A. Maria Hester, MD

Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.

The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.

CDC/Cynthia Goldsmith

I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.

Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.

Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.

I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.

Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.

While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.

The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.

CDC/Cynthia Goldsmith

I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.

Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.

Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.

I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.

Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.

While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.

The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.

CDC/Cynthia Goldsmith

I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.

Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.

Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.

I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.

Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.

While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

The Affordable Care Act has essentially overhauled Medicare’s payment system for hospitals in an effort to improve quality while minimizing wasteful spending.

One such change centers on HACs, or hospital-acquired conditions. These conditions were deemed potentially preventable by the Centers for Medicare & Medicaid Services in 2009 and are a major target for Medicare payment penalties and hospital quality initiatives. Hospitalizations that are complicated by one of these conditions, for instance, the development of diabetic ketoacidosis from poor glycemic control, do not qualify for higher paying diagnosis-related group payment, leaving a gaping hole between the cost of care delivered and the amount reimbursed by Medicare.

Yet to come in fiscal year 2015, Medicare payments for all discharges will be cut by 1% for those hospitals that score in the top quartile for the rate of hospital-acquired conditions, compared with national average.

Upon initially hearing about this provision in the ACA, I was shocked and felt it was both unfair and realistic, but as time has passed, it is clear that a variety of innovative hospital-based quality initiatives have made significant headway into minimizing at least some of the HACs.

Help is also available through the government. The Medicare Shared Savings and Pioneer ACO Models offer participating hospitals a share of the savings if they can reduce spending below historical benchmarks. A healthier bottom line for our hospitals has the potential to ultimately translate into improved resources and support systems to enhance our ability to provide excellent care for our patients, while making our days run more smoothly.

However, a recent study shows that HACs do not appear to be the bottom line in hospital savings after all. Identifying hospital-wide harm associated with increased cost, length of stay, and mortality in U.S. hospitals, was recently released by the Premier health care alliance, and was based on peer-reviewed research in the American Journal of Medical Quality.

Premier evaluated more than 5.5 million deidentified ICD-9 discharge records from hospitals and medical centers in 47 states. They identified 86 potential inpatient complications that were associated with higher cost, increased length of stay, and/or higher mortality.

Surprisingly, this study concluded that the current HACs used by the CMS cover only a fraction of the complications and that of the 86 high-impact conditions they evaluated, only 22 are addressed through the CMS’s federal payment policies. Conditions such as acute renal failure, which was associated with close to $490 million in costs, and hypotension, which had $200 million in costs in this study were far more significant than were the HACs such as air embolism and blood incompatibility, seen in 23 and 8 patients, respectively, in more than 5 million records.

While some of the 86 conditions identified may not be easy to prevent, others, such as acute renal failure and hypotension, have the potential to be significantly reduced through vigilant monitoring of parameters such as nephrotoxin use and blood pressure trends.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

America! America! God shed His grace on thee

And crown Thy good with brotherhood

From sea to shining sea!

I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.

Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.

This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.

Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.

There is a slew of reputable patient information written in different languages available on the Internet as well.

The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.

Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.

America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

America! America! God shed His grace on thee

And crown Thy good with brotherhood

From sea to shining sea!

I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.

Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.

This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.

Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.

There is a slew of reputable patient information written in different languages available on the Internet as well.

The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.

Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.

America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

America! America! God shed His grace on thee

And crown Thy good with brotherhood

From sea to shining sea!

I fondly remember singing "America the Beautiful" with my classmates when I was a little girl. America has grown by leaps and bounds since my childhood – the pulse of the nation as well as its makeup. One of my fondest memories as a child was traveling to New York. We had a layover in Washington and the airport was filled with people of various skin tones speaking all sorts of languages I had never been exposed to before. It was very exciting! It was my first truly multicultural experience.

Funny, I ultimately relocated to the D.C. area, and my neighbors are literally from all over the world: India, Thailand, Jamaica, Africa, China – and it doesn’t stop there. Naturally, the patient population I serve also reflects this great diversity. As the country becomes more diverse each and every day, we, as practitioners, must be able to communicate effectively with our entire patient base, not just the ones who speak English fluently.

This is quite a challenge. Yes, most hospitals have a language line or an on-call interpreter to help out, but I believe we also need to take some responsibility for improving our ability to communicate as well. While I am not advocating trying to master a new language, or two or three, we can all learn a few basic terms of the foreign languages we encounter most.

Consider that language lines do malfunction. Family members are sometimes not present. And interpreters may not always be available at the drop of a hat. Technology, though, is ever burgeoning. It’s easy to download a smartphone app, such as Medical Spanish: Healthcare Phrasebook with Audio. Google Translate can be helpful for scores of languages, though I would use this site with caution when it comes to patient care.

There is a slew of reputable patient information written in different languages available on the Internet as well.

The Agency for Healthcare Research and Quality offers a guide tool: Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. The guide notes that approximately 57 million people speak a language other than English at home and 25 million are defined as limited-English-proficient (LEP). LEP patients were noted to have longer lengths of stay in the hospital and were at greater risk for line infections, surgical infections, falls, and pressure ulcers. They are more likely to be readmitted, as well.

