Family Medicine Notes

Drugstores embrace E-prescription system - Computerworld

Half of the 55,000 pharmacies in the U.S. are due to be connected to an electronic prescription system by year's end as part of a nationwide rollout announced Monday by SureScripts, a technology company founded by two drugstore industry associations.

I think it's good that someone's forging ahead with this - but the technical and legal bumps in this road are significant.  I'll see what else I can learn ...

Posted by Jacob Reider, MD at 02:46 PM | Permalink

Dr. Robot Tested at Hopkins

It lacks the warm bedside manner of Marcus Welby or Dr. Kildare, but a high-tech robot being tested at The Johns Hopkins Hospital could be used to link patients with their physicians in a whole new way.

Yeh -- I'm  a geek -- but I don't see adding one of these to my practice any time soon.

Posted by Jacob Reider, MD at 01:15 AM | Permalink

Posted by Jacob Reider, MD at 12:13 AM | Permalink | Comments (1)

The IDF's e-Atlas  shows some sobering data on diabetes - and reminds us that this is a worldwide problem that is getting worse.

This image (from the home page of the IDF) tells the story well:

Diabetes - one of the most challenging health problems in the 21st century Diabetes mellitus can now be found in almost every population in the world and epidemiological evidence suggests that, without effective prevention and control programmes, diabetes will likely continue to increase globally. Diabetes is now one of the most common non-communicable diseases globally. It is the fourth or fifth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing and newly industrialized nations.

Today I discharged a 500 lb patient from the hospital.  He wanted me to tell him why he was so fat.  "I must have a gland problem" he says.

Yes he does.  And it's taken him many years to get to where he is. 

In the context of the Atkins fad - and all of the other low-carb plans - I do think that we - as a species - are predisposed to overeating in the context of overabundance.  Here's how it goes:

2000 years ago (ok -- even 200 years ago!), when we were cavemen and cavewomen, our ancestors would eat whatever they could get their hands on.  IN the fall - when there were more ample supplies - especially carbohydrates - they ate more.  Eating lots of carbs caused insulin secretion - which made their blood sugars fall ... and made them hungry (recall that insulin makes people hungry) ... so they ate more - which was good.  Fat people in November would survive until March.  People who didn't get fat in the Fall would die in February.

So we've evolved with a great mechanism to eat more when there are abundant supplies.

Our overweight patients are not "weak" or inferior - indeed, they have evolved well.  They're Darwin's success stories!

'cept now it's always harvest time.

Posted by Jacob Reider, MD at 02:06 PM | Permalink

Asked tonight at the Soccer parents meeting if we should require the kids to wear them.

Here's the 1st part:  They won't wear them unless they really fit well. 

There are several papers on the use of mouthguards - but I can't find anything that is specific to this question:  What is the incidence of dental injuries in soccer (Football in non-US papers) players - and is that number significantly reduced in players who wear mouthguards?

Posted by Jacob Reider, MD at 01:54 AM | Permalink | Comments (2)

From the Graham Center - this month's "one-pager:"   Family Physicians Make a Substantial Contribution to Maternity Care

I still meet new patients who are amazed that I deliver babies .. um .. well .. I assist in the delivery of babies .. um .. well .. perhaps it is better said that I attend deliveries .. since the mothers are the ones doing the deliveries .. and (one hopes) the fathers/partners/significant others are assisting ... yes .. attend is a good word for the for the physician's role.

Ideally, there is rather little for a physician attending a delivery to do aside from making sure the little one doesn't hit the floor on the way out.   

Posted by Jacob Reider, MD at 01:19 AM | Permalink

This study reminds us that at least 30% of diagnoses of AOM .. are not AOM.

This review also reminds us that the standard course of treatment if one chooses to use antibiotics (and you all know that I do not as 1st line treatment) is 5 days rather than 10.

I remain surprised (as I have in the past) that so few physicians are using the acoustic reflectometer.  This devide is much cheaper and much easier to use than the tympanometer - and gives very good results.

