Family Medicine Notes

Quiet times on the weblog usually mean busy times in the office .. which is certainly the case.  I'm also finishing up on the revisions to the HHS grant that we're working on for STFM to create FMDRL - the Family Medicine Digital Resources Library, and I'm working on a paper on bipolar disorder for American Family Physician

ok .. now to today's tidbit:  there are 66 companies that make forms of extended-release guaifenesin.  These products are prescribed by many physicians .. and the evidence for their efficacy is scant.  The FDA requires that medications actually do what they claim to do, and Mucinex was the only extended release guaifenesin that could demonstrate efficacy.  So their product is the only one that will remain available.

The immediate release products (cough syrups conataining guaifenesin such as robitussin) are not effected by this ruling.

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

Posted by Jacob Reider, MD at 06:45 PM | Permalink

From the January Bandolier - a review of hypertension prevention:

• Maintain normal body weight for adults (body mass index 18.5 to 24.9 kg/sq metre)
• Reduce dietary sodium intake to no more than 100 mmol per day (about six grams of sodium chloride or 2.4 grams of sodium per day)
• Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)
• Limit daily alcohol consumption to no more than 30 mL ethanol for men and no more than 15 mL for women and lighter weight persons [20 mL ethanol is equivalent to a pint and a half of beer, half a bottle of wine, or 60 mL of average strength spirits]
• Maintain adequate intake of dietary potassium (more than 90 mmol or 3.5 grams per day)
• Have a diet rich in fruits and vegetables and in low-fat dairy products with a reduced content of saturated and total fat

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

Posted by Jacob Reider, MD at 12:32 AM | Permalink

Docnotes doesn't get political very often.   Weakened by fatigue at 3 AM .. I responded to Robert Centor's post on his weblog last night about the Canadian Healthcare system.  I won't replay the dialogue .. but I thought I'd provide a bit of context ..

This morning when I got to my office in the medical school, my assistant asked me if I have any samples in my practice that I could send over to a colleague's office .. as he's run out of some things that several patients really need.  It turns out that he's broke .. and he usually just writes a check to the pharmacy for the patient when they can't affor their medicines.

We're going to see if we can get the local chapter of the NYSAFP to help him out.

... and this excerpt from Johnathon Ross's recent paper provides a good reply to many of the voices who wish to preserve the status quo in this country:

"The necessary economic conditions for an efficient competitive market for health services do not exist. Evidence from the current competition between insurance companies shows that it is likely that these market forces will aggravate the dual problems of high cost and poor access. A tax-financed universal health insurance offers the best alternative and is consistent with both progressive and conservative principles for reform"

Posted by Jacob Reider, MD at 10:25 AM | Permalink

Looks like we missed this one: 

"What if everybody in the world farted at the same time?"

We were all supposed to fart at 4 PM Pacific time today.  Oops.  I forgot.

I was given a gift a few months ago by a family with several young children:  The Gas We Pass.  It's a very funny book.   Perfect for the waiting room.

Lactose intolerance is probably the most common cause of frequent farting:

Between 30 and 50 million Americans are lactose intolerant. Certain ethnic and racial populations are more widely affected than others. As many as 75 percent of all African Americans and American Indians and 90 percent of Asian Americans are lactose intolerant. The condition is least common among persons of northern European descent.

Here's a nice patient handout on Lactose Intolerance.  Patients have usually heard of lactaid, but I usually make sure that they know that they don't need to spend $8.00 for lactase.  Wal-Mart, CVS and several of our local supermarkets carry generic versions of lactase for much less.

Posted by Jacob Reider, MD at 09:15 PM | Permalink

Posted by Jacob Reider, MD at 05:27 AM | Permalink

More questions in today's e-mail about the AAFP Open Health Record project.

It's based on the Oceania EMR.  The company no longer exists .. and I don't know much about what happened .. who currently owns the intellectual property, or what the current status of the software is.  It was a progressive system in its day - developed by folks who were trend setters in XML and applications of SGML to healthcare.

Courtesy of the Internet Archive, You can view a demo of the circa 1999 version (well .. just a few screenshots .. but you can get an idea of what it's all about).

