Family Medicine Notes

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Two interesting articles in this month's issue:

Erythromycin Inhibits Rhinovirus Infection in Cultured Human Tracheal Epithelial Cells

and

Intravenous Sildenafil Lowers Pulmonary Vascular Resistance in a Model of Neonatal Pulmonary Hypertension

Of course the latter paper will get more attention ... though neither paper is patient oriented, and neither paper would change clinical practice at all.  The paper on erythromycin is a bit troubling to me .. as it is another piece of evidence that the use of antibiotics as anti-inflammatories may increase in the near future.  As UniSci news reports, there is much thought and research going into these ideas.

Posted by Jacob Reider, MD at 01:26 AM | Permalink

In a report on the radio this morning, I heard mention of a John Steinbeck quote:

"It has always seemed strange to me," said Doc. "The things we admire in men, kindness and generosity, openness, honesty, understanding and feeling are the concomitants of failure in our system. And those traits we detest, sharpness, greed, acquisitiveness, meanness, egotism and self-interest are the traits of success. And while men admire the quality of the first they love the produce of the second."

Cannery Row by John Steinbeck

It is compelling to me that the features that are synonymous with success in business are in fact the "negative" traits outlined above, and yet the values that we admire in healthcare (and other professions, in fact) are the "positive" ones.  Indeed, our primary goal in healthcare is to enhance the quality of the lives of others.   Perhaps this is why "business" skills & personalities in healthcare sometimes feel & taste like oil in our water.   Yet we can't balance our checkbooks with compassion & generosity.  Finding the balance between good business and simple good-ness is the challenge.   Those of us bred and motivated by the generosity and benevolence so prevalent in healthcare will likely revert to these instincts ... while those bred and motivated by the power, control, and "success" measures so prevalent in business and governmant may fall back into these patterns.  We both need to understand each other to work productively toward our common goals. 

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In this paper, a few internists discover that the spectrum of cases in an ambulatory internal medicine practice is broad.   Let them spend a day in a family physician's office.  

 Today:

• neonatal jaundice
• normal pregnancy
• sarcoid exacerbation
• new dx - rheumatoid arthritis
• asthma
• allergic rhinitis
• depression
• knee pain
• new patient - new dx HSV ("oh I just thought they were cold sores")
• knee pain, back pain (ACL tear, DJD)
• MVA - soft tissue injuries
• depression
• new patient - teenager (outgrew the pediatrician)
• 9 month well-baby
• CHF, HTN
• HTN, hypercholesterolemia
• URI
• Diabetes, HTN
• 1 year-old: Otitis Media

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There is a growing movement of open-source applications in medicine.  In concept .. it's great.  Lots of people join together and agree to build a product that solves the problems we all share.  Freepm is one example, as is Medsouce ... and ther is good discussion of the topic at linuxMedNews. But (of course there is a but) ... the user interface of these products alwasy stinks.  Matthew Thomas makes an excellent pont about the UI problem for open source projects.  UI is the MOST important component of a product's design .. and most often, UI is the last priority.  The 1st Mac had a good UI and the "real" computer users called it a toy.  But it was really the 1st time that people thought about how to make the computer help the user .. rather than the user adapt to the computer's limitations.    We should EXPECT the computer to help us .. rather than expect the user to adapt.  If the software has great functions that are hidden behind rotten UI .. the functions may as well not be there at all.

Posted by Jacob Reider, MD at 11:20 PM | Permalink

From the "and every day my patients teach me something" book ... an e-mail (actually, it was a "healinx" .. a new verb/noun in our office) .. today from a patient (reprinted here with consent, of course): 

I've settled into a routine of checking my BP after I get home from the YMCA, three or four mornings a week.  I alternate jogging days (usually 4.2 miles, sometimes more) with weightlifting days (about 16,000 lbs total).  I noticed that my systolic seemed higher on weights days than jogging days.  So, I decided to do a statistical comparison between the two.  This is a nice experimental design, because time of day, time after exercise (20-40 min), duration of exercise period (about 40 min) and other variables are pretty well equated.  (And I am equally exhausted after both.)  I first did an omnibus 2 x 3 factorial-design analysis of variance (ANOVA) with variables of exercise type and measure (systolic, diastolic, pulse rate). 

The exercise type x measure interaction was highly significant, F(2,28) = 30.915, p < .001.  Separate analysis of each measure confirmed that systolic was significantly higher after lifting (107.9) than after jogging (98.8), t(15) = 3.715, p = .002, BUT pulse rate was significantly lower after lifting (61.7) than after jogging (70.0), t(15) = 6.221, p < .001.  Diastolic did not differ significantly between lifting (58.9) and jogging (59.5), t(15) = .341, p = .742. 

I'm fascinated by the fact that the differences in systolic and pulse rate are so marked a half-hour after exercising.  Any thoughts on the implications of these results?  (Think we can get a publication out of this? Ha ha!).