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

Frog egg reveals malaria drug mechanism spreads. : New target might spawn better drugs as resistance.

I just thought this was interesting,  Maybe you will too.

Posted by Jacob Reider, MD at 12:07 AM | Permalink

Posted by Jacob Reider, MD at 11:55 PM | Permalink

I've been wondering why the reps are "reminding" us about the virtues of atorvastatin so much in the past few weeks ... aha .. CRESTOR is out .. rosuvastatin was approved by the FDA last week.  And now there are Six (not counting Baycol).

Posted by Jacob Reider, MD at 11:48 PM | Permalink

Barbara Supanich, R.S.M., MD - Associate Professor, Michigan State University, Munson Family Practice Residency, Traverse City, Michigan - has developed a great tool for use in residency education.  

The pharmacy representative evaluation form (.doc) (pdf) can be used to help physicians to critically evaluate the information provided to them by pharmaceutical representatives. This is an excellent tool that may even be useful to those who are no longer in training.

Posted by Jacob Reider, MD at 03:33 PM | Permalink | Comments (2)

Posted by Jacob Reider, MD at 11:07 AM | Permalink

I've shared my bias before ... so I won't bore your with it again ... aside from this NY Times link: Panel Urges Shift of Focus in Preparing for Smallpox.   

The vaccine is too dangerous — both to the people receiving it and to those with whom they have close contact — and the risk of an outbreak too small to justify wider use, the panel said.

I agree. 

Posted by Jacob Reider, MD at 11:38 PM | Permalink

Joel on Software is one of the websites that I occasionally read.  Joel writes well about technology and business -- and his foreward to Rick Chapman's new book is compelling, and relevant to medicine.  Joel's argument is that developers should run software companies because the "get it" in ways that non-developers simply wouldn't or couldn't .. and so will avoid the mistakes that the "non-geeks" would make.

I'll make the same statement for medicine -- and even IT in medicine: 

a) Medicine is not "just a business."  As I mentioned last April, there is more to what we do than make money.  If we really are here  to enhance the quality of the lives of others -- then our leaders must have the same core beliefs as we do.   Making money is scondary - providing our services is primary.  Yes, we need to pay the morgage - and the salaries of the nurses, and the phone bill, etc ... so ... yes, we need good business skills.  But good business skills are not enough.  In healthcare, there needs to be a passion.  Yes .. healthcare is not unique .. and there are many professions that share similar qualities: education, some legal services, clergy ... ? journalism? 

 
b) Decisions in healthcare technology can't be made by mainstream IT managers without experience in healthcare.  Why not?  For the same reason that Joel asserts that programmers should run software companies.  One shouldn't have want to have to explain to an IT executive what a CBC is ...  nor should one have to explan the difference between Java and Javascript.  "duh" says the physician/nurse/PA ... "duh" says the geek ... but who knows both?  Sadly, there are rather few. 

My neighbor is a manager for a big company that makes steam turbines for the Navy.  He manages a team of workers, and ... for the most part ... he really understands what the workers are doing.  He tells me that he would have a hard time managing them if he didn't quite get what they were doing.

Managers of software developers have a much tougher time.  They can't always know the details of the work that the workers are doing .. since technology is moving so fast that the workers will nearly alwasy know more about the technology than than the managers do. 

? or do they?  Shouldn't a good manager keep up on this?  Just as a good physician will always keep up on the most recent research?  If web develoeprs start using Flash rather than DHTML .. shouldn't the manager learn about flash too? 

Posted by Jacob Reider, MD at 11:24 PM | Permalink | Comments (2)

We've finally migrated off of Relayhealth.  It was good while it lasted. but overall, I found that we used only 20% of the functions.  I was also frustrated that the system had no way of merging the messages in Relayhealth with our EMR.  This is ironic, of course, since practices "on the cutting edge" would be the ones more likely to be using relayhealth AND using an EMR .. so one would think that Relayhelath would want to give us a method of getting those records into the EMR. 

Nope. 

