Family Medicine Notes

So the series is finally over, and we can get back to our lives.  I was only 4 in 1967 so I don't remember that one .. but I remember 1975 quite well:

October 22, 1975: In game seven, Boston held a 3-0 lead going into the sixth. Pete Rose hit a lead off single; Joe Morgan flew out to right. Johnny Bench grounded to short, but the Red Sox missed a double play opportunity when 2B Denny Doyle threw the ball into the dugout. Bench advanced to second on the mistake. Tony Perez jacked a Bill Lee curve over the Green Monster for his third home run of the Series; Boston's lead was cut to 3-2. 

My favorite player at the time was Doug Griffin - who was always in competition with Doyle for the spot at second base.  So when Doyle blew a double-play that led to a 2 run homer (the Sox eventually lost the game 4-3) .. my dislike for Doyle was enhanced.  The series in 1975 was my first big experience with being a Red Sox fan.  Doyle was my "Bill Buckner."  Nearly 30 years later, I'm happy to have witnessed this historic series .. to wash all of that away.  Congratulations Red Sox Nation. 

Posted by Jacob Reider, MD at 01:08 PM | Permalink

Here's the lancet article (or here in pdf) being cited in the news today.  Free login to The Lancet is required.

Here's the summary:

Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi, Gilbert Burnham

Summary

 

Background In March, 2003, military forces, mainly from the USA and the UK, invaded Iraq. We did a survey to compare mortality during the period of 14·6 months before the invasion with the 17·8 months after it.

 

Methods A cluster sample survey was undertaken throughout Iraq during September, 2004. 33 clusters of 30 households each were interviewed about household composition, births, and deaths since January, 2002. In those households reporting deaths, the date, cause, and circumstances of violent deaths were recorded. We assessed the relative risk of death associated with the 2003 invasion and occupation by comparing mortality in the 17·8 months after the invasion with the 14·6-month period preceding it.

 

Findings The risk of death was estimated to be 2·5-fold (95% CI 1·6-4·2) higher after the invasion when compared with the preinvasion period. Two-thirds of all violent deaths were reported in one cluster in the city of Falluja. If we exclude the Falluja data, the risk of death is 1·5-fold (1·1-2·3) higher after the invasion. We estimate that 98000 more deaths than expected (8000-194000) happened after the invasion outside of Falluja and far more if the outlier Falluja cluster is included. The major causes of death before the invasion were myocardial infarction, cerebrovascular accidents, and other chronic disorders whereas after the invasion violence was the primary cause of death. Violent deaths were widespread, reported in 15 of 33 clusters, and were mainly attributed to coalition forces. Most individuals reportedly killed by coalition forces were women and children. The risk of death from violence in the period after the invasion was 58 times higher (95% CI 8·1-419) than in the period before the war.

 

Interpretation Making conservative assumptions, we think that about 100000 excess deaths, or more have happened since the 2003 invasion of Iraq. Violence accounted for most of the excess deaths and air strikes from coalition forces accounted for most violent deaths. We have shown that collection of public-health information is possible even during periods of extreme violence. Our results need further verification and should lead to changes to reduce non-combatant deaths from air strikes.

We appropriately consider the 3000 New Yorkers who died in the WTC to be a tradgedy, but the scope of the tradgedy in Iraq is greater.   From a public health standpoint, these aretragic times that we live in.  W's myopic focus on Iraq has had devastating effects on our economy, our international credibility, and the lives of 100,000 Iraqi's ... "Most individuals reportedly killed by coalition forces were women and children. "   So Sad.  So Frustrating.

Posted by Jacob Reider, MD at 12:41 PM | Permalink | Comments (2)

 So now there's a Wikipedia entry for the Schilling Tendon Procedure.  We'll have to get that added to the medical textbooks real soon now.  The news reports are not so clear about this as I would like .. and I'm still not certain that the wikipedia entry is accurate .. so please edit it if you know more of the details.  It's my first contribution to the wikipedia.  Not too hard, but the editing takes some getting used to.

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

Referrals are a tough topic in primary care.

Two phone calls today reflect some of these issues:

"JMR .. patient on phone .. wants referral to a back doctor .. ok to make the referral?"

