Spinal Manipulation No Better Than Other Treatments for Acute Lower Back Pain

New evidence by the Cochrane Collaboration shows that spinal manipulation (or adjustments) are no better at treating acute (6 weeks or less) lower back pain, than over the counter ibuprofen or other NSAIDS.  In fact, the back pain resolves on its own in most cases.  Here is what the Cochrane Collaboration had to say about their findings:

Low-back pain is a common and disabling disorder, representing a great burden both to the individual and society. It often results in reduced quality of life, time lost from work, and substantial medical expense. Spinal manipulative therapy (SMT) is widely practised by a variety of healthcare professionals worldwide and is a common choice for the treatment of low-back pain. The effectiveness of this form of therapy for the management of acute low-back pain is, however, not without dispute.

For this review, acute low-back pain was defined as pain lasting less than six weeks. Only cases of low-back pain not caused by a known underlying condition, for example, infection, tumour, or fracture, were included. Also included were patients whose pain was predominantly in the lower back but may also have radiated (spread) into the buttocks and legs.

SMT is known as a ‘hands-on’ treatment directed towards the spine, which includes both manipulation and mobilization. The therapist applies manual mobilization by passively moving the spinal joints within the patient’s range of motion using slow, passive movements, beginning with a small range and gradually increasing to a larger range of motion. Manipulation is a passive technique whereby the therapist applies a specifically directed manual impulse, or thrust, to a joint at or near the end of the passive (or physiological) range of motion. This is often accompanied by an audible ‘crack’.

In this review, a total of 20 randomized controlled trials (RCTs) (representing 2674 participants) assessing the effects of SMT in patients with acute low-back pain were identified. Treatment was delivered by a variety of practitioners, including chiropractors, manual therapists, and osteopaths. Approximately one-third of the trials were considered to be of high methodological quality, meaning these studies provided a high level of confidence in the outcome of SMT.

Overall, we found generally low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.

 

 

References:

http://www.aansneurosurgeon.org/2012/10/02/spinal-manipulation-no-better-than-other-treatments-for-acute-lower-back-pain/

http://summaries.cochrane.org/CD008880/spinal-manipulative-therapy-for-acute-low-back-pain

http://www.ncbi.nlm.nih.gov.proxy.libraries.uc.edu/pubmed/22972127

 

Selective Digestive Decontamination (SDD) – The ICU Book

Lately I’ve been reading The ICU Book by Paul L. Marino.  Everyone in crticial care recommmends this book as standard reading for interns and junior residents, and I have to say it has been quite the read so far.

One of the articles in Marino’s book that has really stuck out to me has to do with selective digestive decontamination (SDD). Marino explains that in the presence of severe chronic illness, the G.I. tract becomes populated with more pathogenic organisms capable of causing invasive infections. He quotes one study that showed that hospitalized patients are often colonized with pathogenic organisms in the G.I. tract most notably aerobic gram-negative bacilli like Pseudomonas. This paper noted that the change in microflora is not environmentally driven, however it is directly related to the severity of illness in ICU patients. Marino recommends selective digestive decontamination for all ICU patients.

One example of this regimen includes a three-step decontamination process.

1. Oral cavity: a paste containing 2% polymyxin, 2% tobramycin, and 2% amphotericin to be applied inside the mouth with a gloved finger every 6 hours.

2. G.I. tract: 10 ml solution containing 100 mg polymyxin, 80 mg tobramycin, and 500 mg amphotericin and given via nasogastric tube every 6 hours.

3. Systemic: intravenous cefuroxime, 1.5 g given every 8 hours for the 1st 4 days of this therapy

Multiple years of randomized controlled trials have shown that ICU acquired infections are dramatically reduced with this kind of regimen. In one study that Marino quotes all 3 types of infections common in ICUs–pneumonia, urinary tract infections, and septicemia septicemia from vascular catheters–were significantly less frequent in patients who received selective digestive decontamination. Many clinical trials are showing a combined 40% relative reduction in the frequency of acquired infections in the ICU.

