Fall 2019 - Volume 23 Number 4

Original Research

CME A 10-Year Analysis of 3693 Craniotomies during a Transition to Multidisciplinary Teams, Protocols, and Pathways
Paul T Akins, MD, PhD; Amit Banerjee, MD; Kern Guppy, MD, PhD; James Silverthorn, DO; John Fitzgibbon, MD; Yogesh Nandan, MD; Elaine O Yu; Luis Pacheco; Jack Rozance, MD; Rob Azevedo, MD; James Chang, MD; Mark W Hawk, MD
This observational study involved sequential implementation of a multidisciplinary team, protocols, and a craniotomy pathway. Retrospective review of admissions (2008-2017) revealed reduced craniotomy complication rates, case volume increased 73%, and hospital length of stay improved by 63%, as well as increased professional collegiality and satisfaction. A searchable craniotomy discharge summary is an important tool for continuous monitoring of quality and efficiency of care. The authors present outcomes data, including craniotomy indications, operative timing, complications, functional outcomes, delays in discharge, and discharge destinations using the craniotomy discharge summary.

Predictive Factors for Early Relapse in Multiple Myeloma after Autologous Hematopoietic Stem Cell Transplant
Andrew Mayer Pourmoussa, MD; Ricardo Spielberger, MD; Jilian Cai, MD; Odelia Khoshbin, OMS; Leonardo Farol, MD; Thai Cao, MD; Firoozeh Sahebi, MD
A total of 141 patients were included in this retrospective analysis. Factors found to be associated with inferior progression-free survival were disease status less than complete response at the time of hematopoietic peripheral stem cell transplant (HSCT), no use of maintenance therapy after HSCT, International Staging System stage III, and high Freiburg Comorbidity Index. Disease status less than complete response, stage III, higher Freiburg Comorbidity Index, no use of maintenance therapy, and male sex were the most predictive factors for early relapse (< 18 months). These results highlight the need for consideration of alternative therapy in such instances.

Lifestyle Interventions and Carotid Plaque Burden: A Comparative Analysis of Two Lifestyle Intervention Programs in Patients with Coronary Artery Disease
Rachid A Elkoustaf, MD, MPH; Omar M Aldaas, MD; Colombus D Batiste, MD; Adina Mercer, MD; Mario Robinson, MD; Darlene Newton, DrPH; Raoul Burchett, MA, MS; Cynthia Cornelius, RVT; Heidi Patterson, MPH; Mohamed H Ismail, MD, MPH
In a randomized, single-center, single-blind study in 120 patients with established coronary artery disease (CAD), neither the Complete Health Improvement Program (CHIP) nor an ad hoc, nonsequential combination of various healthy-living classes was effective in inducing plaque regression in patients with established CAD after a 9-month period. However, both were effective in improving several CAD risk factors, which shows that the nonsequential offering of healthy-lifestyle programs can lead to similar outcomes as a formal, sequential, established program (CHIP) in many aspects.

Spontaneous Coronary Artery Dissection: Clinical Characteristics, Management, and Outcomes in a Racially and Ethnically Diverse Community-Based Cohort
Stephanie Chen, MD; Maqdooda Merchant, MSc, MA; Kenneth N Mahrer, MD; Robert J Lundstrom, MD; Sahar Naderi, MD; Anne CH Goh, MBBS, MPH
A retrospective cohort study of patients (mean age 48, 93% women, 49.5% nonwhite) with spontaneous coronary artery dissection (SCAD) at Kaiser Permanente Northern California during a 10-year period compared 111 SCAD cases with 333 healthy, matched controls. Only pregnancy and hyperlipidemia were associated with SCAD compared with controls. Fifty-five patients (49.5%) were successfully treated without revascularization; of the 54 who had urgent percutaneous coronary intervention, 2 required coronary artery bypass grafting for SCAD extension. For the SCAD cases, major adverse cardiovascular events occurred in 8.1%, and race did not influence outcomes.

Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality
Mary Anderson Wallace, MD; Andrew Hammes, MS; Micol S Rothman, MD; Anastasiya A Trizno; Christine D Jones, MD, MS; Ethan Cumbler, MD; Kelly McDevitt, RN, MS, ONC; Nichole E Carlson, PhD; Jason W Stoneback, MD
In a retrospective cohort study of patients (age 65 years and older) admitted to an academic medical center with an acute fragility hip fracture (1/1/2012-3/31/2016), the authors identified 243 index admissions, including 135 before and 108 after a comprehensive geriatric hip fracture program implementation (10/2014). The postintervention cohort trended toward a lower unadjusted 1-year mortality rate (15.7% vs 24.4%) and had a significantly higher overall survival rate than did the preintervention cohort.

