, the recommendations differ for which one you should get.

The national Centers for Disease Control (the CDC) explains the basis for their recommendation for near universal influenza vaccination here. It’s a bit heavy reading in spots, but it is the best expert opinion available on the matter.

The impact of children with complex chronic conditions on children’s hospitals

November 19, 2010  |  General  |  No Comments

I’ve been doing pediatrics since 1978, and over that time have seen a transformation of children’s hospitals. I trained at a then intermediate-sized one (Vanderbilt University Children’s Hospital), that has since grown into quite a big one. When I was a resident we had some children who had complex chronic medical problems, but they were in the minority. Most of the children in the hospital were there for problems that you could call bread-and-butter pediatrics. That situation has now changed, not just at places like Vanderbilt, but at all hospitals that care for children.

Over the past three decades we’ve made huge advances in pediatric care of children with complicated medical needs — premature infants, children with brain and spinal cord problems, those with severe respiratory issues, and many other categories. In the not too distant past, children such as these would not have survived beyond their early years; now many of them are becoming adults. Yet such children are often quite medically fragile, such as being susceptible to what would be minor infections for other children, and many are dependent on advanced technology to live.

These children need hospitalizations more frequently than do their peers who do not have such problems, and their increasing presence has had an impact on the population of America’s children’s hospitals. Two recent studies (here and here) document this evolution of what children’s hospitals do. It only covers a decade — 1997 to 2006. If it were cast back to the 1970s I’m sure the changes would be even more dramatic. The authors found that children with complex chronic conditions now account for 10% of all hospital admissions. However, they use 25% of all hospital days and 40% of hospital costs, numbers which reflect their complicated situations.

I don’t think these findings are unexpected or troubling in any way. Rather, they are a reflection of our success in allowing children who previously would have died to be part of their families, to participate in society. What is clear, however, is that as we plan for what it is that children’s hospitals do, we need to understand that more and more our role will be to care for these children. Young pediatricians completing their training also need to understand that, more and more, they can expect to have several such children at least in their practices. They need to be ready for that. This was also the conclusion of the authors of an excellent accompanying editorial: we need to be ready to give these children the care they need in the best place to receive it.

(Some of the links may only be to an abstract — if anybody wants the complete articles, and can’t obtain them, let me know.)

Wheezing in infants and toddlers: we still don’t know what’s best to do

November 13, 2010  |  General  |  No Comments

The winter virus season is fast approaching, bringing with it the old dilemma of what to do about infants and toddlers who wheeze. Last year I noted that we had no specific treatment that worked.

A few months after my post, investigators in Canada published a large study that compared two of the standard treatments traditionally used for wheezing infants and toddlers: oral steroids and nebulized (inhaled) epinephrine (or albuterol). The randomized, placebo-controlled study compared children who came to the emergency department for breathing difficulties. They received either, both, or none of those therapies. The endpoint the researchers studied was how many of those children progressed to get sick enough to need admission to the hospital during the subsequent week.

The results showed that maybe — maybe — there was a slight beneficial effect of both treatments together in keeping kids out of the hospital, but neither treatment alone helped. An accompanying editorial in the same issue pointed out the problem here: when infants and toddlers come with their first episode (or episodes) of wheezing, we don’t know if they are going to continue to have problems in the future (such as progressing to asthma) or not. These treatments clearly help asthma. So if we give them to all comers with wheezing symptoms there will be some, those who are destined to have asthma later, who will benefit. But that’s not at all the same thing as saying that these treatments (which are not risk-free) will help kids with bronchiolitis, by far the most common cause of wheezing in this age group.

Over the past year the authors of the study, probably a bit stung by the pooh-poohing of their findings, have churned through their data from a different angle. This sort of data-mining in search of positive findings is common, especially if the original findings were not earth-shaking (or even useful). After all, people’s careers in academic medicine may be at stake. Anyway, they’ve just published an article on the cost-effectiveness of of using the combination of inhaled epinephrine and oral steroids. They conclude that these therapies, which medically don’t help much, still save a little money — to society, not necessarily to the family. I don’t find that argument convincing, either.

So what do most of us do with wheezing infants and toddlers, especially those who have bronchiolitis? I think most of us give a trial of the inhaled medicine to see if it helps. If it does, we continue it; if it doesn’t, we don’t. If there is dramatic improvement with the inhaled medicine, we consider giving the steroids. The presumption is that kids who respond dramatically to the inhaled medicine are more likely to become asthmatic, so what we are really doing is treating early asthma, not bronchiolitis.