Marino mentions that over 20 years of experience with selective digestive decontamination and numerous reports of its efficacy clearly show the benefits related to selective digestive decontamination. However there continues to be a debate over the merits of this practice. Marino states two concerns that feed this debate. First the impact of SDD on mortality and also the possibility of the emergence of antibiotic resistant organisms. Marino points out that studies that support the relative reduction in mortality in ICU patients that have received selective digestive decontamination and also he points to studies that show no evidence of antibiotic resistance with use of a standard selective digestive decontamination regimen.

So the question is why don’t hospitals use this regimen in the ICU? I cannot speak for all hospitals, however I can speak for the UC Health. In our ICU we do not use a selective digestive decontamination regimen. I’ve questioned the fellows about this practice, and I usually receive an answer dealing with the concern of the emergence of antibiotic resistant organisms. When I explained that this was a huge part of Dr. Marino’s ICU book the fellows question the studies stating that most of these are over 10 years old. This prompted me to look again at the current data to see if SDD is still the huge benefit that Dr. Marino felt that it once was.

I found an article in the Expert Opinion of Pharmacotherapy, a metanalysis from this year which included 65 randomized controlled trials with over 15,000 enrolled patients, over a 25 year period.  This article concluded:

From an objective, and strictly evidence-based, perspective we conclude that SDD is recommended because there is level 1 evidence to support its use. Moreover, intensivists should be aware that SDD is a life-saving strategy: only 18 patients need to receive the full protocol of SDD to save one life. This makes the ethics of withholding SDD highly questionable.

This was incredibly shocking to me, because I felt that I have stumbled upon something in medicine with evidence so clear and for such a long term period that there seems to be absolutely no debate in the clinical literature.  With evidence this clear and strong, why isn’t SDD a routine in ICUs across the country? Are physicians really that set in their ways?

 

References:

Marino, Paul L. The ICU Book. 2007. Third Ed. Chapter 4 pg 63-80.

Silvestri L, van Saene HK, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother. 2012 Jun;13(8):1113-29. Epub 2012 Apr 25.

Patient Decisions

In my short 3 weeks as a resident, I have seen some incredibly tough decisions that have needed to be made.  Some of the toughest being, whether or not to operate on a patient, and watching families decide whether or not it’s the right time to stop trying to save their loved one and provide them with a comfortable death. It’s widely known and aggressively taught (at least at my medical school) that three ethical principles are important when speaking with patients, autonomy, beneficence, and non-maleficence.

 

Autonomy, the principle that recognizes that patients should make their own decisions.  This is the most ethical thing to do according to our teachings. But is it the correct thing?  Two Ted talks I have seen question the current practice of autonomy as it is in current medical practice.  Should patients be required to make every single medical decision?  Or should they be given the option to let the medical team make some of the decisions?

 

Reference:

1. Baba Shiv: Sometimes it’s good to give up the driver’s seat

2. Sheena Lyengar: The art of choosing

 

Medical Students Have To Learn Sometime

[The dude in this picture is just a random guy I googled, not the real patient talked about in this post]

Another medical student and I were hanging around the emergency room at a small town hospital the other day.  The weather had been particularly nice that day and a man decided to fix some of the gutters and siding on his home.  So he climbed up his ladder and started working, but his guardian angel must have taken a coffee break and his ladder broke.  The man fell 15 or so feet down to the concrete, and was transported by ambulance to the ER.

Unfortunately this man had a large laceration across his forehead, and another long his arm.  Lucky for us medical students, this man had two large lacerations that required stitches.  For story completeness – this guy was completely stable and had absolutely no life-threatening injuries.  The lacerations were the only injuries he sustained as a result of his fall.

The doctor working in the ER with us decided this was a great opportunity for us to practice our suturing skills, and so the doctor told the other medical student and I to come over “and assist him with stitching up.”  The man’s wife did not like the sound of that at all, and she asked if the students would be allowed to put in the actual stitches.  The doctor told her that we would, under his close supervision.  The wife wasn’t convinced that this would be ok.  So she asked if there was ANY way that the doctor could call in another physician to help “assist” with the stitches.  He said that the other doctors were too busy to be called in for this, and the medical students were available and have had plenty of training in this type of procedure.  The man’s wife told the doctor that she really didn’t want students practicing on her husband, and the doctor reassured her that we have had lots of training and that medical students can do this.

