Dushyant Viswanathan, MD

One of the ways we can cut costs and improve quality in hospitals today is to measure what I call “interval improvement” in our patients. Basically if a patient is admitted to the hospital, likely it is because they have a life-threatening medical problem. After a few hours, and definitely after the first day, there should be a demonstrable interval improvement in the patient’s clinical status. This can be measured via subjective questionnaire, physician documentation after rounding, labs, vitals, test results, etc. We need to focus on interval improvement as a way to ground clinical care in efficient, effective methodologies.

Already in the management of septic shock, we do have parameters measuring interval improvement. Also in the management of pneumonia, we have a six-hour window in which antibiotics are administered. We know from the evidence that if certain parameters are not met in a discrete time interval in the management of pneumonia and septic shock, the patient generally does clinically worse, has longer hospital stays, more complications, and more morbidity.

We need to apply this aggressive, efficient, quality-based approach to care in the management of all inpatient illnesses, especially heart failure, liver failure, infections, kidney failure, complications of hypertension and hyperglycemia, and COPD decompensations. With regards to gastrointestinal bleeding, myocardial infarction, and stroke, there already is a sense of pressing urgency to the clinical care, so I leave these three out. But the illnesses I do mention have a tendency to be recurrent and frequent, and often because of their frequency, less attention is paid to them, less of a sense of urgency.

Make no mistake: Every episode of decomensated heart or lung function is a sign of significant inflammatory burden. The patient basically is moving towards death. We need to be alarmed at even routine decompensated heart, liver, kidney, or lung failure.

So in measuring interval improvement, there is a long view and a short view. The short view is simply seeing if the patient is better six hours, 12 hours, 24 hours, 36 hours after admission. If they aren’t getting better, something needs to be done.

The long view is the overall arc of the patient’s health over months to years. If a patient over several months to years is noted to have deteriorating quality of life, functionality, cognitive function, and more hospitalizations, then this must be aggressively addressed. Insurance companies, case managers, and primary-care physicians need to keep tabs on the patients who do not have long-view interval improvement. Perhaps such patients need a home care physician or perhaps palliative care. Remember, as soon as a patient is diagnosed with a chronic illness, palliative care should be considered in the plan of care.

Having the interval improvement of patients measured on the second day of a hospital stay will likely significantly decrease hospital length of stays, decrease costs, and preemptively avoid disasters.



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One of the ways we can cut costs and improve quality in hospitals today is to measure what I call “interval improvement” in our patients.

‘Interval Improvement’ Should Be a Marker in Patient Care

I have never been as impressed with the state of modern medicine as I was during the Integrative Healthcare Symposium this past weekend (Feb. 8-11) in New York City. While the attendees ranged from acupuncturists to physicians to naturopaths, homeopaths, and body workers, the faculty presenters were mostly integrative medical physicians with strong backgrounds in internal medicine, strengthened by additional training in other fields such as naturopathic medicine, myofascial release methods, and nutrition. 

Besides the fact that the presenters were technically highly trained and skilled, what impressed me so much was the absolute unshakeable commitment to getting patients better. Far from the depressing reality of reimbursement-based mainstream allopathic medicine, the compassionate, thorough, evidence-based care espoused by these practitioners reminded me of my own personal dreams, and of why I entered the healthcare field to begin with.

Especially memorable was the presentations given by UC San Francisco cardiologist and founder of the Preventative Medicine Research Institute, Dean Ornish, and integrative physician Richard Horowitz of Hyde Park, N.Y. Ornish spoke of his research in healing chronic illness, particularly ischemic cardiomyopathy and early stage prostate cancer. Horowitz spoke about pain management strategies in patients with multiple chronic infectious disease syndrome and Lyme disease. Both practitioners convey a sense of compassionate dedication to proper diagnosis and treatment, always using clinical literature to back up any claims. I’ve never seen a more thorough presentation than that given by Horowitz.