"uhh .. put her through please"

I want to talk with the patient so that I can understand why she wants the referral and why she thinks this is something that requires a specialist.  Clearly I am not a back doctor or a front doctor or a foot doctor ... but I may be able to help people with problems of these parts.  Turns out that the chiropractor hasn't helped much despite thrice-weekly treatments for 3 months.  She has low back pain.  No symptoms of anything bad.

What to do? 

• I can require that she come in to the office .. but then I am being the "gatekeeper."
• I can just refer her to the orthopoaedist .. but then I am making an inappropriate referral.
• I can refer her to physical therapy (which is what would most likely occur as a result of a visit with me or the orthopoaedist).
  
  Hmm ... which is the right answer?

Ok .. number two is harder.

I care for many physicians in my practice.   Caring for other physicians is tough.   Our office got a phone call a few weeks ago from a specialist about a referral that they needed from us so that they could see a patient who was there for an office visit that day.  The patient never called me .. never asked if I thought that a referral was necessary .. and never asked our office for a referral.  By making the appointment directly with the specialist - a message is sent to the primary care physician that our training and opinion is inferior to the patient's own ability to triage the situation.  For this scenario (I won't go into the details) I am certain that I would have been able to provide the service that the patient was looking for myself.    grrr...

Posted by Jacob Reider, MD at 12:52 AM | Permalink | Comments (4)

 .. and Bush overall ... according to this poll

.....

But Tennesseans not all that issue savvy

Despite the impression the above findings might give, a close look at five domestic agenda items suggests that Tennesseans as a group hardly qualify as well-informed, ideologically consistent policy wonks. For example, only about half of Tennessee adults can accurately name Kerry as the candidate who supports rescinding the recent federal income tax cuts for people earning over $200,000 a year. About a quarter (23%) incorrectly attributed the proposal to Bush, and 27% admit they don't know which candidate supports the measure. Similarly, only about half (50%) rightly name Bush as the candidate who favors giving parents tax-funded vouchers to help pay private or religious school tuition. Thirteen percent attribute the plan to Kerry, who actually opposes it. Over a third (37%) admit they don't know.

Knowledge levels are even lower on the other three issues. Well under half (42%) are aware that Bush wants to let younger workers put some of their Social Security withholdings into their own personal retirement accounts. Nineteen percent incorrectly think Kerry supports the measure, and 40% say they don't know one way or the other. Just over a quarter (28%) rightly name Bush as the candidate who supports giving needy people tax breaks that would help buy health insurance from private companies. Thirty percent inaccurately name Kerry as the measure's proponent, and 41% admit not knowing. Finally, just 39% know that Kerry advocates requiring plants and factories to add new pollution control equipment when they make upgrades. Fifteen percent wrongly attribute the policy to Bush, and 45% don't know.

So goes another non-medical post.  My second in as many weeks.   ... now back to your regular programming .. already in progress...

Posted by Jacob Reider, MD at 01:49 PM | Permalink | Comments (1)

Here's a nice review of insulin forms and insulin dosing.

Posted by Jacob Reider, MD at 11:44 AM | Permalink

ok .. so it took me about a year to get back to this .. but only a few hours to actually get it functional!  OnCalls, the web-based medical scheduling software that Dave and I developed, will now sync with a Palm OS or PocketPC.  If you really want to try it, you can log in with username: "demo" and password "demo."  There aren't many people on-call in the demo group, so there may not be anything to sync (I just put in a few folks for this week just in case you go look).  Palm sync is certainly in test mode, but it weems to work pretty well, and I've heard from quite a few users that they discovered it and like it very much.  Here's the audience-particpiation question:  how much extra should I charge for Palm Sync?

Posted by Jacob Reider, MD at 08:06 AM | Permalink | Comments (1)

A few days ago, I wrote about the (new) flood of medical weblogs and wondered out loud how we could work together to make weblogs.com (or medical weblogs in general) more useful.  There were a few good comments and Nick had some ideas for medblog guidelines. (read the comments of the entry to see Nick's thoughts).  I had sent Nick an e-mail offering to gather the "grand rounds" at one predictable URL .. and I wonder if he worried I was trying to take it over.  Far from it .. I just want to make it possible for readers to find the grand rounds in one predictable place every week .. ok .. back to what I'm thinkin ..