It felt weird to be in the middle of that disagreement.  On the one hand, I completely understand the wife’s concern of having medical students essentially “practice” on her husband.  Yes we’ve had 6 years of post high school training, but in all honesty probably less than 5 hours of suture only training at this point.  But on the other hand, us medical students need to practice on someone.  If you only had the most experienced people do the job every time, then how would you train the next generation?  Also, if I completely mess up and a suture falls out, then we can always put another in or just let it heal without the missing stitch.  It won’t make a big difference.  I also understand that the wife may not have known that this was a fairly low risk procedure on the grand scale of things, and so I can understand where she’s coming from.

Yes we have to learn sometime.  If everyone says no to medical students, then there will never be an experienced group of physicians.

The Perfect Medical Career

What are the characteristics of the perfect career?

This is a crucial question I’ve been trying to answer all of my adult life.  Sure, it’s true that I know I am going to become a physician, but what specialty will I pursue?  I’ve heard the same advice picking out my specialty that I had when I was trying to figure out which career I wanted to pursue.

It usually starts with something like ‘you need to figure out what your personality is.’  Then once you know yourself, you can assess your passions, likes and dislikes, and main interests.  Figure out your talents they say.  Find your passion.  Which specialty suits your interests?

The truth is I won’t find happiness using these methods.  Science (I personally haven’t read the literature on this but I have taken people’s word for it) has figured out what people truly want in their dream job.  And I was surprised to find out that it’s only three things…

  1. Autonomy
  2. Mastery 
  3. Purpose 

This is a huge revelation for me as I am trying to choose my future specialty.  And I think this is an incredible piece of knowledge for anyone trying to choose a future career.

Lets look at my situation.  Becoming a physician allows me to knock out two out of these three career characteristics automatically.  First, I’ll be a master at something.  Whether it be the brain, radiology, or taking care of the family’s medical problems, I’ll be a “master” no matter what my specialty.  Second, my career will serve a purpose.  Doctors, whether directly or indirectly, effect peoples’ lives and their health, which can obviously be very rewarding.  But the last one is the most tricky, autonomy.

I believe it is this last trait that many physicians feel like they are now missing in their practice, and may possibly be the main reason for physician burn-out.  Here are some immediate examples of this that I can think of right off the bat…

  •  – Surgeons at the beck and call of the ER.  Surgeon numbers are always much smaller than their medical counter-parts.  Thus, they usually take call much more often then their medical colleagues.  And by the very nature of their job, they have to take care of traumas and emergencies at all times of the day and night. So, surgeons are usually tied to their hospital.
  • – The doctor that I am shadowing mentioned that he’d love to go on mission trips around the world to help those in need.  But he feels like he cannot, because his nurse, the employees in his clinic, and his patients depend on him to be around.  So, he feels like he cannot leave.  I bet many physicians feel this way.  
  • – Student loans.  Physicians are graduating with some of the most atrocious student loan debt in the world.  When exactly are they suppose to take time off or pursue other interests?  

These are just three examples of the lack of autonomy in medicine.  I suspect there are probably way more.  I also suspect these are huge contributors to burn-out.

Now that I’ve learned this, I am definitely going to be looking into how my specialty choice will effect my autonomy.  Because honestly, that may be the one big factor that is keeping many physicians from being happy in their career.

[Via Study Hacks and TED – Daniel Pink]

What Do Doctors Make?

Great question.  While it’s easy to just google and find something, here is some American Medical Group Association referenced data compiled after a compensation survey in 2009.  This information seems legit because I got it from the U.S. Dept. of Human & Health Services.