---

Meanwhile .. back in our 50+ physician practice .. we struggle with decisions about what to do about an EMR.  We've been using the Mysis EMR on a trial basis for 18 months.  Lot sof problems recently with it recently.  I'm becoming convinced -- after using it for all of this time -- that this product just won't do.  There are too many basic problems with the system to make it clinically useful.  Usability is sacrificed, and complexity dominates.  I'm trying my best to give it a 'college try' but is still frustraing on a daily basis.

I visited another group of family physicians this afternoon.  They're implementing the Greenway practice management system and EMR.  High hopes to reduce their $150,000/year of transcription costs.  I was suprised by how little they knew about the details of the Greenway product.  They didn't do much homework.  I'll do a demo of Greenway later in the week.  Will post my impressions here.

Posted by Jacob Reider, MD at 05:26 AM | Permalink

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Posted by Jacob Reider, MD at 12:25 PM | Permalink

In this long, but well written paper from the CDC, there are a few clear suggestions for using fluoroquinolones that make good sense:

1) for most gram-negative infections of the skin and urinary tract, including P. aeruginosa infections, ciprofloxacin monotherapy is appropriate.

2) Ciprofloxacin, levofloxacin, and gatifloxain all achieve high concentrations in urine; thus, they would all be appropriate choices for treating urinary tract infections in the community. Ciprofloxacin would be the most appropriate therapy in cases where P. aeruginosa is a known or suspected pathogen. For other gram-negative infections, levofloxacin or gatifloxacin should be prescribed in appropriate doses to surpass the mutant prevention concentrations at the infection site.

3) For infections in which S. pneumoniae is anticipated to be the most likely pathogen (e.g., community-acquired pneumonia), moxifloxacin, which currently has the best antipneumococcal pharmacodynamic activity and the lowest mutant prevention concentrations against this organism, would represent a prudent therapeutic choice.

4) By contrast, levofloxacin MIC₉₀s against S. pneumoniae are significantly higher than those of moxifloxacin and gatifloxacin.  Levofloxacin is therefore not an appropriate choice for respiratory infections.

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

As Vaccination Rates Decline in Ireland, Cases of Measles Soar. Across the Irish Sea, public health officials blame latent fears about the M.M.R. vaccine for measles, mumps and rubella for a measles outbreak. By Brian Lavery. [New York Times: Health]

This story clearly illustrates what can happen if we let down our guard too much with vaccines.

Posted by Jacob Reider, MD at 08:37 PM | Permalink

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

While clicking on a poorly formed link to an article on HIPAA privacy enforcement (it's interesting .. but I'll let you go there and read it .. no comment from me for today) .. I stumbled on this error when I reached the site (as you will if you click on the heading above).

So what?  It reveals a security flaw that has been well known by coldfusion programmers for years.  As this Allaire Security Update from 2/99 suggests .. URL variables should not be use as variables in SQL statements directly.  Let's hope someone tells the programmers at Health Data Management that their database is vulnerable!

Posted by Jacob Reider, MD at 04:32 PM | Permalink

Medfusion is a small company with big goals.  Nice talk on the phone the other day with Jeff Dolan from Medfusion.  They're doing lots ... and Jeff says they're trying to solve real problems.

They're doing interesting things with the Instant Medical History to help physicians with the narrative portion of the chart note.  The concept is that the patient will create this themselves -- either online before the visit -- or on the physician's office before the physician comes into the room.

I'm lukewarm about the whole idea.  While many patients would embrace this .. many others would not ... and it's hard for the physicians to grasp a true return on investment figure for such a service.

The other components of their product line are similar to those provided my relayhealth, aboutmyhealth, mdhub, etc.  .. and I'm still not convinced that the complex components of these services are valuable at all.  It's tempting for most of these companies to develop components that gather complex pieces of data from patients and physicians .. but the core functions .. "hey doc I have a rash between my toes what should I do about it?"  ... don't require complex structures interviews .. nor should they.  Indeed, it was pretty easy for me to confuse the "Instant Medical History" demo -- causing it to give me a "I don't understand" screen .. with no option to enter free text as an alternative to the structured interview.

Alas .. the companies that develop complex tools are often missing the point of how technology can help us in our practices.  The tools can be very complex on the "back end" but for patients and physicians to embrace them, they need to retain simplicity on the front end.  