Although it is always best to have a qualified interpreter to help us care for LEP patients, there may be times when one is simply unavailable in an acceptable period of time. Friends and family members can help fill some of the gaps in those instances, but it never hurts for the clinician to know a few vital words as well, such as pain or shortness of breath.

America’s culture is ever evolving, and we must evolve with it. Being able to provide high-quality care to all of our patients is our goal. Standards are important, but sometimes thinking out of the box can be effective as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.

The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).

©Dušan Zidar/Fotolia.com

This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.

I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.

Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?

After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.

These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.

The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).

©Dušan Zidar/Fotolia.com

This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.

I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.

Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?

After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.

These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

The devastation of an acute stroke is something relatively few of us have experienced personally, but professionally we see it very regularly. An estimated 690,000-plus adults in the United States suffer an ischemic stroke annually, and an additional 240,000 experience a transient ischemic attack.

The good news is that the current estimated annual rate of future stroke in this patient population (3%-4%) is historically low, thanks to preventive measures, according to the new "Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals," which was published online in Stroke in May (Stroke 2014 May 1 [doi: 10.1161/STR.0000000000000024]). This updated guideline gives evidence-based recommendations on secondary stroke prevention as well as primary prevention in those who have suffered a transient ischemic attack (TIA).

©Dušan Zidar/Fotolia.com

This very extensive guide from the American Heart Association and the American Stroke Association addresses a wide variety of scenarios, ranging from general risk factor modification to specific circumstances, such as myocardial infarction and thrombus, cardiomyopathy, pregnancy, arterial dissection, and aortic arch atherosclerosis.

I welcome the recommendation to consider adding clopidogrel 75 mg/day to aspirin for 90 days in patients with a recent (within 30 days) stroke or TIA attributable to high-grade stenosis (70%-99%) of a major intracranial artery. I used to feel rather helpless to improve the long-term outcome in these patients, but now there seems to be something more we can do, other than just using statins and single antiplatelet therapy.

Other new recommendations stress nutrition. One item suggests performing a nutritional assessment for patients with a history of ischemic stroke or TIA. While many patients may never get around to seeing a nutritionist as an outpatient, no matter how often their primary care physician stresses the importance, when they are in the hospital we have a captive audience. So why not order a nutrition consult, along with the consult for physical, occupational, and speech therapy?

After having experienced an acute neurologic event, many patients and their families are highly motivated to make whatever changes are necessary to prevent a future, potentially catastrophic stroke. Reduction of sodium from 3.3 g/day to 2.5 g/day or less is reasonable, according to the guidelines, though lowering intake to less than 1.5 g/day will lower blood pressure even further. A nutritionist’s input into how to attain these levels without eating a diet that tastes like cardboard can be invaluable. The new guidelines also suggest counseling patients to follow a Mediterranean-type diet – emphasizing whole grains, fruits, vegetables, nuts, olive oil, legumes, fish, poultry, and even low-fat dairy products – instead of the traditional low fat diet.

These new recommendations are only the tip of the iceberg, and this document is highly worthwhile for all practicing clinicians.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.

Fortunately, there appear to be some very viable solutions at hand.

Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.

©ERproductions Ltd/thinkstockphotos.com

Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.

Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.

Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.

Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.

With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com

We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.

Fortunately, there appear to be some very viable solutions at hand.

Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.

©ERproductions Ltd/thinkstockphotos.com

Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.

Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.

Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.

Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.

With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com

We are all painfully aware that falls are not uncommon in hospitalized patients, but I was shocked and appalled to learn that there are approximately 11,000 falls that are ultimately fatal in U.S. hospitals each year, according to the Joint Commission Center for Transforming Healthcare.

Fortunately, there appear to be some very viable solutions at hand.

Hospitals that use the center’s new measuring systems and solution have been able to slash the number of patients who fall by 35%, as well cutting the percentage of patients injured when they fall by 62%. Extrapolating these results to an average 200-bed hospital, an estimated $1 million could be saved each year through fall prevention efforts.

©ERproductions Ltd/thinkstockphotos.com

Hospitals participating in this study ranged from small community-based hospitals with fewer than 200 beds to large medical centers with more than 1,700 beds. All used a data-driven, Lean Six Sigma–inspired "Robust Process Improvement" methodology to determine the causes of falls and create solutions to prevent them. One solution was simply providing hourly rounding which included proactive toileting. When you think about it, this makes perfect sense. Patients with an immediate need may not be able to hold it until it is "their turn" for the nurse to assist them. In their haste to avoid soiling their clothes, a mechanical fall is very understandable, especially if they are impaired due to weakness or medication.

Other solutions included teaching patients how to actively participate in their own safety, engaging patients and family members in their fall safety program, using a validated fall risk assessment tool, and increasing awareness and participation among staff so that patients did not walk alone.

Most of us have received that dreaded call from the nurse about a patient who was injured from a fall. I once had a patient who slipped and fell, breaking a hip while in the hospital for a relatively minor issue. If she had been more stable on her feet, she probably could have caught herself prior to hitting the hard floor. Had a close relative not witnessed the incident, it would have been very difficult (and embarrassing) to explain to the family why their loved one experienced such a traumatic event while in a seemingly protected environment. Her son was very understanding, though the event was very disconcerting all the same.