Diffusion of Excellence: Accelerating the Spread of Clinical Innovation and Best Practices across the Nation’s Largest Health System
Ryan Vega, MD, MSHA; George L Jackson, PhD, MHA; Blake Henderson; Carolyn Clancy, MD; Jennifer McPhail, MS; Sarah L Cutrona, MD, MPH; Laura J Damschroder, MS, MPH; Saurabha Bhatnagar, MD
Using a 5-step systematic approach refined over time, 1676 practices have been submitted by frontline Veterans Health Administration (VHA) staff since the Diffusion of Excellence Initiative’s inception; 47 of these have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated 412 times in VHA hospitals across the country, reaching an estimated 100,000 Veterans and creating approximately $22.6 million in cost avoidance for VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) have saved Veteran lives.

Association of Type and Frequency of Postsurgery Care with Revision Surgery after Total Joint Replacement
Heather A Prentice, PhD; Priscilla H Chan, MS; Robert S Namba, MD; Maria CS Inacio, PhD; Art Sedrakyan, MD, PhD; Elizabeth W Paxton, MA, PhD
Postmarket surveillance is limited in the ability to detect medical device problems. Using an integrated health care system’s total joint arthroplasty (TJA) registry, the authors identified primary TJA (22,953 knees and 9904 hips) from 4/2001-6/2013. Knee arthroplasty recipients with 3 or more outpatient orthopedic allied health/nurse visits within 90 days had a 2.2 times higher risk of revision within 2 years postoperatively and 10.1 times higher risk after 2 years. Patients with 6 or more outpatient orthopedic office visits had a 15.7 times higher risk of revision.

Clinical Use Cases for a Tool to Assess Risk in Superficial Bladder Cancer
Carmit K McMullen, PhD; Maureen O’Keeffe Rosetti, MS;Sheila Weinmann, PhD; Michael C Leo, PhD;Matthew E Nielsen, MD, MS, FACS
As a preliminary step in developing and validating a risk assessment tool for superficial bladder cancer in a population-based clinical cohort, the authors interviewed 5 urologic oncologists and 4 general urologists, with 4 or more endorsing: 1) provide evidence to guide clinical management in specific situations, 2) generate patient-facing communication aids, 3) improve documentation about recurrence/progression risk, and 4) create scheduling and callback supports to improve the quality of follow-up care. Their findings demonstrated several potential clinical-use cases for a risk calculator and clinical-decision support tool.

CMEFeasibility of a Telemedicine-Administered, Pharmacist-Staffed, Protocol-Driven, Multicenter Program for Kidney Stone Prevention in a Large Integrated Health Care System: Results of a Pilot Program
Mark E Gasparini, MD; Toby W Chang, PharmD; Mark St Lezin, MD; John E Skerry, MD; Andy Chan, PharmD; Krishna A Ramaswamy, MD
Among 500 patients (referred from 3 Northern California Kaiser Permanente facilities) enrolled for 3 months, 99% self-reported compliance with at least 3 of 5 aspects of dietary advice. A significant improvement in all urinary parameters occurred in 52 patients with calcium stones who repeated 24-hour urine testing. A telemedicine-administered, pharmacist-staffed, protocol-driven program can provide dietary advice and obtain compliance with metabolic testing for patients at high risk of recurrent kidney stones. This report represents the first telemedicine-administered, pharmacist-staffed, kidney stone prevention program published in the literature.

Feeding Jejunostomy Tube Placed during Esophagectomy: Is There an Effect on Postoperative Outcomes?
Mohammed H Al-Temimi, MD, MPH; Anya M Dyurgerova, DO; Michael Kidon, DO; Samir Johna, MD
A feeding jejunostomy (FJ) tube was placed in 45% of 2059 patients undergoing esophagectomy. FJ tube placement was associated with higher overall morbidity (46% vs 38.6%, p = 0.002), superficial wound infection (6.3% vs 2.9%, p = 0.001), and return to the operating room (16.7% vs 12.5%, p = 0.016). In a subgroup of patients with anastomotic leak, FJ was associated with shorter hospital stay (20.1 days vs 24.3 days, p = 0.046). These mixed findings support selective rather than routine FJ tube placement during esophagectomy.

