Rheum With a View

Dr. Panush

This month we’re going to look at the literature through the lens of that childhood game of “animal, vegetable, or mineral” (having 20 questions to guess which), and some thoughts about relocating to Southern California (I’ve no idea what category that would belong to).

Animal…

One of the strengths of rheumatology here at the University of Southern California (USC) is our division chief, Billy Stohl, MD, and the excellence of his science. His interest focuses on the etiopathogenesis of lupus and translating understandings from animal models to better care of our patients. Certain recent observations by him and his colleagues were recently discussed at one of our conferences and just appeared in the literature.¹ These were an elegant, complex, and kind of arcane series of experiments. The studies were designed to probe of the role of interferon alpha (IFN-a) in driving or sustaining disease in the context of B-cell or B-cell activating factor (BAFF) deficiency. This is relevant because of the ability of therapeutic agents in use or in clinical trials to deplete B cells or neutralize BAFF. The studies by Stohl and colleagues found that IFN-a promoted virulent lupus in genetically predisposed mice, and that disease was largely absent in strains deficient in B cells or BAFF. Other findings suggested that IFN-a–related exaggerated disease in certain mice may reflect B cells and/or the innate immune system more than T cells. For clinicians this means that even if IFN-a is overexpressed, it may still be possible to successfully treat lupus patients by targeting BAFF or B cells.

Animals of a Different Stripe

I’m writing this on June 30. That means the new residents (and fellows) begin tomorrow. It’s an exciting time. I recall, from my day, the admonition, “Never go to a hospital in July.” It was common knowledge that this was a dangerous time. Care and outcomes would suffer from the inexperienced new residents at teaching hospitals. That was the widespread perception. But, was it true? It turns out, the answer seems to be “maybe.”^2,3 (I thought it would be fun and timely to mention this adage at this particular time—and it fits in my “animal” category for this column. The game of 20 questions to identify an “animal, vegetable, or mineral” included all living things, and residents are categorized, despite their duress during internship, as “animals.”)

Several studies addressed this “July phenomenon” in the 1980s and 1990s, mostly not finding a poor outcome at teaching hospitals during the month when trainees start. A good summary study and paper found no increase in ICU mortality or hospital length of stay from July through September in major or minor teaching or nonteaching hospitals.² A report from 2010, however, found a significant spike in fatal medication errors during July (but not overall deaths).³

My guess for explanations for the absence of reports of more medical problems in July are, in part, that hospitals and training programs compensate for new resident inexperience early in the academic year by systematic redundancies, scheduling of upper levels of residents, and greater oversight by attending physicians, fellows, and other staff, and probably also that more subtle yet clinically and economically important performance issues are simply not well documented nor identified in studies.

Vegetable…

I’ve tried not to select articles from our mainstream rheumatology journals for comment. But how many of you read the paper in Arthritis & Rheumatism last April about berberine?4 Berberine is a “vegetable,” an isoquinoline alkaloid present in certain plants that have been used in traditional Chinese medicine. Berberine has been found to have antiinflammatory and immunosuppressive effects in vitro and in animal studies. This paper extends those observations by noting that berberine induced apoptosis in dendritic cells, selectively, and ameliorated collagen-induced arthritis in mice while also suppressing humoral and cellular responses to collagen. This is the not the first time we’ve discussed a potential new antirheumatic therapy derived from plants, and it won’t be the last. Perhaps we will hear more about berberine in clinical trials.

Californians enjoy some beach activities.

…And Mineral

How many of you have electronic medical or health records (EMRs or EHRs)? We all are supposed to, eventually. I didn’t have one as I left Saint Barnabas in the fall of 2010. With my responsibilities as department chair there, for quality, safety, efficiency, efficacy, clinical performance, utilization, documentation, legibility, reduction of paper and paperwork, implementation of clinical prompts, evidence-based care, care pathways and guidelines, managing variations in care, understanding variations in costs and outcomes, assuring ready availability and access to records/charts, and other matters, my counterparts and I yearned for an EMR, hoping that it would almost magically resolve these and related issues.

