Family Medicine Notes

Tonight I was in the hospital seeing a patient ...and a nehprologist colleague stopped me in the hall and we blabbed for a few minutes.

I asked him about a patient of mine who has IgA nephropathy.  After 10 years without any trouble, she developed mastitis  (btw - this link is a great review of mastitis and its causes and management) and then developed gross hematuria.

His first thought was that this was odd because he usually sees "IgA nephropathy worsening with infections of organs that involve .. IgA .. like the lungs."   Then I reminded him that breasts sure do involve IgA.  

Interestingly, there are only two case reports of mastitis causing exacerbations of IgA nephropathy in the literature.  Perhaps we need a third. 

So then he teaches me about suggesting fish oil to my patients with IgA nephropathy. 

uh .. since the prevalence is about 1:4500, it's not likely I'll have more than 1 patient with IgA nephropathy for a few years.  Ther are about 3000 patients in our practice -- of which about 1,000 call me their primary care physician.

Nonetheless, it's something that I'm interested in.  If fish oil will really alter the progression of this disease ... I'm all for it.  Here's a great review  (pdf) of the state of affairs with fish oil and IgA nephropathy.

Posted by Jacob Reider, MD at 11:53 PM | Permalink

My patients google me .. which isn't a surprise (hi folks!) ...  Here's a weblog written by someone who prefers to remain invisibe. 

Invisible Adjunct: Everybody Googles Everybody

Posted by Jacob Reider, MD at 09:39 PM | Permalink

The Momdocs project is moving along a bit.  We originally built it because we use an Emr with not-so-good prenatal module. A few years ago, this company lost out to GE in a bidding war for Logician.  The plan, of course, was to throw their old EMR in the trash and use Logician.    Now there are rumors again about this company in the market for another EMR ... I wonder if these rumors have any basis ...

Anyway ...  Momdocs was an effort to make a perinatal record that didn't take forever to manage.  The Misys EMR simply can't build a record that the hospitals would accept.  So we were filling out the ACOG sheets by hand -- transcribing them from the EMR when our patients were approaching delivery.   It's too bad that we had to create another home-grown solution, but momdocs - like everything else we've built - is user-focused.  

The residency program is using it more and more, and I've not had much feedback ... so I guess that means they like it.

You can try it too ... log in with username:demo and password demo.  Looks like Barney Rubble is overdue.  We'll need to induce him soon.

Posted by Jacob Reider, MD at 12:10 AM | Permalink

If we think about what physicians do, the physician-patient interaction is what springs to mind first.  

But ... we do other things too ...  how much else?

We've had our home-grown messaging system in place for about 18 months now, and I just did a little analysis of some of the data in the system.   We use the system for phone messages and patient - initiated e-mails.   When a patient calls with a question, a message is generated to the nurse or physician.  It's much better than paper messages - which we outlawed in the summer of 2002.   An average of 71 messages were generated in the system per day.  We have 2.5 physicians (2.0 until 11/03) and 2 nurses.  The 2.5  physicians received an average of 42 messages a day  -- so about 15 messages per physician.

Some messages are just FYI:  patient calls and nurse gives advice, sends FYI to physician.

Other messages represent work to be done -- either calling a patient or calling a physicians or (ugh) calling an insurance company.  This varies, but I find that when I call home with my ETA for dinner, if I have more than 10 items in my "in" box, It'll be more than 40 minutes to get home (I live about 90 seconds from the office).

The other work we do is review labs and make calls or send messages based on the lab results.  Our labs are scanned in to our "in" box as well.  In the same timeframe, we have scanned 42,562 pages -- about 170 per day (about 70 per physician per day).  Reviewing these takes time too.

When we did this work in the paper world, it was all represented by a pile of paper on the desk.  Now we can quantify how much work this represents, and perhaps we can figure out how much time to expect this to take -- which would ultimately determine how we budget our time and human resources.

.. no wonder I'm up so late ...

Posted by Jacob Reider, MD at 11:50 PM | Permalink

Access ePocrates Rx Online for free during the month of February, 2004..

Click here: http://openhouse.epocrates.com

epocrates is a staple of physician practice in 2004.  Like most physicians - I use it many times every day.  Our nurses have started to use the desktop version (web-based) and it's one of the three or four applications always open on their desktop. 

"normal humans" can take a look at it too ... as the free trial is open to everyone.