Making (keeping?) medical weblogs useful. 

What do I mean by useful? 

The Usefulness Equation:

To be useful, medical information should be relevant to everyday practice, correct (valid) and easy to obtain.  Slawson and Shaughnessy describe a formula which relates these three factors in a "Usefulness equation": 

I won't repeat the whole discussion of usefulness here. Please review the link above for more detail.  The important idea here is that in the past .. when there were only a handful of medical weblogs ... they were truly useful.  I wrote mine as an effort to provide to myself and my colleagues an important and useful source of information .. and .. yes .. an outlet for my thoughts and concerns. 

Nick's commentary describes his appropriate concern for the "outlet" component of weblogs.  I've always thought of medical weblogs as a way to provide transparency into the thoughts and actions of real physicians.  This sort of transparency is rare, and patients who see how we think may understand more about how to interact with their physicians, how to critically assess the news reports, and ultimately how to care for themselves better. 

So the readers of medical weblogs could be:

• Patients (aka real humans)
• Physicians
• Residents
• Students (medical, pre-med, high school, etc)
• Health Industry Workers .. (from executives to bench scientists to nurse assistants)
• and so on ..
  

And I suppose that the view of the usefulness of a post (or weblog) depends on the perspective of the reader.  When I post a lot about technology or dry medical topics, my wife complains that she misses the reflections of the life of a family physician.  But would Nick complain if I whine too much about life in my practice? 

A good (useful) medical weblog will weave the clinical usefulness with the personal components -- just as any good teacher will weave the content they want to convey into an interesting an compelling tapestry.

Sydney and Dr Bob make liberal use of cutting and pasting from the text of important articles in addition to linking to them.  This increases the usefulness of their posts, since it reduces the work.  Fewer clicks for the reader -- no need to follow the link .. read read read .. click "back" and then read the bloggers commentary.

So how do we improve Medlogs.com to filter the blogs/posts in a way that causes the most useful to bubble up to the top?  It's NOT the most linked-to blogs (like the Daypop top 40)  that are the most useful ... and I would agree that it's not likely the most "hits" from the medlogs home page.

This week, Kevin (next week's Grand Rounds editor) posted a request for people to send him suggestions for inclusion in the Grand Rounds.  I would assume that people who think a given post is suitable for consideration means that the post is useful.  Hmm.  But this isn't automatic.  A long-term sustainable solution would not require so much work on the part of Kevin (reading the e-mails, following links, etc) .. nor would it require so much work from those suggesting the posts. 

Would a scoring system work?  Let's say ... we had a little hunk of code that would be embedded in everyone's weblog that would create a little form with every post like with radio buttons .. rating the post on its usefulness from 1 - 5.   The forms would submit to medlogs, which would track the ratings and then generate a "most useful" page of the most useful blog posts .. and perhaps another with a list of the recent posts from the most useful blogs.   Hmm ..

Posted by Jacob Reider, MD at 05:57 AM | Permalink | Comments (5)

George Soros made a compelling speech last week at the National Press Club.  This election is too important to remain idle.

Last week, I heard a local commentator on the radio describing his assessment of the Bush Administration's "Compassionate Conservatism."  While he acknowledged that one could argue with the Bush Administration's compassion -- his real beef was with their Conservatism.  Dr Leibo's essay is wonderful. 

So when I read essays like Dr Leibo's and Mr Soros -- I honestly wonder how anyone could consider voting for Bush.  It just doesn't make sense ...

Posted by Jacob Reider, MD at 05:49 AM | Permalink | Comments (5)

Clusty the Clustering Engine now replaces google as my default search engine.

Posted by Jacob Reider, MD at 07:16 PM | Permalink

Today, I added the 200th blog to Medlogs.com.  Here's how blog addition works. 

