This study was publised in 2000, but I just stumbled on it today. It's an interesting paper, because it validates what we've been teaching (?preaching?) for years. Family physicians are trained to address psychological issues as primary medical problems. This is a required longitudinal component of family medicine education. While many internal medicine residencies do educate their residents in this domain .. many do not .. and this is not explicitly a component of their training. All family physicians are trained in this way.
Now there is a study that demonstrates that family physicians actually are more attentive to psychological problems.
From The Lancet:
The following story should be taken as a serious warning against use of a laptop computer in a literal sense. The patient, a previously healthy 50-year-old scientist and the father of two children, had been writing a report one evening in his home. Sitting comfortable in an armchair, he had placed his laptop computer on his lap while writing for about 1 h. The next day he noticed irritation and oedema of his penile prepuce. Furthermore, the ventral part of his scrotal skin had turned red, and there was a blister with a diameter of about 2 cm. ...
Ouch
Yesterday our server decided to shut down at 5 AM. We have a spare. Just hadn't set it up yet to step into place all-of-a-sudden. Turns out that the power supply, which has three fans, detected that fan #1 is not working. So to protect the rest of the computer ... it shut down.
So I fedexed the power supply from our backup server to the web host that we're using because Compaq couldn't get their act together and help me .. despite many wasted hours on the phone with them. Turns out that they have had persistent problems with this power supply. Hmm.
Soo .. Sorry about the blackout .. and thanks for your patience.
So I'm surfin Medscape today, and I notice that they published my article from the AAFP conference. Cool. Of course, I want to e-mail my pal Dave in Seattle and tell him about it .. so I copy the link and e-mail it to him. (actually, I use the "e-mail this article" button on the page .. well designed).
Trouble is .. Dave's not a Medscape member. Maybe he should be. He's an internist. I'll bet they want him to be a member .. and so they want me to e-mail him a URL to the article.
Since I'm already logged in, when I click on the URL, I get right in to the site and I see the article. But if one isn't logged in, all you get is the login page.
This is bad design.
Perhaps Steve will appreciate a little constructive criticism:
The recipient of the URL has no idea what the sender has sent. Is it worth the time to sign up? "ugh .. not now" most will say .. as they wade through their morning e-mail pile. Now the sender's e-mail hasn't accomplished much, and the recipient just gets annoyed.
Ironically, I was reading my (paper) copy of eweek today, and I found Jim Rapoza's "last word" article today on how deep linking draws visitors. He's right. Medscape should show the user the article I've linked to.
At first, I thought that they should put a teaser paragraph up on this login page, with instructions on how to sign up, as NEJM does for their recently published articles. Want full text? Gotta log in.. But as I think more about it, Medscape's goal is to have me see their site as a valuable resource. The user won't see the site as a valuable resource if they don't see the whole article. Piss them off ans give them a few paragraphs and it's not likely they'll be coming back to type in their DEA number..
I can already hear the "security" team whining about how jerks like me could then create web pages full of "deep" links to Medscape content that would be available to people without logging in.
So what. Medscape could rather easily permit a full text "deep link" without login from external URLs (cgi.referrer <> "medscape.com) .. but require login for viewing from internal URLs. This way, deep linking is preserved, but if the user wants to go anywhere within Medscape, they are encouraged to log in.
"Medscape is free" you say .. "why make users log in at all?" Steve will (I hope) weigh in on this one .. but I'm sure that it's very important for them to be able to report to their advertisers who the users are. If I can't log in .... I'm just an IP address.
So . if we build it this way .. more openly .. users can see the article they linked in to .. but not others, but "internal" clicks would bring the user to a login page. Yes .. of course there would be ways to circumvent this to see the content (copy/paste comes to mind!) .. but a minority of users would do this .. and it's too hard to do this on a regular basis. The more they do this .. the more motivated they'll be that the content is good and they should make life easier for themselves by logging in.
