Family Medicine Notes

I didn't know I'd be commenting so soon on PSA screening.  This Week's American Journal of Public Health  has an article on men's understandnig of PSA testing:

Objectives. This study examined knowledge about prostate-specific antigen (PSA) screening among African Americans and Whites. Because PSA screening for prostate cancer is controversial, professional organizations recommend informed consent for screening.
Methods. Men (n = 304) attending outpatient clinics were surveyed for their knowledge about and experience with screening. Results. Most men did not know the key facts about screening with PSA. African Americans appeared less knowledgeable than Whites, but these differences were mediated by differences in educational level and experience with prostate cancer screening.
Conclusions. Public health efforts to improve informed consent for prostate cancer screening should focus on highlighting the key facts and developing different approaches for men at different levels of formal education and prior experience with screening.

The study made headlines in the Reuters Health News this week:

A number of prominent groups, including the U.S. Preventive Services Task Force and the National Cancer Institute, are opposed to routine PSA screening, saying that the risks of follow-up tests and the side effects of treatment may outweigh the possible benefits for many men.

This is a good thing.  The mainstream press rarely discusses the fact that PSA testing is so complicated. 

I'm on the lookout for good PSA testing patient handouts.  Haven't found much.  The American Cancer Society's website recently featured this article on calls for informed consent prior to PSA testing.

But until physicians have good tools (educational materials) that will help them provide patients with adequate and reliable information, I'm not sure we'll be improving our track records much.  While I often try to have this discussion with patients, I find that it's a tough one to present in an unbiased manner.  Men who expect to have test done "because I get one every year .. cuz I'm supposed to" don't want to hear much about the complexity of this decision ... and men who don't want to bother with any tests ... don't want to bother with any tests .. so they don't get very engaged in the discussion either.

If you use .. or have seen good PSA education materials, please post a comment and share with the rest of us!

Posted by Jacob Reider, MD at 03:10 PM | Permalink | Comments (2)

What is ISABEL?

 a sophisticated paediatric clinical decision-making support system designed as a near-patient working tool for doctors, nurses and health care workers

An analysis of the system was recently published (pdf)

It's free for physicians to create an account.  the system is easy and kinda fun to use.  YOu type in free twxt descriptions of the signs and symptoms, and the system attempts to develop a differential diagnosis.

It's easier to use than the "gold standard" decision support tool DXplain -- but I wonder about how it does the parsing of the free text entries ... what if I spell things wrong?

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Posted by Jacob Reider, MD at 01:40 AM | Permalink | Comments (1)

AMNews: May 5, 2003. Do-it-themselves diagnosis: Patients pick their tests

 This atricle from American Medical News highlights several intersting and problematic issues, yet overlooks the "patient-initiaed-testing" that occurs behind the closed doors of the physician's office.

"Doc .. I think I need an MRI" says the man with a headache.

He may .. but then again .. he may not.  Depending on the patient and the physician .. the decision to order the test or not will vary - even in the context of identical presentations of signs and symptoms.

A few weeks, ago, I saw a 39 year old for a sore throat.  He'll be 40 in a few weeks, and scheduled a visit for this event.  "I'll see you in a few weeks, Doc"  He says ... "I'll need a full work-up at 40 .. y'know .. exercise stress test, chest x-ray, EKG, CBC and complete chem panel."

"oh boy" .. I says to myself ... I'd better get the screening guidelines ready. 

So it gets tricky.  I do want to reassure him that he's healthy.  And I certainly want to do my best to keep him healthty.  But these tests simply aren't indicated. 

I usually bring up a copy of the guidelines on the web in the exam room so that we can discuss them.   Traditions die hard, though ... and it's hard to educate away a fixed belief that something that was "essential" 10 years ago is no longer necessary.

Barbara Starfield has written about the importance of primary care .. but one of her most often cited papers is from 1994 in which she determines that lower cost care often provides the same quality of case as high cost care.