• Someone wants a blog added to medlogs.  They click "add a feed" and fill out the little form.
• The form enters the blog into the database and sends me an e-mail requesting approval.
• These days, perhaps due to the increasing popularity of the site, we're getting more commercial submissions.  Rarely true spam ... but medically related sites or services that want to increase their exposure.  Since Medlogs isn't a web directory .. I don't add these, and I don't e-mail the submitters with an explanation.  Perhaps I should .. but I don't have infinite free time.  So I don't.  I add medical weblogs .. or weblogs that are relevant to medicine.  the "geeks" section includes some technology stuff that is not directly to medicine .. and the "law" section does as well, but I find that these sections are both frequently visited ... and are of course potentially relevant medicine.  The "more" section is a bit more complicated.  I invented it for the "mercola" blog (absence of hyperlink is intentional) which is on a physician's website .. but it is not clear that the physician actually does all of the writing .. and the website is devoted to selling his books.  So this is a commercial blog.  But he clearly has a passion and I didn't want to be accused of censoring him (his views are unconventional, and several medlogs readers objected to his inclusion at all) .. so I created a new category and left him in.
• Once I review the blog and see that it is relevant to medicine & Non-Commercial .. I add the feed and put the last few posts into medlogs.  From there on .. it will flow, and we'll pick up all future feeds.
• Of course, the RSS or ATOM needs to be working.  I would say that the most common reason that a blog is not included is that I can't find an RSS/ATOM feed.  No feed, no inclusion.  Simple as that.
  

Here's the "I remember when" part:  Nearly five years ago, I started Docnotes.  Here's the first post.  I think I was writing a similar web-based discussion for a while before that, but my entries are not archived .. so .. lost forever.  The first iteration was with Userland Frontier.  Then I moved to Seth Dillingham's Conversant.  Next it was back to Userland Radio .. and then to MovableType, where the blog remains.  I'm tempted by Ray Camden's BlogCFC.  We'll see.  I like MT .. and it's working pretty well, despite some quirks.  I also have a TypePad account, which is used for other little blog projects.

Here's the question: (you didn't know there was going to be a question .. did you?) .. as Medlogs has grown, I've been finding that the signal:noise ratio is decreasing.  Medical Blogs used to be a good way to find useful information quickly.  They were also a way for us to provide a window into our thinking and our practices .. which I think all of us agreed was good.  There have been several well written articles on medical weblogs .. but I still think the best was in Medicine on the Net .. by Bonnie Darvies.  Unfortunately, it's not free or (!) available on the net .. which of course is silly.  Kinda like Gartner research .. it's good stuff, but you have to pay to get to it.

Oh yeah .. I was asking a question.  How to we keep the usefulness of weblogs high.  Go ahead and click on that one .. it's a link tot he UVA website, and includes an image of the Pyramid of Information Mastery.  Where do weblogs fit on this pyramid?  How can I help to filter this (or how can you help filter this) .. so that weblogs remain (become?) a part of the pyramid. 

One thought that I have had is "hits."  Since we changes the main medlogs pages to include only excerpts of every post (the poll is still open .. but preference for partial feed remains at about 75%) the number of times that readers click the link to go read the full post is sored and displayed on the page.  Presumably, the authors who generate the most hits are of the greatest interest to the readers.  Are these the most useful Blogs?  Should they be "featured" in some way? 

Is the recent "grand rounds" effort a good way of accomplishing this?  Perhaps ... hmm .. maybe I link to (or include full text of) the current week's grand rounds on a special page on medlogs .. hmm

Please share your opinion .. either with a post of our own .. or with a comment here.  We didn't address this much at last year's bloggercon (video feed of the medical session is here ... moderated by some nerd .. yeh .. me).

If you're going to Bloggercon III this year, I'd suggest that this may be a topic for conversation at the medical weblogs session .. which Enoch will be moderating.

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Posted by Jacob Reider, MD at 09:09 AM | Permalink | Comments (5)

SoloDoc writes a nice entry on family medicine .. and the problems we're having recruiting students to go into our specialty:

One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

At our local Medical Mecca, we graduate 130 students every year.  Back in the old days - 7 or 8 years ago, we would routinely see 20% of the class go into family medicine.  This year, it may be less than 5%

Of course, this is exacly the opposite of the trend that should be ocurring, if we consider the healthcare needs of the United States (or the world, for that matter).  But the pressures that generalists feel are real, and the solution is unclear.

Posted by Jacob Reider, MD at 02:16 PM | Permalink