Medical Specialties
Allergy $241,138
Cardiology $398,034
Cardiology – Branch ** $446,891
Cardiology – Cath Lab $471,746
Cardiology – Echo Lab/Nuclear $414,500
Cardiology – Electrophysiology Pacemaker $437,000
Critical Care Medicine $268,250
Dermatology $350,627
Dermatology – Branch $334,135
Dermatology – Mohs $516,468
Endocrinology $212,281
Family Medicine $197,655
Family Medicine – Branch $187,727
Family Medicine with Obstetrics $202,047
Family Medicine with Obstetrics – Branch $188,785
Gastroenterology $389,385
Gastroenterology – Branch $447,184
Genetics $193,344
Geriatrics $211,425
Hematology & Medical Oncology $315,133
Hematology & Medical Oncology- Medical Oncology Only $248,623
Hospitalist $211,835
Hypertension and Nephrology $246,049
Infectious Disease $222,094
Intensivist $273,520
Internal Medicine $205,441
Internal Medicine – Branch $189,187
Internal Medicine – Office Only $168,133
Neurology $236,500
Occupational/Environmental Medicine $214,146
Ophthalmology – Medical $231,493
Orthopedic – Medical $265,345
Pain Management – Non-Anesthesiology $260,350
Palliative Care $186,924
Pediatrics & Adolescent – Adolescent Medicine $205,395
Pediatrics & Adolescent – Allergy $195,973
Pediatrics & Adolescent – Branch $183,892
Pediatrics & Adolescent – Cardiology $244,944
Pediatrics & Adolescent – Developmental Behavioral $170,769
Pediatrics & Adolescent – Endocrinology $185,901
Pediatrics & Adolescent – Gastroenterology $236,700
Pediatrics & Adolescent – General $202,832
Pediatrics & Adolescent – Hematology/Oncology $205,999
Pediatrics & Adolescent – Hospitalist $167,953
Pediatrics & Adolescent – Infectious Disease $199,165
Pediatrics & Adolescent – Intensive Care $256,913
Pediatrics & Adolescent – Internal Medicine $208,838
Pediatrics & Adolescent – Neonatology $265,000
Pediatrics & Adolescent – Nephrology $217,767
Pediatrics & Adolescent – Neurology $209,955
Pediatrics & Adolescent – Pulmonary $176,974
Pediatrics & Adolescent – Urgent Care $196,934
Physical Medicine & Rehabilitation $236,500
Psychiatry $208,462
Psychiatry – Child $214,304
Psychiatry – Inpatient $218,472
Psychiatry – Outpatient $184,946
Pulmonary Disease $278,000
Pulmonary Disease – Sleep Lab $259,444
Reproductive Endocrinology $317,943
Rheumatologic Disease $219,411
Sports Medicine $214,249
Urgent Care $215,625
Surgical Specialties
Bariatric Surgery $360,000
Cardiac & Thoracic Surgery $507,143
Cardiovascular Surgery $509,302
Colon & Rectal Surgery $366,895
Emergency Medicin
e
$267,293
Emergency Medicine – Pediatrics $217,551
General Surgery $340,000
General Surgery – Branch $309,750
Maternal/Fetal Medicine $394,121
Neurological Surgery $548,186
Neurological Surgery – Pediatrics $612,851
OBGYN – General $294,190
OBGYN – Branch $280,606
OBGYN – Gynecological Oncology $406,000
OBGYN – Gynecology only $218,607
OBGYN – Obstetrics $301,773
OBGYN – Urogynecology $301,777
Oncology – Surgical $337,475
Ophthalmology $325,384
Ophthalmology – Branch $277,975
Ophthalmology – Pediatrics & Adolescent $283,853
Ophthalmology – Retinal Surgery $443,827
Oral Surgery $380,500
Orthopedic Sports Medicine $484,320
Orthopedic Surgery $476,083
Orthopedic Surgery – Branch $483,400
Orthopedic Surgery – Foot & Ankle $399,445
Orthopedic Surgery – Hand $465,006
Orthopedic Surgery – Joint Replacement $580,711
Orthopedic Surgery – Pediatrics $424,367
Orthopedic Surgery – Spine $641,728
Orthopedic Surgery – Trauma $465,773
Otolaryngology $365,171
Otolaryngology – Branch $343,698
Otolaryngology – Head & Neck Surgery $334,250
Pediatric Surgery $400,591
Plastic & Reconstruction $388,929
Thoracic Surgery $405,842
Transplant Surgery – Kidney $348,000
Transplant Surgery – Liver $433,333
Transplant Surgery – Medical $354,158
Trauma Surgery $399,558
Urology $389,198
Urology – Branch $317,322
Vascular Surgery $403,041
Radiology/Anesthesiology/Pathology Specialties
Anesthesiology $366,640
Anesthesiology – Pain Clinic $379,000
Dermapathology $333,250
Diagnostic Radiology – M.D.s Interventional $478,000
Diagnostic Radiology – M.D.s Neuro-Interventional $458,187
Diagnostic Radiology – M.D.s Non-Interventional $438,115
Diagnostic Radiology – Mammography $513,402
Nuclear Medicine (M.D.s Only) $386,506
Pathology – M.D.s Anatomic $285,173
Pathology – M.D.s Clinical $272,500
Pathology – M.D.s Combined $344,195
Radiation Therapy (M.D.s Only) $413,518
Midlevel Providers
Dentistry $167,389
Podiatry – Medical $190,596
Podiatry – Surgical $232,121
Podiatry – Surgical – Branch $175,565

