Family Medicine Notes

Posted by Jacob Reider, MD at 09:02 PM | Permalink

Posted by Jacob Reider, MD at 09:14 AM | Permalink

In today's e-mail from the AAFP:

Errors in primary care are likely to affect patients in similar ways in countries with similar primary health care systems, according to the first international patient safety study. The results of the study, coordinated by the AAFP's Robert Graham Center in Washington, show that for six countries with similar systems -- the United States, Australia, Canada, England, the Netherlands and New Zealand -- about 79 percent of the mistakes deal with"process" (including office administration, lab reports, medication, communication, payment and workforce management), while about 21 percent pertain to gaps in knowledge and skill on the part of physicians and others involved in providing care.

This is another call, I beleive, for enhanced emphasis on the use of information systems to enhance the essential components of patient care that we now understand are the most likely source for errors.  If the process works well, patients get good care and good service.

Posted by Jacob Reider, MD at 06:30 AM | Permalink

I didn't know that para-phenylenediamine was such a dangerous component of temporary tattoos.  For some reason, this made front-page news today.  But judging from the results of a quick Medline search, this is not new news.  We should counsel our pateints to avoid this stuff.

Posted by Jacob Reider, MD at 11:44 PM | Permalink

In its zeal to rid the nation’s health care system of waste, fraud, and abuse, Congress has passed a blizzard of new federal criminal statutes targeting the health care industry, including those contained in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Congress created new "health care" laws on top of the existing mountain of rules and regulations and funded an army of enforcement agents.

Posted by Jacob Reider, MD at 08:07 AM | Permalink

INDUSTRYWEEK:

One would be hard-pressed to find another industry even one-tenth as large that's so backward when it comes to the use of information technology.  
 
Despite the massive payoffs in efficiency and profits gained by other industries and the continuous improvements that make IT products and services more reliable and available, health-care professionals are still dragging their feet.  

Posted by Jacob Reider, MD at 08:03 AM | Permalink

Posted by Jacob Reider, MD at 08:00 AM | Permalink

A good review of the current HRT confusion:

Women who are currently taking continuous combined oestrogen-progestogen should not panic, as it is most unlikely to have caused considerable harm. Certainly the risk of breast cancer is not appreciably increased during the first four years, so women wishing to take this therapy for the short term relief of menopausal symptoms should be reassured. However, they need to discuss with their doctor whether they should shift to a different preparation, which could theoretically have a more beneficial effect on the cardiovascular system.

Posted by Jacob Reider, MD at 12:51 PM | Permalink

Posted by Jacob Reider, MD at 12:48 PM | Permalink

On a lighter note ... baseball coaches should put the best batters up second .. and the worst seventh .. according to this study.

Posted by Jacob Reider, MD at 01:46 AM | Permalink

Tough day in the office.   My last patient was a 35 year old woman with asthma exacerbation.  Her kids have it too (they saw my partner last week).  Ironically, I saw them leaving the office last week in the parking lot.  They all enthusiastically said hello to me as the drove away .. and I was struck by the father's cigarette fuming away in the car .. as they all smiled at me.

Dad is the only smoker in the house, and .. as mom says ... "he doesn't agree with how smoking is bad for us."  At frist I didn't believe her.  So I went out to the (empty) waiting room while she was getting her nebulizer (peak flow went from 200 to 400).  I suggested that his smoking may play a role in the health of his family.  His father smoked and he doesn't have asthma.  He knows that I am wrong because of this. 

This episode only briefly preceded dinner at our house .. where we were joined by my father-in-law .. who states medical "facts" at the dinner table so preposterous that I simply cannot respond.

Nor shoudl I.  These are his health beliefs, and I have no business "correcting" them simply because I went to medical school.

But how to I educate our wayward smoking father?  Don't I have an obligation (to his family) to correct his beliefs? How do I educate him? 

Trolling the Internet this evening, I have found some educational materials .. but nothing yet that fits the bill.  The resource must be:

1. Easy to read.  4th or 5th grade level
2. Evidence based.  We need facts .. not conclusions.  "second-hand smoke causes asthma" won't work.  We need a document that will say something like:
   • 100 families with smokers in them will have 20 kids with asthma
   • 100 nonsmoking families will have 10 kids with asthma.