Based on their staffing, resources, and creativity, different hospitals may develop different innovative solutions to prevent falls. There is room for a wide variety of options. Yes, early ambulation is crucial to help prevent unnecessary complications, such as pneumonia and blood clots, but we should be mindful of the individual patient’s circumstances. A simple order requesting the nurse to ambulate a patient in the room or down the hall two or three times a day may be adequate for some, while in other cases a formal physical therapy consultation may clearly be in order. If there are any concerns over the patient’s ability to ambulate safely and I am not sure if a physical therapy consult is really needed, I sometimes call the nurse into the room and the two of us walk with the patient. That way, I can get an immediate sense of the likelihood of falls, the need for dedicated strengthening exercises, and, on occasion, the impact that medications are having on gait. And for those difficult, unmotivated patients, family members can frequently provide invaluable encouragement, as well as the emotional, and sometimes physical safety net many patients desire.

With safety interventions and highly engaged care teams in place, even steady patients never walk truly alone.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

"Superbugs" is a catchy term, and one that piques the interest of many patients. It gives the microbes a certain mystique, an unusual, sometimes unharnessed power to seek out and destroy.

Physicians come into contact with so many drug-resistant organisms that some have become virtually immune to that bright contact isolation sign on the door. They boldly enter the rooms unprotected, mistakenly believing that as long as they don’t touch anything, they will be safe. But, even when you just want to ask the patient a quick question or two and donning a gown and gloves is cumbersome, it’s extremely important nonetheless.

©David Parr/thinkstockphotos.com

According to UpToDate, the environments in these rooms are often highly contaminated with notorious organisms, such as MRSA, VRE, and the dreaded C. diff., and one can become exposed to them without ever even touching the patient.

You know what happens next: The bugs are taken from room to room. They are carried into the nurses’ station, where a brief brush against the counter deposits fresh inocula for others to spread. They are deposited on computers, where physicians, nurses, and even case managers work, only to be picked up to by unwary workers (who practice great hand hygiene) and spread around even further. And ultimately, they are taken home on our clothing, making yet another leap when our spouses or children greet us at the door with a big bear hug.

We see the devastation these bacteria have on the lives of our patients and their families, but now they are getting the attention of a much higher authority. The Obama administration recently unveiled its proposal to increase spending to combat antibiotic-resistant microorganisms in hospitals. Specifically, the Centers for Disease Control and Prevention seeks $30 million to fund specialized labs in five areas of the United States to assist local hospitals in diagnosing and combating these infections; it also calls for all hospitals to develop a program to track and improve antibiotic prescribing.

Yes, top-down politics (and medicine) has a very important place. But we are the foot soldiers, the ones who actually take care of patients and prescribe (and sometimes overprescribe) the antibiotics that put them at risk for developing drug-resistant organisms. No doubt, responsible antibiotics stewardship saves lives. Most of us have encountered at least one unfortunate patient who, as a result of antibiotics, developed fulminate C. diff and required a partial colectomy, changing his life forever.

While it may be tempting to continue the broad-spectrum antibiotics that rescued a septic shock patient from the brink of death, if the culture results provide a clear path to streamline treatment and narrow the spectrum, be diligent about making the change. If you think, "In my experience, a patient generally does well continuing on broad-spectrum antibiotics for the course of her treatment," think again. Chances are we will not be the ones readmitting that patient a few weeks later with a new case of sepsis – drug-induced sepsis from the C. diff we predisposed her to.

In addition to our practicing good antibiotics stewardship, educating our patients on the proper use for (and of) antibiotics will empower them to have a role in this battle as well. We have a long way to go in this battle against drug-resistant organisms, and everyone has a part to play.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

"Superbugs" is a catchy term, and one that piques the interest of many patients. It gives the microbes a certain mystique, an unusual, sometimes unharnessed power to seek out and destroy.

Physicians come into contact with so many drug-resistant organisms that some have become virtually immune to that bright contact isolation sign on the door. They boldly enter the rooms unprotected, mistakenly believing that as long as they don’t touch anything, they will be safe. But, even when you just want to ask the patient a quick question or two and donning a gown and gloves is cumbersome, it’s extremely important nonetheless.

©David Parr/thinkstockphotos.com

According to UpToDate, the environments in these rooms are often highly contaminated with notorious organisms, such as MRSA, VRE, and the dreaded C. diff., and one can become exposed to them without ever even touching the patient.

You know what happens next: The bugs are taken from room to room. They are carried into the nurses’ station, where a brief brush against the counter deposits fresh inocula for others to spread. They are deposited on computers, where physicians, nurses, and even case managers work, only to be picked up to by unwary workers (who practice great hand hygiene) and spread around even further. And ultimately, they are taken home on our clothing, making yet another leap when our spouses or children greet us at the door with a big bear hug.

We see the devastation these bacteria have on the lives of our patients and their families, but now they are getting the attention of a much higher authority. The Obama administration recently unveiled its proposal to increase spending to combat antibiotic-resistant microorganisms in hospitals. Specifically, the Centers for Disease Control and Prevention seeks $30 million to fund specialized labs in five areas of the United States to assist local hospitals in diagnosing and combating these infections; it also calls for all hospitals to develop a program to track and improve antibiotic prescribing.