So by providing more access to content, the content vendor can actually increase the likelihood that these users will end up as long-term members.
This week's chin-scratcher is looking more and more like this condition. It's a terrible situation .. in a patient who is otherwise quite healthy and "with it" despite her rather advanced age. She's given her permission for me to post these images and brief summary. 88 year old woman who had hip surgery 1 month ago presented to the hospital with lower extremity swelling. Doppler studies of the lower extremities showed some thromboses. She was started on Heparin and then warfarin. She was therapeutic on warfarin after a few days .. and then heparin subsequently stopped according to protocol.
The left 4th digit became discolored and it was initially thought to be an isolated incident. INR was therapeutic. That evening, the right arm and right foot became discolored. INR went up to 6.2. We corrected this with FFP, and she has not progressed since then.
Heparin antibody has been negative, which still makes me think of warfarin necrosis in the bask of my head .. though the hematologists are confident that HIT is the diagnosis .. as the antibody can be negative in 10% of cases with HIT.
Biopsy showed thromboses without inflammation .. making vasculitis or some other inflammatory process unlikely.
From BMJ:
What is already known on this topic
Small trials have suggested that an ultrasound screening programme to detect abdominal aortic aneurysms in older men may be effectiveThere is uncertainty about the cost effectiveness of routine screening, with widely varying estimates
What this study adds
A cost effectiveness analysis of data from a large randomised trial with follow up over four years showed 47 fewer deaths and additional costs of £2.2m in the group invited to screeningThe adjusted net cost per patient was £63.39 and per life year gained was £28 400
The projected cost per life year gained after 10 years was £8000, which is substantially lower than the perceived NHS threshold value
We may want to start screening for AAA. My grandfather died of a ruptured AA. It's still a very common cause of death in the US. And AAA can be treated.
Eckerd is now offering folks who have a TogetherRX card a discount on generic medications in addition to the medications offered by the TogetherRX member companies. Hard to interpret this. TRX is a program that was developed to provide seniors with a discount on medications. This is good. But it was/is also a method of directing patients toward the medications that the companies sell .. and not their competition.
So now with Eckerd offering doscounts on generics .. it looks good. But this is also a method for getting more folks to get the card .. hence more people shifthing their brand name medications to those offered by the TRX partners.
No free lunch.
Physicians and patients make decisions together .. right?
A sample of today's shared decisions:
Mammogram at 36? (no)
Antibiotics for acute otitis media? (no)
Aricept for Alzheimer Disease? (yes)
Biopsy to confirm diagnosis of condyloma? (yes)
Incision & drainage of sebaceous cyst vs. trial of antibiotics? (yes)
PSA at 54? (no)
Colonoscopy at 56 (yes)
Counseling and/or family meeting for gambling addiction (no)
Antidepressant medication for depression/anxiety (yes - maybe)
Choesterol testing at 30 (yes)
Medication for smoking cessation (yes)
Physical therapy for back pain (yes)
Annual Pap smear at 35 (yes)
Some decisions, of course, are not final. The prescription for antidepressants is written, but not necessarily filled. Is it bad if the patient doesn't fill this prescription? No. I make it clear that it's not. Indeed, despite the paternalisitic nomenclature that we use .. patients are not necessarily noncompliant .. they just decide not to take the medications that we prescribe. Today I made it clear to my patient that the prescription was my method of putting the power into his hands. If he decides to try the medication after reading about it and thinking and perhaps talking with his wife ... that's OK. If he decides NOT to take the medication, that's OK too. I won't be mad. If he has more questions about it ... he should feel free to call me.
I met a couple this afternoon who were looking for a new physician for their 3 year old daughter, and we started talking about shared decisionmaking. I heard myself saying that I see myself as a resource for them. I won't dictate what to do .. I'll just help guide them. Yes . I may know a few things about medicine .. and yes .. I'll have opinions about what may be best for their daughter .. but they may know some things too .. and if we are all open to each others' opinions ... we can make good prevention and treatment decisions together.