Posted by Jacob Reider, MD at 07:17 PM | Permalink

A month or so ago, I discussed (via e-mail of course) an idea with Enoch.  Here goes:  Develop a mechanism for providing Continuing Medical Education credit to physician readers of medical weblogs.  I suppose that nurses and NPs/PAs could do the same .. and I'm happy to help with that .. but our inital idea was to focus on the physicians.  Dr Bob already offers CME on his weblog, but it's a challenge to follow the path toward that credit .. and since he's an Internist - he can't offer AAFP credit - which is important to me (and my family physician colleagues).

Here's my proposal ... now that we're nearly ready to begin working on it.   We'll change medlogs.com a bit to highlight Medical weblogs that provide CME. 

Huh? ... ok .. here's goes ...

We identify 12 medical weblogs that qualify as high quality sources of medical information that would qualify as CME.  Sure .. if we have more than 12 .. that's ok, I suppose.  We'll need to form a core group of us to determine some criteria for inclusion  Pennie?  Bob? Enoch? Steve? ...

• We make sure that these weblogs meet the ACCME's ciriteria for web-based CME. 
• We define the GNOME for the learning experience
• Goals:  what we hope the learner will accomplish
• Needs: What do they need to reach these goals
• Methods:  How will we do this
• Objectives: What are the measurable events that we can track on the way toward the goals?
• Evaluation:  How will we evaluate what the learner has learned .. and whether our process was implemented properly.
• We identify 12 medical weblog authors who will volunteer to be responsible for a given month of the year.   Each volunteer would review all 12 weblogs every (week? 2 weeks? month?) and would develop a quiz that would test the participant's learning - and survey the particiant on the quality of the CME activity.
• We've got quiz-making software here at AMC, so it won't be too hard to get the feedback and quiz done every month.
• Splitting this up among 12 people will minimize the work we have to do individually.
• We'll need to do some work on this end to file the appropriate paperwork to be able to grant CME credit. 

Please post feedback to this post and/or send me a message if you would like to volunteer to be an author/collaborator. 

Posted by Jacob Reider, MD at 04:06 PM | Permalink | Comments (3)

This British Journal of Cancer paper suggests that childhood infections may prevent leukemia. 

The study was deigned to determine risks .. so we can't really draw any conculsions about prevention.  But it's an interesting idea.  We'll keep our ears open ...

... and it seems intuitively related to the literature on allergies .. and the observation that the cleaner we live ... the more likely we are to develop allergies. 

Posted by Jacob Reider, MD at 01:57 AM | Permalink

A few notes today ...

• Aside from the entries in which I mention not-to-be-mentioned body parts, this post from nearly two years ago is one of the most linked-to posts I've written.  I like it too.  Kinda poetic, eh?  .. and if you ask "googlism.com" what Jacob Reider is ... the answer comes from this post.  I now know what I am .. or at least what I'm doing! 
• I have a heckler now that my wife  has found the weblog.  Sorry ... Cerumen = "ear wax"
• Jacob's famous chicken surprise .. goog and good for you.
• Handful of frozen chicken breast strips.  Get a 5 pound bag at BJ's or Costco for $10 
• Plop into hot cast-iron skillet .. fire on at med-hi
• Splash of Olive Oil
• ok ... another splash of Olive oil
• Blob of mild salsa ...
• Splash of V8 juice
• 2 oinions - sliced well.
• Get the onions UNDER the chicken now ... cover and cook for about 15 minutes.  As Maura always said ... "Chicken is not like a burger ... you don't need to flip it"

Posted by Jacob Reider, MD at 01:42 AM | Permalink

CFBlog v.005 is Dave's next big hit.  It's built on Mach II.

Here's a spec-on-a-napkin (the best kind)

• Imports Radio and MovableType
• Generates RSS 2.0
• Won't Generate Atom (just to spite them!)
• Tackback
• Searching
• Multiple Blogs
• Multiple Authors
• "easy" mode with layout templates, etc (like Radio or TypePad)
• "hard" mode with customizable tags .. this will require basic coldfusion skills.
• Support for static or dynamic page generation
• RSS subscription (supporting the creation of mini-aggregators)
• Make breakfast
• WYSIWYG editing for posts and comments
• Spam-proof comments
• Support for categories

Posted by Jacob Reider, MD at 01:04 AM | Permalink

Posted by Jacob Reider, MD at 12:54 AM | Permalink | Comments (1)

Dave responded to my post below.

