"Information in practice" is an interesting literature review on the impact of computing in primary care. 

Posted by Jacob Reider, MD at 10:41 PM | Permalink

Last night, I got a frantic phone call from a new mom:  "the baby's head is lopsided!"  I hadn't noticed anything at the 2-week visit.  The child had developed normally,  and examination of the head had been normal ... so I didn't think it was an emergency ... but she was quite concerned, so I told her I'd meet her in the office.    On examination, I found that the child had positional plagiocephaly.  This is a problem that's increasing in frequency due to back sleeping .. but this child's head wasn't flat.  Rather, it was asymmetric.  Turns out, grandma holds the baby in her left arm all day .. watching TV. 

Posted by Jacob Reider, MD at 09:28 PM | Permalink

Seems like this is updated every year.  Notable changes for 2002:  Catchup sequences are clearly depicted, emphasis for Hep B in hospital is added, and consideration of influenza is added for all childern -- not only high risk patients. 

But schedules are subject to availability, and there is a website provided by the CDC that provides information on which vaccines are in short supply, and what the timeframe is.

Posted by Jacob Reider, MD at 03:06 PM | Permalink

Looks like terbinafine is much better at treating onychomycosis than itraconazole.  I'm surprised that nearly 1/2 of patients retain cure at 5 years.  I may alter my prescribing habits based on this one ... as I usually refuse to treat onycomycosis based on other studies that suggest much lower long term "cure." rates.

Posted by Jacob Reider, MD at 10:58 AM | Permalink

I've imported all of the old Docnotes postings from blogger.  They go back to Novermber, 1999! ...  I'm not sure how to get the Conversant posts into Radio.  I really want to get searching to work next.

Posted by Jacob Reider, MD at 10:54 AM | Permalink

Written for the layperson, this website provides a great overview of what most lab tests are, and how results can be interpreted.  For those of us who use electronic means to communicate lab results, this may be a great adjunct:

Dear Bob:

Your Total Cholesterol result was 250.  Take a look at the FAQ for high cholesterol and I'll call you tomorrow so that we can discuss what our next steps will be.

Posted by Jacob Reider, MD at 10:30 AM | Permalink

From BMJ: "Tribal people do not like lying on the ground in the recovery position while wearing no clothes as the penis dangles in the dust and can get bitten by insects."  This is actually a very interesting article about how we humans are actually quite well engineered, yet the habits of Western Culture have changed our posture, sleeping position, etc ... so that we are much more prone to physical injury, back pain, etc. 

Posted by Jacob Reider, MD at 12:23 AM | Permalink

Diabetes is so commin .. not a week goes by that I don't diagnose a patient with type 2 diabetes.  Some great education material is out there.  I found this on the Diabetes and footcare weblog. 

Posted by Jacob Reider, MD at 12:15 AM | Permalink

Going Solo: Making the Leap: "Why one family physician left the security of salaried practice to pursue ideal patient care completely on his own"  Thsi two-part series appeared lat month and this month in Family Practice Management It's a compelling story of what's wrong with medicine these days, and what could be right.

Not unlike Gordon Moore, I left what was a safe job, and wne out on my own in the last year.  Our motives were in fact quite similar to his, yet our method was quite different.

The explanation is too long for today's weblog.

Posted by Jacob Reider, MD at 11:50 PM | Permalink

As technology commentators discuss the hollings bill, the Bush administration has proposed big changes to the health information privacy rules that were promulgated by the Clinton administration.

I'm not sure how to respond to all of this.  The origianl privacy rules were rather onerous in many ways, and if taken literally, would have altered the practice of medicine in many ways.  

Nonethelss, privacy is imporatnt, and there are many ways that patient privacy is compromised in the name of convenience, marketing, research or simple careleness. 

On the topic of privacy ... I often read the Diary from a week in practice published every month in American Family Physician.  It's often instructive .. and our medical students find it an ejoyable snapshot of the "real life" of a family physician.  I preferred the writing of Walt Larimore to the current authors.  In these short notes about their patient encounters, we see the humanity of physicians as many people may not traditionally encounter.

