Family Medicine Notes

medpundit is opening a new practice.  I hope that she does well.  One of my favorite readers commented the other day that Docnotes doesn't have much of the personal thoughts of a family physician anymore .. and as I read the last few weeks/months .. she's right. 

Here goes:

1) Our practice is going well, but I'm finding it harder and harder to keep up.  My efficiency in the office leaves something to be desired.   The nurses say that I'm too slow ... but the patients, of course, disagree.  Nonetheless, this is the perpetual stuggle of primary care.  Spending time with patients does not pay the rent as well as not spending time with patients.    I enjoy the diversity of family medicine, but this diversity also creates complexities of relationships and temporal demands that can pull me in 8 directions at once.

2) Electronic Medical Records.   Our practice is part of a larger group that is in the proccess of making a decision on am EMR vendor.  It's very tough.  when the group started - about 5 years ago - chey chose the practice management system over others because of the promise that the EMR would provide an integrated PM/EMR system.

It's well known that our EMR is weak.  In our office, we've been using it for two years, and while I would agree that there have been incremental improvements, it remains a very difficult system to use on a daily basis.  While the family physicians and pediatricians seem to agree that this is the case, our internist colleagues disagree.  They feel that this product is just fine.

We're looking carefully at Practice Partner as an alternative to the system.

Family physicians and pediatricians seem to prefer Practice Partner.  Internists seem to prefer the other one. 

Hence our challenge in making a decision.  It's clearly more expensive to implement Practice Partner - as we would need two servers and the pricing of our current product - since it's bundled with the practice management system - would be much less.

But a less expensive option is not always better -- especially if it's not usable.

While usability may seem to be less important to some ("it's a training issue") .. I consider usability to be one of the most important features of a system.  If I can't use it, any money spent at all would be wasted. 

Final decision comes from our elected board of nine physicians: three FP, three peds and three IM.

I'm so fed up with the Misys product that I think I'll have to go back to dictation if Practice Partner isn't selected.  ugh.

Posted by Jacob Reider, MD at 11:40 AM | Permalink | Comments (1)

A new article on Bandolier: Pneumococcal vaccination update

These results are broadly consistent with results of several meta-analyses of randomised trials, none of which showed any effect of pneumococcal vaccination on pneumonia

  AHRQ doesn't say much about pneumoccal vaccine.   From the study cited in Bandolier, it looks like there was no reduction in pneumonia or hospital admissions, but there was a reduction in pneumococcal bacteremia.

Posted by Jacob Reider, MD at 10:28 AM | Permalink

Dave Winer's uncle died suddenly the other day.  One of my patients - (and the son of a good friend) died suddenly yesterday - and I've not been very functional since. 

Sam and I are off to Atlanta today for the STFM meeting.  We're going to the Braves goame tomorrow afternoon.

Posted by Jacob Reider, MD at 08:41 AM | Permalink | Comments (2)

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Amazon.com: Books: How to Good-Bye Depression: If You Constrict Anus 100 Times Everyday. Malarkey? or Effective Way?

And a comment from a reader: "I am afraid I must chime in and say that I didn't find this book very helpful. It was  recommended by my doctor, whom I now regard as somewhat of a quack."

OK .. so I won't be suggesting that anyone buy this book any time soon ;-) 

Posted by Jacob Reider, MD at 10:45 PM | Permalink

I've signed up with Google's AdSense to see what all of this advertising talk is all about.  There are now ads at the top of all archived posts.  No ads on the main entry page  - so I've not sold out entirely.  Most of the ~ 400 or so hits to the site every day  come from search engines, and point to individual posts.  Google puts up ads on those pages that are relevant to the searches.  There's no way for the ads to influence my writing (as would be the case with explicit sponsors), and it's reasonably easy to remove if I get lots of hate-mail.  Perhaps it will generate the $7.95/month that I pay for hosting docnotes on pure nrg's servers. 

Posted by Jacob Reider, MD at 10:06 PM | Permalink | Comments (1)

Steve remains a great motivator.  I've posted a first draft of a Medical Weblog discussion description on Dave's BloggerCon discussion forum.