I didn't have my facts right.  Dave called his primary care physician first.

I posted a response to the Boston Common weblog   post  (and his response) ... here's what I said:

Dave is sharing some tidbits of his personal life with us, and I shouldn't chastise him for doing so .. I should applaud him. This sort of transparency is educational. Dave is teaching ... and I suppose my goal was/is to teach as well.

Dave - I didn't mean to infer that you were casual about your care. My inference (albeit incorrect!) was that you -- like many -- have been taught -- by a system and culture that values specialty care above primary care -- to seek specialty care before the problem was evaualted by a family physician or general internist.   As point out, I was wrong about how this panned out.  Given your "celebrity" status, and your willingness to share these details of your personal life with us, I used this event as an example of a component of our healthcare system that I believe is dysfunctional.

It turns out that the example was a rotten one, but my sentiment about the dysfunctional system/culture remains the same.

Most patients who reach out to me are seen promptly and are referred to specialists only when necessary. Yes - we see patients on Saturday and Sunday and even at night.  Had you called me, I would have offered to see you in the office.  This is the core of what we do - we are the primary care physicians and we specialize in primary CARE -- not primary referral. We take care of very sick people and very well people. Young, old, pregnant, depressed, sexually active and impotent.

As one who teaches family medicine to medical students, I struggle with the biases against primary care every day. Specialists tell our students that family physicians are "stupid" or that the only role we should have is to "pop the pimples on farmers' butts and refer the rest of the patients to appropriate specialists." No kidding .. this came right out of one of my specialists colleagues' mouths.

My comment speaks to a culture of medicine -- and the role of primary care in how we treat our patients.

Yes .. I have a bit of a chip on my shoulder. (see above re: farmers butts). Primary care physicians are the Rodney Dangerfields of medicine.

We earn respect in an 8 x 10 room with our patients one-by-one-by-one. My post starts with a comment about Dave's encoiunter, but if one reads the whole post, you can see that I discuss much more than that.

Some places - and Harvard is one of them - have developed a culture that remains specialty -focused. I grew up in Boston - where I didn't know what a family physician was until I was 18.   Boston was one of the last of the major cities to host a residency in Family Medicine (There are several in the Boston Metro area now), and there remains NO family medicine education at Harvard. See this note in Harvard Medical School's weekly paper about the dearth of family medicine education at Harvard, and how unhappy the students are about this.  

Finally - since we're all in this to educate ... here's a link explaining why you shouldn't use q-tips in your ears .. and a reminder (I've posted on this one before) that colace (Docusate Sodium) is very good at softening earwax.  I sometimes suggest that people use this once a week to avoid impaction problems alltogether.

Posted by Jacob Reider, MD at 11:14 PM | Permalink

Posted by Jacob Reider, MD at 03:56 PM | Permalink | Comments (1)

Dave needs a good primary care physician.   His post today reveals his ignorance of the importance of primary care.   This is common in people who are wealthy and/or have "very good" insurance that gives them access to specialty care without referral.

I'm not saying that specialty care is bad -- but I can't even count on my fingers how many times each week I provide services to someone who initially called asking for a referral.  This week's struggle was a dad who called and demanded an emergency referral to a dermatologist for the rash that his daughter had for the past 6 weeks.

"Now .. nothing against you, doctor, but I think that this condition has gotten so bad that we need a specialist."

"I'm happy to refer you to a dermatologist if that turns out to be necessary - but since I have not seen the rash - nor have you even called me about it - it's hard for me to tell the dermatologist why I'm referring the child to him."

"Well you saw her in October for her well-child visit and you said she was fine."

"uuh .. yes .. was she not fine then?"

"Yes she was but now this rash is real bad and we want to make sure it goes away."

"We all want the rash to go away.  I'm happy to see her today and if I can't help you, I will be sure to refer her promptly to the dermatologist."

The child has eczema.  I did a quick google search and found some good handouts to reinforce my counseling and diagnosis.  It's unlikely we'll need to send this kid to derm. 

When I was 15 and living in Cambridge, I scratched my cornea with some sawdust as I was cutting something with a circular saw.  Like Dave, my parents decided that the "experts" would be best to evaluate this and drove me down to the Medical Mecca and I received appropriate treatment for this very common problem. 

So what? 