Minimally Invasive Repair of Pediatric Morgagni Hernias Using Transfascial Sutures with Extracorporeal Knot Tying
Lian Lim, MD; Sarah M Gilyard, MD; Roman M Sydorak, MD, MPH; Stanley T Lau, MD; Edward Y Yoo, MD; Donald B Shaul, MD
This is a retrospective chart review of pediatric patients who underwent minimally invasive repair of a Morgagni hernia from November 2009 to September 2017 within a defined population. Eleven Morgagni hernias were repaired through a completely minimally invasive approach. Three repairs were completed using a soft-tissue patch. All minimally invasive repairs were completed with transfascial sutures using an endoscopic suturing device, and 2-0 nonabsorbable synthetic sutures with extracorporeal knot tying. Median follow-up was 40 months (range = 2.6 months to 7.3 years). No patients had postoperative pectus excavatum defects. There were no recurrences.

Statin-Associated Cardiomyopathy Responds to Statin Withdrawal and Administration of Coenzyme Q10
Peter H Langsjoen, MD, FACC; Jens O Langsjoen, MD; Alena M Langsjoen, MS; Franklin Rosenfeldt, MD, FRACS
Of 142 identified patients with heart failure, 94% presented with preserved ejection fraction (EF) and 6% with reduced EF (<50%). After 2.8 years, New York Heart Association class 1 increased from 8% to 79%. In patients with preserved EF, 34% had normalization of diastolic function and 25% showed improvement. In patients with reduced EF at baseline, the EF improved from 35% to 47%. Statin-attributable symptoms including fatigue, muscle weakness, myalgias, memory loss, and peripheral neuropathy improved. The 1-year mortality was 0%, and the 3-year mortality was 3%.

Function of the Medical Team Quarterback: Patient, Family, and Physician Perspectives on Team Care Coordination in Patient- and Family-Centered Primary Care
Marlaine Figueroa Gray, PhD; Jennifer Sweeney, MA; Wendy Nickel, MPH; Mary Minniti, BS, CPHQ; Katie Coleman, MSPH; Karin Johnson, PhD; Tracy Mroz, PhD; Barb Forss; Robert Reid, MD; Dominick Frosch, PhD; Clarissa Hsu, PhD|
Nine focus groups with 92 participants were held in 3 major cities. Patients (35) and family members (36) were recruited through market research groups. Physicians (21) were recruited by the American College of Physicians. The quarterback emerged as an important function for addressing care gaps and improving the care experience, with 6 themes: Overseeing care; coordinating diagnoses, tests, and treatments; advocating for patients; identifying and respecting patient values; proactively communicating; and solving problems. Patients and family members in our sample were open to different members of the care team acting as quarterback in coordination with the physician.

How to Move a "Giant": 7 Lessons Learned for Making a Change in a Large Organization
Eric Yahney, PhD; Susan Ambrose, LISW-S; Ryan Vega, MD, MSHA
About change in a large organization, the authors learned: 1) share your project with a megaphone, because feedback results in a better product; 2) be enthusiastic and engage others; 3) focus on those who are willing to participate in your vision; 4) use the language of your audience; 5) present enough information to remove the frightening unknown, 6) share your results, successes, and struggles; and 7) couple passion with determination of commitment.

Prognostic Impact of Chronic Kidney Disease in Patients with Heart Failure
Nektar Nikki Hakopian, PharmD; Derenik Gharibian, PharmD; Marlene M Nashed, PharmD, BCPS
A total of 27,366 patients (1/12-1/17) were identified with comorbid heart failure (HF) and chronic kidney disease (CKD). At the first year of follow-up, patients with HF and late-stage CKD had higher all-cause hospitalization, HF-related hospitalization, and 30-day readmission rates compared with patients with HF and early-stage CKD. In subsequent follow-up years, patients continued to have higher all-cause and HF-related hospitalization rates in late-stage CKD.

Special Reports

CMEThe Power of Plants: Is a Whole-Foods, Plant-Based Diet the Answer to Health, Health Care, and Physician Wellness?
Benjamin Ha, MD
It is estimated that more than 70% of health care dollars are spent addressing the result of unhealthy lifestyles, which are increasing the rates of obesity, diabetes, and cardiovascular disease. There is also a severe and worsening epidemic of physician burnout in the US, which threatens the health of physicians and patients alike. The author shares why a whole-foods, plant-based diet is a powerful prescription for optimal health and the answer to health, health care, and physician wellness.