* This information was obtained from the 2009 Medical Group Compensation and Financial Survey published by the American Medical Group Association® (AMGA). For further information, visit AMGA’s Web site at http://www.amga.org/

** Branch is defined as: A physician who practices at a satellite clinic or office removed from the main campus and may be subject to different practice patterns and productivity standards.

A couple notes about this chart, first I didn’t know that according to the government Emergency Medicine is a surgical specialty and being a dentist makes one a mid-level provider.  I also didn’t find any statistics related to this chart.  So I am unsure if survey responses over/under represent a certain region or demographic.  Also, unsure if survey responses are from a fair number of new, current, and soon-to-be retiring practitioners – as the point of one’s career would make a large difference on current income. Next, I do not know if these compensations take into account any physician owned medical building or property (ie: physician hospitals, physician owned MRIs, etc).  Lastly, I couldn’t find out if this was net-pay or gross pay or before malpractice premiums pay or something other than those.

Average Take Home
Medical Specialties — $252,106
Surgical Specialties — $390,866
Rads/Anesthesia/Path — $389,041
Mid-Level Providers — $191,418

As I looked at this whole table, I was a little surprised.  Not really by the amount physicians made, I had a good idea already, but the fact that just yesterday I posted that physicians are having a hard time keeping their practices open.  This data just by itself strikes me as odd that physicians cannot make enough money to keep practicing in some instances.
This makes me wonder, how much are those student loan payments?  I am figuring that I’ll be close to $200,000 in debt post-med school.  By bringing home a salary of $160,000/year, am I really not going to be able to pay off loans, pay for a family, and pay for a decent mortgage?

Something doesn’t seem like it connects here.  Either student loan repayment is VERY expensive (which I guess I wouldn’t really be too surprised by that – the banks definitely know how to steal everyone’s money) or these surveys aren’t accurate in some way. Or it could be something else entirely.  Who knows?

The patient interview

As I continue along my medical school education journey, I am really starting to realize one of the real ‘arts’ of medicine is the patient interview.


The Sanford SOM does a great job teaching medical students the basics of a good patient interview. During one of these teaching sessions I was stunned to learn that may doctors do not get around to addressing the patient’s main concerns during the patient interaction. How could this happen? When the patient calls in to setup an appointment, don’t they tell you the main concern they are having? I guess it’s not really that simple.

One gold nugget of interviewing knowledge we have gained during our patient interview sessions, is to ask the patient an obvious open ended question to get the interview rolling. Ask a question such as, “What brings you into the clinic today?” or “How can we help you today?” This may seem silly, as the chief complaint is probably already on the chart when you walk in, but it’s amazing how quickly the patient will tell you the main points they want covered in the visit and how much time it really saves.

After following a couple doctors who cut off the patient very quickly and try to do all the talking themselves, I am really amazed at the lack of basic interviewing skills these physicians have. While they are extremely smart clinicians who really cared about their patients, the fact that they didn’t acknowledge obvious patient concerns during the interview worried me.