Last week, as I was just finishing a visit with a patient, she reflected to me how she was so appreciative of the way that I treated her "like a real human."   Somehow patients have come to expect the "meet-em, treat 'em and street 'em" interactions.    Too bad that patients are so pleased and surprised when we treat them with respect.  This is the bare minimum of good care.  As Joe Scherger says:  Your patients don't care how much you know until they know how much you care."

 

 

Posted by Jacob Reider, MD at 11:23 PM | Permalink

On Bandolier this month:

Evidence and migraine trials

"Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."

Bandolier is a wonderful resource for good evidence-based clinical information.  The writing is clear and light -- without the self-importance of many medical infromation resources. 

Posted by Jacob Reider, MD at 11:26 AM | Permalink

This month's American Family Physician has an excellent review on smoking cessation.  There's a patient handout too.  I often print these handouts in the office and give to patients, but I don't like the HTML views when printed.  Especially the otherwise excellent handouts that are available on familydoctor.org.  Doesn't seem like it would be so hard to make pdf's out of these.

Posted by Jacob Reider, MD at 10:12 AM | Permalink

Motivated my Dave Winer's new weblog directory, I've moved the docnotes stuff up to the docnotes server.  It's a static site for now, so no search engine (yet).  When I started this "weblog" in1999, I used blogger.  I still don't have all of the blogger posts migrated into radio .. but I've almost got them in.  Conversant was my next tool, which I (mostly) liked, but I found the user interface confusing and I never quite clicked with it.  I'm a physician, not a rocket scientist!   I really liked the fact that conversant had a search engine though.  Now macrobyte has released a search engine for radio .. and this looks like it'll give me exactly what I need.   

Only problem is that the server you're reading this on isn't running radio .. and it's already running quite a lot (IIS, Coldfusion, mdaemon, SQLServer, and simpleDNSPlus).  It's our only server for oncalls.com at the moment .. and obviously takes care of many tasks.  We're shopping for another server .. and once we get that up, we'll  probably put a copy of radio and RCS up there.   For now, Docntoes will be static.

Posted by Jacob Reider, MD at 09:49 AM | Permalink

Extending Life, Defibrillators Can Prolong Misery: "Extending Life, Defibrillators Can Prolong Misery"

Posted by Jacob Reider, MD at 09:35 PM | Permalink

Psychologists Get Prescription Pads and Furor Erupts: "And she noted that a majority of prescriptions for psychiatric drugs nationwide were written by primary care physicians, not psychiatrists."

Posted by Jacob Reider, MD at 11:27 PM | Permalink

I've started looking at the NY Times health notes ever since they're included in Radio.  Some very good things there .. like this ..

Yeast Infection: The Pitfalls of Self-Diagnosis. Only a third of the women buying over-the-counter vaginal antifungal products accurately self-diagnose their conditions. By Jane E. Brody. [New York Times: Health]

Posted by Jacob Reider, MD at 05:12 PM | Permalink

Bring on Berton Rouche:    Cause and Effect: Lessons From a Poisoned Coffeepot. Workers in an auto factory in the Midwest were hospitalized with thallium poisoning from a communal coffeepot. By John O'neil. [New York Times: Health]

Posted by Jacob Reider, MD at 05:11 PM | Permalink

Doctors Face a Big Jump in Insurance. Doctors in the New York area face sharp increases in their medical malpractice insurance costs, which are already among the highest in the country. By Joseph B. Treaster. [New York Times: Health]

This one seems to apply to New York City more than it odes to our region, but the trend is ominous

Posted by Jacob Reider, MD at 05:10 PM | Permalink

Diagnosis: Supersize. Despite what experts call an "epidemic" of obesity, fast-food outlets are sprouting up in schools and hospitals. By Howard Markel. [New York Times: Health]  This appears to be a uniquely American phenomenon .. and one which has progressed unabated for years and years.  Hard to know what the next step to resolution is...

 

Posted by Jacob Reider, MD at 05:09 PM | Permalink

The Winona project: Developing an electronic link ... American Medical News  A good look at the real status of the bleeding edge of health technology

 

Posted by Jacob Reider, MD at 11:41 PM | Permalink

Another long night .. two more deliveries .. man, I am feeling like an obstetrician! ... This morning I had a long talk with two new parents about circumcision.