I sort of have an EMR now at USC and USC-LA County medical centers. I think the only improvement is legibility. I’m not sure that the EMRs, even the simple versions we have here now, necessarily lead to better, or even better documented, care yet in and of themselves. Oh, there are the terrific advantages (usually) of availability, portability (to a degree), accessibility, size, cost reductions, and such. But they bring their own set of problems. These concerns have been reported in the literature.^5-9 Although a study from a government office found that 92% of recent articles reported “positive” conclusions about the implementation and use of health information technology, another systematic review could find no evidence of improved patient outcomes or cost effectiveness from ehealth technologies.^7,8 Certainly the transition to them is not always smooth.^5,6,9

There are real problems with the use of templates, algorithms, “cutting and pasting” notes (Is this not a form of clinical plagiarism?) and information, and creating “ipatients,” where the computer record becomes the focus of attention and we neglect the real person in bed who has become “a mere placeholder for the virtual record.”⁹ Do we pay more attention to the computer and the intricacies of its capabilities than to the patient? Do we become a “Dr. Computer”? Do we really think patients speak in templates?⁶ Will the rich information from “narrative” medicine be forever lost?

I have found that sometimes in teaching settings I will be presented patients with extensive information, but that information often will be the same as was saved in the electronic or written record on the last visit, and the visit before, and so on. I will hear the “past medical history” and prior impressions, not all always correct. I will hear about the patient, not uncommonly reduced to “positives” and “negatives” (like the wrist was TTP positive or negative, meaning there was or wasn’t tenderness to palpation, not necessarily what structures were identified, with what if any abnormalities, and to what degree), rarely nuanced or qualitative. The most absurd example I can recall was the patient who was “ROMI” positive, meaning he had definitively “ruled out” a myocardial infarction.

In these reports, I will too frequently hear little about the person, how he or she has coped with illness, responded or not to prior and recent treatments, how he or she functioned, what his or her goals and expectations were, and what we could best do to help this person. I will hear about the exam, often carried out without disrobing the patient; and finally I will hear many numbers and other findings, particularly imaging studies, always presented with the authority presumed implicit in quantitative or reported data.

So, I perceive one of my—indeed our—challenges is still to teach students, residents, and fellows what we can about clinical rheumatology and medicine and taking care of sick people in this era of the EMR. I don’t think that an EMR, however fabulous or sophisticated, supplants the need to learn and do good clinical, “bedside” medicine, particularly in rheumatology. I try to remember what I learned as a resident from Eugene A. Stead, Jr., MD, the legendary chair of medicine at Duke University, who said, “Take care of people, not illness … the future of medicine belongs to those… who… in spite of bureaucratic systems, pressures and financial disincentives to spend time with patients continue to care for the patients as human beings.”^9,10 We cannot lose sight of the imperative to always thoughtfully perform the ritual of obtaining the “bedside” clinical history and carrying out a careful examination followed by formulation of an informed impression, and then, to paraphrase Verghese, concluded by providing an essential treatment administered by ear—words of support and comfort.⁸ We must not stop practicing thinking and caring clinical medicine.

And Sunny Southern California…

On a more personal note, I’m still adjusting to certain aspects of my new life in Southern California. Since growing up in Detroit, I’ve mostly lived in college towns (Ann Arbor, Mich.; Durham, N.C.; and Gainesville, Fla.) or pleasant suburbs. Even during fellowship in Boston, we lived in Brookline, and I could walk to the Harvard campus and hospitals; urban living and commuting are new to us. Going to work is now very different. I can’t walk, or run, or bike, like I sometimes used to do. The driving is a big change. The fastest part of my commute in Los Angeles is going out my driveway.