 ... and the distant physiology lectures from medical school seep back in.  (ooh . here's an interesting one )   Dynamic exercise (bike, walk, run,swim) involves high blood flow, and a decrease in peripheral resistance.   The body's responses to dynamic exercise are designed to get blood to active muscles, dissipate heat, and maintain blood supply to vital organs.  As acidity increases, (H+ and CO2 produced as metabolites of increased muscle contraction), bloow flow to the areas in "need" of blood flow will increase.  To as Total Peripheral Resistance (TPR) decreases ... vasoconstriction will increase in inactive tissue .. diverting blood away from there and preferentially toward the organs in demand of oxygen.

... yet in isometric exercise, there is constant contraction, which limits blood flow.  This is primarily due to the mechanical occlusion of the vessels during contraction.  Blood pressure must therefore be increased to force blood through the contracted muscle. 

So dynamic exercise is thought to be better for lowering blood pressure, yet there remain compelling reasons to continue isometric exercise as well.

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Yikes.  The floodgates will open again over this article. Some things to consider:  HPV can likely live better in warm, moist places.  Uncircumcised men have warmer, moister "places" than circumcised men.  So what?  The issue here is whether we should advocate a surgical procedure to remove a part of a person's body .. or whether we should counsel them to live their lives in such a way as to prevent STDs  (practice safe sex).   Should we remove all kids tonsils to they don't get tonsillitis?  Certainly we won't have anyone with tonsillitis if we do this at birth.  While we're at it .. let's remove their toenails.  I saw several patients this week with ingrown toenails.. boy is that painful! ... could be prevented if we just removed them alltogether when they were babies!

We take an oath to "first do no harm." While some interventions may be necessary .. I think that the case still has not been made for circumcision to become a routine, medically indicated procedure.    Association does not imply causilty .. and all that this study demonstrates is a correlation.  Does TICK cause TOCK?  Of course not .. but the correlation = 1.  So What?   Exactly.

Posted by Jacob Reider, MD at 02:30 AM | Permalink

Howard Brody is a very bright man.  In this editorial, he reminds us that many of the techniques we so proudly master .. as we BATHE our patients (see below) ... may in fact be as culturally insensitive as our less thoughful colleagues.

As the match is over, all-of-a-sudden it's recruitment season already.  Not at the residency level (yet) but in the medical school.  The 3rd-year students are all doing their best to make a decision about what they want to be when they grow up, and our colleagues in other specialties are pontificating the "don't go into family medicine" speech rather loudly these days.  Of course the most vocal are from obstetrics and pediatrics.  I think that the general internists are starting to undersatnd and appreciate us a bit.   It's hard NOT to be offended by these stuffed-shirts ... telling my advisees that the are "too smart" to go into family medicine.  It hasn't been so bad for several years.  Not sure why the resurgence. 

The University of Washington has a good FAQ on family medicine.  I like their discussion of Medicine-Pediatrics:

Combined programs do not require as much time in outpatient training and their residents do not care for whole families over a three-year period. They also do not provide, to the same extent, many of the elements offered by family practice training, such as community medicine, preventive medicine, techniques for home visiting, patient education and training in the understanding of family systems.

A follow-up study of two combined internal medicine-pediatrics residencies revealed that only about one half of the graduates continued with the primary care of children and adults; the rest pursued just internal medicine, pediatrics, or a subspecialty.

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

On Halley's Comment today ... a saddening and inspiring discussion about a family member's death.  Death .. as we family physicians are educated .. is part of life.  We witness and guide our patients toward this event ... with respect and understanding.

I'm often struck by the paucity of such "behavioral science" training in other specialties.  We teach our residents to be active listeners, so that the can take advantage of the 15-minute hour.  The Internists seem to have discovered this recently too.

A year or so ago I was in the emergency department ..called down there for the 3rd time in a week to admit a patient who "refused to go home."   The previous two had happily departed after we (I was rounding in the hospital with our family medicine residents that week) arrived and BATHEd them.  The Emergency Department attending physician happened to be the Department Chair.  He challenged me as we arrived in the Emergency Department:  "THIS one really won't go.  No way she'll leave.  I'm certain of it."  

A 40ish woman with anxiety and abdominal pain was lying on her side in the room.  All bloodwork, a CT scan of her abdomen, pelvic exam, and abdominal exam were all negative.   A family member had recently been admitted to the hospital in California for appendicitis.  She was scared that she might have appendicitis as well.

After we listened to her story for about 10 minutes, I asked her what else was going on in her life, how she was feeling, what troubled her the most about her situation, and how she was handling it all.  I affirmed her predicament by restating her concern about her abdominal pain, and I remarked how I was impressed with her ability to "hold it all together" in the context of so many life stressors.

I asked her if she would like to go home, and she eagerly agreed that this was the best course of action.    A follow-up was arranged in the office for the following day.

On the way out of the Emergency Department, our colleagues were in awe.  Dr ED Chairman exclaimed:  "How did you do that!?"  "I was in there talking to her for 30 minutes!"   .... "That was the problem"  I smugly replied.  "We listened."