Integrative internal medicine begins where standard mainstream reimbursement-based allopathic medicine ends. The former is about taking the patient from a state of disease to a state of health. The latter is about quantity of tests, billing, and self-protection from liability. The former is about integrating effective therapeutic methods into a comprehensive strategy that works for the patient, and that emphasizes personal responsibility on the part of the patient as well. The latter is paternalistic, aggressively treating “at” the patient, with no emphasis on lifestyle or food intake. The former appreciates the complicated electromagnetic matrix which is the living organism. The latter is materialistic and positivistic, and basically ignores the emotional, spiritual, and quality-of-life issues which are essential in the human experience. The former appreciates pharmaceutical drugs, nutraceutical formulations, physical medicine, and even homeopathic formulations, always sticking to what works with minimal side effects, in an evidence-based way. The latter has been enslaved to the insurance and pharmaceutical companies since its inception. 

Most piquantly, the former will undoubtedly represent the future; the latter will clearly be the past.

F

ind out more about Dushyant Viswanathan and our other 

While attending the Integrative Healthcare Symposium, what impressed me so much was the absolute unshakeable commitment to getting patients better.

Integrative Medicine: The Future of Healthcare is Here

You can fix all kinds of physical problems. But if you don’t address emotional health and disease, the patient will deteriorate. Any practitioner who denies this is basically a Neanderthal. 

We are human beings who react to the world. Reactions are typically emotional in nature, and such emotions are remembered. They are buried deep in the subconscious, and frequently in the conscious brain centers. Emotional reactions are stored in joints, muscles, and nervous tissue. Even the heart manifests emotional reactions (sympathetic nervous system activation, apical ballooning syndrome, etc).

We need to integrate the patient’s emotional health into basic clinical care. This requires more than merely establishing rapport and appreciating the patient’s human nature; it requires methods which when applied, lead to emotional healing. When a provider can address the body, emotional body, and mind, the result is success, and even reversal of disease states. We need more community doctors doing this. Too often it is the naturopaths and complementary medicine practitioners who are expert at addressing emotional health, while allopaths who address the burden of chronic disease in America today, pay little attention to it.

Why? Why must we do this? Because despite reductionist positivistic paradigms (which have been discarded in more evolved fields such as physics), there is far more to a human being than their macroscopic, easily observable organ function. We need to pay attention to the invisible aspects of our patients. Invisible? Am I getting mystical here? No; just being comprehensive. The emotional body of a person is intimately connected to their organ functions. How? Via the sympathetic nervous system, the hypothalamic-pituitary-adrenal axis, the limbic system, the enteric nervous system, etc.; the science is there. What is lacking is clinical applicability, which is why medicine lags far behind other fields (such as physics).

What practical methods are there to effect emotional healing? Here they are: yoga, tai chi, meditation, emotional freedom techniques, psychodrama, hypnotherapy, etc. Is there evidence that these methods work? Yes, under the guidance of a masterful practitioner, these methods work. Do they have reproducible results? Well even medications do not have reproducible results. Like any therapeutic modality, they work for some and don’t work for others. In my experience, I’ve never had a patient fail to glean benefit from yoga, but that’s my experience, and I don’t expect the typical practitioner to echo my views. 

The point is: various methods are available. They typically fall outside the domain of conventional medicine. But if conventional medicine doesn’t address emotional pain, then maybe that’s why conventional medicine usually doesn’t work in the long run.



If you don’t address emotional health and disease, the patient will deteriorate. Any practitioner who denies this is basically a Neanderthal.

Caring for the Emotional Health of Your Patients

We need to face a basic fact; it’s a fact so basic, yet difficult to fully comprehend, that it is virtually ignored throughout the country in boardrooms addressing healthcare reform. The fact is this: Internal medicine and family practice hospitalists provide essential primary care 

for the extremely sick, chronically ill patient population that is responsible for the majority of Medicare spending in America today. These patients are routinely dealing with life-threatening decompensated organ failures - heart, brain, lung, liver, kidney - and of course we must mention gastrointestinal bleeding and septic shock. 