So in this context, every decision is shared. There are some issues that I'll feel strongly about. Do I sometimes lobby for a given approach? Certainly I do. Do I mandate a given approach? No. Will I refuse to do something that I don't think is appropriate? Yes. (I often refuse to treat colds with antibiotics ... but I do so in the context of education .. )
Is an intervention really going to be effective if I impose it? Not likely. So we shouldn't bother imposing interventions .. right?
How many physicians does it take to change a lightbulb? (answer) Get it? If patients don't make the decisions with us .. then any decision we make for them is really irrelevant.
yes yes .. there are exceptions. Self-destructive behavior may be one of them .. but even that's a grey issue. Where do we draw the line? Certainly a suicidal patient needs a decision made for them (but only after we fail to make a decision with them). Is eating a Big Mac self destructive? How about unsafe sex? Smoking?
So I'm searching google for links on shared decisionmaking and I find what looks like a question from a final exam in a medical ethics class:
In a survey performed by the Presidential Commission for Study of Ethical Problems in Medicine, doctors were asked to consider 3 issues: (1) the issue of whether a pregnant woman over 35 should have amniocentesis; (2) the issue of which antibiotic to use for strep throat; and (3) the issue of whether to continue aggressive treatment for a cancer patient in whom such treatment had already failed. The doctors regarded (1) as a patient decision, (2) as a physician decision, and (3) as joint. Do you agree? What are the relevant differences among these issues?
What's the answer?
Today was the 1st time I've had a patient tell me that they actually bought a q-ray bracelet. Yes .. as-seen-on-TV. "These things are REMARKABLE" according to the very happy people on the infomercials. My patient wasn't so pleased. His shoulder still hurt .. and he's out the $90 for the bowling league since I told him to give it a rest for 2 weeks.
In this month's Mayo Clinic Proceedings is a paper that will likely (let's hope!) spread the work about these things. In a randomized placebo controlled trial, the ionized bracelet was just as ineffective as the placebo bracelet.
Next on the agenda... magnetized back brace. Not much in the literature (that I can find) on this yet. There was a pilot study a few years ago that showed no effect. I've heard anecdotes from several patients (including one today) that this is effective. We'll have to see.
How Perils Can Await the 'Worried Wealthy'. Hordes of consumers are flocking to centers around the country to have their bodies scanned by three-dimensional computerized X-rays. By Jane E. Brody. [New York Times: Health]
This is a compelling article that I'll print out for the office. Too much testing CAN be a bad thing. The article clarifies how false positives on screening tests can lead to serious problems .. and great expense and hardship.
Today I saw a 53 year old man for a "annual physicial." Unfortunately, the common misperception is that a physicial examination is the conerstone of this annual visit. It's not. As a primary care physician, my job is to assess risk, and prevent disease. I always ask patients if they wear seatbelts, since automobile accidents are more likely to contribite to their death or illness than anything I hear when I listen to their lungs. Testing always comes up too. "Do the all of the bloodwork" I often hear ... "I want to be sure everything is OK" Hmm ... How do I respond?
Of course, I can't do "all of the bloodwork." Doing so would be both impossible and irresponsible. I need to help my patients make careful, informed decisions about which screening tests are appropriate and indicated. I often make use of the USPSTF screening guidelines to guide the disucssion. To some, "It's just a blood test" and the risk of a false positive or ambiguous result isn't appreciated. I don't want to talk my patients OUT of getting a PSA. ? or do I?
It's interesting to look at the access and referrer logs for the docnotes website. Rererrer logs tell me who has linked to docnotes .. access logs tell me who has visited .. and often .. from where.
Where do people come from?
Most often ... it's either "unknown" meaning they typed in the link or used a bookmark on in the browser ... or from a search engine.
Other referrers are the medical weblogs .. or weblogs.com
Where are people logged in from?