As a parent, what this controversy means to you is that the correct answer is still unknown, although the preponderance of expert opinion is that bronchiolitis — wheezing in small children — requires supportive care, such as help with feeding, clearance of respiratory mucous, and sometimes oxygen, but there are no good data showing the benefit of anything else.

Pertussis vaccination: our gift to others and to the common good

November 5, 2010  |  General  |  No Comments

Whooping cough (pertussis) has been in the news for the past several months. For example, there’s been a sizable epidemic in California over the summer that has caused several deaths in infants. I’ve cared for several cases myself recently, including a couple of infants who needed mechanical ventilators to breathe, and who coughed so much for weeks afterward they could barely eat. It’s a serious and potentially lethal infection for infants, although in older children and adults it mainly causes only a nagging cough.

We have a vaccine for pertussis. It’s combined with other vaccines — diphtheria and tetanus — in a single shot, called DTaP. Each capital letter stands for one of the three vaccines in the shot; the little “a” indicates that the pertussis vaccine component is “acellular,” to distinguish it from the older version (the DPT) made from whole pertussis bacteria. That version caused more reactions (mainly high fever) in children who received it than does our current, acellular variety. A child should receive the DTaP at 2, 4, 6, and 18 months, and again at 4-6 years of age.

Overall, pertussis vaccine has been a success, with the number of annual cases, and death rates, dropping enormously. (You can read about its development here.) But the pertussis vaccine has never been a very good one, compared with most of the other ones, such as those for polio or measles.

The ideal vaccine confers life-long immunity. Generally this requires a series of shots to boost immunity, but, once achieved, the person can never get the disease. In practice, all immunity wanes with age and with the passage of time from the last booster shot. This waning is quite pronounced with pertussis vaccine; probably the majority of adults who received their shots as children are no longer immune. They can get pertussis, although when they do their symptoms are just those of a nagging, chronic cough. Even though their symptoms are not severe, they can still infect others — especially infants. And their disease can be life-threatening.

The persons most vulnerable to getting severe or fatal pertussis are infants, often before they can even get their first vaccine shot. So the only way to protect them is for everyone else to be vaccinated so as to be unable to bring the infection to them. Our current vaccine works in older children. And we now have a pertussis booster shot that restores immunity in adolescents and adults. It is called Tdap, and I strongly encourage every adult to get this, especially if you are exposed to young children.

Pertussis vaccine is unusual in this way. All vaccine strategies for protecting populations involve what is called herd immunity, but the principle for controlling pertussis is primarily based upon keeping those for whom the disease is only mild vaccinated, so that they may be prevented from passing the infection to infants who are too young to join the vaccinated herd. We do it for the common good.

You can find an enormous amount of useful and reliable information here, at the Vaccination Education Center maintained by the Children’s Hospital of Philadelphia.

Fear of QALY

October 30, 2010  |  General  |  1 Comment

We badly need effectiveness research — which medical treatments work and which ones don’t. After all, some reasonable estimates are that a third or so what we spend on medical treatments is for things that aren’t known to work, or worse, don’t work. Effectiveness research means comparing two competing therapies to see which works better; if both work the same, our preference should be for the less expensive one. We have very little of that now.

There is another way to think of effectiveness research, a more global one. This approach looks at the bottom line — does a treatment make people’s lives better and/or make them live longer? A key metric for this kind of research is the quality-adjusted life year, or QALY. The idea is simple: to what extent does the treatment add meaningful years of life to people? This notion has been around for decades. It’s particularly useful because it crosses all disease categories, simply comparing life outcomes.

The idea of the QALY, however, can create fears that it will somehow be used to judge lives, one against the other, regarding which has a higher “qualtiy.” Could QALY measurement be a stalking horse for rationing, of allocating heathcare resources to those some committee deems more deserving. The political traction that Sarah Palin’s nonexistent “death panels” received shows the depth of this distrust.

This fear is, in fact, embedded in the recent healthcare reform bill, the Affordable Care Act. The Act established an outcomes research center, called the Patient-Centered Outcomes Research Institute. But, as a recent editorial in the New Journal England of Medicine notes, the Act specifically forbids the use of QALY measurement “as a threshold.” It is not clear at all what that means, but, like the authors of the editorial, I think it reflects a fear that some lives will be judged more worthy than others, leading to unfair (or unethical) rationing of care.