 .. and ... in the context of last week's post on the Futures of Family Medicine project, Dr Starfield's lectures provide a wonderful outline of the reasons that Primary Care is better for a community than specialty care:

• New Paradigms for Quality in Primary Care
• The Primacy of Primary Care in Health Services Systems
• The Primacy of Primary Care in Health Services Systems
• Primary Care: 21st Century Challenges to Quality

The last one is a fantastic overview of the complex pressures on health policy.  The 2nd half of the presentation includes a classic slide. Take a look at it carefully.  The Question it asks: should we do an exercise stress test on our patients before they begin jogging?  The answer:  No.  Doing the test may in fact expose them to greater risk than not doing the test. 

This is a concept that patients often find hard to grasp.   It comes up in the dicussion of PSA testing, of course ... a discussion for another day.

Posted by Jacob Reider, MD at 01:16 AM | Permalink | Comments (1)

This is the first non-medical post in a while ... but bear with me .. we're just back from our long weekend in Montreal .. with a brief stop along the way home in Lake Placid.

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Macromedia has released another product that simplifies the creation of rich internet applications.   Mike's post on the Flash MX Data Collection Kit reveals a bit about what Macromedia is inching us toward.  It's an interesting twist in the movement of the intelligence of an application .. and clearly it is what Macromedia thinks will represent is the next phase in the function of web-based applications.

• Phase 1: The Web Was Born.  Simple servers respond to http requests and send back HTML pages. 
  • Dumb Servers
  • Dumb Clients (browsers 1.0)
• Phase 2: Servers get smarter and interact with databases.  Browsers get smarter too
  • PHP, Coldfusion, .asp
  • Javascript, JAVA Applets, ActiveX Controls
• Phase 3 (according to Macromedia) .. Move much of the business logic and processing code away from the server and onto the client - permitting the client to interact with the database intelligently.
  • Flash MX

It's interesting how this paralles the evolutions of database interaction in general.  Phase 1: have processing on the server side - with complex SQL required -- and an expectation that many users would interact with dumb terminals.  Phases 2-3 brought richer clients - MS-Access, PowerBuilder, Visual Basic .. and even the whole .NET framework.

But the Flash MX method is much better than the "thick clients" of old .. since there is no application to install or update .. or find the missing .dll file ... or fix the conflict .. or reinstall on the upgraded hard drive, etc etc.

The Web ironically shifted many "thick" client applications to "thin" ones again .. which constrained application designers (including most Electronic Medical Records vendors) .. as the web didn't offer a rich enough palette with which to paint their software.

So Macromedia now has tipped their cards, I think.  With the departure of Jeremy Allaire, former brainchild and Chief Coldfusion Evalgelist at Macromedia .. is seems that the development efforts are shifting away from Coldfusion MX, and toward the tools that will enable developers to create more robust clients - with or without  the browser.  Is this Bad?  I'm not yet sure.  I like Coldfusion very much, and  I think that the rich front-end certainly needs a robust back-end.  Developers should be able to choose the right tools for the job.  So .. if they do this right -- and continue to devote adequate resoruces to Coldfusion .. it could go very well for Macromedia indeed.  But neglecting Coldfusion could backfire .. and could certainly alienate a generation of web developers.  I think that there is a real risk of this.  With Jeremy gone, and even Ben Forta writing more and more about the client side ... no one seems to be keeping the CF fire burning.  It's been nearly a year since the release of "NEO" .. and there isn't much talk about what CF 7.0 is going to look like ...

Posted by Jacob Reider, MD at 11:28 PM | Permalink

Quick post today .. .

a) BMJ has a new Interactive Case Report section

b) When I moved "Docnotes" from Userland Radio to Movabletype, I turned off the default template with "comments" on .. as I didn't think that it added much to the weblog.

Today, (at the request of several readers) .. I turned them on again ... and noticed that comments may very well be good.