Alas .. I can't find this (yet) .. but I have found some interesting data:

Pubmed links:
Parental smoking and respiratory tract infections in children.

Prevalence of bronchial asthma and association with environmental tobacco smoke exposure in adolescent school children in Chandigarh, north India.

Posted by Jacob Reider, MD at 01:36 AM | Permalink

As you know from the Rational Clinical Examination Series in JAMA¹, the all-too-common study of the accuracy and precision of the clinical examination comprises 4 experts examining 40 patients, the latter selected to confirm the biases and reputations of the former. The pioneering work of the US-Canadian Co-operative Research Group on the Clinical Exam reversed this trend, but even it has faced formidable problems in participation rates and patient numbers.

This is ground-breaking work.  They're doing studies on UTI and sore throat.  Their pre-op study is complete.

Posted by Jacob Reider, MD at 01:55 AM | Permalink

Posted by Jacob Reider, MD at 01:22 AM | Permalink

Posted by Jacob Reider, MD at 01:16 AM | Permalink

A few years ago, I was involved in a medical-internet-startup company.  No .. not oncalls .. it was Medremote.  The "product" of medremote is the technology behind transcription.  They provide all of the technology that enables physicians to dictate, transfer, and receive (and retreive) their progress notes.  It's good stuff, and the poeple at Medremote are extraordinary.  They "get it" .. so it was easy for me to work with them.  Back in the dark ages of the www, there was of course much excitement .. and many "experts" told us what doctors wanted.  "Stock Quotes" we were told ... "disease management" and so on .. The truth, of course, is that we just want good tools to do our work.  Medremote .. like some other companies .. managed to keep their focus on just that .. delivering to the physicians the tools that made it easier and more efficient to get the work done.  Period.  As the fluff falls away .. and the meat of the internet survives .. it's no surprise that more physicians are embracing these tools:

Almost half of physicians report that the World Wide Web has had a major impact on the way they practice medicine, according to a new study released today by the American Medical Association (AMA). The rising influence of the Internet on clinical medicine has propelled an increase in the frequency and duration of Web use among the 78% of physicians who now make use of cyberspace.Almost half of physicians report that the World Wide Web has had a major impact on the way they practice medicine, according to a new study released today by the American Medical Association (AMA). The rising influence of the Internet on clinical medicine has propelled an increase in the frequency and duration of Web use among the 78% of physicians who now make use of cyberspace.

Posted by Jacob Reider, MD at 11:44 PM | Permalink

In the US, the specialty of Family Practice remains poorly understood.  While we care for millions of patients, there are many more who have never been cared for by a family physician and/or consider what we do equivalent to the "GP" that they had "years ago."

Family Practice was established as a specialty in 1969.  A short history of the establishment of this specialty can be found on the American Board of Family Practice Website:

The American Board of Family Practice was born many years before it was officially recognized in February, 1969 as the 20th primary medical specialty.

The history of the Board is a fascinating saga of travails, with frustrations and impediments punctuating its formative days. Despite the fact that by the early 1960's the number of physicians in a general type of practice was dwindling rapidly, the medical establishment opposed the creating of a specialty that would fill this void. Therefore, the founding fathers of the Board deemed it necessary and rational, particularly in the face of this opposition, to document meticulously and persuasively the need for the specialty.

Various studies in the 1950's and 1960's concluded that "General Practice" was moribund. An analysis was made of specialty distribution of all graduates of every medical school by five-year periods since 1900 and from this data it was learned that the number of general practitioners was rapidly and steadily dwindling. In 1964, the percentage of graduates going into General Practice fell to 19% down from 47% in 1900 and continuously diminishing. It was also noted that the ratio of physicians in private practice was dropping rather rapidly, and the deficit was obviously in what was termed the "Family Physician Potential."

The general response to this precipitous decline was, "this is an age of specialization." The founders of the Board could only affirm this fact, believing that this response to the dearth of General Practitioners strengthened their argument for a new generalist-type of specialty called "Family Practice." Many students expressed the concern that the broad body of knowledge required for general practice was too great. This concern was also based in truth, in light of the tremendous expansion of medical knowledge and skills in the past few decades. Four years of medical school and a year of internship was indeed not adequate. The inadequacy of this training could be remedied only by having residency programs in a new specialty, Family Practice, argued the proponents of the specialty.

