Light Pollution

Cities and towns are shifting their outdoor lighting to LED bulbs (Light Emitting Diodes) because they use less energy and fuel to burn and are more environmentally friendly.  They last longer and ultimately will be cheaper. The cities of New York and Seattle have replaced, or are in the process of replacing, all their street lights with white LED bulbs at a color temperature of 4000 – 5000k.  Why then did this environmentally friendly and economically sound decision result in the American Medical Association (AMA) issuing a statement condemning this practice?

It seems that the older less efficient street lamps or incandescent bulbs had a color temperature of 2400 K or less Candle light is actually a bit less than 1800 CT. At the higher color temperature the light contains more of the blue spectrum of light which has a shorter wavelength than the former incandescent bulbs which had more yellow and red. The result is that the new bulbs produce significant glare resulting in pupillary constriction and reduced vision. In addition, blue light scatters more on the retina and at sufficient levels can damage the retina in addition to making driving and night walking more difficult.

The American Medical Association believes the white LED light suppresses natural production of melatonin by the brain more than five times what the former bulbs were capable of. This has a major effect on human’s circadian rhythm and ability to fall asleep. For the animal kingdom it can adversely affect the migratory pattern of animals and can adversely affect aquatic animals such as turtles and their nesting and reproductive habits.

The AMA statement called for using the lowest level of blue wavelength light possible to reduce glare. They encourage the use of 3000k or less CT for outdoor lightings and roadway lighting to reduce glare and improve safety.  They additionally asked for dimming of these lights for off peak periods. They did not condemn or call for a ban on LED lights just for municipalities to be aware of the dangers of using the products with a high color temperature (CT) above 3000k and blue wave length predominant light.

Benefits of Smoking Cessation Outweigh Negatives of Weight Gain

A196HJ Woman smoking a cigarette Exhaling tobacco smokeIf you wish to extend your life and stay healthy then giving up smoking tobacco is a major positive step. The benefits include an immediate drop in your cardiovascular disease risk profile, a drop in the possibility of developing numerous types of cancer and a decrease in the likelihood of developing chronic obstructive lung disease.

Smoking is an expensive, dirty habit that not only sickens you but exposes those around you to an increased chance of disease due to others breathing in your second hand smoke. Asthma in children is now believed to be related to the children’s exposure to their parents’ second hand smoke. One of the negatives of stopping smoking is that individuals tend to put on weight. Weight gain and obesity are known risk factors for the development of heart disease and vascular disease.

In the March 13th issue of the Journal of the American Medical Association (JAMA), Carole Clair, MD, of the University of Lausanne in Switzerland examined the question of whether the weight gain was detrimental to your heart health. She accessed data from the famed and long term Framingham Offspring Study looking at the years 1984 through 2011 for 3251 study participants who were free of cardiovascular disease at the start of the analysis. These participants underwent a checkup every four years and were placed into categories such as “recent quitter” (stopped smoking within 4 years),” long term quitter” (nonsmoker for > 4 years) and nonsmoker.

As anticipated, smoking cessation was associated with a weight gain of 5.9 lbs. in the recent quitters and 1.9 lbs. in the long term quitters. Smokers also gained weight during the study period while the country underwent and obesity epidemic. Smokers gained an average of 1.9 lbs. while nonsmokers gained about 3 lbs.

They followed these people for 25 years and defined 631 “cardiovascular events.” In reviewing the data they concluded that former smokers had about one half the risk of developing cardiovascular disease as smokers. When they factored in the weight gain associated with smoking cessation it had no effect on the reduction in cardiovascular disease.

They concluded that the findings support, “a net cardiovascular benefit of smoking cessation, despite subsequent weight gain.” The goal is clear. Stop smoking and then we will work on the weight gain.

Hospitalists and Community Physicians- It’s All About the Handoffs

I referred my second patient to a specialty surgery department at a local university center last month. The patient is a practicing physician with severe lower back disc disease and structural abnormalities. He saw a highly acclaimed surgeon who won the patient’s confidence.

I performed the required preoperative evaluation requested by the surgical team, called the surgeon to make sure we were on the same page, and made sure all the appropriate records and labs arrived at the center prior to the patient’s surgical date. Three days after the scheduled procedure I received a phone call after-hours from a nurse at a local rehabilitation facility telling me my referred patient had been transferred from the university center after discharge and requesting confirmation of  admitting orders to their facility for postoperative rehabilitation.

I had not received a phone call from the surgeon or his staff to discuss how the surgery had turned out. I had received no phone call, fax or email telling me when they planned to discharge the patient. I received no communication discussing discharge instructions and medications.  The surgeon is a chief of a department responsible for teaching fellows, residents and students how it should be done. He fumbled the handoff and sent a patient on his way with a bunch of handwritten chicken scratches on a form filled out by a case worker. In the era of cell phones , smart phones , email , faxes , instant messages and tweets it seems like communication between practitioners has gotten worse not better due to lack of effort and failure of practitioners to acknowledge that it is their job to take the time to make the transition smooth and seamless.