Why does this happen?  All too often, I've found that the physicians advising developers and business strategists involved in these companies are the technology enthusiasts.  I'll never forget the time we were interviewing physicians to serve as advisers at Medremote, and this guy comes in with a flurry of ideas and enthusiasm.  It was great talking with him .. lots of fun and he certainly had energy for what could be done.  This guy had not just one PDA .. but two! .. a WinCE device on the right hip, and a Palm OS device on his left hip.    This sort of physician often gets involved in informatics projects because they're so excited about all of the potential.  They're unusually smart, and often have programming experience from college or even graduate school. 

They're great to have for the white-board sessions to generate ideas .. but these folks are the worst people to have involved in shaping the framework of a development project or feature set of a product that should be designed to assist physicians and patients.   They're smart and very comfortable with complexity -- so they don't recognize when the software is too complex for the user to understand.  Of course, this happens to developers too .. since they too are smart and comfortable with complexity.

The best physician-consultants, then, are those who understand the software and hardware, but have a low tolerance for complex processes.  Keeping it simple is top priority, but remains elusive for all but the best teams.   The hardest part, of course, isn't deciding what to could be done ... but figuring out what should be done.

Medfusion is weaving partnerships with companies that have managed to create moderately successful niche products.   Seems that the business model is to broaden this niche into the mainstream by integrating these solutions with other existing products like EMRs. 

We'll see where all of this gets Medfusion.  So far, it's not clear to me that they are yet focused on keeping things simple enough to make it beyond the niches and into the mainstream. 

Posted by Jacob Reider, MD at 09:43 AM | Permalink

The U.S. Preventive Services Task Force recommended yesterday  that adults with high blood pressure or high cholesterol be screened for type 2 diabetes.  It concluded that further research is needed on whether widespread screening of the general adult population would improve health outcomes. The task force also found insufficient evidence to recommend for or against routine screening for gestational diabetes in asymptomatic pregnant women.

Posted by Jacob Reider, MD at 10:18 PM | Permalink

A pediatrician friend recently referred one of his former patients to me. 

The 21 year old forklift driver was reasonably healthy, but clearly smelled of cigarettes.

I asked him if he was interested in quitting, and asked how long he had been smoking.

"About 10 years"

My math skills aren't that great .. but this one .. I got in a millisecond  (!)

Turns out that he grew up as the youngest kid in the development, and learned to smoke from the 16 year-olds.

But the pediatrician never knew.  He never asked.

As one who also cares for kids, I know how this goes.  We've seen these kids since they were infants.  Hard to see them as adults.  I think that sometimes our judgement is influenced by what we WANT to hear.  "I can't imagine that Johnny would ever smoke .. nah .. not little Johnny ... I remember when he was just a little .. "  So maybe we don't ask the questions.

A few years ago I was teaching interviewing skills to the third-year medical students.  We have a great program with so-called "standardized patients."  These folks are actors who have been trained to be "patients" for the medical students.  We videotape the interviews, and play them back with the students to give them feedback.

One student was taking a sexual health history from a "patient."  It's a hard history to take for many students .. and there are parts of the history that they are often uncomfortable with.  "You're not gay are you?"  Asked the student .. shaking his head ever-so-slowly as he asked the question.  "Of course not" confirmed the patient.  oops.

You'll get the answer you're subconsciously looking for if you make mistakes like this.  Yet we all do it in some way .. telegraphing our cultural biases.  The more aware we are about such biases .. the more prepared we'll be to ask questions in an honest, open manner.

A few ways to ask a teenager if they smoke:

"Do you Smoke?"  (Not-so-good: literal teens will say no if they only smoke occasionally)

"Have you tried smoking yet?"   (Better .. lets them say yes .. opens door for more detail, but may offend sensitive folk)

"Do you have friends who smoke?"  (Easy entry .. follow-up with "how about you .. have you smoked?")

(Don't froget to learn WHAT they're smoking)

And give parents this handout  - available in quantity from the CDC for free.

Posted by Jacob Reider, MD at 02:44 AM | Permalink

"DOCTOR SAYS YOGA MAY BE PRESCRIPTION FOR BETTER HEALTH"

My good friend Richard Usatine wrote this book with a Yoga instructor.  Back in December, 2002 when he was Associate Dean of the FSU medical school, the press release featured Dr Usatine.