Additional factors explaining the decline were the lack of "prestige" assigned to the general practitioner in comparison to his/her more "specialized" colleagues as well as the difficulty experienced by the general practitioner in obtaining hospital privileges which were being given increasingly only to those physicians who were board certified.

In view of the data gathered by the Board proponents, it was proposed that:

• Family Practice IS a specialty, and
• as a specialty, Family Practice deserves well-defined but flexible graduate training programs, and
• that a Board of Family Practice is essential for the certification of competency of Family Physicians and for the participation in the guidance and approval of training programs.

The specialty of Family Practice, based on the heritage of General Practice, would have graduate programs (residencies) for physicians whose training would encompass 1) first contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

The key difference, then, between family practice and the General Practitioners trained in the 1960's and before is that we have been explicitly trained to practice primary care.  The GPs did a rotating internship (usually in the hospital) for one year after medical school and then went out to practice medicine.  While many of them were (are) wonderful physicians, many (appropriately) argue that they were inadequately trained to skillfully manager the complexity of problems that we face on a daily basis.

Posted by Jacob Reider, MD at 02:42 PM | Permalink

Posted by Jacob Reider, MD at 07:21 PM | Permalink

Shouldn't have been eating them anyway!

Posted by Jacob Reider, MD at 12:04 PM | Permalink

Posted by Jacob Reider, MD at 09:52 AM | Permalink

The US Public Services Task Force has updated the screening guidelines for colon cancer:

The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer. Grade A recommendation.

The USPSTF found fair to good evidence that several screening methods are effective in reducing mortality from colorectal cancer. The USPSTF concluded that the benefits from screening substantially outweigh potential harms, but the quality of evidence, magnitude of benefit, and potential harms vary with each method.

The USPSTF found good evidence that periodic fecal occult blood testing (FOBT) reduces mortality from colorectal cancer and fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. The USPSTF did not find direct evidence that screening colonoscopy is effective in reducing colorectal cancer mortality; efficacy of colonoscopy is supported by its integral role in trials of FOBT, extrapolation from sigmoidoscopy studies, limited case-control evidence, and the ability of colonoscopy to inspect the proximal colon. Double-contrast barium enema offers an alternative means of whole-bowel examination, but it is less sensitive than colonoscopy, and there is no direct evidence that it is effective in reducing mortality rates. The USPSTF found insufficient evidence that newer screening technologies (for example, computed tomographic colography) are effective in improving health outcomes.

There are insufficient data to determine which strategy is best in terms of the balance of benefits and potential harms or cost-effectiveness. Studies reviewed by the USPSTF indicate that colorectal cancer screening is likely to be cost-effective (less than $30,000 per additional year of life gained) regardless of the strategy chosen.

It is unclear whether the increased accuracy of colonoscopy compared with alternative screening methods (for example, the identification of lesions that FOBT and flexible sigmoidoscopy would not detect) offsets the procedure's additional complications, inconvenience, and costs.

Posted by Jacob Reider, MD at 01:07 AM | Permalink

Posted by Jacob Reider, MD at 07:44 PM | Permalink

WWPP World Wide Pursuing Perfection in Health Care is a shared weblog.  It's hard to tell exactly what's going on here until one digs rather deep.   Looks like this is a local initiative in Whatcom County to improve healthcare delivery, quality and services in a whole community.  This is ground-breaking stuff, and very exciting to see this group of people working to develop models of coordinated healthcare delivery.  One example is that they will aim to create a single community-wide medication list:

A single medication list across the community is closer to reality due to the excellent work of a CHF Medication Team under the guidance of Carol Boston-Fleischauer.  This team with 3 patients as full participants, retail pharmacy, and home health joined clinicans from the pilot sites to identifiy significant barriers to safety.  They have made recommendations about first steps and implementation teams will begin the work of process improvement in this area.

I wonder what the HIPAA implications are .. hmm

Posted by Jacob Reider, MD at 04:28 AM | Permalink

I've re-read my last two posts.  Every time I read them again .. I find more typos.  Radio sure does need a spell checker!.

Maybe I'll try JSpell - Java and HTML Form Spell Check  ... They'll send me a copy just for posting their URL.  We'll see how that works.