Periodontal Diseases and Age-Related Macular Degeneration: Is There a Link? A Review
Zocko Ange Désiré Pockpa, MSc; Xavier Struillou, PhD; Dramane Kone, DDS; Gnaba Samson Mobio, DDS; Assem Soueidan, PhD; Zahi Badran, PhD
In a comprehensive literature search, persons with age-related macular degeneration (AMD) showed more periodontal diseases, fewer teeth, and more alveolar bone loss than those without AMD. Also, a significant association was observed between periodontal diseases and AMD, but only in the youngest individuals studied. According to the studies included in this review, periodontal disease may be a plausible risk factor for AMD and may have a potential role in the earlier stages of this eye disease.

Health Literacy among Individuals with Disabilities: A Health Information National Trends Survey Analysis
Jenn Nguyen, PhD, MPH; Lauren Gilbert, PhD, MPH, MA
Data analysis using the Health Information National Trends Survey, a nationally representative survey sponsored by the National Cancer Institute, were conducted to examine the association between sociodemographics, disability status, and health literacy concerns. Results show 2 areas of concern for individuals with disabilities: The effort to find needed information and being frustrated during the search for information. There was no difference detected regarding being concerned about the quality of information found and believing that the information found was hard to understand.

Impact of Central Intake Development and System Change on Per Capita Child and Adolescent Mental Health Discharges from 2002 to 2017: Implications for Optimizing System Design by Shaping Demand
Karen Melathopolous, RN; David Cawthorpe, PhD
From 117,500 referrals to all regional services, 16,750 unique males and 17,140 unique females were admitted and discharged (4/2002-4/2017). Per capita system capacity increased but did not change in linear relation to investment, even though wait times and length of stay decreased. Steps focusing on future optimization of system capacity are discussed using a novel concept termed shaping demand, which refers to strategies for orienting/educating families after referral and before admission.

Review Articles

Abdominal Aortic Aneurysm: A Case Report and Literature Review
Kate Clancy, DO, MPH; James Wong, MD; Allison Spicher, MD
Abdominal aortic aneurysms (AAA) more commonly affect men and are estimated to affect 4%-8% of men older than 60 years of age. Mortality from rupture is high, but elective repair is an effective and relatively safe intervention. A literature review of proper screening, referral timeframe, the most common surgical techniques, potential complications, and postoperative surveillance was conducted. Early detection, referral to vascular surgery, and possible open or endovascular repair are key to limiting the morbidity and mortality associated with AAA.

Supraclavicular Artery Island Flap in Head and Neck Reconstruction: A Case Series and Literature Review
Shelley Wong; Malia Brennan; Scott Nishikawa, MD; Jae H Lim, MD, PhD
Eight patients underwent supraclavicular artery island flap (SCAIF) reconstruction of head and neck defects. Various anatomic sites were reconstructed including the neck (4), oral cavity (1), and parotid/lateral skull base (3). Two patients had partial flap necrosis, requiring débridement and wound care. There was no total loss of the flap or donor-site complication. SCAIF is an excellent choice for reconstructing various head and neck defects, with low complication rates and donor-site morbidity.

Clinical Practices

CMEThe Mindful Doctor
Michael Chun, MD
The author used to wake up on Monday morning with the typical blues, thinking of what had happened the few days before and his plans for the weekend. Now, he wakes up looking forward to the day and that moment, knowing that the current moment is the most important one and the only one that he can control. Mindfulness can make every patient encounter, every day, and every moment as good as it can be, and could bring back the joy in medicine and life to physicians and their patients.

Case Reports

Treating Vitamin D Deficiency and Insufficiency in Chronic Neck and Back Pain and Muscle Spasm: A Case Series
Chunbo Cai, MD, MPH
Vitamin D deficiency and insufficiency can cause or worsen neck and back pain and muscle spasm. Correction of vitamin D deficiency and insufficiency plays an important role in the treatment of chronic neck and back pain and muscle spasm among patients having concurrent vitamin D deficiency and insufficiency because it can be prevented and treated easily, and can increase the quality of care but also reduce the cost.