It's usually possible to determine the domain from which a user is coming from. So if a user is on AOL .. I can tell .. or AT&T .. or MSN. More interesting is when the domain is from a health related webiste. Today's interesing login is from Medfusion. It's a company that offers several services to physician practices. They do their programming in ColdFusion, which is good .. and they seem to offer services to practices including online lab result reporting, online scheduling (for patient appointments) and online bill payment. It's not clear, though, how they interact with the myriad practice management systems. There is no mention of interfaces on the website. This is important to know. INdeed, the reason that we're moving out of relayhelath is because we don't want to have several separate data repositories. We want out patient information to live in ONE place. So we're building our own simple (yeh .. coldfusion, of course) replacement for RelayHealth. It's going to run as a webservice on our external server. The internal server will poll the exteral server every few minutes. If there are new messages, The external server responds with the (encrypted) data, and the internal server will post the messages to our internal messaging system.So it's not clear to me what the role of Medfusion will be. No mention on their website of pricing. Id be surprised if it's cheap. Build vs buy? I'll continue to build.
Evaluating technology projects is hard .. and many organizations don't (yet) have an infrastructure for doing so.
Using Reider's Rule (see below) is my method. But it's more complicated that that. Using technology in a business, an organization, a school .. or even a medical practice ... It's important to make certain that there is a clear process for how such projects are identified, prioritized, and implemented. In the absence of such a process, one can't be sure that the right projects are getting implemented.
...
I'm off to the Airport .. more tomorrow ...
Couple Remain Hospitalized With Bubonic Plague. A man who is battling bubonic plague in a Manhattan hospital is a former top official of the New Mexico agency responsible for investigating criminal cases of insurance fraud. By Cecilia M. Vega and Tina Kelley. [New York Times: Health]
In addition the news reports ... I've received three e-mails about this from the Health Department. It's a great use of technology to communicate important information in a timely manner.
The Not-So-Crackpot Autism Theory. Reports of autism seem to be on the rise. Anxious parents have targeted vaccines as the culprit. One formerly skeptical researcher now thinks it's an issue worth investigating. By Arthur Allen. [New York Times: Health]
This is a compelling article. There are no simple aswers to the questions about vaccines. And no certainty.
OK .. so I'm warming up to this Online CME thing. Medscape's got a nice article on Adult ADHD that I just read. Here's the thing. I read the article. Getting the CME is as easy as taking the post-test. We read articles all of the time. Medscape allows you to print it out .. then come back and take the CME .. so you're not locked in to the computer.
I had never seen this before. My patient looked worse than the one in the picture. This paper (link above) is the only reference I can find (Medline finds none) that associates Viagra to penis fracture. He was taking Viagra.
"Jargon and technical language dominate the way things are communicated to users. Hierarchies of information reflect the internal engineering hierarchy, rather than categories or groupings of information that will make sense to customers. "
It's hard for programmers to think like real humans
Busy at the office recently. It's good and bad. Good because we may be able to make rent this month without borrowing (again) .. bad because there is less time with each patient.
Was told last week that the three physicians in our practice "really listen" unlike physicians our patients had previously seen. It's nice to hear this once in a while .. As Joe Scherger says: "your patients don't care how much you know until they know how much you care."
Many new babies in the last few weeks. Two of them were in the NICU for a few hours ... (one didn't really need to be there though .. a source of some disagreement .. This month's AFP has a good review on sick children.
I'm going to the AAMC meeting on Friday .. but not staying very long .. as I need to get back and be with my family .. which is so precious these days. The tree-house is almost finished. It's got a roof, but no roof shingles yet.
Lots going on at the Medical Center recently as well. We're still plugging along with our friends from Siemens. We're an "early adopter" for the new Soarian product .. which is (predictably) slipping a bit from its originally scheduled release date. We've met some great people working for Siemens on this project ... so it may really turn out "just right." Time will tell.