For example, construction worker in his early 30’s comes into clinic with a chief complaint of headaches. He is being seen again after having come into clinic with this complaint last month. Last visit, the doctor diagnosed migraines, ordered a two medications, and highly recommended a CT scan of the brain. This week, the patient comes in stating that he has been having headaches of the same frequency and duration. The quick acting medication works, but he has not been taking the preventative medication, and he didn’t get the CT done. During the interview, the doctor is trying to gather information using almost all yes/no or very short answer questions, while at the same time lecturing the patient at the importance of getting that CT scan done. During this time the patient seems to almost offer excuses why he didn’t get the scan done but at the same time trying to voice these as concerns. He stated that this is a very stressful time of year for him, he hasn’t been sleeping well, and that he thinks he may have something wrong in his chest. The doctor did not acknowledge any of these, brushing them all off very quickly with the response, “I know.” Then fixated on the caffeine usage and the importance of the CT scan.

I can tell you right now, I am not a doctor. But, it seems to me that just asking about the stress, sleep, and worries about the chest may have eased the concerns of the patient and wouldn’t have taken the doctor too much longer. To me, it seemed like stress, problems sleeping, and the chest worries easily could have been the things causing the headaches. But again, I’m no doctor.

At the start of our patient interview classes, I thought we were really wasting our time. I thought it really couldn’t be that hard to address our patient’s concerns and that teaching us a standardized patient interview was a waste of time. I also thought that doctors were probably more competent at fishing out a patient’s underlying concerns better than our instructors and the statistics would have us believe. After a few clinicals, I can say that I am glad I’ve been getting this patient interview training. I have been amazed at the basic patient interview skills some physicians lack, and really appreciate the ‘art’ of the patient interview.

Primary Care Preceptorship

Today, I had my preceptorship with a Family Medicine doctor at the McGreevy clinic on west 41st street in Sioux Falls. It was a good day, we saw a well rounded sample of patients from psych to a red toe.


First of all, during my day today, I really felt like I was connecting with the little kids. Something about the pediatric cases really seemed like it was up my alley. I was not expecting to ever go into any kinds of pediatric specialty, but now I might have to give it some consideration.

The other thing that I really noticed today was the door dance. The equivalent of the middle school dance in the exam rooms. During our after-clinic medical student dinner get-together, we brought up how weird it was to stand in a little exam room and try to get out the door. Other medical students went in to see a patient with an attending and a resident or another student. So a medical student, an attending, a second student (or resident) and a patient crammed into a tiny exam room.

As you can probably imagine the patient and attending would be the farthest into the room, while the first year medical student would be closest to the door (ie: farthest from the patient). When the clinic visit wraps up, as a first year trying to make a good impression, you want to open the door for the patient and higher up medical people to go out the door ahead of you. But due to the tremendously small amount of room you have to work with, you just throw open the door and walk out first like you’re dying to get out of there.

This probably doesn’t leave a good impression on the attending, but what can you do?

University of Nebraska Medical Center (UNMC) Neurosurgery Shadow

So I skipped school today.  


Yesterday I went down to Omaha, NE to spend the night with Bryan Krajeski – one of my good friends from my fraternity.  I would like to thank him for his hospitality.  

This morning at 3:30 am (because I was too excited to sleep), I got out of bed at Krajeski’s house and took a shower.  I left his house at 4:30 am for UNMC and arrived in the Neurosurgery residents’ office at 5 am.  Soon after I arrived, a third-year medical student from UNMC (actually his 7th year because of the MD/PhD) came in.  Then the intern arrived who was an ENT intern rotating on the neurosurgery service.  Then the chief and another resident.  Everyone was extremely welcoming and nice.  I felt like a part of the team from the very beginning (albeit a stupid, inexperienced, and useless part of the team – the point is I felt welcome and not a burden).  

The intern and the other student went to start rounding at one floor and the chief and I started rounding on all the patients in the random parts of the hospital.  Lady with really bad seizures, a girl who attempted a flip and broke her noggin, guy in car accident before christmas and still in coma, gigantic aneurysm in the basilar artery, another aneurysm in the carotid artery, headache guy who ended up having a pituitary adenoma were seen all before 7 am.  Then off to Tumor Board, which was at another hospital.  Interesting, but when you dim the lights to look at films its really hard to keep your eyes open.  

Back to UNMC, angiogram, clinic, aneurysm clipping, rounding.  Done at the hospital at 7 pm.  Made it home at 9 pm. I am physically exhausted, but still feel so excited.  

 I learned tons.  I met a lot of friendly residents and attendings.  I think I may have setup my research for the summer.  And I’m so glad I skipped class today.