Hospitalists – a good idea?

When we got the letter from the hospital – offering the new hospitalist service to us .. we told 'em we would give it a try.  So for the past few weeks, if an adult patient of ours comes to the ED, we are supposed to get a call from the ED physician.  S/he will describe the situation, and we will have a choice of whether to admit the patient ourselves, or allow the hospitalist to care for the patient.  They assured us that there would be excellent care and good communication.  So we said we would give it a try.

It makes sense.  We usually have only one or two patients in the hospital.  Just driving there and back takes more time than seeing the patients, so it's a lot of time .. and one could argue that the patients may get better care and/or service from someone who is always in the hospital. 

But ..

Two nights ago, the husband of a patient called because his wife was in the hospital.  She was admitted "with a kidney infection" and now urology said that it wasn't .. and neurosurgery said it wasn't a herniated disc .. but no one had been "in charge" of the visit (from the family's perspective) .. and they were frustrated and angry.

"uhhhh"  says me.  I didn't even know she was in the hospital.  They never called me.  Just admitted her to the hospitalist service. 

So … like any geek-physician, I logged on to the hospital's computer system and saw that her WBC on admission was 6.5 .. and there were scant RBC (no wbc) on a cath urine specimen from admission.  Renal ultrasound was negative, and an MRI of the l/s spine showed mild herniation at L4/5 .. with no nerve root impingement.

Then I visited her in the hospital yesterday morning.  The admission H & P was dictated and very thorough.  From there, the four day admission read like a team of blind men were treating an elephant.  A different hospitalist saw her every day and ordered new tests and new specialist consultations.  She was confused and angry and the bottom line is that this poor woman had back pain.  Frustrating and painful .. but something that probably should have been managed outside of the hospital from the beginning. 

I nudged the very nice physician's assistant who was seeing her yesterday (for the first time) for the hospitalist service to discharge her asap .. and I would see her in the office in a few days.  I sat with her for five minutes and listened … something no one had done in four days .. and she felt much better … eager to go home.

Maybe this hospitalist thing isn't gonna work …

Family Medicine – What is it?

Robert Bowman's been writing an essay called Family Physicians Are Different. It's a compelling reminder. Fall is the time of year that our students start to think about what/who they want to be when they grow up.

For some the choise is easy. For others, they feel like a push-me-pull-you. Such a struggle … their Internist mentors whisper in their ears about the opportunities to subspecialize. OB/GYN describes "comprehensive women's healthcare" (oh puleeze!) and the Family physician is often left explaining how we are different .. without maligning the other specialties .. despite the fact that they all mailign us. Yeh yeh .. I'm whining a bit. But any family doc will back me up here. Our students hear this every day. "Oh .. you don't want to go into family medicine .. you're too smart for that. You should be a _____ ." I heard it all 10 years ago .. and unfortunately, not much has changed.

Last week, a student we've worked with for years confided that she is likely to apply to Internal Medicine residencies. She was scared I would be mad at her.

Of course I'm not mad. But I am a bit disappointed. She reminds me of the student from 3 or 4 years ago who made the same decision – influenced by a very nice, charismatic pulmonologist (who is a friend of mine) to abandon her plans for Family Medicine in order to pursue a "more academic" career. The student was miserable in Internal Medicine.

The limited attention to the social context of the patient's condition, the focus on developing a long differential diagnosis .. etc etc. She transferred after her first year and .. as she reported to me a few years ago .. "Family Medicine Fits like a glove." Family Medicine is very hard to do well, and when I see a student who seems to know the secret handshake, and will fit this specialty well, it does disappoint me that they get enticed by other specialties. But I do my very best to support them and respect their decisions. We don't "win" by having more students go into our specialty .. so we needn't fight over them!

EMR Usability

I've written before about EMR usability.  It's the missing feature in many EMR evaluations.  They all have bullet points:

  • Prescription Writing
  • Problem Lists
  • Medication Lists
  • Allergy Checking
  • Scanning support

And so on … but

  • Is easy to use

Isn't necessarily on anyone's list .. and even if it is .. this is hard to measure.  While usability is subjective .. there should be simple ways for us to define usability.  How many mouse clicks does it take to accomplish a task?  How long does it take to do something?  Vendors brag about ease of use … but it depends on the context, the user's skill level, the hardware that the product is used on .. etc etc etc 