Yes, top-down politics (and medicine) has a very important place. But we are the foot soldiers, the ones who actually take care of patients and prescribe (and sometimes overprescribe) the antibiotics that put them at risk for developing drug-resistant organisms. No doubt, responsible antibiotics stewardship saves lives. Most of us have encountered at least one unfortunate patient who, as a result of antibiotics, developed fulminate C. diff and required a partial colectomy, changing his life forever.

While it may be tempting to continue the broad-spectrum antibiotics that rescued a septic shock patient from the brink of death, if the culture results provide a clear path to streamline treatment and narrow the spectrum, be diligent about making the change. If you think, "In my experience, a patient generally does well continuing on broad-spectrum antibiotics for the course of her treatment," think again. Chances are we will not be the ones readmitting that patient a few weeks later with a new case of sepsis – drug-induced sepsis from the C. diff we predisposed her to.

In addition to our practicing good antibiotics stewardship, educating our patients on the proper use for (and of) antibiotics will empower them to have a role in this battle as well. We have a long way to go in this battle against drug-resistant organisms, and everyone has a part to play.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

"Superbugs" is a catchy term, and one that piques the interest of many patients. It gives the microbes a certain mystique, an unusual, sometimes unharnessed power to seek out and destroy.

Physicians come into contact with so many drug-resistant organisms that some have become virtually immune to that bright contact isolation sign on the door. They boldly enter the rooms unprotected, mistakenly believing that as long as they don’t touch anything, they will be safe. But, even when you just want to ask the patient a quick question or two and donning a gown and gloves is cumbersome, it’s extremely important nonetheless.

©David Parr/thinkstockphotos.com

According to UpToDate, the environments in these rooms are often highly contaminated with notorious organisms, such as MRSA, VRE, and the dreaded C. diff., and one can become exposed to them without ever even touching the patient.

You know what happens next: The bugs are taken from room to room. They are carried into the nurses’ station, where a brief brush against the counter deposits fresh inocula for others to spread. They are deposited on computers, where physicians, nurses, and even case managers work, only to be picked up to by unwary workers (who practice great hand hygiene) and spread around even further. And ultimately, they are taken home on our clothing, making yet another leap when our spouses or children greet us at the door with a big bear hug.

We see the devastation these bacteria have on the lives of our patients and their families, but now they are getting the attention of a much higher authority. The Obama administration recently unveiled its proposal to increase spending to combat antibiotic-resistant microorganisms in hospitals. Specifically, the Centers for Disease Control and Prevention seeks $30 million to fund specialized labs in five areas of the United States to assist local hospitals in diagnosing and combating these infections; it also calls for all hospitals to develop a program to track and improve antibiotic prescribing.

Yes, top-down politics (and medicine) has a very important place. But we are the foot soldiers, the ones who actually take care of patients and prescribe (and sometimes overprescribe) the antibiotics that put them at risk for developing drug-resistant organisms. No doubt, responsible antibiotics stewardship saves lives. Most of us have encountered at least one unfortunate patient who, as a result of antibiotics, developed fulminate C. diff and required a partial colectomy, changing his life forever.

While it may be tempting to continue the broad-spectrum antibiotics that rescued a septic shock patient from the brink of death, if the culture results provide a clear path to streamline treatment and narrow the spectrum, be diligent about making the change. If you think, "In my experience, a patient generally does well continuing on broad-spectrum antibiotics for the course of her treatment," think again. Chances are we will not be the ones readmitting that patient a few weeks later with a new case of sepsis – drug-induced sepsis from the C. diff we predisposed her to.

In addition to our practicing good antibiotics stewardship, educating our patients on the proper use for (and of) antibiotics will empower them to have a role in this battle as well. We have a long way to go in this battle against drug-resistant organisms, and everyone has a part to play.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.

When I moved to Maryland over a decade ago, my first job was at Kaiser Permanente, where I had a panel of office patients and occasionally rounded at the hospital. Ultimately, management gave us the option of being solely office-based and giving up hospital rounds or continuing to do both. Most of my colleagues jumped at the chance to give up the grueling 24-hour shifts – a full day in the office followed by in-house night call at our hospital. Ouch!

But a little voice inside my head told me not to give up my hospital skills, and I’m so glad I listened. Little did I know that I would soon be offered a full-time hospitalist position. What a lifestyle change! I went from working Monday through Friday with occasional weekend and night shifts, counting the months until my next vacation, to working block shifts and having "vacation" time every month. What’s more, unlike my days in private practice, when I often struggled to make ends meet, I could count on a steady paycheck.

And while many of our office-based colleagues currently thrive in primary care, the Affordable Care Act has made many rethink their future. The ACA has ushered in new payment rates and regulations that make it more challenging for some small practices to stay afloat, and impossible for others.

Since the ACA was passed in 2010, many hospitals have aggressively pursued and acquired physician practices, which allows them to reap the benefits of some incentives available under the Affordable Care Act, potentially a win-win for hospitals and struggling physicians alike. In addition, many primary care physicians have joined independent accountable care organizations to mitigate the challenges and reap the potential rewards of the ACA.