These ill people suffer through acute life-threatening illnesses in the larger context of debilitating chronic illness. Their chronic illnesses are either too complicated for outpatient providers to manage, or never get to be managed by outpatient providers because the patients simply bounce in and out of hospitals, nursing homes, assisted living facilities, etc.

These patients consume the majority of healthcare services billable to Medicare and major insurance companies; they put the bread on the table for cardiologists, pulmonologists, and other hospital-based providers. These patients are routinely admitted under the primary inpatient service of an internist, hospitalist, or family practitioner with inpatient skills. In one day, the physician can do what outpatient providers do in 6 months: check LDL, A1C, blood pressure, check for occult cancers, check heart function, maximize cardioprotective medication dosages (beta blockers, ACE inhibitors, etc). In one six-hour period, the patient gets more attention paid to each organ system and their inter-connectedness, thanks to the attending internist, compared to the years of care they’ve received by outpatient practitioners. 

Why? Simply because if you are admitted to the hospital, that means your life is in danger. The doctor caring for you is vigilant against any possible threat to your life. Tests are ordered, perhaps in excess, in anticipation of the pulmonary embolus about to kill you. We inpatient practitioners work very hard in a 12-hour period to make sure you don’t die on our watch.

Consequently, we provide extremely good care. Good enough to prevent readmissions because the underlying issue has been solved? No; absolutely not. Let me state it here in case you haven’t heard it elsewhere: 

Medical readmissions are not attributable to poor quality care; they are for the most part due to extreme burden of illness.

 We have an epidemic of chronic illness. We have more human beings living with minimally functioning organs than ever before in the history of mankind. 

I routinely deal with demented (brain not working) patients with heart failure (heart not working) which leads to kidney failure (kidney not getting blood flow from aforementioned heart) and lung failure (lungs filled with fluid from sad heart), which leads to complications such as pneumonia (septic burden compromises multiple organ systems)…etc etc. 

The regular frequent flyer patients that come in and out of hospitals receive their primary care in the hospital from vigilant internists. The moment we accept this fact, and we change pay structures and priorities according to the consequences of this fact, we will be more likely to meet the enormous challenge of chronic illness in 2012.



Hospitalists provide essential primary care in the hospital for the extremely sick, chronically ill patient population responsible for the majority of Medicare spending.

Hospitalists Play Critical Role in Primary Care

As many of you know, we are in the midst of an epidemic of chronic pain and abuse/diversion of oxycodone. Oxycodone now kills more people than cocaine and heroin combined, and has left a sordid trail in Ohio, Florida, and Maryland. I have witnessed many lives deteriorate because of oxycodone-related issues. Who is to blame? Doctors? The drug itself? The patients? Well major relevant organizations such as the American Pain Society and the American Association of Family Physicians regularly publish articles and editorials emphasizing that main is often undertreated, precisely because of prescriber fears related to abuse/diversion. Moreover most doctors are aware of the importance of treating pain, but are even more aware that narcotics aren’t the sole answer, despite what many patients believe. 

We need to have a systems-based approach to chronic pain. That doesn’t mean automatically refer chronic pain patients to a pain specialist. In fact, the Medscape “Chronic Pain in America” series emphasizes that pain specialist referrals should only be made if the patient’s problems require more than what the primary-care provider can offer; (this suggests a larger point that consultants should only be called when their services are needed, not immediately upon elicitation of the chief complaint - I only call consultants when a patient is deteriorating under my care or for a procedure I cannot do myself).