Novel Antiplatelet Perioperative Bridging Protocol for Lung Lobectomy: A Case Report
Sora Ely, MD; Dana A Dominguez, MD; Jeffrey B Velotta, MD
Some patients with cardiac stents will need thoracic surgery during the dual antiplatelet therapy (DAPT) period. When surgery cannot be safely delayed to allow 1 year of uninterrupted DAPT, appropriate perioperative management of anticoagulation is critical. This ticagrelor-eptifibatide perioperative bridge resulted in decreased preoperative hospitalization compared with eptifibatide alone. There were no associated perioperative cardiac or bleeding complications.

Poststreptococcal Reactive Arthritis: Diagnostic Challenges
Colleen Chun, MD; Daniel J Kingsbury, MD
Poststreptococcal reactive arthritis (PSRA) is associated with prior group A β-hemolytic streptococcal infection and has a reported annual incidence of 1 to 2 cases per 100,000 persons, approximately twice that of acute rheumatic fever (ARF) in the US. The authors review the diagnostic criteria for PSRA, the pertinent features of the 2015 ARF diagnostic guideline from the American Heart Association, and the major characteristics that differentiate PSRA from ARF.

Paroxysmal Kinesigenic Dyskinesia Symptoms Markedly Reduced with Parenteral Vitamins and Minerals: A Case Report
Alisha Bruton; Leslie Fuller, ND
Paroxysmal kinesigenic dyskinesia (PKD) is a rare movement disorder triggered by sudden involuntary movements. This 61-year-old woman who presented with a 13-year history of PKD had frequent episodic attacks so severe she had difficulty with ambulation and other activities of daily living. She was given weekly parenteral doses of vitamins and minerals, which almost completely eliminated her symptoms between treatments. Genetic testing, not related to her PKD diagnosis, revealed several mutations that could offer an explanation for the apparent efficacy of parenteral therapy in this patient.

Changes in Cortisol Awakening Response Before and After Development of Posttraumatic Stress Disorder, Which Cannot be Avoided with Use of Cannabidiol: A Case Report
Lívia Maria Bolsoni, MS; Thiago Dornela Apolinário da Silva, MD; Silvana Maria Quintana, MD, PhD; Margaret de Castro, MD, PhD; José Alexandre Crippa, MD, PhD; Antonio Waldo Zuardi, MD, PhD
A 15-year-old girl, a survivor of acute sexual violence, received a 7-day oral treatment with cannabidiol. She was followed-up from the first 24 hours after the event for 6 months for assessment of the effects of this treatment on the reconsolidation of memories related to the traumatic event. Cannabidiol treatment did not prevent the onset of PTSD. Cortisol awakening responses after the onset of the disorder were attenuated.

Capecitabine-Induced Takotsubo Cardiomyopathy: A Case Report
Prarthna V Bhardwaj, MD; Vinod Kumar Chaubey, MD; Ashequl M Islam, MD
An 80-year-old woman presented to the hospital with chest pain after recent initiation of capecitabine (an oral prodrug of 5-fluorouruse, known to cause cardiotoxicity) for anal cancer. Results of cardiac catheterization revealed moderate nonobstructive coronary disease. Overall, the findings were highly consistent with a clinical diagnosis of takotsubo

Duplicate Omohyoid Muscle Causing Progressive Dysphagia and Dyspnea: A Case Report
Rijul Kshirsagar, MD; Jason Gilde, MD; Raul Cruz, MD
Although rare, a duplicate omohyoid muscle should be considered in the differential diagnosis of dysphagia and dyspnea with concurrent central neck deformity. The authors report the first case (in this 20-year-old man) of an anomalous omohyoid that caused significant progressive clinical symptoms. Direct excision of the restrictive anomalous tissue proved curative.

Image Diagnosis

Image Diagnosis: An Unusual Cause of Upper Gastrointestinal Bleed—Isolated Duodenal Varices
Bipadabhanjan Mallick, DM; Preetam Nath, DM; Dibya L Praharaj, DM
Duodenal variceal bleeding is an uncommon complication of portal hypertension with very high mortality rates. Cirrhosis is the most common cause of duodenal varices, and in most cases, it occurs concomitantly with esophageal varices and/or gastric varices. Isolated duodenal varices are less frequently reported.