But this is only the tip of the iceberg. For instance, in its recently released 2015 budget request, the administration proposed cutting an additional $2 billion from health care through decreased payments to rural hospitals, reductions to postacute care, and reimbursements for care given to those Medicare beneficiaries whose bills go unpaid. Meanwhile, the Federation of American Hospitals, an organization representing over 1,000 providers of health care, is working on a study it hopes will help persuade lawmakers to forgo the proposed cuts.

In this seemingly never-ending flux of our new health care system, it appears that we hospitalists, for the moment, are faring quite well. And, relatively unburdened by these forces of flux, we are free to focus our energies on top-notch patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

When I moved to Maryland over a decade ago, my first job was at Kaiser Permanente, where I had a panel of office patients and occasionally rounded at the hospital. Ultimately, management gave us the option of being solely office-based and giving up hospital rounds or continuing to do both. Most of my colleagues jumped at the chance to give up the grueling 24-hour shifts – a full day in the office followed by in-house night call at our hospital. Ouch!

But a little voice inside my head told me not to give up my hospital skills, and I’m so glad I listened. Little did I know that I would soon be offered a full-time hospitalist position. What a lifestyle change! I went from working Monday through Friday with occasional weekend and night shifts, counting the months until my next vacation, to working block shifts and having "vacation" time every month. What’s more, unlike my days in private practice, when I often struggled to make ends meet, I could count on a steady paycheck.

And while many of our office-based colleagues currently thrive in primary care, the Affordable Care Act has made many rethink their future. The ACA has ushered in new payment rates and regulations that make it more challenging for some small practices to stay afloat, and impossible for others.

Since the ACA was passed in 2010, many hospitals have aggressively pursued and acquired physician practices, which allows them to reap the benefits of some incentives available under the Affordable Care Act, potentially a win-win for hospitals and struggling physicians alike. In addition, many primary care physicians have joined independent accountable care organizations to mitigate the challenges and reap the potential rewards of the ACA.

But this is only the tip of the iceberg. For instance, in its recently released 2015 budget request, the administration proposed cutting an additional $2 billion from health care through decreased payments to rural hospitals, reductions to postacute care, and reimbursements for care given to those Medicare beneficiaries whose bills go unpaid. Meanwhile, the Federation of American Hospitals, an organization representing over 1,000 providers of health care, is working on a study it hopes will help persuade lawmakers to forgo the proposed cuts.

In this seemingly never-ending flux of our new health care system, it appears that we hospitalists, for the moment, are faring quite well. And, relatively unburdened by these forces of flux, we are free to focus our energies on top-notch patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

When I moved to Maryland over a decade ago, my first job was at Kaiser Permanente, where I had a panel of office patients and occasionally rounded at the hospital. Ultimately, management gave us the option of being solely office-based and giving up hospital rounds or continuing to do both. Most of my colleagues jumped at the chance to give up the grueling 24-hour shifts – a full day in the office followed by in-house night call at our hospital. Ouch!

But a little voice inside my head told me not to give up my hospital skills, and I’m so glad I listened. Little did I know that I would soon be offered a full-time hospitalist position. What a lifestyle change! I went from working Monday through Friday with occasional weekend and night shifts, counting the months until my next vacation, to working block shifts and having "vacation" time every month. What’s more, unlike my days in private practice, when I often struggled to make ends meet, I could count on a steady paycheck.

And while many of our office-based colleagues currently thrive in primary care, the Affordable Care Act has made many rethink their future. The ACA has ushered in new payment rates and regulations that make it more challenging for some small practices to stay afloat, and impossible for others.

Since the ACA was passed in 2010, many hospitals have aggressively pursued and acquired physician practices, which allows them to reap the benefits of some incentives available under the Affordable Care Act, potentially a win-win for hospitals and struggling physicians alike. In addition, many primary care physicians have joined independent accountable care organizations to mitigate the challenges and reap the potential rewards of the ACA.

But this is only the tip of the iceberg. For instance, in its recently released 2015 budget request, the administration proposed cutting an additional $2 billion from health care through decreased payments to rural hospitals, reductions to postacute care, and reimbursements for care given to those Medicare beneficiaries whose bills go unpaid. Meanwhile, the Federation of American Hospitals, an organization representing over 1,000 providers of health care, is working on a study it hopes will help persuade lawmakers to forgo the proposed cuts.

In this seemingly never-ending flux of our new health care system, it appears that we hospitalists, for the moment, are faring quite well. And, relatively unburdened by these forces of flux, we are free to focus our energies on top-notch patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I’m guilty. I feel a sense of entitlement, as many of us do. I have always had access to the best health care available. Even as a child, whenever I had a runny nose, my parents not only knew what to do but could afford whatever it took to make me feel better. And vaccine-preventable illnesses? They didn’t stand a chance at my house. I remember the day when I was a little girl and my father, a general practitioner, figured out my plan to wait him out as he stood patiently outside the bathroom door, vaccine in hand. He eventually got tired of waiting, barged in, oblivious to the fact that I was sitting on the potty (twiddling my fingers), and shot me right in arm. The nerve!