While waiting for the JSpell folks .. I've just downloaded the evaluation version of Hotlingo. Not bad.  It found 3 more typos in the previous post. 

Web Browser Spell Check seems to work OK too .. though it's more expensive (much) .. and uses Microsoft Word to do the heavy lifting.

And iespell is free.  So far, I would say that I like iespell .. though we'll see how JSpell is when I get it.

Update: got jspell (quick service .. they e-mailed it to me in only about 2 hrs) .. it's user interface is clean, and it works well.  Now it's a toss-up.  For now, I have all 3 installed.  will do more testing.

Posted by Jacob Reider, MD at 03:42 AM | Permalink

This is an interesting article in the Boston Globe .. about Larry Weed, a guy who many consider to the be the father of the SOAP note (no .. this has nothing to do with web services!).. and certainly a leader in medical informatics.    Larry is a dynamic guy and a great thinker.  He questions many of the "truths" about medicine, and reveals, I think, some of the true weaknesses of human decision making -- specifically that we don't remember everything we learn/read etc.

My recognition of this human fallibility was in fact what kept me away from practicing medicine for so long.  As a college student, I avoided courses that would lead toward medical school because I recognized that I didn't remember everything .. and I was fearful that I would make mistakes as a physician.  Computers, I found, were more forgiving.  Indeed, as we write computer software, we EXPECT to make mistakes.  We call them bugs .. and when we work all of them out, our software is (for now) finished and presumably "done right."   In this way, software development is an iterative, creative process that we can do without the fear that our errors can have permanent consequences.   "oops .. syntax error ... recompile .. done!"

I was teaching a class of medical students today and somehow we got onto the topic of physicians as decision makers.     The best medical care, I argued, is provided by those who make the best decisions.  This is why I'm so interested in medical informatics.  We can't make good decisions without good information.   Good information about this patient (physical exam, labs, history, etc) .. and good information from the expanse of medical "knowledge" that we have presumably acquired during our years of practice and training.    But Larry Weed is right:  not only can't we remember it all .. we can't even acquire all of the relevant information due to it's vastness.   The point, of course, is that we don't have to.   

And so we come full circle to computers.    Bring the information to the physicians .. (palm pilots, internet) and we don't have any excuses.   Don't memorize everything .. just know where to find it within 30 seconds.

Of course we make the very best decisions WITH our patients .. not for them (or TO them) ... and so .. taking a history and doing a good physical exam are important components of information gathering as well as LISTENING to our patients' hopes, fears and preferences regarding their health care. 

Posted by Jacob Reider, MD at 11:33 AM | Permalink

These guidelines, which made news headlines today, are really nothing new .. yet they call for more screening, and more agressive lifestyle modification than previous guidelines.  They emphasis is on prevention of cardiovascular disease, rather than on the management of it once it is documented.  Of course .. this is nothing new to primary care physicians, but it's a reminder that we are not necessarily doing our best:

The evidence that most cardiovascular disease is preventable continues to grow. ... Clearly, the majority of the causes of cardiovascular disease are known and modifiable.

Posted by Jacob Reider, MD at 10:15 AM | Permalink

New cases drop below 500, a 99 per cent decrease since the Global Polio Eradication Initiative was launched. Just ten polio endemic countries remain: Afghanistan, Angola, Ethiopia, Egypt, India, Niger, Nigeria, Pakistan, Somalia, and Sudan.

Polio is one a handful of diseases that is nearly eradicated.  Vaccines can clearly save lives, as this website demonstrates.  The website is not developed my a pharmaceutical industry marketer -- or a member of some sort of pro-vaccine consipracy.

The vaccination issue is a complex and very emotional one.  Many parents have questions about vaccinations, and I find I have inadequate time to properly discuss the risks and benefits.  For parents who choose to vaccinate with minmal discussion, I sometimes wonder if they are adequately informed.  For parents who choose not to vaccinate, I struggle with how much of the "mainstream" medical  information I want to share with (impose on?) them.  Most certainly, I want to hear from the parents what their concerns are, but I want to know that the openness and critical thinking goes both ways.   By questioning the "standard" immunization strategy, these folks are telling me that they are critical thinkers .. which I applaud and respect.     But I sometimes find that they are not necessarily questioning the rhetoric of the anti-immunization voices with an equally thoughtful critical eye.     