The hospitalist program at my community hospital is no better. Physicians employed by the hospital were supposed to “move “patients and facilitate discharges helping the hospital’s financial “bottom line.”  Hospital administration contracted with non-fellowship trained hospitalists to admit patients who arrive through the ER and have no doctor. The hospitalists are only too happy to admit patients of staff members who do not wish to attend their patients in the hospital.

The problem is that the hospitalist do not enjoy coming in at night. When a patient with a hip fracture shows up at our ER, the orthopedic surgeons on call for the ER now believe they are consultants not doctors. They will not admit a surgical case. They want the PCP or hospitalist to do it for them. If a broken hip case arrives after 7:00 p.m. “the hospitalist “admits the patient sight unseen over the phone and then comes in by 7:00 a.m. to see the patient.

Our hospital has some patient unfriendly bylaws. If the ER doctor calls you and says your patient requires admission you have 30 minutes to provide admitting orders over the phone or in person but you have 12 hours to arrive and actually see the patient.  Showing up 12 hours later often pushes the surgery back a day negating the main reason hospitalists were hired. When the patient is ready to leave the hospital it is rare that the facility has introduced the patient to an outpatient physician for follow-up care.  If the patient actually has an outpatient physician it is even rarer that the hospitalist contacts them to discuss the hospital course and discharge medications and instructions.

The system in the Intensive Care Unit is no better. After years of debate and disagreement based primarily on economic issues and turf and privilege battles, administration contracted with a pulmonary group on staff to provide fulltime intensive care physicians. They went out and hired a bunch of young ICU specialists and salaried them.  These physicians run the critical care areas.

I have always favored fulltime ICU physicians in our community hospital because with no interns or residents there are no physicians in the facility after hours. I was a bit surprised when the contract allowed the ICU doctors to go home at 11:00 p.m. leaving no one in the units until the next morning. My first contact with the intensivists came after a weekend away during which my associate covered for me.  He admitted a patient to the hospital with a raging pneumonia.  Since the patient was taking an anticoagulant Coumadin he had to specifically choose an antibiotic that didn’t alter the affects of the blood thinner. Later that first night the patient had some respiratory distress so my associate came in and transferred the patient to the ICU. He called the intensivist and discussed the case in detail.  He made rounds the next day and reviewed the chart and pointed out to the ICU specialist that the antibiotic he had switched the patient to potentiated the Coumadin effect. He suggested checking the clotting study and adjusting the dose of the Coumadin.

When I came in on Monday I found the patient lying in a pool of blood from the rectum. His PT/INR had been elevated the day before and required lowering the Coumadin dose. No action had been taken. His PT/INR on Monday was even higher.  I called the charge nurse and barked out some orders. She reminded me that the intensivist was in charge. The intensivist that morning was a young woman in her early thirties. When I asked her why the monitoring of his Coumadin dose was left unattended she took great offense and answered, “I wasn’t on call this weekend, why don’t you take it up with the doctor on call.  He’s asleep now so I would give it a few hours before you call him.” I gather she wasn’t willing to “take one for the team.”

Within the last six months an editorial in the Journal of the American College of Physicians was critical of hospitalist programs for the poor communication when a patient leaves the hospital and returns to his doctor in the community without communication occurring.  A recent research article in the same journal revealed that patients treated by hospitalists require re-admission to the hospital for some complication of the original problem far more often than if their personal physician cared for them. The ultimate cost to the system was higher. The problem is the communication and handoffs.

Part of the problem is that physicians no longer feel it is their responsibility to contact their peers. In the past, physicians had close knit referral circles and patterns using physicians they trusted and worked well with. Insurance company managed care programs destroyed those referral patterns forcing physicians to use the doctor on the panel or else they would not pay the bill. Often the consulting doctor on the panel was resentful of receiving a consult from a doctor who had never used his services but would now use them at the panels discounted rate. They felt no strong compulsion to contact the referring physician and discuss the case. T

The referring physicians are not without blame either, often sending patients to physicians they have little contact with accompanied by little if any information as to why they were being consulted. A culture of communication and sharing of information professionally became a culture of “I am too busy to make a call.” The one that suffers is the patient and the people paying more for care because of communication breakdowns.

The American Medical Association and the American College of Physicians have supported the development of the specialty of hospital medicine long before I believe they should have. These organizations are heavily dominated and supported by specialty physicians who are paid handsomely to stay in the operating room and perform procedures rather than care for the patients.  Having hospital employed physicians to be their “scut “workers and take care of the patients with their nurse practitioners and PAs makes sense to them. It breaks the link of good continuity of care and just isn’t very good for patients or overall costs.

Legislators, politicians, employers, insurers, medical school faculty keep looking for ways to overcome the shortage of primary care physicians and the large gap in payment between cognitive services and procedural services. The solution to the problem is to pay the primary care physicians well for their evaluation and management services, train them thoroughly and completely and allow them to care for their patients in all our health care venues.