ECG Diagnosis: Dextrocardia
Cameron Mozayan, MD; Joel T Levis, MD, PhD, FACEP, FAAEM
When the position of both the thoracic and abdominal viscera are reversed, this is referred to as dextrocardia with situs inversus (situs inversus totalis). The physical finding in patients with dextrocardia is the presence of right-sided heart sounds on auscultation, with the maximum cardiac impulse located on the right side of the chest.

ECG Diagnosis: Brugada Syndrome
Alisha A Othieno; Dayna J Isaacs, MPH; David R Vinson, MD, FACEP, FAAFP; Joel T Levis, MD, PhD, FACEP, FAAEM
Brugada syndrome is an inherited sodium, calcium, or potassium channelopathy associated with an increased risk of ventricular fibrillation and sudden cardiac death, most prevalent in men and individuals of southeast Asian descent (mean age of onset of symptoms is 41 ± 15 years. This case highlights the presentation, electrocardiographic findings, and management of a patient.

Image Diagnosis: Classic External Jugular Vein Aneurysm
Uttam Thakur, MBBS, MS; Ajay Savlania, MS, MCh; Swapnesh Kumar Sahu, MBBS; Abhinaya Reddy, MBBS, MS
According to Mohanty et al, “The presence of unilateral, nontender, soft, reducible, and nonpulsatile swelling that enlarges with straining, sneezing, or Valsalva maneuver is a characteristic of venous aneurysm.”

Image Diagnosis: Bullosis Diabeticorum
Ashok Kumar Pannu, MD; Varun Suryadevara, MD
Certain skin conditions like diabetic dermopathy, bullosis diabeticorum, and necrobiosis lipoidica diabeticorum are frequently associated with an increased likelihood of microvascular complications of diabetes mellitus. Thus, their presence indicates poor glycemic control and enables early recognition and treatment of microvascular disease.

Healthcare Communication

The Best Physicians Are Destined to Hell
Scott Abramson, MD
Physician burnout is real. But the solution involves courage—the courage to look inside one’s heart and the courage to ask for help.


Creating World-Class Care and Service for Our Nation’s Finest: How Veterans Health Administration Diffusion of Excellence Initiative Is Innovating and Transforming Veterans Affairs Health Care
Carolyn Clancy, MD
The Veterans Health Administration (VHA) is the largest integrated health care system in the US. The author describes the VHA’s Diffusion of Excellence Initiative, which highlighted practices being implemented: 1) direct scheduling, 2) access to health care in rural areas, 3) access to mental health care, and 4) interactive and patient-centered care. The author outlines the current transition plan to elevate lessons learned and transform the initiative from a nascent start-up to a sustainable part of VHA’s culture.

Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk
Christian D Becker, MD, PhD; Katherine Dandy, Esq; Max Gaujean, Esq; Mario Fusaro, MD; Corey Scurlock, MD
There is a paucity of legal data regarding the effect of tele-intensive care unit (tele-ICU) implementation on medicolegal risk. In this second article the authors discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU, and they systematically discuss the effects of tele-ICU on the various root causes of medical error.

Maintaining our Humanity in the Digital Age of Medicine
Jeffrey Siegel, MD
This critique on the changes in health care delivery is from a physician’s viewpoint. He believes that modifying these changes, with humanistic values in mind, will benefit both patients and clinicians going forward.

Time to Revamp Nutrition Education for Physicians
Vanita Rahman, MD
Ample scientific evidence supports that nutritional interventions involving plant-based diets can be effective in the prevention and treatment of obesity, diabetes, and cardiovascular disease. The author launched programs to educate our physicians and patients about the benefits of plant-based diets, with an overwhelmingly positive response. Because physicians are at the forefront of fighting the obesity epidemic, it is imperative to emphasize nutrition education for current and future physicians.

Why Compensation Tied to Group Quality Metrics Makes Sense
Kathryn Teng, MD, MBA; David Margolius, MD; Bernard Boulanger, MD, MBA
Group quality metrics in a compensation plan help foster team-based care toward quality goals and shared accountability for the health outcomes of attributed patients; defining the work team is important and should include members who share responsibility for the same groups of patients; information technology infrastructure and dashboards for performance and feedback are critical to the success of a quality incentive program; inclusion of key stakeholders early in the process of designing team-based incentives is important for acceptance; and ongoing education is needed to ensure continued focus on quality goals.