Many of us have no concept of what it is like to be ill. I mean really ill with no one to help, and no way to pay for that help even if we could find it. In the March 6, 2014, issue of the New England Journal of Medicine, authors of "Global Supply of Health Professionals" note that there’s a worldwide crisis of severe shortages, as well as maldistribution of health care professionals intensified by three global transitions: redistribution of the disability burden, demographic changes, and epidemiologic shifts. An estimated 25% of physicians in America come from other countries. Naturally, in some cases the countries of origin have their own health care challenges, so the trend to immigrate to America has significant potential to exacerbate an already critical shortage.

© Matthew Benoit/Fotolia.com

Of the estimated 9.2 million doctors worldwide, 8% reside in the United States. Of the 18.1 million nurses, 17% are in here. To put it in perspective, only 4% of the world’s population lives in the United States, yet we command a lion’s share of the global health care workforce, leaving the citizens of many other countries vulnerable to excessive suffering, premature death, and preventable diseases.

With all that America has to offer, I don’t see the pendulum shifting back in the other direction any time soon, but many of us are in a position to provide much needed health care to our brothers and sisters in even the most remote areas of the world.

As squeamish as I am about charting unknown territory, even I went on a medical missions trip to Nicaragua a few years ago and I will never forget it. We had to climb up the side of a mountain to get to a clearing that would hold the makeshift medical clinic. Of course, the locals came out in large numbers to receive much-needed medical care.

On the way back to the hotel I noticed some little boys tossing an object back and forth in the street. It seemed like pleasant fun until we got closer and I saw the object they were tossing was a dead rat. Even what we consider an inexpensive child’s toy is a luxury for many. If you consider salary and benefits, we hospitalists make more, on average, in a single shift than many Nicaraguans make in an entire year.

Every physician should spend some time caring for the poorest of the poor, whether it be in a needy foreign country, Appalachia or rural America, or in the inner city, often just 30 minutes from our homes.

Surely it will help or change the patient’s life. But, too, it just might change your perspective, forever, and renew your passion for what we do – help others.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I’m guilty. I feel a sense of entitlement, as many of us do. I have always had access to the best health care available. Even as a child, whenever I had a runny nose, my parents not only knew what to do but could afford whatever it took to make me feel better. And vaccine-preventable illnesses? They didn’t stand a chance at my house. I remember the day when I was a little girl and my father, a general practitioner, figured out my plan to wait him out as he stood patiently outside the bathroom door, vaccine in hand. He eventually got tired of waiting, barged in, oblivious to the fact that I was sitting on the potty (twiddling my fingers), and shot me right in arm. The nerve!

Many of us have no concept of what it is like to be ill. I mean really ill with no one to help, and no way to pay for that help even if we could find it. In the March 6, 2014, issue of the New England Journal of Medicine, authors of "Global Supply of Health Professionals" note that there’s a worldwide crisis of severe shortages, as well as maldistribution of health care professionals intensified by three global transitions: redistribution of the disability burden, demographic changes, and epidemiologic shifts. An estimated 25% of physicians in America come from other countries. Naturally, in some cases the countries of origin have their own health care challenges, so the trend to immigrate to America has significant potential to exacerbate an already critical shortage.

© Matthew Benoit/Fotolia.com

Of the estimated 9.2 million doctors worldwide, 8% reside in the United States. Of the 18.1 million nurses, 17% are in here. To put it in perspective, only 4% of the world’s population lives in the United States, yet we command a lion’s share of the global health care workforce, leaving the citizens of many other countries vulnerable to excessive suffering, premature death, and preventable diseases.

With all that America has to offer, I don’t see the pendulum shifting back in the other direction any time soon, but many of us are in a position to provide much needed health care to our brothers and sisters in even the most remote areas of the world.

As squeamish as I am about charting unknown territory, even I went on a medical missions trip to Nicaragua a few years ago and I will never forget it. We had to climb up the side of a mountain to get to a clearing that would hold the makeshift medical clinic. Of course, the locals came out in large numbers to receive much-needed medical care.

On the way back to the hotel I noticed some little boys tossing an object back and forth in the street. It seemed like pleasant fun until we got closer and I saw the object they were tossing was a dead rat. Even what we consider an inexpensive child’s toy is a luxury for many. If you consider salary and benefits, we hospitalists make more, on average, in a single shift than many Nicaraguans make in an entire year.

Every physician should spend some time caring for the poorest of the poor, whether it be in a needy foreign country, Appalachia or rural America, or in the inner city, often just 30 minutes from our homes.

Surely it will help or change the patient’s life. But, too, it just might change your perspective, forever, and renew your passion for what we do – help others.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I’m guilty. I feel a sense of entitlement, as many of us do. I have always had access to the best health care available. Even as a child, whenever I had a runny nose, my parents not only knew what to do but could afford whatever it took to make me feel better. And vaccine-preventable illnesses? They didn’t stand a chance at my house. I remember the day when I was a little girl and my father, a general practitioner, figured out my plan to wait him out as he stood patiently outside the bathroom door, vaccine in hand. He eventually got tired of waiting, barged in, oblivious to the fact that I was sitting on the potty (twiddling my fingers), and shot me right in arm. The nerve!