Like Dave - I could have received appropriate treatment for this problem by any competent primary care physician.   This would have been a better use of the limited healthcare resources that exist in this country.   I treat scratched corneas and impacted cerumen all the time.  So do most primary care physicians.   These propblems are not rocket science - nor do they require the services of specialty care.

The Boston area is hyper-specialized.  There are relatively few primary care physicians and an overabundance of specialists - which is a function of the overabundance of wealthy, educated healthcare consumers, and an abundance of training programs.

While I would agree that the folks at the Mass Eye and Ear Infirmary may be some of the best in the world at what they do - we should only use them when we have conditions that the primary care physicians can't handle.  A good primary care physician would have removed the cerumen from Dave's ears, and would have given him the same lecture about not using q-tips as he received from the specialists.

The disjointed care that people get from a horde of specialists is clearly worse care than the care they get from one primary care physician. 

Yet there remains a perception that the care they provide is better.  We can't combat this work our words - we have to re-educate our patients by providing the comprehensive, care that they deserve. 

IN the context of my patients requesting specialty care - I've been seeing more specialists in MY office.   Caring for another physician is always challening, and initially, this was intimidating to me - yet I've become better at navigating this complex relationship.  Like the otolaryngologist or the ophthalmologist or the CT-surgeon, I am a specialist too - in primary care. 

Posted by Jacob Reider, MD at 02:50 PM | Permalink

isography is my brother's website.  Yesterday he posted a wonderful review of his efforts to record TV shows at home without buying a Tivo.

Very well done.

Posted by Jacob Reider, MD at 12:14 AM | Permalink | Comments (2)

This week in BMJ : how frequently should we have patients follow-up for management of hypertension?

• Every Month
• Every 3 months
• Every 6 months

?

Posted by Jacob Reider, MD at 08:20 PM | Permalink

BMI Calculators from the CDC.  Very useful.

Posted by Jacob Reider, MD at 11:41 PM | Permalink

From Gut:

... after adjustment for the covariates age, sex, erosive oesophagitis, hiatus hernia, degree of gastritis, and severity of symptoms at baseline, H pylori eradication was the only predictor of treatment failure.

This is quite interesting.  I don't have access to full-text of this article - so let's not jump on this bandwagon just yet - but it's an interesting topic - and a common clinical problem.

Posted by Jacob Reider, MD at 11:30 PM | Permalink

The title is a joke.  I can spell pretty well.  I just can't type - especially on this little keyboard on my Tablet. 

Microspell looks like it may work for me.  I used to use IEspell, but it's slow and hard to access from mt's edit-entries windows.  Microspell copies over the whole text of an entry, helps me to edit out the typos and plops it back. 

We'll see. 

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

Dr Bob's entry On obesity provokes response.  Like several of those who comment on his entry - I applaud his honesty - and will come clean like he has:  when we care for patients who have been participants in their illness, it is tempting to blame them, and in our weaker moments, we do. 

Bear with me here ...  

Addiction is a powerful disease - whether to drugs or tobacco or food.   Working with addicts is challenging.   We try so hard to listen, understand, counsel and advocate.

Posted by Jacob Reider, MD at 11:18 PM | Permalink

Dr. Bob rants about how we interact with patients and how we interact with each other.  He says that we need to model professionalsm, and I would concur.

How we act at the bedside is an entirely different discussion which we may have another time.

Now seems like a good time, eh? 

Last summer, I made note of Carl Gandola's weblog.   Like Dr Bob, Carl is an attending physician in a residency program.  Carl describes sitting down at the bedside and listening to his patients.   While the quote on Dr Bob's post today may be accurate ("some doctors put on a better show than others") ... listening can't be faked.  We say much more with our actions than with our words:

We know that physicians interrupt their patients:

Patients spoke, uninterrupted, an average of 12 seconds after the resident entered the room. One fourth of the time, residents interrupted patients before they finished speaking. Residents averaged interrupting patients twice during a visit. The time with patients averaged 11 minutes, with the patient speaking for about 4 minutes. Computer use during the office visit accounted for more interruptions than beepers.

I find that I sometimes bite my tongue (literally!) to remind myself to keep quiet.   I've posted on this in the past as well  .. so follow the link and take a look if you like ...  it's a real-life example of how listening just a little can save a lot more time and money than you think.