Assessing Impact of Biomedical Scholarship in the Information Age: Observations on the Evolution of Biomedical Publishing and a Proposal for a New Metric
Robert Hogan, MD
This essay contains a discussion on the state of the art of biomedical publication and the history and development of indexing, its evolution, and complexity. A traditional method of journal assessment is in use—the journal impact factor—but it is compromised by well-documented deficiencies. Present-day alternatives to the journal impact factor are listed, and a proposal to develop a novel metric of merit in publication, the influence factor, is described.

Narrative Medicine

911 Emergency. What Is Your Emergency and Location? My Road to Mindfulness
Phil La Borie
My reaction is electric. I feel like a huge weight has been removed from my shoulders. Am I suddenly taller? I feel like it. It’s all in my head? Just Panic Attacks? Eureka, I’m saved! The doctor returns with what turns out to be a lengthy excerpt from Eckhart Tolle’s remarkable best seller, The Power of Now. “I want you to get this book, read it, and report back to me. It’s your homework. Don’t argue. Just do it!”

Strength and Vulnerability
Shankar Mundluru, MD
My uncle made a full recovery, and since his shattering health crisis, his vulnerability in that moment made him see the beauty in life, despite life’s delicate propensity for tragedy. Subsequently, he got a law degree in his 70s, traveled around the world, and wrote a biography of my grandfather.

Good Cooking Stories … for Now
David Baer, MD
I look forward to Lucy’s appointments. Lucy is friendly, full of life and energy, and endlessly enthusiastic. She used to be a chef but now teaches cooking at a community college. I ask her about her class: how she goes about her work, and why she loves it so much. Her stories are endless. It happens that another patient once told me he had been a student at the community college where he learned how to run a restaurant.

The Check-in People at the Hospital Make Me Cry
Jimmy Unger, MD
A Somali immigrant describes the painful process of checking in at a medical office in terms that evoke an even more intense emotional response than the traumatic events he experienced in his homeland.

The Late Patient
John Davenport, MD, JD
The seconds were ticking away as I tried to find the right words to start with, when I felt the gentle touch of her hand on my arm and her words, which were spoken with more empathy and understanding of me than I’d ever shown her: “Don’t worry, Doctor. It will be okay.”

The Death Dog
Jonathan Peng, MD
As time went by, we noticed a strange pattern. Snowball would be very engaging with specific patients—jumping up on the bed, playful and interactive—and with other patients he would remain distant. There was no obvious pattern, disorder, or common denominator among patients except one: Each patient he played with would have a life-threatening event in the next 24 hours.

"Lou's" Disease, Sedation, and Physician-Assisted Death
Paul Rousseau, MD
But what I can do is what he and I discussed, and what’s in his advance directive: Gradually sedate him, stop the ventilator, and keep him comfortable until he dies. It wouldn’t be long, perhaps minutes. I don’t think there would be a difference between sedation and assisted death as far as comfort or how soon he would die.

My Exit
Henry Bair
This short story is based on and told from the perspective of a real patient the author encountered as a medical student. The story explores the thoughts of an elderly patient, who is hospitalized because of multiple organ failure, as she contemplates the voluntary refusal of food, fluid, and antibiotics. The patient weighs these options in light of her beliefs and experiences, and in the face of seemingly futile medicalization.

Book Reviews

Promoting Biodiversity in Food Systems
Sarah Delcourt, MS, RD
Overall, the common theme found in Promoting Biodiversity in Food Systems is that both individuals and communities can help “restore biodiversity, stability, and resilience in local ecosystems and beyond.” The book emphasizes that we all make a difference, and we can make little and big changes in our lifestyle patterns to support planetary health.

Picture of Health: Transform your self-care and health care through Ayurvedic and Integrative Medicine
Sanford Nidich, EdD
Picture of Health is a practical guide for people
who seek to improve their health by integrating conventional and holistic medicine. It offers disease-specific guidelines, inspiring illustrations, recipes, and many practical tips for those who are ready to take the next step toward ideal health.

Soul of the Healer

Dia de los Muertos
Jorge A Ramirez, MD

Fall Colors
Jorge A Ramirez, MD

Feathered Breath
Ronan Allencherril

Rule 1: Recognizing the Rules and Patterns to Solve Problems and Puzzles Brings Internal, Fundamental Joy
Mihal Emberton, MD, MPH, MS

On the Cover

California Lilac
Latifat Apatira, MD


Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.


2 million page views of TPJ articles in PubMed from a broad international readership.


Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.




ISSN 1552-5775 Copyright © 2021 thepermanentejournal.org

All Rights Reserved