It's a challenging decision these days .. as the (mis)information about this procedure propagates across the internet .. both for the procedure and against it.  Even "unbiased" resources like "dr Spock" come down on one side or the other .. and the usually excellent patient education materials from the AAFP are just so-so .. and the AAFP's recently released policy statement reviews some of the literature, but actually says very little.

Missing from most discussions is an ethical component.  As a physician, I take an oath to assist my patients' healing .. not perform what may be a cosmetic surgery.  If done for religious reasons, perhaps we should call the rabbi instead.  And as one who facilitates health and healing, I don't want to perform what may very well be unnecessary surgery on a person who cannot make a decision for themselves!

.. and I don't buy the "I want him to look like me" bit I hear from fathers sometimes.  They look different.  Period.  Big ones and small ones and fat ones and thin ones.  They are all different .. and a circumcision isn't going to change a kid's relationship with his dad either way.

In the end, the couple from this morning are going to think about it for another week ...

Posted by Jacob Reider, MD at 09:50 PM | Permalink

Hmm .. something's not working.

I changed my community server .. and RCS tells me "congrats" .. but when I edit the weblog .. it still goes to radio.userland and "home" on the radio home page still points to the userland cloud .. not mine ..

Posted by Jacob Reider, MD at 05:36 AM | Permalink

Testing RCS.  I'm at home (finally).. 2 deliveries tonight .. both babies doing well .. though I was in the hall for #2 and the nurse caught it!

Testing RCS .. will go to bed soon.  Installation was easy but there were just a few bumps

Will document in the AM

Posted by Jacob Reider, MD at 05:17 AM | Permalink

bmj.com : "The quality of health information on the internet"  answer? poor.   BMJ devotes a whole issue to this topic today, and comes up with a compelling picture, and some good suggestions for both physicians and patients.    A must-read for all.

Posted by Jacob Reider, MD at 01:10 AM | Permalink

found on Amazon.com:"How to Good-Bye Depression : If You Constrict Anus 100 Times Everyday. Malarkey? or Effective Way?" um .. I must be missing something here.

Posted by Jacob Reider, MD at 02:55 PM | Permalink

Oncalls version 1.5 is (finally) out to the beta testers.  I wrote an article for a healthcare newspaper about it (yet to be published).  They had asked for an article on the topic of physician scheduling .. in which I was encouraged to "mention" our product.  So I did it.   A little odd .. trying not to advertise, yet clearly (in <750 words) describe the problem we're trying to solve.   I've done my best to keep the product focused on really defining  a solution to a problem. 

Some have noticed that the problem of "on-call" management isn't unique to healthcare.  Who else shares call?

• TEHNOLOGY SUPPORT WORKERS
• 7-11 WORKERS
• FIREFIGHTERS
• NURSES
• POLICE
• YOU?

Oncall solves several real-life problems.  It wasn't developed as a solution looking for a problem.  Real humans had real problems.

• Making the schedule is challenging
• It's hard to keep track of who has asked for a day off .. and when.
• People always argue about who'se done more weekends than whom
• There needs to be ONE schedule of who is on when.  Faxed copies or paper versions on bulliten boards get out-of-date too quickly.  One authoritative schedule has to live in one place, accessible to everyone.

Our software does not automatically create the schedule for you.  Someday it will be able to, and I'm hoping that this will be soon.  This is not the most challenging part of making the call schedule .. nor have our users been calling for it.   Our strong point is how we cahn share the information.  Users can do a palm synch, or even hear the schedule (using Voice-XML)  on the phone.. or see it on their web-enabled phone or palmpilot.  There's a lot going on behind the scenes.

That's the point of good software design.   Hard work behind the scenes makes it easier in front.   As Joel and Jakob remind us,  good usability is the key to success.  We've worked hard to make this software usable .. and meet the expectations of the user -- rather than make the user adaprt to the limitations of our programming.

Posted by Jacob Reider, MD at 11:53 AM | Permalink

Yahoo! News - Pediatricians Urge Vision Screening for All Kids: "Pediatricians Urge Vision Screening for All Kids"

So Yahoo and AAP says that photoscreening should be used.  But it's unclear that this is a good test.  Indeed, other groups are suggesting a more cautious approach, citing high false positive rates and high referral rates for this.