Posted by Jacob Reider, MD at 08:06 PM | Permalink

We family physicians don't know everything ... and if we knew it once .. we may have forgotten.  Clincial problems that we don't see often will cause us to make referrals to specialists - and this teamwork is often a good model for patient care.  Yesterday's call to a local pediatric hematologist reminded me of a simple formula I learned in medical school, but hadn't used in 10 years. 

Mentzer Index = MCV/RBC
Ratio < 13 then the patient most likely has Thalassemia
Ratio >13 then the patient most likely has iron deficiency anemia

Though we often look at a low h/h and low MCV and think iron deficiency right away ... recall that ferretin is a better measure of iron deficiency ... and the Mentzer Index can always help us to identify Thalassemia.  Remind me of this in 2014 ...

Posted by Jacob Reider, MD at 09:57 PM | Permalink

Posted by Jacob Reider, MD at 09:25 PM | Permalink | Comments (1)

I started this entry with a link to one of the online pharmacies, but I've now erased the link.

Longtime readers of Docnotes will know that I added Google sponsored advertisements in September or so.  the ads appear only in the archives of the weblog.  So if you're reading this in an RSS reader or you logged in to the home page at www.docnotes.net or www.docnotes.com, you never see them.  But people arriving here from web searches will see them, and while I won't say how much I make on these ads, I will say that they earn me far more than it costs to run host the weblog every month. 

Since google chooses the ads on every page based on the topics that I discuss, theya re hoping that the ads are relevant to what the user is interested in.  The ads can't influence my writing - since the writing happens before the ads do.

But I just looked at an archved page where I discussed a certain medication (and how bad it was) .. and there at the top of the page are three ads for how to buy that medication over the Internet without a prescription.

Hmmm.  I don't like this.  I don't like it that one can buy prescription medications over the Internet.   Yes .. I'm gonna use the same argument you'll hear from most physicians .. I don't think it's safe.   Sure, it may be safe to sell some things (I don't dare name them here!) that have recently become OTC .. or will soo become so. 

But if my role as your physician is to be a resource - to help you make decisions about your health - then I'm hoping that you will let me do my job.  A few months ago I saw a patient in the office who was buying an antidepressant on the Internet.   He had tried another - didn't feel much better in 2 weeks, and tried a second one.  He wasn't dosing either one properly.   It was a  tricky situation, and I was oddly reminded of it a month ago when Ray blogged about how he was over his head trying to replace a wood floor:

Sunday was "Install the Wood Floor" day, which quickly turned into "What in the hell was I thinking" day. So, today I'm on the phone with a few companies to find someone else to come in and finish the job. I have to remember - people pay me to do what I consider to be very easy stuff... so I shouldn't feel bad paying other folks to do things that are probably easy for them. ;)

Ray is a great programmer, but he's never coming over to my house to install my wood floor.   Dosing antidepressants isn't very hard for me to do ... and it may seem so easy that an intelligent person like my patient ccould do it too.  But he can't.  This doesn't mean he's dumb and I'm smart.  Indeed - he's likely much smarter than I am.  I just have a different skill.

In this era of the Internet - with medical information everywhere - I don't doubt that the opportunities to bypass the physician are ample - and sometimes appropriate.  Finding the line between appropriate and inappropriate  medical "self-service" is going to be the hard part.

So .. back to the office ... this was tricky because I don't want to chastise him or be insulting (as I can expect Ray feared when he called the wood floor guys:  "hey bob .. this guy onthe phone wants us to come fix his botched floor.  yuk yuk yuk") ... I want to understand why he did it, and make it safe for him to ask for my help .. now and in the future.

Posted by Jacob Reider, MD at 06:48 PM | Permalink

The Medicine on the Net Front Page article this month is on medical weblogs.  It's a good article, but you have to pay to read it all.  I hadn't read Medicine on the Net before.   It looks like they are publishing a trade journal that aims to keep people informed of what is happening in the Internet related to the business and practice of medicine.

Last week, Bill Reith (Bill - do you have a weblog?  I can't find it if you do!) .. asked me to write more about my "other job" and I recognized that I don't write much about it here.

I'll try to write some more about medicine and technology.  It's an important topic, and I believe that technology and medicine have always influenced each other. 