After nearly 46 years of marriage to a lovely forbearing wife who sings opera, I’ve finally begun to appreciate opera, so I sometimes listen to CDs while driving to and from work. One day last week I went through the complete Wagner ring cycle (for those who may not know opera as I now do, trust me, that is a very long time). Dress in Southern California and on the USC campus is incredibly casual, far more so than even I would dress, and I’m pretty informal. Here, I’m usually the only one wearing a tie, let alone not in scrubs; I can’t tell faculty from residents from students from orderlies. I’m trying to learn Spanish, but so far haven’t gotten much past “No hablo Español.” I’m determined to do better.

Cuisine and dining are very different too; I’m learning to differentiate Sumatran from Ethiopian coffee. My wife, Rena, knows which restaurants have the freshest arugula, whatever that is. My five-year-old grandson, Etan, calls his teachers by their first name; my eight-year-old granddaughter, Lia, had a teacher who wore flip-flops and sunglasses to school each morning; we think her next teacher will have purple hair, a nose ring, and will moonlight as a spiritualist named Breeze.

We haven’t had an earthquake yet, but we’re ready. Our daughter was watching—not helping—while we unpacked and set up our new home; she exclaimed with horror when we put a picture with a heavy frame over our bed. Here, that’s potentially lethal. Unlike New Jersey, I don’t pay attention to weather reports and forecasts, as it’s the same every day.

I haven’t gone to a meeting since September 2010 when I left Saint Barnabas. I’m quite content with my new roles (clinical, educational, scholarly, and advisory) in rheumatology and medicine here at USC. I still savor walking across campus on warm, sunny days and sometimes stopping for coffee. Mornings I often run on the beach with my dogs. Weekends, if I don’t run, I cycle with my daughter on bike paths along the nearby creek with the ocean and surrounding mountains in the background. Rena can have, and prepare, our traditional Friday night Sabbath dinners to include family each week, which is just wonderful. Lia came over for dinner the other night—they’re five blocks away—for the only food I know how to prepare: Cookie Crisp cereal. Last Saturday I woke up to find Etan asleep in our bed.

I recently returned from taking Lia to Israel for c 10d for a wedding and bar mitzvah (my sister lives there; her youngest son’s wedding and her oldest son’s son’s bar mitzvah). Rena and our daughter were certain I would either lose Lia or that we’d be abducted and taken hostage or something equally dire. Perhaps I’ll have an opportunity to comment about our experiences and impressions in a future column in The Rheumatologist. So, we’re doing fine and enjoying our new life.

Dr. Panush is professor of medicine, Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles.

References

1. Jacob N, Guo S, Koss MN, et al. B cell and BAFF dependence of IFN-alpha-exaggerated disease in systemic lupus erythematosus-prone NZM 2328 mice. J Immunol. 2011;186:4984-4993.
2. Barry WA, Rosenthal GE. Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med. 2003;18:639-645.
3. Phillips DP, Barker GEC. A July spike in fatal medication errors: A possible effect of new medical residents. J Gen Intern Med. 2010;25:774-779.
4. Hu Z, Jiao Q, Ding J, et al. Berberine induces dendritic cell apoptosis and has therapeutic potential for rheumatoid arthritis. Arthritis Rheum. 2011;63:949-959.
5. Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. New Engl J Med. 2008;358:1656-1658.
6. Lewis S. Brave new EMR. Ann Intern Med. 2011;154:368-369.
7. Black AD, Car J, Pagliari C. The impact of ehealth on the quality and safety of health care: A systematic overview. PLoS Med. 2011;8:e1000387.
8. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: A review of the recent literature shows predominantly positive results. Health Aff (Millwood). 2011;30:464-471.
9. Verghese A. Treat the patient, not the CT scan. New York Times. February 27, 2011, p. 10.
10. Stead EA. Just Say For Me. Collected by F Schoonmaker and E Metz. Denver, CO: World Press;1969:13.
11. Stead EA. A Way of Thinking. A Primer on the Art of Being a Doctor. In: Haynes BF, ed. Durham, NC: Carolina Academic Press;1995:Dedication.