Many of us have no concept of what it is like to be ill. I mean really ill with no one to help, and no way to pay for that help even if we could find it. In the March 6, 2014, issue of the New England Journal of Medicine, authors of "Global Supply of Health Professionals" note that there’s a worldwide crisis of severe shortages, as well as maldistribution of health care professionals intensified by three global transitions: redistribution of the disability burden, demographic changes, and epidemiologic shifts. An estimated 25% of physicians in America come from other countries. Naturally, in some cases the countries of origin have their own health care challenges, so the trend to immigrate to America has significant potential to exacerbate an already critical shortage.

© Matthew Benoit/Fotolia.com

Of the estimated 9.2 million doctors worldwide, 8% reside in the United States. Of the 18.1 million nurses, 17% are in here. To put it in perspective, only 4% of the world’s population lives in the United States, yet we command a lion’s share of the global health care workforce, leaving the citizens of many other countries vulnerable to excessive suffering, premature death, and preventable diseases.

With all that America has to offer, I don’t see the pendulum shifting back in the other direction any time soon, but many of us are in a position to provide much needed health care to our brothers and sisters in even the most remote areas of the world.

As squeamish as I am about charting unknown territory, even I went on a medical missions trip to Nicaragua a few years ago and I will never forget it. We had to climb up the side of a mountain to get to a clearing that would hold the makeshift medical clinic. Of course, the locals came out in large numbers to receive much-needed medical care.

On the way back to the hotel I noticed some little boys tossing an object back and forth in the street. It seemed like pleasant fun until we got closer and I saw the object they were tossing was a dead rat. Even what we consider an inexpensive child’s toy is a luxury for many. If you consider salary and benefits, we hospitalists make more, on average, in a single shift than many Nicaraguans make in an entire year.

Every physician should spend some time caring for the poorest of the poor, whether it be in a needy foreign country, Appalachia or rural America, or in the inner city, often just 30 minutes from our homes.

Surely it will help or change the patient’s life. But, too, it just might change your perspective, forever, and renew your passion for what we do – help others.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I remember that day like it was yesterday, though it occurred more than a decade ago. I stood leaning over a black entertainment center in my family room, legs wobbly, heart weary – a surreal and solemn snapshot in time. From a speaker streamed a now-favorite Donnie McClurkin song, called "Stand," with its introspective lyrics: "You’ve prayed and you’ve cried ... . After you’ve done all you can, you just stand."

In the next room I could hear her softly gurgling on her secretions. I needed a moment, no, two or three moments, to collect my thoughts and pull myself together before I returned to face the nightmare I was living. My mother was actively dying in my guestroom. Why? I believed then and, today, many years later, believe just as strongly it was because she had not been getting her mammograms.

National Institutes of Health/Department of Health and Human Services

As a writer, sometimes I struggle with how personal to get in my blogs, but rest assured. I got her permission to share her story while she was still very lucid and competent. You see, she did not want others’ lives to end as hers was ending. She realized, in her final stages of life, that things would have likely been much different had she had her screening mammograms as recommended.

By the time of her diagnosis in her early 60s, the cancer had already spread. Would a mammogram in her late 50s have saved her life? I believe so, and I’m not alone. So I take issue with a recent article published in BMJ that downplays the significance of mammography (BMJ 2014;348:g366).

In 1980, Canadian researchers randomized 89,835 women, aged 40-59 to receive five annual mammograms or physical breast examinations. They followed these women over a 25-year period, and concluded that yearly mammography in women aged 40-59 did not decrease breast cancer mortality "beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available."

Well, how many of us have taken care of women in their 50s, 40s, and even 30s with terminal breast cancer? How many of us would advise a mother, aunt, sister (or self) not to have routine mammography? Not many, I’m sure. There is the art of medicine and the science of medicine. Sometimes these two clash, but I believe the art of medicine is realizing that the science of medicine really doesn’t matter to dying patients and their family members. Sometimes, we have to act in the best interest of individual patients and not rely too heavily on the "data." Data changes, risk factors emerge, or research findings may prove to be skewed or wrong in hindsight. Explains Dr. Poornima Sharma, an oncologist/hematologist at the University of Maryland Baltimore-Washington Medical Center: "While the methodology, mammographic technique, and equipment used in the Canadian study is being assessed and compared to the mammography standards used in the United States, the standard in this country remains annual mammography starting at age 40."

 Still, many women consider themselves at low risk for breast cancer if they have no close relatives with the disease. As erroneous as this assumption may be, this subset of women may be particularly vulnerable to the implication that yearly mammography is not needed.

So do this: Discuss screening mammography with your own family and then use those feelings when a teachable moment presents itself at bedside.

Our patients rely on us to look into their eyes and give them our best advice. Even though I am a hospitalist, there are still those women I feel compelled to counsel about screening mammography, and this study will not lessen my fervor. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I remember that day like it was yesterday, though it occurred more than a decade ago. I stood leaning over a black entertainment center in my family room, legs wobbly, heart weary – a surreal and solemn snapshot in time. From a speaker streamed a now-favorite Donnie McClurkin song, called "Stand," with its introspective lyrics: "You’ve prayed and you’ve cried ... . After you’ve done all you can, you just stand."