The important thing to remember about technology is that teh hard decisions are nto about what we can do with technology.  The list is as long as my arm - and it's easy to dream up cool new applications of technolgoy.  What we should do is much a harder question - and deserves great thought and understanding of both the technology and the process to which technology is being applied.  In a paragraph - this is what I do.  I help make the decisions about what we should do.  It's therefore my job to know as much as I can about the work that we do in a hospital ("we" includes physicians, nurses, residents, medical students, ward clerks, phleotomists, pharmacists, speech therapists, administrators, billing clerks, finance specialists, and so-on), and I also need to know as much as I can about technology.

I can't have the "usa-today" version of how to build an electronic health record in my head.  I really need to know the nuts-and-bolts of how this is done.

Posted by Jacob Reider, MD at 06:24 PM | Permalink | Comments (1)

An article in the current issue of Neurology demonstrates that Gabapentin may be useful in the treatment of daily chronic headaches:

 A total of 133 patients were enrolled (41 men, 92 women, mean age 43 years). All were eligible for safety analysis. Ninety-five received sufficient treatment to allow evaluation of efficacy. There was a 9.1% difference in headache-free rates favoring GPT over placebo (p = 0.0005). Benefits for GPT were also demonstrated for headache-free days/month (p = 0.0005), severity (p = 0.03), VAS (p = 0.0006), headache-associated symptoms of nausea (p = 0.03) and photophobia/phonophobia (p = 0.04), disability affecting normal activities (p = 0.02), attacks requiring bed rest (p = 0.001), and QOL related to bodily function (p = 0.01), health/vitality (p = 0.0001), social function (p = 0.006), and health transition (p = 0.0002). Reduction in headache days/month was seen across the spectrum of prerandomization headache frequencies.

This looks like a well designed study.  I've used it a few times for patients in this situation - but I wouldn't say that I have considered it first line.  The treatment of a problem depends on the cause fo that problem -- and chronic headaches can be caused by many many things.  Is the use of gabapentin just masking the symptoms - or treating the problem?  Hard to know.

Posted by Jacob Reider, MD at 05:52 PM | Permalink

JABFP -- Gold and Igra 16 (5): 458

Treatment with the fluoroquinolone class of antibiotics has become increasingly popular. Clinician preference for quinolones stems from their excellent gastrointestinal absorption, superior tissue penetration and broad-spectrum activity.1,2 However, this has led to widespread and indiscriminate use, affecting microbial resistance patterns and increasing drug-related morbidity.3 Although quinolone-induced tendonopathy and tendon rupture have been previously described in the literature, reports of tendon rupture in association with newer quinolones such as levofloxacin are now emerging.4,5 We describe a patient with levofloxacin-induced partial rupture of the Achilles tendon and review the literature, pathophysiology, predisposing factors, and treatment recommendations.

I can remember vividly how my grandmother's ruptured achilles tendon was blown off by her physician 9  or so years ago.  She had asked whether it could be the Cipro that she had been taking for a UTI that caused the tendon rupture, and he said "no way."

Of course it could.  At that time, there was only letter in NEJM that I could find .. but since she was paying for much of my medical school tuition ... I guess I did more research on it than he did. 

The report above reminds us that even the newer quinolones can do this - yet another reason to avoid them.

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

Mrs Jones (not her real name)  .. asked me tonight how many bananas she needs to eat instead of her 20 Meq Potassium tablets:

Here's a very rough guide on some common sources of K+ in Meq)

Banana			13
Orange			7
1  Avocado			15
1/2 Cantaloupe			18
4 ounces spinach			16

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

From Trust Me, I'm a Doctor:

I've quit doing screening rectal exams. Unfortunately, it takes more time to tell the patient why we don't need to do it than just getting it over with.

He's right.  The PSA conversation takes 20 minutes, but just ordering it takes about 20 seconds.  No wonder so many physicians just to the rectal and the PSA and .. treat bronchitis with antibiotics. 

My nurse complained to my wife yesterday that I take too much time with my patients.  She's right that I do.  But shouldn't I explain things?  She asks "what in the world are you doing in there for so long?" 

I'm mostly listening - but sometimes I'm explaining.

We physicians do a rotten job in general to explain things to people.  we use this secret language to communicate with eath other.  We learned it in medical school, and some of us forgot how to actually speak English when we graduated.

"Mrs Jones, you have microcytic anemia and your ferretin is decreased.  YOu need to take the feso4 tid.  We'll check a CBC in a month."    No kidding .. I've seen it this bad.  