TinyMCE, medblogs, etc

I really don't like the default editor screen for MovableType.  There's no way to do even elementary editing.  Originally, I had HTMLArea installed as my WYSIWYG editor .. then Dave put in FCKedit .. which was fine .. but when I installed MT 3.1, he suggested I try TinyMCE and I really like it.  It took about 30 seconds to install .. (ok .. 30 seconds plus about 2 weeks until I has the time to carefully trace the file location paths to make the javascript load).  For MT geeks, here's how I did it:

  • Download the software and install it to the base MT directory.
  • Find header.tmpl in the /mt/tmpl/cms directory and add this code:

    <script language="javascript" type="text/javascript" src="<TMPL_VAR NAME=STATIC_URI>tinymce/jscripts/tiny_mce/tiny_mce.js"></script>
    <script language="javascript" type="text/javascript">
       tinyMCE.init({
        mode : "specific_textareas"
       });
    </script>

  • Now find edit_entry.tmpl in the same directory and add:

    mce_editable="true" to the textarea definition for the Entry Body textarea … (about line 188 or so .. but your mileage may vary .. )

  • Done!  .. I'd like to get this workin in typepad too .. but not sure if I can get it to work.  Why can't Sixapart just license one of these little editors?  Seems silly that Typepad is locked into plain text entry.

I did a bit of work on medlogs .. added a week's worth of new feeds yesterday .. interesting additions:

e-prescribing

I went to a meeting of the New York Health Plan Association this week. Lots of talk about EMRs and e-rx. For a little review of e-rx .. read this RAND paper.
What's compelling to me is that e-rx and EMR are such separate processes, and very rarely integrate. For example – if I want to implement e-rx, I need to work with a company that is doing e-rx. But most EMR products will happily print or even fax an rx, but this is NOT e-rx .. and if I use a separate e-rx product, I don't generate a medication list in my EMR.

A key component of e-rx is that the states need to figger out how to facilitate this. In general, they are not. It's ironic that I can call a pharmacy and say who I am (even if I call from a pay phone) and call in a prescription for a patient — even a 5 day supply for a controlled substance — yet e-prescriptions are subject to vague guidelines.

Centor Scores, etc

This article in the current Journal of Family Practice is hard to get at, as the site is poorly designed and only subscribers are allowed in. This is odd, since the journal is mailed free to all family physicians. Who are they really keeping out? And there are advertisements inside the site. Today I couldn't remember my password, so I clicked the little thing that told me to enter my e-mail address to have them e-mail it to me. But it didn't recognize my e-mail address. So I figger it forgot who I am .. so I went into the study and found a copy of the paper version not-yet-recycled .. found the billion-digit secret subscriber ID and typed it in. "This account is already enabled."
huh?
So then I have to go back and type in all of the e-mail addresses that I've ever had since 1997 and finally hit on one and then they e-mail me the dumb password.
This isn't how it should work. If I found the long secret number — they should say OK and at least send an e-mail to the account associated with the number – or permit me to edit my record.
Oh … was I posting about the poor usability? no .. sorry ..
… the article was actually quite good. It's a clinical question/answer on pharyngitis, which includes this pretty table on Centor Scores … and a well written little review on the non-controversy on whether to do culture follow-up on rapid antigen assays:

"A retrospective outcome study reviewed the frequency of suppurative complications of GABHS among 30,036 patients with pharyngitis diagnosed with either RAD testing or throat culture. Patients included adults and children in a primary care setting. Complication rates were identical. A prospective study of 465 suburban outpatients with pharyngitis assessed the accuracy of RAD diagnosis using throat culture as a reference. The RAD accuracy was 93% for pediatric patients and 97% for adults.5 In another retrospective review of RAD testing, investigators performed 11,427 RAD tests over 3 years in a private pediatric group. There were 8385 negative tests, among which follow-up cultures detected 200 (2.4%) that were positive for GABHS. In the second half of the study, a newer RAD test produced a false-negative rate of 1.4%.7 Because of the possibility of higher false-negative RAD test rates in some settings, unless the physician has ascertained that RAD testing is comparable to throat culture in their own setting, expert opinion recommends confirming a negative RAD test in children or adolescents with a throat culture.1 Patients at higher risk of GABHS or GABHS complications may also warrant throat culture back up of RAD testing."

The money is in the pre-test probability. The nursery school teacher who called Sunday afternoon with a Centor score of 4 deserved a trip to the office to meet me and get tested (positive). The stock broker who called Saturday with no ill contacts, no kids and a Centor score of 3 was given instructions for symptom relief.