Systems-based approach means an approach mutually agreed upon by all interested parties - physician, medical board, insurance company, patient, etc. Many problems in the treatment of chronic pain are related to these multiple parties not being on the same page. For example, I recently discharged a patient from my service in the hospital with prescriptions for long-acting opiate medications and a short course of short-acting narcotics. The patient is informed upon leaving that their insurance company would not pay for the long-acting medication, so I replaced it with another long-acting medication, trying to stick to the least expensive ones. As the patient’s pain worsened, it eventually dawned on him that his insurance company would not pay for 

 long acting narcotic. But the pain guidelines emphasize the need for long-acting agents in the use of chronic opioid therapy for chronic non-malignant pain. The patient had uncontrolled pain at home, and within one week, came back to the emergency room, and was re-admitted. 

Maybe this was my fault for discharging him before working out all the inane details related to what his insurance company would cover and what it would not. But frankly, the hospital isn’t the place to work this out - it should be done in the primary-care physician’s office. Of course, his primary-care physician has no interest in providing narcotics to this patient, who is clearly dependent on them for management of chronic pain. Here is an example of how primary-care physicians need further training in the management of chronic pain, and this can be achieved with online CMEs.

Pain specialists may do spinal injections and other fancy procedures of dubious value, and their credentialing perhaps has more merit in the courtroom, but as I say above, they should not be first in line in the treatment of chronic pain with narcotics. An internist or family physician should be able to do that, using a multi-modal approach to chronic pain involving methods that have been shown to be effective- exercise training, stretching/yoga, nutrition, prolotherapy, psychotherapy, emotional freedom techniques, and the multiple pharmacologic agents at our disposal. 



Many problems in the treatment of chronic pain are related to these multiple parties not being on the same page.

Physicians One Part of Needed Systems-based Approach to Chronic Pain

Chest pain admissions and observations are possibly the most ridiculous aspects of internal medicine. Routinely, possibly 40 times daily, ER physicians call internists to admit patients complaining of pain somewhere below the chin and above the pelvis. Because of the fear of litigation and of missing a potentially fatal coronary occlusion, every patient is admitted and evaluated for ischemic chest pain. This usually involves a stress test, and a night’s stay in the hospital.

I may be casting too wide a net, but the majority of ER physicians seem concerned about chest pain occurring while the patient is at rest. But so often, the patient in question had an episode of pain at rest, but meanwhile swims 40 laps daily with no exertional pain. Clearly such a patient’s pain is 

 in origin. A simple history (history-taking is an example of cost-effective care!) can identify those patients with exertional chest pain. Exertional chest pain is emotional, physical, and cold-induced typically. If a patient has unimpaired exercise capacity and nonexertional symptoms, there is no reason to admit them for an ischemic chest pain workup. (Often the history is unclear or the patient’s story is confusing, and so it is prudent to err on the side of caution and simply admit the patient and perform the workup - but what I refer to here are the cases of clearly nonexertional chest pain).

The lack of history-taking when it comes to chest pain admissions is noted by every internal medicine physician I know, and is a common complaint we have of ER physicians. Sure, we know that they have a lot of patients to deal with, and would prefer to defer to cardiologists when it comes to chest pain. But in a world where cardiologists are receiving cuts in reimbursements and are not able to wantonly perform invasive procedures (cardiac catheterizations), deferring to them is not the best choice of action. After all, 

Hospitals need to create a system-based policy on how to evaluate chest pain admissions and observation patients. It begins with a history and physical, possibly bedside echo and chest x-ray, troponin, CPK, and CK-MB measurement. If the patient has stable angina, they need no further inpatient workup. All patients in such situations need lifestyle modification (slowly up-titrated exercise capacity and a plant-based diet). If necessary, a stress test should be performed.

But clinical decision-making should be intelligent and systematic. Unfortunately the reality of the current situation, (symptomatic of the failing medical system) is that defensive medicine (expensive and unnecessary) is the standard of care. Yet outcomes get worse, more money is spent, and people do not heal. The system needs to change.

Chest pain admissions and observations are possibly the most ridiculous aspects of internal medicine.