Of course in my "other job"  (of which I rarely speak here, it seems) I see this even worse.   I work with computers in a hospital.  It's a bit more complicated than that -- but -- you get the idea , right? 

Computer people are worse at the translation from their secret language than physicians.   Interacting with humans was never a required component of their education like it is in medical school (albeit a small component).  So it is rare to find someone in technology who communicates well with "the other side."  Today was no different - and I felt bad reminding them again how speak English instead of TecnoSpeak.   

When I teach medical students how to un-learn the DoctorSpeak - they are appreciative and - yes - a bit ashamed.  I don't mean to make them feel silly - but sometimes when we have a student in the office and we're in a room together with a patient and the student says "do you have any dysuria?" and  I say to the patient "did you understand that?" and the patient says "no" and I ask the student to try again and they say "does it hurt when you pee?"  And we all wonder why the "dysuria" question would EVER be asked.  But it is .. very often.

Maybe the poor student has just finished surgery where some jerk told them that it's important to "be precise with your language."  ugh.

Posted by Jacob Reider, MD at 12:01 AM | Permalink | Comments (6)

According to this POEM - there is no difference between Azithomycin and Amox-Clav in the treatment of otitis media.

Bottom line
For every 10 children with persistent or recurrent otitis media who get high-dose azithromycin for 3 days instead of high-dose amoxicillin-clavulanate for 10 days, there is one additional clinical cure at 1 month and 1 less episode of diarrhea. There is no difference, however, in clinical success at 2 weeks. (LOE = 1b)

But where's the placebo group?  The study referenced above

A reminder that Chris Cates' EBM website has excellent resources on otitis media. 

It's odd - because I do recall seeing many cases of recurent otitis when I was in residency - and even when I was at the Albany Medical Center residency program - where I was on the faculty.  But in my current practice, my  colleagues and I are so conservative with antibiotics that we rarely treat kids who present initially.  We're seeing fewer cases overall - and fewer cases of resistant otitis and VERY few cases of recurrent otitis.  I can't think of the last kid I referred to ENT. 

Questions for the literature:

• Do delayed prescriptions reduce antibiotic prescriptions?  Yes
• Is there a way to clinically predict which organism is causing an episode of otitis? YES (cool!) (viruses?)
• Why does AOM cause persistent OME?
• Are there well established international guidelines?  No

Posted by Jacob Reider, MD at 08:24 PM | Permalink

CRAP:  Clinicians for the Restoration of Autonomous Practice Writing Group:

Clinicians for the Restoration of Autonomous Practice (CRAP) has written this report and nailed it to the door of the BMJ. We have done this anonymously and under cover of darkness to protect ourselves from retaliation from grand inquisitors in the new religion of Evidence Based Medicine (EBM).

Take a look at the article.  Very well done.

Posted by Jacob Reider, MD at 03:11 PM | Permalink | Comments (2)

Posted by Jacob Reider, MD at 02:04 PM | Permalink

Delfini

• Our Mission is to assist medical leaders, health care professionals and others interested in and affected by health care decisions by
• Bringing science into medical practice in an easy-to-understand way. Using simplified methods to help navigate the complexities of such areas as evidence-based medicine and other topics.
• Building competencies and confidence in improving medical care through our consultations, educational programs and tools.
• Providing inspiration to others to improve medical care and help bring about needed change.

This is an interesting endeavor - it will be interesting to see if they can make a living by providing EBM consulting.  The problem wityh excellent healthcare practices is that there is no clear ROI for the people who would pay for it.  For example - in my few years with medremote, we developed WONDERFUL prototypes proptotypes for bayesian algorithms that would extract salient items from free text notes.  This has enormous protential for improving the quality and potentially the quality of care.

Huh?

ok .. here's how it goes:  The progres note says "Marge has a hx of hypercholesterolemia, hypertension and type 2 diabetes.  She's not allergic to anything but her mom had hives when she took Bactrim."

ITEA would be able to make this:

• Hypercholesterolemia
• HTN
• Diabetes - Type 2
• Allergies: NKDA

(notice that it isn't fooled by the mom's Bactrim Allergy).

Now we can use the computer to prompt the physician to check A1c, treat or monitor the cholesterol, etc ... and this is all WITHOUT an EMR.  That is the cool part. 