This comment on circumcision reminds me of the power of the weblog. 

...  OK .. we're off to the Expos game now ..

Posted by Jacob Reider, MD at 12:23 PM | Permalink

We're in Montreal this weekend .. since the conference in Toronto was cancelled.  No SARS here.

Posted by Jacob Reider, MD at 12:08 PM | Permalink | Comments (3)

Medscape has a good article on "HIT" this week. (Free registration required)

I'm a visual learner though .. and they've got no pictures.  Asture "Docnotes" readers will recall my post on HIT last fall with some pictures (with permission, of course) that you won't ever forget.

Posted by Jacob Reider, MD at 01:12 AM | Permalink

Medline has a Medical Dictionary.  It's good, but not so good as another dictionary that most people don't know about:  Google's Glossary.

Let's see if we can look up "hemmeroyds"  .. google asks "Did you mean hemorrhoids?" .. cool .. Google helps with spelling too .. and so does Medline's Dictionary.

Posted by Jacob Reider, MD at 01:45 AM | Permalink

OBGYN.net - Suctioning Doesn't Alter Meconium Aspiration Risk

Suctioning Doesn't Alter Meconium Aspiration Risk

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In next week's American Medical News appears an interesting article on medical weblogs.

Bob Cook's the author. He's got things mostly right .. 'cept ...

a) David Theige's MedEdNEws was the first medical Weblog (1998!)  .. though it's now dormant.  You can see the early stuff here on the Internet Archive

b) No mention of Family Medicine Notes ... ;-( .. I'm sooo insulted.  (And this was the second medical weblog)

c)  He's "outed" out another medical weblogger's real identity .. something I've been careful not to do.

Anonymity was important to her .. and I think that it's an interesting component of what medical weblogging is for this weblogger:  an opportunity to discuss and inform .. without being concerned that the opinions she voices on the web will cause her patients to respond to her differently.

I hadn't thought about this until I had an e-mail conversation with her about it a few weeks ago -- but it does make sense:  The opinions that we physicians share on our weblogs do reveal how we feel about certain issues.  Sex, drugs, Rock 'n roll, vaccinations, antibiotic overuse, abortion, etc etc etc. 

I've had many patients comment on the weblog postings on Docnotes .. and the feedback is always positive .. but what have I said on the weblogs that has alienated my patients? How would I know? 

So I am respectful of those who choose to 'blog' anonymously ...  I wonder if Bob asked if it was OK ...

Posted by Jacob Reider, MD at 12:53 AM | Permalink | Comments (1)

An Editorial in last week's American Family Physician on the recent USPSTF guidelines for cervical cancer screening.

 Advances in understanding the natural history of HPV infection and cervical cancer biology have revealed that HPV infections generally are transient. Among high-risk HPV subtypes, 70 percent of infections regress within two years, suggesting that less aggressive testing among younger women will allow for the spontaneous regression of HPV-associated abnormalities before screening is initiated.

I've been discussing these revised guidelines with patients since early this year. 

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New from our friends at the CDC:

Guidelines for Persons Traveling to SARS-Affected Areas - Severe Acute Respiratory Syndrome (SARS)

If I go to Toronto next week .. I think I will pack one. (thanks to SARSWatch.org)

Posted by Jacob Reider, MD at 11:28 PM | Permalink

.. and the New York Times also reports that F.D.A. Approval of Nasal Vaccine for Flu Expected.

Flumist - developed at the University of Michigan - and to be sold by MedImmunie - will be indicated for people 5 to 50 years old.

Yes .. you heard that right.  The populations for whom influenza vaccine is reccomended are the populations for whom Flumist is not indicated.

It'll also cost much more. 

We lost about $1500 last season on flu shots that we bought and never gave to people .. so I don't think I'll invest in any flumist this coming winter

Posted by Jacob Reider, MD at 11:25 PM | Permalink

New York Times: To Curb Cravings, and Maybe More

An interesting look at the use of Topamax and Zonegran for eating disorders.