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..."officials at Boston University, which administers the study on behalf of the National Heart, Lung, and Blood Institute, have formed a company to mine the data for genes that contribute to diseases such as dementia, arthritis and the onset of deafness in adults.

Framingham Genomic Medicine plans to spend millions over the next several years to organize the information and begin large-scale DNA testing. “The amount of data ready to be culled out of this study is limitless,” says chief scientific officer Fred Ledley."

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The CDC is beginning this campain in a continued attempt to curb antimicrobial resisntance.  Looks like a good project .. but I always wonder if these sort of outreach efforts are effective.  We did one here in Albany a few years ago, and it seemed like the folks who we needed to reach were never listening .. and those who were already "believers" were all ears.   ?how do we change the practices of the physicians who aren't paying attention to this issue?

This handout from the CDC gives parents a good understanding of otitis media with effusion, and is part of the CDC's campain as well.

Posted by Jacob Reider, MD at 07:50 PM | Permalink

"Steiner and his colleague, Ita Wegman, MD, taught how through inner development and careful observation, nurses, physicians and other healthcare professionals could care for patients in a manner more accurately assisting the whole being of the patient. "

Had two families in today with their kids .. because of their anthroposophic views, they choose not to immunize their kids.  I'm doing my best to understand their perspective.   Respect and trust are the cornerstones of a healthy relationship between physician and patient.

Posted by Jacob Reider, MD at 06:25 PM | Permalink

A useful compilation from Hardin libary .. This series of links and pages will take you directly to citations in medlilne for which there exist full-text references.

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The summary from this paper in BMJ: 

"What is already known on this topic The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour ward.  

Opinion varies about its value in identifying a potentially compromised fetus In low risk women, the incidence of intrapartum fetal compromise is low

What this study adds Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk women

Admission cardiotocography results in increased obstetric intervention, including operative delivery "

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Like Chris Cates, I don't routinely use antibiotics to treat otitis media.  It's very clear that antibiotic use .. especially macrolides.. will lead to antimicrobial resistance.   When I do use antiobotics, I always use 1st-line agents.  Making the decision to use antiobotics remains a challenging one.  Gotta make the right doagnosis to start. 

A recent addition to our practice is an acoustic reflectomoeter.  The only brand that I've been able to find is the Ear-Check Pro. The device is simply wonderful!   There are a few papers from the mid-1990's on this topic.  The compelling feature is that the decise permits us to confirm normal ears quite well:  "[ears]were found to be highly predictive for normal ears as much as tympanometry." {ref}    So we can distinguish the red normal ear from the infected red ear without the struggles required for insufflation & observation of mobility.  The Acoustic reflectometer does not require that a seal be established, and takes only 1-2 seconds to provide a good reading.  No .. I don't own stock in the company ... and I doubt they're doing very well.  We bought ours last summer, and the AA batteries in the package had expired in 1998!

ref: Int J Pediatr Otorhinolaryngol 1999 May 5;48(2):137-42

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The transaction was valued at approximately $12.7 million based on an average closing price of AOL Time Warner's common shares for a seven-day period ended March 30, 2002. Under the terms of the transaction, AOL Time Warner issued 1,502,776 shares of AOL Time Warner common stock in exchange for all of the outstanding securities of Slingerlands, New York-based Docnotes. The acquisition has been accounted for as a purchase.

The transaction, which is expected to close in April, is contingent on obtaining necessary consents and approvals from various regulatory agencies.

AOL Time Warner CEO Gerald M. Levin said, "this acquisition will really increase the depth of our content coverage, and will allow us to extend our brand reach into the weblogging world." Docnotes editor Jacob Reider MD said, "Hey, I figured that if you can't beat 'em, join 'em. Plus, they threw in free television and Roadrunner high speed access for life."

About AOL Time Warner
AOL Time Warner (NYSE:AOL) is the world's first Internet-powered media and communications company, whose industry-leading businesses include interactive services, cable systems, publishing, music, networks and filmed entertainment.

About Docnotes
Docnotes contains articles, medical reseach summaries , and musings about healthacre and technology written by Jacob Reider, MD . Docnotes topics include everything from electronic medical records to e-health business, Internet culture to patient care issues, and health technology strategy to random bits of useless information. Not to mention the occassional April Fools' Day joke.

Caution Concerning Forward-Looking Statements
This document includes certain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. These statements are based on management's current expectations or beliefs, and are subject to uncertainty and changes in circumstances. Actual results may vary materially from those expressed or implied by the statements herein due to changes in economic, business, competitive, technological and/or regulatory factors, and factors affecting the integration of the businesses of Time Warner Inc. and America Online, Inc. More detailed information about these factors may be found in filings by AOL Time Warner with the Securities and Exchange Commission, including its most recent annual report on Form 10-K and its most recent quarterly report on Form 10-Q. AOL Time Warner is under no obligation to, and expressly disclaims any such obligation to, update or alter its forward-looking statements, whether as a result of new information, future events, or otherwise.

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