But it's hard to get anyone to invest in this component of the services .. and I'll be surprised if people become instantly motivated to push EBM either.   EBM is a religion (of which I am a faithful congregant) yet it's hard to convert the masses.  As CMS devises methods of reimbursing better practices .. perhaps this will fall into place.  Then again .. maybe not.  Time for Matthew Holt to chime in.  I feel like we're getting into his terrritory.

Posted by Jacob Reider, MD at 02:00 PM | Permalink | Comments (3)

E-mail today from Theresa, the office manager in the Department of Family and Community Medicine at Albany Medical College:

Hello,
I received a phone call from Dr. Bob P yesterday with a request for help and I'm asking each of you in the small chance that one of you can help or may have some ideas for Bob. Dr. Bob will be leaving next week on another trip to Africa with a group of AMC medical students. To date he has taken countless AMC medical students with him on 21 medical missions. When our students travel with Bob, they are 100% responsible for the cost of their trip. One third year student, Oteng W, is from a village very near where Dr. Bob is going with his group this year. Many of Oteng's family is still living in this village and he was very excited about the opportunity to be part of this medical team and have the opportunity to help his village and family. Dr. Bob was also very excited to have a student who was from that area and felt it would be a great learning experience for the rest of the medical students to have Oteng be a part of their team. Unfortunately, Oteng's financial support fell through just this week and he no longer has any funding for his travel. Bob did not want to take the chance of Oteng not being able to go and put the airline ticket on his own credit card. For those of us familiar with Bob, we all know he does not have $1,500 to cover a student's travel. His response was typical Bob, "This is a gift I can give to Africa and to our medical school - it's worth it no matter how much it costs." So.............I asking anyone and everyone who knows of Bob and his work with our medical students to try and come up with any way we can help reimburse him for the cost of this airline ticket. I don't know if there are any funds that can help support a medical student - but if we find a little bit of money from a few different sources, it could lessen the financial burden on Bob. If you know of any funding or agency that might be able to help Dr. Bob, please let me know as soon as possible. His team flies to Africa on the 17th of January.

Bob and I were calssmates in medical school.   He is a guy who has given his life to serving the community - and he continue to make enormous personal sacrifices so that he can meet the needs of others.  Click the button below to send Bob money via paypal so that he's not spending $1500 of his own money to send this student to Africa.  I'll forward the cash to Bob.

Posted by Jacob Reider, MD at 01:30 PM | Permalink | Comments (1)

Kent e-mailed me a few days ago .. and now I'm finally getting to updating my reference to Shots 2004 - which remains available for free from the STFM group on immunization resources.

He's updated this Palm-OS immunization reference.  It's excellent.  A true must-have for anyone who cares for kids.

The best part is that his weblog now has an RSS feed. 

Posted by Jacob Reider, MD at 12:15 AM | Permalink

I missed the article last year that I've exerpted below. It's a good one to know about.  A few observations:

1. I found it on findarticles.com - which has free full text of many journals -  including some medical journals.
2. This study is interesting, since it brings up the issue (again) of whether prophylaxis of the cord is appropriate.  In our area, we have good representation of both of the study arms.  One hospital stopped applying triple-dye a few years ago - and the other still uses triple-dye as a component of routine neonatal care.
   
   In the group of kids who don't get the trople-dye .. I am seeing far more cords that seem to last for a very long time.  The kid who comes in a at two weeks of age with a cord still on is not so rare as it once was.  These cords often have an umbilical granuloma at the base, and are often "sealed" with the abdominal skin .. so the base of the cord never dries out and just sits there ... barely viable yet .. rotting slowly. 
   
   A little alcohol and some manipluation (for drying .. not necessarily for antibacterial effect) seems to work well to dry these out in another day or so .. though I sometimes have to tie off the granulomas if they continue to weep.

Pediatrics: To dye or not to dye: a randomized, clinical trial of a triple dye/alcohol regime versus dry cord care.

Our study suggests that omphalitis remains a clinical entity and that there is potential risk in discontinuing bacteriocidal treatment of the umbilical cord stump. Cessation of bactericidal care of the umbilical stump must be accompanied by vigilant attention to the signs and symptoms of omphalitis. In our study, some infants were treated after discharge with local antibiotics in response to developing symptoms of infection The initial presentation of NF is one of foul-smelling umbilical discharge, erythema, and induration around the umbilicus, with rapid progression to frank gangrene

Posted by Jacob Reider, MD at 08:04 PM | Permalink