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Posted by Jacob Reider, MD at 02:36 PM | Permalink

From BMJ:

Delayed immunisation is a specific risk factor for admission to hospital with pertussis rather than being a marker of infants at increased risk of admission to hospital for any acute respiratory illness. Improving on-time delivery of immunisations can be expected to decrease the admission rate for pertussis in New Zealand

Parents often ask if it's ok to delay immunizations "until they are older and the immune system is stronger."  It's important to listen to these concerns so that parents know that we're hearing them.  Yet it's also important to inform them of the science that causes us to suggest the recommended schedule.  This short paper from New Zealand reminds us of the importance of "immunising" infants appropriately.

Posted by Jacob Reider, MD at 08:59 AM | Permalink

The Future of Family Medicine project releases preliminary data. These are tough times for family physicians.  Hailed in the 1990's ... we're now a speciality that struggles for identity. 

It's been years since I was treated disrespectfully because of my speciality choice .. but our medical students hear this often.  Today I was brushed off by a physician who considers family physicians inferior to other physicians.  "I don't understand why patients would see a family physician when they could see someone with more training specific to the problem that they have."

I had heard about his bias ... but I honestly didn't expect him to be so rude to me .. and my colleagues.

.. and he clearly doesn't understand what I do for a living .. and how the way that we provide care may in fact better than the care provided by specialists or even other generalists. 

Indeed, not two hours after he said this to me, I had a visit with a newborn baby and his parents.   The baby is doing very well, and the parents, while fatigued, are also doing well.  As they were leaving, "dad" asked if we wer accepting new adult patients too .. "maybe we can all come here!" .. He says.  "Of course we are ..."  says I.

Something like this happens every week or two.  

Yet the report above mentions that:

 "The public still does not understand the role and value of a family physician. Some patients do not have an appreciation of continuity relationships, and many patients do not see the family physician as scientifically and technologically astute."

And it's not just "the public" that needs the education.  It's our colleagues in other specialties.  Perhaps we can have some of them "shadow" us for a day .. as we shadowed them during medical school.

Posted by Jacob Reider, MD at 09:26 PM | Permalink | Comments (1)

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From The Graham Center: Family Physicians Are an Important Source of Mental Health Care

Family Physicians Are an Important Source of Mental Health Care While comprising about 15 percent of the physician workforce, family physicians provided approximately 20 percent of physician office-based mental health visits in the United States between 1980 and 1999. This proportion has remained stable over the past two decades despite a decline in many other types of office visits to family physicians. Family physicians remain an important source of mental health care for Americans.

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AMNews: April 14, 2003. Paperwork reduction bill is caught in coding crossfire ...

Washington -- A bill designed to reduce the hassle factor for physicians in the Medicare program may wind up causing more headaches than it cures.

Meanwhile, read codes have been in use across the pond for quite some time, and are a better refelection of how physicians think.

.. and despite rumors about this for years ... HHS has yet to license snomed from CAP.   Speaking of CAP .. they've got myhealthtestreminder.com which patients can use to send themselves an e-mail when the time is right.   It's flashy and a good idea .. but the tried-and-true mailtothefuture.com would work just as well .. with fewer annoying graphics.

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I've been looking for this a few days ...  finally  found it.   The Choice of Outpatient CPR's: Questions to Ask

This is a good review of many components that one should expect in an outpatient EMR.  Missing is a tool to help asess the importance of any feature .. and then how well that feature is implemented.

Recall Reider's Rule:  P = V/ W

Priority = Value / Work.

We'll need to modify it a bit to compare one EMR against another ...