Mercury free vaccines are available and have been for some time.  And while many parents worry that giving many vaccines to infants can be harmful because the weaken immunity, there are no studies to corroborate these concerns. In fact, there is an extremely well written book (available online for free) on this topic.

hmmm

Posted by Jacob Reider, MD at 10:02 PM | Permalink

Big news:     NHLBI has stopped early a major clinical trial of the risks and benefits of combined estrogen and progestin in healthy menopausal women due to an increased risk of invasive breast cancer. The large multi-center trial, a component of the Women's Health Initiative (WHI), also found increases in coronary heart disease, stroke, and pulmonary embolism in study participants on estrogen plus progestin compared to women taking placebo pills.

Should we take our patients off prempro?  Seems so.  Wyeth's stock took a hit.  Hmm

Posted by Jacob Reider, MD at 01:41 AM | Permalink

Posted by Jacob Reider, MD at 06:11 PM | Permalink

This website provides links to the compelling, and concerning problem of the pharmaceutical industry's influence on medical practice.  From the Pharmaceutical facts page:

• According to industry estimates, drug companies spent $15.7 billion dollars on promotion in 2000, up from $ 13.9 billion in 1999. (IMS Health)
• Sixty million “details” were made by 83,000 drug reps in the year 2000. Astra-Zeneca added 1,300 reps solely to promote Nexium. (Scott-Levin Consulting)
• $7.2 billion dollars worth of free samples were distributed in the year 2000. (IMS Health)
• The “Research-based” pharmaceutical industry spends more on promotion and administration than it does on research and development. (Families USA)
• Drug costs increased 18.8% to $131.9 billion dollars in 2000. Over a third of this increase was due to a shift to the use of more expensive drugs.  (National Institute for Health Care Management)
• Two and one-half billion dollars were spent on advertising to consumers in 2000, a 35% increase from 1999; $468 million dollars were spent on journal ads. (NIHCM)
• Increases in the sales of the 50 drugs most heavily advertised to consumers were responsible for almost half (47.8%) of the $20.8 billion increase in spending in 2000.(NIHCM)
• In 2000, Merck spent $161 million on advertising for Vioxx. That is more than Pepsico spent advertising Pepsi. ($125 million), and more than Anheuser-Busch spent advertising Budweiser.($146 million) (NIHCM)

Posted by Jacob Reider, MD at 11:37 AM | Permalink

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

More good psychiatry links:

The MacArthur Initiative Depression Toolkit is useful and quick.

Depression Screening (I don't see any signs of pharmaceutical sponsorship)

Geriatric Depression screening tool  - Stanford University

A discussion of the Mood Disorders Questionnaire  .. and and Editorial on this topic from the (full text available) Primary Care Companion to the Journal of Clinical Psychiatry.

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

Posted by Jacob Reider, MD at 10:02 PM | Permalink

Todays' New York Times Magazine features a compelling and extremely well written article on the paradox of how the dietary changes that "modern medicine" advises have been coincident with increasing obesity, type 2 diabetes, and cardiovascular diease -- despite decreasing intake of fat and cholesterol.  Carbohydrates -- dare we say -- are likely to play a role in these pathologies, and yet the fact that this agrees with Dr Atkins makes everyone in the medical community a little nervous.  

If we step back for a moment .. this all does make sense.  It's endocrinology 101, as the article says .. but Dr Atkins advice to eat as much fat as we like is also not likely to help us at all.  The take-home message may be that low fat AND low carbohydrate intake would be best.  duh.

Posted by Jacob Reider, MD at 01:28 AM | Permalink

Posted by Jacob Reider, MD at 09:37 PM | Permalink

This is an important study.  Those of us who prefer not to use antibiotics routinely still struggle with concerns about which kids really would benefit.  In the study, kids with otitis media with a raised temperature and vomiting are more likely to benefit from immediate treatment with antibiotics than children with no fever or vomiting. These folks used data from a randomized controlled trial and identified predictors of poor outcome. Children who did not have raised temperature and vomiting were unlikely to have poor outcome and unlikely to benefit from immediate antibiotics. 

Posted by Jacob Reider, MD at 09:11 PM | Permalink