"Print them" was what their (nice) customer service rep told me last year.  

So ...  as usual .. we built our own.  We call the system the Slingerlands Family Medicine PatientSite ... at .. www.slingerlands.com.  Slingerlands is the name of the small town near Albany, New York where our practice is located.    Yep .. I registered the name back in the bad old days when no one knew what the Internet was.  Thought it would come in handy some day.  If you are interested in how the system works, please send me  a message and I'll e-mail you a test username and password.  It's pretty simple.

Posted by Jacob Reider, MD at 08:02 PM | Permalink | Comments (1)

Google Web Search Features holds a function that is hidden yet wonderful.  Convert metric to US .. easy ... type "45 kilograms in pounds" into google's search form and get the answer.

Neat.  Very useful for calculations too.  To Do a BMI, for example .. WT (lbs) / height (inches) squared * 703. So mine is 165 (yes, I need to exercise more) / 70 * 70 *(703) = Google calulates Jacob Reider's BMI.

Posted by Jacob Reider, MD at 07:55 PM | Permalink

Posted by Jacob Reider, MD at 11:47 PM | Permalink

Patient info handout on premature thelarche?

Posted by Jacob Reider, MD at 12:36 PM | Permalink

New computer system gives hospitals quick access to patients' records - Thursday, 08/07/03

Nashville health-care entrepreneur Ken Perry says that if hospitals ran more like restaurants, they could make more money and their patients would be happier.

He's right.  But Moving quicky in healthcare IT is tough.  physicians risk adverse .. and our IT Colleagues are even MORE risk adverse ... so moving forward quickly is very tough indeed.

Posted by Jacob Reider, MD at 10:46 AM | Permalink | Comments (1)

Pediatrics -- Abstracts: Titus and Wright 112 (2): 282

The risk of SBI in febrile infants with RSV infection seems to be very low, particularly in comparison with a control group of RSV-negative infants. These data suggest that full septic evaluations are not necessary in nontoxic-appearing infants with a positive RSV test. It seems to be prudent to examine the urine in these infants, as there is a clinically relevant rate of urinary tract infection.

This study confirms that the standard of care for children with RSV is symptomatic.  We needn't chase our tails doing a full septic workup in these kids.

Posted by Jacob Reider, MD at 10:31 AM | Permalink

Sometimes I look at the referrer logs to see why/how people find the website.  Today's most popular search terms:

What does this mean?  I'm not sure yet .. but it's interesting .. and interesting in the context of Steve's persistence in attempting to get Dave's attention for medical weblogs at BloggerCon.  Maybe we'll have to storm Cambridge some Thursday. I grew up about 4 blocks from where they have the meetings ...

So .. egged on by Steve .. I sent Dave an e-mail about why medical weblogs are good:

 

From:	Jacob Reider
To:	(Dave with cc to steve)
Date:	Thursday - August 7, 2003 11:28 PM
Subject:	RE: Invite: BloggerCon, Harvard Law, Oct 4

Steve .. thanks.

Dave ... we ARE wondering about how you feel about the medical weblogs. Seems thay you've not felt they would be an interesting adjunct to BloggerCon.

You may wonder ... so what?  

hmm ...

a) People look for medical information on the Internet:  

   "Searches for medical information:

Fully 80% of adult Internet users, or about 93 million Americans, have searched for at least one of 16 major health topics online. "


b) The physician-patient relationship is a tenuous partnership ... ideally with shared decisionmaking and a carefully navigated intimacy. Yet the history (and many patients' experiences) of the profession have defined a different landscape:  one of potential mistrust, fear, and power struggles (whether real or imagined).

Medical weblogs come in many forms, but they all serve one common function:  they enhance the transparency of the work we do.  Whether this is through vignettes of daily experience .. or tidbits of medical news ... or even .. yes .. a bit of ranting ... they REVEAL our inner thoughts, our research, our fatigue, our failures and our excitement. 

Before medlogs ... most of this was hidden from the majority of Americans .. aside from the occasional PBS documentary.