But here’s the problem: QALY analysis is one of the most powerful tools of effectiveness research, and it’s absurd to pretend is should not or will not be used. From the article:

“The antagonism toward cost-per-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness further down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints.”

I suppose the fear-of-QALY clause made into the bill because the legislative sausage-making machine contains many pet items of the various legislators. But this particular one is absurd.

What medical jargon may be doing to our brains

October 22, 2010  |  General  |  No Comments

Everybody knows that doctors sometimes have the annoying habit of using medical jargon when speaking to patients and their families. It’s annoying because it gets in the way of communication, and many people feel inhibited from saying that they just don’t understand what the doctor is talking about. So on and on the doctor drones, assuming the absence of questions from the other side means both are communicating. Some doctors do this more than others, of course, but I think it’s a problem for all of us to some degree.

Lately, though, I’ve wondered if talking in medical jargon means thinking in medical jargon. After all, an old theory among linguists, the Whorf-Sapir Hypothesis, proposes that language literally is the stuff of thought, that we think in language, or at least in linguistic categories. A corollary to this notion is that people with very divergent languages probably think in very divergent ways.

George Orwell, in his famous novel 1984, clearly was a Whorf-Sapir believer. Here is what he has to say about Newspeak, the new language invented by the state (Ingsoc) to control thought by driving out traditional language, or Oldspeak:

“The purpose of Newspeak was not only to provide a medium of expression for the world-view and mental habits proper to the devotees of Ingsoc, but to make all other modes of thought impossible. It was intended that when Newspeak had been adopted once and for all and Oldspeak forgotten, a heretical thought–that is, a thought diverging from the principles of Ingsoc–should be literally unthinkable, at least as far as thought is dependent on words. Its vocabulary was so constructed as to give exact and often very subtle expression to every meaning that a Party member could properly wish to express, while excluding all other meanings and also the possibility of arriving at them by indirect method. This was done partly by the invention of new words and by stripping such words as remained of unorthodox meanings, and so far as possible of all secondary meanings whatever.”

That’s a chilling passage. But I think there is some truth to the notion that corrupting the speech easily leads to corrupting the speaker. Professional vocabulary — jargon — has its place when used among members of the profession. But when I hear doctors speaking entirely in mealy-mouthed or impenetrable jargon, both to patients and to each other, I wonder how clear their thinking is. For a doctor, plain speaking may be more than just good communication; it may be good for his or her brain.

Carrot or stick? On training medical students

October 16, 2010  |  General  |  4 Comments

Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?

The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?

Recently I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a recent post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:

“On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.”

It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.

If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.

For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.

In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. That was interesting.

Adoption of smoke-free legislation reduces childhood asthma

October 8, 2010  |  General  |  2 Comments

We’ve known for a long time that tobacco smoke causes asthma exacerbations in children. And it doesn’t have to be the actual smoke; for children with asthma, simple exposure to rooms where people have smoked, or even to the clothing of smokers, can trigger breathing problems. A principal argument for banning smoking in public places is that these environments can be downright toxic for asthmatics. Do these anti-smoking regulations actually work? The bottom line question would be this: after these laws are passed, is there any change in the number and severity of asthma attacks? An important recent report in the New England Journal of Medicine gives us an answer. Yes — these regulations help children breathe better.

The research was done in Scotland, where all smoking at enclosed public places was banned in 2006. The premise of the study was simple: look at how many children were hospitalized for asthma before the ban and afterward. The results were striking: throughout Scotland, there was a reduction of asthma admissions in children of 15%. That may not seem like much, but the ban had only been in effect for 3 years when the data were collected. The direction of the trend line strongly indicates that there will be further reductions.

It’s important to understand that correlation doesn’t imply causation. That is, there’s no way to know if the drop in asthma attacks was really caused by the ban. But the authors did a large number of adjustments and corrections to the data set to rule out confounding variables (such as rural/urban, socioeconomic status, age, severity of previous asthma attacks). The reduction occurred in children of all ages — toddlers up through school-age.

The link above is only to the abstract of the article (you need a subscription to get the full text), but the key figures are there in the abstract. If anyone wants the complete article and can’t get it, let me know.