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Much to say -- I've been idle here for a few days.

First - this paper in Mayo Proceedings provides a well done overview of the genomics research of the last few years - and how it may be relevant to real-life practicing physicians.    It's a primer on genetics, and I agree that it is probably required reading for most of us.

I'll admit that I have not been blown away with the relevance of genomics to my daily life. The residency director of one of the residencies at the Academic Miracle Center here has a habit of telling anyone in the room that all of his residents are required to know genomics in detail "because it will impact their practice so much."  I won't say who he is .. but I will say that his residents don't agree with either statement.

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

This report (RealAudio) on NPR's Marketplace yesterday, highlights a component of the current generic drug system that I wasn't aware of.  This is another reminder that the laws in this country on pharmaceutical production and distribution favor the big guys .. not the little people.

Posted by Jacob Reider, MD at 08:09 AM | Permalink | Comments (3)

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Here's the result of my PubMed search on trigger thumb in kids.  There remains no concensus on what is the best method of treatment.  I've referred him to the local hand surgeons - who specialize in adults.  They suggest no spinting and observation until at least 1 year of age.  This seems fine, but several studies suggest that spinting may actually help. 

In the absence of a good evidence, expert opinion may be my best bet.  I think I'm going to call Boston.

Posted by Jacob Reider, MD at 01:14 AM | Permalink

Kent has updated shots again to the 2004 version.  It remains free.

Posted by Jacob Reider, MD at 11:29 AM | Permalink | Comments (1)

Ken Ong's article on  Just-in-time Database-Driven Web Applications appears this month in the Journal of Internet Medical Research.  It's an excellent look at how web-based applications can facilitate improved work processes in a medical setting.   In the hospital and in our office, we've built many web-based applications, and I would agreee with Ken that this technology fits our needs quite well.   The powerpoint presentation at the end of the paper is also an excellent overview of many of the applications they are using internally at SVCMC.

Posted by Jacob Reider, MD at 10:15 AM | Permalink

Tim's response to the post last week about e-prescribing (and duct tape) deserves a few words:

1. Tim mentions that expresscrips has been doing e-prescribing for some time .. and he's right .. and in fact several other vendors have been doing things like this for a few years, but this initiative is different.  Why?
• They claim that most US pharmacies will be connected.
• There will be methods for physician practices to electronically transmit prescriptions to the pharmacy directly.  One EMR vendor has already announces support.  More will soon follow.  This thing seems to have more momentum than any previous e-prescribing initiative I've seen.
• It's not linked to one system like express scripts or PCS
• There may be methods for practices who are not "e-enabled" to transmit prescriptions to a pharmacy.  we'll see who they partner with in the hand-held arena.  Don't be surprised if it's epocrates or e-physician.
2. Tim asks about Duct tape for warts.  Sicne this post last fall, I've used duct tape in my practice many times.  I can say that my results are similar to those that are reported in the study - though I'll admit that my "n" has been rather small.  Probably fewer than 20 patietns in each group.  One man had warts on both knees - we duct taped the left (a small square of duct tape on the wart - changed every few days - until the wart is gone - usually 3 weeks or so)  .. and used cryo on the right.  The result?  Both warts were gone in 3 weeks, but the cryo took 3 applications.   I always bring up the Duct tape option now, and will often use cryo on the 1st visit (patient is already there) .. and suggest either duct tape or one of the OTC Salicylic Acid products such as wart-off .. and if things don't improve -- a return visit in about a month.  For warts anywhere other than the feet, the duct tape seems to work very well.  Plantar warts remaim tough to treat.

Posted by Jacob Reider, MD at 09:52 PM | Permalink | Comments (1)

This Survey published in the Journal of Urology highlights a common problem that we often miss in primary care.  In our practice, I can think of several kids who have been trained by their schools to "hold it" for so long (as such a young age) that frequent problems have ocurred. 

Perhaps we need to do a better job at teaching the teachers. 

Posted by Jacob Reider, MD at 09:21 PM | Permalink