 

Posted by Jacob Reider, MD at 11:50 AM | Permalink

Physician Scheduling www.oncalls.com Who’s On-Call? By Jacob M. Reider, MD “Who’s on-call?” Anyone who works in a hospital understands that the answer to this question is of paramount importance to patient care. Despite advances in technology over the last few years, many call schedules are still created on paper. The time may have come, however, for the pencils to finally rest. Software that supports the creation and management of a call schedule is now available from any computer for quick and easy access to the physician’s whereabouts What is the call schedule? The call schedule for a group of physicians or healthcare workers is a sensitive and important document that is created and updated on a regular basis. Holidays, vacations, illness, and equity are key factors that must always be considered in the creation of a call schedule. Otherwise, conflicts over accountability and responsibility are inevitable. In residency programs, the chief resident is often charged with the task of building the call schedule. For physician groups, often the junior member earns this “privilege” … putting him/her in the middle of a whirlwind of expectations that may have been brewing for years. Often, debate over who has done more (or less) call will become an issue; and the one who worked Thanksgiving last year will most certainly object to working it again this year! The process the “old fashioned way” Creation of a manual call schedule often begins with the solicitation of requests. Since people need to plan vacations ahead of time, often there will be negotiations among members of a group to determine who will take call for the major holidays of the year. Larger groups and many residency programs have request forms that need to be filled out in order to request time off. Smaller groups may just ask the person in charge of the call schedule to “make sure I’m off on the 14th it’s my wife’s birthday.” What happens when four people ask for the same week off? Tracking the requests and determining the status of a request is a key element in the initial steps of building a call schedule. When too many people vie for the same time off , there has to be a fair, systematic way of determining who does and gets what. Tracking the requests and the date and time that they came in is therefore an imperative component of the creation of a fair call schedule. In addition to requests for time off, many providers will express preferences for when they want to work. For example, Dr. Jones may like Tuesdays, while Dr. Smith prefers to work Wednesdays. The creation of the manual call schedule is usually performed at this point: requests and preferences have been determined, and now the administrative member of the group puts together a schedule for a given time period usually a month which will determine who works when and where. This is a painstaking process when done at the kitchen table with pencil and eraser. Part of the scheduler’s duties include calculating days on & off for each provider, while ensuring that requests and preferences are honored whenever possible. Publication When complete, the call schedule is faxed, e-mailed, mailbox-stuffed, and hand delivered to everyone involved including hospital and office operators, answering services, and hospital emergency rooms. While the sharing of this schedule in so many forms is a great feat, a challenge remains for the manager of a call schedule at this point: how to update the already published schedules when the inevitable changes occur? While faxes, a-mails and mailbox-stuffing can deliver a newer version of the schedule, there is no way for the end-users of this schedule to know with certainty that the schedule in their hand is the most recent revision. The Technological Solution With the advent of the Internet, publication of call schedules via the world-wide-web is an obvious alternative to the analog delivery methods. Users would know that the version that they are accessing is the most authoritative one, and the schedule could be updated from anywhere, and accessed from anywhere. Users could log in to the website, enter requests and preferences, and run reports so an accurate count of who’s done the most Saturday nights would be only a mouse-click away. Administrators could use such a system to automatically count the calls, and even insure that Dr. Jones isn't scheduled to work at the Hospital when she’s on vacation in Hawaii. The paper schedule simply can't do that by itself. Over the last 24 months, a small team of physicians and software developers in Albany, New York, has developed an end-to-end tool for the creation and management of call schedules. Oncalls (www.oncalls.com) is a simple, robust application that performs all of these functions well. There will always be arguments over who worked Thanksgiving in 1988, but with web-based call schedule software, management of this complex and thankless job can be much less challenging. Jacob M. Reider, M.D., is a practicing family physician in Albany, New York. He is the Associate Dean of Biomedical Informatics at Albany Medical College, Medical Director of Hospital Informatics at Albany Medical Center, and is the founder of Oncalls. - # # # -

Posted by Jacob Reider, MD at 10:26 AM | Permalink