In the next room I could hear her softly gurgling on her secretions. I needed a moment, no, two or three moments, to collect my thoughts and pull myself together before I returned to face the nightmare I was living. My mother was actively dying in my guestroom. Why? I believed then and, today, many years later, believe just as strongly it was because she had not been getting her mammograms.

National Institutes of Health/Department of Health and Human Services

As a writer, sometimes I struggle with how personal to get in my blogs, but rest assured. I got her permission to share her story while she was still very lucid and competent. You see, she did not want others’ lives to end as hers was ending. She realized, in her final stages of life, that things would have likely been much different had she had her screening mammograms as recommended.

By the time of her diagnosis in her early 60s, the cancer had already spread. Would a mammogram in her late 50s have saved her life? I believe so, and I’m not alone. So I take issue with a recent article published in BMJ that downplays the significance of mammography (BMJ 2014;348:g366).

In 1980, Canadian researchers randomized 89,835 women, aged 40-59 to receive five annual mammograms or physical breast examinations. They followed these women over a 25-year period, and concluded that yearly mammography in women aged 40-59 did not decrease breast cancer mortality "beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available."

Well, how many of us have taken care of women in their 50s, 40s, and even 30s with terminal breast cancer? How many of us would advise a mother, aunt, sister (or self) not to have routine mammography? Not many, I’m sure. There is the art of medicine and the science of medicine. Sometimes these two clash, but I believe the art of medicine is realizing that the science of medicine really doesn’t matter to dying patients and their family members. Sometimes, we have to act in the best interest of individual patients and not rely too heavily on the "data." Data changes, risk factors emerge, or research findings may prove to be skewed or wrong in hindsight. Explains Dr. Poornima Sharma, an oncologist/hematologist at the University of Maryland Baltimore-Washington Medical Center: "While the methodology, mammographic technique, and equipment used in the Canadian study is being assessed and compared to the mammography standards used in the United States, the standard in this country remains annual mammography starting at age 40."

 Still, many women consider themselves at low risk for breast cancer if they have no close relatives with the disease. As erroneous as this assumption may be, this subset of women may be particularly vulnerable to the implication that yearly mammography is not needed.

So do this: Discuss screening mammography with your own family and then use those feelings when a teachable moment presents itself at bedside.

Our patients rely on us to look into their eyes and give them our best advice. Even though I am a hospitalist, there are still those women I feel compelled to counsel about screening mammography, and this study will not lessen my fervor. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

I remember that day like it was yesterday, though it occurred more than a decade ago. I stood leaning over a black entertainment center in my family room, legs wobbly, heart weary – a surreal and solemn snapshot in time. From a speaker streamed a now-favorite Donnie McClurkin song, called "Stand," with its introspective lyrics: "You’ve prayed and you’ve cried ... . After you’ve done all you can, you just stand."

In the next room I could hear her softly gurgling on her secretions. I needed a moment, no, two or three moments, to collect my thoughts and pull myself together before I returned to face the nightmare I was living. My mother was actively dying in my guestroom. Why? I believed then and, today, many years later, believe just as strongly it was because she had not been getting her mammograms.

National Institutes of Health/Department of Health and Human Services

As a writer, sometimes I struggle with how personal to get in my blogs, but rest assured. I got her permission to share her story while she was still very lucid and competent. You see, she did not want others’ lives to end as hers was ending. She realized, in her final stages of life, that things would have likely been much different had she had her screening mammograms as recommended.

By the time of her diagnosis in her early 60s, the cancer had already spread. Would a mammogram in her late 50s have saved her life? I believe so, and I’m not alone. So I take issue with a recent article published in BMJ that downplays the significance of mammography (BMJ 2014;348:g366).

In 1980, Canadian researchers randomized 89,835 women, aged 40-59 to receive five annual mammograms or physical breast examinations. They followed these women over a 25-year period, and concluded that yearly mammography in women aged 40-59 did not decrease breast cancer mortality "beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available."

Well, how many of us have taken care of women in their 50s, 40s, and even 30s with terminal breast cancer? How many of us would advise a mother, aunt, sister (or self) not to have routine mammography? Not many, I’m sure. There is the art of medicine and the science of medicine. Sometimes these two clash, but I believe the art of medicine is realizing that the science of medicine really doesn’t matter to dying patients and their family members. Sometimes, we have to act in the best interest of individual patients and not rely too heavily on the "data." Data changes, risk factors emerge, or research findings may prove to be skewed or wrong in hindsight. Explains Dr. Poornima Sharma, an oncologist/hematologist at the University of Maryland Baltimore-Washington Medical Center: "While the methodology, mammographic technique, and equipment used in the Canadian study is being assessed and compared to the mammography standards used in the United States, the standard in this country remains annual mammography starting at age 40."

 Still, many women consider themselves at low risk for breast cancer if they have no close relatives with the disease. As erroneous as this assumption may be, this subset of women may be particularly vulnerable to the implication that yearly mammography is not needed.

So do this: Discuss screening mammography with your own family and then use those feelings when a teachable moment presents itself at bedside.

Our patients rely on us to look into their eyes and give them our best advice. Even though I am a hospitalist, there are still those women I feel compelled to counsel about screening mammography, and this study will not lessen my fervor. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.