CME at BMJ Learning

BMJ Learning: Learning resources 

Want a fast, evidence based update? Here are the essentials on everyday conditions.

BMJ has learning resources that seem to fit my short attention span.  I just did the hypertension module in about 8 minutes. 

Good:  It's a good, quick overview of common problems with a short quiz and references. It has a well done user interfact with a nice feature that tells you what your answer was on a given item and how other people answered.  So if you're MUCH smarter or much stupider than everyone else .. you know.

Bad:  I didn't learn anything new.   I'll have to try another module when I have 8 minutes free sometime.   


Guidelines, screening

I'm cleaning off my desk today

Items in the pile:

a) Junk mail from Life Line Screening Radiology.  It's targeted to our zip code — not just physicians.   Like the Bookmibile … they'll be in the area next week.  It looks like they set up shop in the parking lot of a local church.  I can get a carotid u/s for $45 … Screen for an AAA for another $45 .. etc .. or  a "complete package" for $99.

I'm not sure what to think about this.  It's certainly not indicated in young people.  I wonder who shows up at such events. 

b) Another version of treatment guidelines for community acquired pneumonia.  As usual, this one suggests that we use:

  • A macrolide such as erythromycin, clarothromycin, or azithromycin
    • or
  • Doxycyxline
    • or
  • An extended spectrum quinolone

When I was in training, I recall wondering what the "right" answer was.  I thought I was stupid because I didn't get it .. that somewhere in the guts of the guideline was the right answer hiding from me.  Instead .. it seemed elusive.  "You CAN do this …  you could choose one of these .. " It all seemed so ambiguos.

Now that I'm a jaded mid-career 40 year old physician .. I see that these things are vague because no one has the right answer, and they are fearful in such a guideline to dictate what the physician shoudl do.

This is odd.  We need more clarity .. not more ambiguity.   We all end up at an answer when we reach for the prescription pad.   Are some answers better than others?  Yes.  Why?  … ooh .. we're getting closer.

So the guidelines need to help physicians parse out the distinctions.

Why is azithromycin NOT my first choice for community acquired pneumonia?

    • It's expensive
    • It's too broad-spectrum
    • It causes resistance in all macrolides – likely due to its very long half-life and the verly long time that it remains in tissue at levels below MIC


More on otitis

Enoch's post on medmusings makes a good point about avoiding antibiotics in the context of a prolonged fever in his child. I think that those of us with kids have an advantage over physicians without kids. We've been there. We've worried about the fever that won't go away. We've been up all night with the crying baby (?Is it the ear? Is it teething .. or is it just … behavior?)

Working with patients in a similar predicament – we have much more credibility than even the most knowledgable, thoughtful, compassionate physician in the world.

No antibiotics for ear infections

It's that time of year again … and we're seeing kids in the office with otitis media. With each pasing year, more parents seem to understand that antibiotics for acute otitis media in children are largely unnecessary.

Several years ago, I developed a guideline that was part of a regional effort to reduce antibiotic overuse.   I still print out the patient information that we developed as part of this project, but these days I find that parents already know much of the contents.

When making the decision of how to treat a child with otitis these days, I find myself sharing the decision with the parents. 

JMR:  "Well .. 80% of kids in this situation will get better by themselves."

Mom: "Yes .. it seemed to work last time.  Johnny got better in 2 days .. but the time before that, he needed the antibiotics."

JMR: "Well, that's the problem .. we don't yet have a way to twll which kids are going to be that 20%"

Mom: "Let's wait and see.  I'll call you in 2 days if he's not better."

On Fridays and before holidays, I usually write the prescription, and ask the parents to hold on to it for a day or two.  It's not uncommon that they bring it back to demonstrate proudly all was well without the antibiotics.

In this process, I always focus on the concept that otitis media, like sinusitis, is a problem with obstruction .. rather than one of infection.  There's a nice monograph on this topic.   Te bugs are there anyway.  A little H. flu, S. Pneumo and Moraxella are components of the normal flora of the nasopharynx and therefore the eustacian tube.

But as the mucosa thickens in the context of a cold, the bugs are trapped.  A system that is usually dynamic and flushed on an ongoping basis .. is now stagnant.  Warm, moist place with bacteria.  Infection?  Duh.  But as with any abcess .. we need to enhance drainage FIRST .. not necessarily treat with antibiotics.

Too bad we can't just pop open the eustacian tubes with a remote control.  Hmm … maybe I'm not the only one with this idea.

Reviewing the last 20 cases of otitis media that I saw in the office .. I wrote prescriptions for antibiotics in 6 of them within 48 hours of the visit.  Many of these prescriptions were on Fridays .. so I don't really know how many kids actually got the antibiotics.   I wonder how Chris Bradley or Enoch  or Bhavesh handle this in urgent care settings. 

In our area .. urgent care and ERs have been the biggest problems for us in curbing antibiotic oversue.  Patients seem to get what they ask for in such settings .. which then builds the expectation that antibiotics are indicated for sinusitis, otitis or bronchitis … and of course, this is a concept that I don't agree with.

In the context of the recent flu scares .. and a rather persistent "flu-like-illness" that has been quite prevalent in the past 2 weeks (though waning now, it seems) … I spoke on the phone with a friend in the ER the other day:

JMR: "How are you guys dealing with this high-fever/cough viral thing going around?"

ERDOC: "Man .. it's bad.  Clearly not flu .. but most people think it is … which is just semantics, I guess.  The worst part is that many of the urgent care docs are prescribing Azithromycin for it … so the patients come here 3 days later because the z-pak isn't working and they want us to give them a stronger antibiotic"

JMR: "yikes."

Slipped Capital Femoral Epiphysis

It's been a very long week or two. 

The boy I saw last week with hip pain turned out to have Slipped Capital Femoral Epiphysis.  This is a diagnosis that is easy to miss .. and I didn't know that he had it when I saw him.  The x-ray didn't show anything .. which was reassuring .. though his pain persisted .. which prompted a referral to orthopaedics. 

The orthopod ordered more views of the hip .. one of which showed the SCFE .. prompting surgery.



Smoking kills …


Randy Daniels Fiddles While Baby Burns

It's been two and a half years since New York passed fire-safe cigarette legislation. To be implemented, however, the law requires Secretary of State Randy Daniels to issue fire-safe standards. While Daniels delays, a series of fatal cigarette-caused fires have occurred. The following story describes the plight of a family whose baby was severely burned in a recent cigarette-caused fire.

This compelling story of how a family is struggling with the consequences of cigarette smoking.  I often counsel parents about the dangers of cigaterette smoking, but this story may provide a different image of some of the health risks