That's why medlogs are interesting and important.

</medblogs sales pitch>

Posted by Jacob Reider, MD at 01:17 AM | Permalink

uuh .. no ... not yet.  Annals of Internal Medicine: Article Benefits of Losartan in Patients with Hypertension and Left Ventricular Hypertrophy but No Vascular Disease.

Fewer patients in the losartan group had strokes and developed diabetes. Similar numbers of patients in both groups had heart attacks. More patients in the atenolol group (10%) had drug-related side effects than did patients in the losartan group (6%).

So .. fewer strokes .. same # of MI ..less diabetes.

Posted by Jacob Reider, MD at 01:37 AM | Permalink

From down-Under (with full text of the article available free): Diagnosis and treatment of hand-arm vibration syndrome: And its relationship to carpal tunnel syndrome

I have a patient with this disorder.  A 45 year old who worked as a custodian and used a floor buffer for 20 years.  Now he can't use his right arm at all, and the use of his left arm is severely limited. 

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

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

Corey Nahman is a pharmacist and former pharmaceutical marketer. His website is a cross between a newsfeed aggregator and a weblog and a commercial news website. With too much advertising and a so-so user interface (should I throw stones?  I'm no Jakob either!) it is hard to get right to the meat of the site - which is actually a rather good source of links to useful medical and pharmaceutical information on the Internet. There is no RSS feed (hint, hint) - although it seems that the content of the site is available by contacting the webmaster - so I assume that this means that this means it would cost money.

Posted by Jacob Reider, MD at 11:24 PM | Permalink | Comments (1)

Carvedilol Or Metoprolol European Trial (COMET)

If you really want to look smart, you know the cool name of the trial in addition to knowing what it means, and why it's important. 

The COMET trial is important because it suggests that there may be something special about Carvedilol as compared to a generic beta blocker for the treatment of heart failure.  Now .. is a 6% difference in outcomes worth the millions of dollars we'll spend on this medication rather than metoprolol or atenolol?  Hmm

Posted by Jacob Reider, MD at 12:57 AM | Permalink

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

Pediatrics -- Abstracts: Paradise et al. 112 (2): 265

In otherwise healthy children who are younger than 3 years and have persistent MEE within the duration limits that we studied, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at 4 years of age. In such children, persistent MEE within the duration limits that we studied is negligibly associated with and probably does not affect developmental outcomes at 4 years of age.

Soooo ... from the Mecca of otitis media research comes a paper on how interventions does not improve outcomes.  A welcome feather in the cap of those who prefer to wait till this goes away.  So in the past 15 years, the treatment of persistent MEE has been

• 1988: Antibiotics - and t-tubes if no resolution
• 1994: Observation - and t - tubes if no resolution
• 2003: Observation and more observation if no resolution.

Primium non nocere!

Posted by Jacob Reider, MD at 02:21 AM | Permalink | Comments (2)

Posted by Jacob Reider, MD at 01:37 AM | Permalink

CDC - Antimicrobial Susceptibility Breakpoints and First-Step parC Mutations in Streptococcus pneumoniae: Redefining Fluoroquinolone Resistance

"Since effective surveillance depends upon the ability to detect the emergence of resistance, the prevalence of pneumococci that harbor resistance mechanisms to the fluoroquinolones may not be accurately represented if surveillance systems that rely on levofloxacin MIC data are used."

The article is a bit hard to follow, but it's important -- so worth the read.  My quick summary:  The method that is currently used to determine quinolone resistance is innacurate, and cannot adequately measure what we intend to measure. 

In summary, levofloxacin susceptibility testing that uses current MIC clinical breakpoints does not identify most S. pneumoniae isolates with only first-step parC mutations. This finding may not only have implications for the ability of surveillance programs to detect emerging resistance, but therapeutic implications as well.

Tharaputic implications indeed.  Despite great populatiry, I've never embraced quinolones for the treatment of anything other than gram negative UTI's (as a second-line agent, of course!). 

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