S = sum(Q/w)
where:

• S = Score.  The highest score will yield the best product
• Q =  Quality = (QI x V)
• V = the perceived value of a given function.  For example, prescription writing is a function that is very important.  So we may give it a "10."  This number remains the same for all products, since we're scroing the value of the function.
• QI = Quality of Implementation.  How well does This vendor's product implement this function?
• w = Work.  Work is usually expressed either in dollars, or as a 0 - 10 score.  It's an expression of how hard it is to implement and support the product or function.  Charge Capture, for example, may require an additional interface, which adds cost.  One vendor may charge $5000 for the interface, while another charges $10,000.

Posted by Jacob Reider, MD at 04:23 PM | Permalink

Another from Health Data Management on the breadth of influence that the CIO commands in a healthcare environment:

"Almost uniformly, when it comes to applications, the organization or unit that derives the benefits provides the executive sponsor"
- CIO Tom Martin, UW Medicine, Seattle Washington.

A CIO that has such a "hands-off" policy for the smaller projects is likely to succeed.  By attempting to control the minutiae, conflicts can overshadow the shared success of implementations "done right." 

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

In this week's Health Data Management: Is There a Doctor in the I.T. Department?

Perhaps there should be.  And a nurse too.  Despite their expertise in Information Technology -- and their growing understanding of health-care, our colleagues in IT remain an arm's length or two away from the true workflow and usability issues that are paramount to a well implemented IT project in health-care.

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Tom Bodenheimer has a compelling article in this week's BMJ :

Summary Points:

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Primary care in the United States is facing difficult times: doctors are overworked and dissatisfied with it, and medical students are not very interested in it

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Primary care is unable to deliver everything expected of it and offers neither timely access to acute care nor state of the art chronic care

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A redesign of the primary care sector that addresses these problems is gaining acceptance in the United States

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The redesign envisages the development of clinical teams, open access scheduling, implementation of a new model of management of chronic care, training patients to manage chronic conditions themselves, and group medical visits

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An article about EMR Evaluation Tools.  

More on this later ..

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Found on the Internet: and interesting and well written analysis of quality in Healthcare and how we might enhance the quality of our 'product' with information technology.

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BestTreatments:

We can help you find out which treatments really work. Our information comes from the British Medical Journal's worldwide survey of the best, most up-to-date medical research, used by doctors everywhere.

It's a good site that attempts to marry evidence-based medicine with patient education.  Well. done.

Posted by Jacob Reider, MD at 08:15 AM | Permalink

Stenotrophomonas Maltophilia was in a patient's ear recently. Healthy boy who had 382.01.

hmm ..

Should I treat him with tmp/smx instead of Amox?

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NEJM -- Effects of Estrogen plus Progestin on Health-Related Quality of Life In this trial in postmenopausal women, estrogen plus progestin did not have a clinically meaningful effect on health-related quality of life.

Not only did the WHI demonstrate that there may be health risks of these combinations, this paper (pre-published online - to appear in print on 5/8/03) demonstrates that they don't do much good for quality of life either.

Posted by Jacob Reider, MD at 11:08 PM | Permalink

Data Bulletin No. 24 Between 1995 and 1999, at a time when most wages and salaries in the United States were rising sharply, average physician net income from the practice of medicine, adjusted for inflation,1 dropped 5.0 percent (see Figure 1). The reduction of 6.4 percent in primary care physicians' average real income was particularly notable and greater than the 4.0 percent drop for specialists.

I'll not share the exact details .. but mine's fallen quite a bit more than 6.4%

Posted by Jacob Reider, MD at 11:05 PM | Permalink

 From Pediatrics:

Thickening of formula feedings with carob bean gum is an efficient therapy for uncomplicated GER in infants.

This is a well-done study (yes .. I did read the paper .. not just the abstract!) that was placebo-controlled, and used objective outcomes.  Now .. where does one get "carob bean gum" .. and what is it?

• Carob Tree (St. John's Bread)
• WHO Food Additives series report on Carob Bean Gum
• Carob Beans are available online
• Carob Bean Gum is an ingredient of many foods

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