Last week brought another FSU press release -- announcing that Joe Scherger and Richard Usatine were no longer holding positions of authority in the medical school. 

With an upcoming LCME site visit, it seems that FSU felt they needed someone else at the helm.  I don't know enough about the politics or the particulars, but I do know that Richard and Joe are two of the finest family physicians in the country, and it is a shame to see them treated in this manner. 

As Richard was quoted in the Talahassee Democrat last week:

"I think that we at FSU had developed a state-of-the-art, wonderful curriculum for our students," Usatine said. "The curriculum was preparing them to be humanistic physicians with excellent skills in every aspect of medicine."

I hope that FSU does well, and that Richard and Joe can land on their feet -- whether at FSU or elsewhere.  

Posted by Jacob Reider, MD at 01:50 AM | Permalink

Saw a man today for hyptertension follow-up, who mentioned to me in passing that he had been in the Emergency Department over the weekend.  He had felt and heard a "pop" in his arm as he was lifting something heavy.

He had bruising at the base of the biceps tendon, and the telltale biceps bulge.  It was feeling better, he said .. so when the ED physician told him the x-ray didn't show fracture ... he was relieved .. and was expecting full recovery.

It was a good thing he was scheduled for the hypertension follow-up.  A short drive the orthopaedist's office .. and fast-track MRI .. and the tendon injury will be repaired soon.  While repair is optional, better results are acheived when the repair is done promptly.  If it's not repaired,  biceps muscle strength will be diminised by roughly 50%.

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

This article appeared last summer in the Boston Globe.  Well done.  Listen up, physicians.

Today I saw more patients than I would have liked.  Felt too rushed to really listen as much as I should have.  Mondays are getting to be like this.

Many new babies today.  Some still inside .. some not.  We see more neonatal jaundice in our office than I had seen in the past.  I think it's because most of our patients breastfeed.   Back when I worked in Schenectady, I rarely saw jaundiced neonates. Two flavors I see most often:  Physiologic Jaundice - which usually peaks by day 3 or 4 and is often resolved by day 7, and Breast Milk Jaundice - which usually peaks at day 7 - 10 and doesn't resolve for weeks thereafter.

Patient handout on Jaundice

Another (in pdf  - so this one  prints well)

A Cochrane Review from 2000 on fibreoptic phototherapy.  If you've never seen one of these things .. call a local home therapy equipment reps and ask them to bring one over.  I hadn't seen one until I'd been in practice for several years ...

A Revidw of Hyperbilirubinemia in the Term Newborn in the 2/15/2002 American Family Physician.

Several of the yellow kids I've seen recently have been delivered by local midwives, who often delay clord clamping.  It seems intuitive that delayed clamping produces more RBC load -- therefore more jaundice.  But I haven't found much in the literature on this.  This article reviews 20 years of literature and claims that the benefits of delayed cord clamping are clear.  Another paper from the nurse-midwife literature reviews the beliefs and practices of nurse midwives in the US: The majority of CNMs (87%) place the baby on the mother's abdomen immediately after birth and 96% avoid clamping a nuchal cord whenever possible. Although Varney's Midwifery was cited most frequently as a reference, 78% of the respondents listed no references reflecting, in part, the absence of evidence-based recommendations for cord clamping practices.

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

"Misconceptions about the appropriate treatment of colds are predictive of increased health service utilization. Targeted educational interventions for families may reduce inappropriate antibiotic-seeking behavior and unnecessary health service utilization for colds."

This article reminds us that many parents beleive that bacteria cause colds, and that colds get better with antibiotics.   Office visits are therefore more frequent in the context of such beliefs.

Trouble is ... with fee-for-service healthcare, we have no clear incentive to correct this.  In a way, there remains a disincentive to adequate education.   

Posted by Jacob Reider, MD at 05:39 PM | Permalink

Posted by Jacob Reider, MD at 02:43 PM | Permalink

Microsoft has released a "Slammer Scanner" to detect servers on your network that may be vulnerable to the "slammer Worm."  It's a small download, and I think that it's a good idea for most people to get it, as MSDE may be installed on even desktop machines.

Posted by Jacob Reider, MD at 02:41 PM | Permalink