Family Medicine Notes

Medical Decisions are hard to make.  Even when they seem easy.  

I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor? 

In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors. 

We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes:

• I "actually listen" to my patients (who doesn't?   I wonder ...)
• I spend lots of time with my patients (no wonder I come home late every day!)
• I hear what they mean - not just what they say (the hardest part)

I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients.

The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done. 

Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it. 

The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school.

Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted.

We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.   

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When my patient called this morning - I overheard Amanda our nurse explain why I couldn't just call in an antibiotic for this problem (as was his request).   Taking my time in our visit  this morning to really learn his needs - while I taught him about the science behind our treatment options - took me 35 minutes more than it would have taken to prescribe azithromycin and shoosh him out the door.   Yet when he left the office - I was enthusiastically thanked  for helping him to understand this problem in a way that no other physician had ever done.   Not only will he get better this time (sans antibiotics, btw) - he'll also know how to manage the problem on his own next time - preventing his discomfort and his need for the visit to the office.  Had I given him what he asked for - I wouldn't have given him what he needed. 

Posted by Jacob Reider, MD at 10:00 PM | Permalink

It has been a long week.  I was at the STFM meeting in San Francisco.  Over 1000 family physicians were there.  This was the one-year anniversary of the release of the Family Medicine Digital Resources Library (FMDRL).   It's been a slow road, but the software is really working well in no small part due to the hard work of David Ross.   The greatest thing about FMDRL is what you don't see about it.  The user interface is clean and it's very easy to use.  Yet the base architecture of the application is very robust and will allow it to be maintained or extended fairly easily.  This is in sharp contrast to many similar digital resource libraries such as Heal and MedEdPortal.  Those applications are much more complex internally.  Even small changes require programmer support whereas we built FMDRL so that nearly everything about it can be configured by a non-programmer.  None of the categories or taxonomies are hardcoded.

This makes FMDRL a likely candidate for product-ization.  Would medical schools, colleges or universities want to use such a system to support peer review and sharing of digital resources?  I would think so.  Indeed, the peer review system of FMDRL is as robust as the peer review systems used by professional journals.   I'm trying to figure out how to evalgelize this in some way.   The software is wonderful.  It does things that no other software does: when a document is submitted, FMDRL reads the document in its entirety and make suggestions (often correctly) for MeSH terms.  In the background, it's also finding SNOMED concepts.   Very cool.   There's a discussion that's attached to every resource.  These discussions and act like listservs:  It's a combination of a web-based discussion and a listserv.  When it e-mails you (optionally), you can reply to the e-mail and your response will go into the correct thread of the discussion.

OK.  Enough of that and Dave's genius. I'll get back to writing my progress notes

Posted by Jacob Reider, MD at 07:18 PM | Permalink | Comments (1)

Osler is the new weblog from the first  medical blogger.  Welcome back to David Theige.

 

Posted by Jacob Reider, MD at 12:47 PM | Permalink

So I'm having dinner tonight with this group of happy medical students and they are bummin out about their EBM course and they ask me if I really use "EBM" and I say yes and then I do this little strep throat thing like this:

I see an adult in the office with a sore throat.  No kids.  No contact with kids

So I assume pre-test probability of about 5% Yeh - I made it up.  I'm probably close.

And the sensitivity of the test I'm doing is 85% (possibly better -- but we'll be safe)

Specificty is very good - 99%

So let's do the poor man's version that I use to explain to the patient:

You have a 5% chance of having this BEFORE I do the test - so after the test you have a 15% chance of the 5% chance of having strep throat.

.15 x .05 = .0075 ... let's round it up to 1%.

"Mrs Jones - you have a 1% chance that you have strep throat after this negative rapid-strep. Go home and drink warm tea with honey and you will feel better soon." (ok .. go find the evidence for THAT!)

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Students get confused.  "That's too easy" they seem to say. "We have to do all of those crazy calculations."

No - just understand.  I say.  Do the math and you'll get the same result here.

So here goes.

Given my number above - we need to calculate the Negative Likelihood Ratio - which is:

Negative Likelihood=(1-SENS)/SPEC

So:  (1-.85)/.99 = 0.15  

So our negative Likelhood Ratio is .15 = 15%

Now we need to relate this to our patient.  For this - the EBM disciples use the Fagan Nomogram which really uses the formula:

Pos-test odds =  Likelihood Ratio x pre-test odds

So ... Post-test odds = 15% x 5%

which is the same as

15 x .05 = .0075 ... let's round it up to 1%.

Look familar?

 

 

 

 

 

Posted by Jacob Reider, MD at 01:26 AM | Permalink | Comments (3)

I (usually) enjoy reading the evaluations that students write when I teach at the medical school. Today there was a funny one:

Dr. Reider is really easy to listen to – he’s entertaining and educational (the PBS of Med School).

Hmm .. not sure what that means .. but I guess it's a compliment!

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

Wow .. it's been quite a while since I've made an entry.  Here's why:

1. I'm busy.  Yeh .. I was always busy .. so .. no excuse
2. There are hundreds of other weblogs now.  Many are very good.  The reasons that I started writing this were:
1. Put annotated bookmarks up on the www so that I could find interesting and important information again .. once I had found it.
2. Expose some of the human side of the physician's world.  Much of what we do is mystery to our patients.  I wanted to reveal some of that .. and openly reflect on what I do .. and why.
3. In the context of #1 and #2 above -- both are now being done rather well by others.  In the 4+ years since I started writing the weblog, many other physicians have gotten on board and are in fact doing this just as well as I was.  Perhaps better.  I don't feel the ned to write a post today on the availability of influenza vaccine and the panic of OVERsupply that is now occurring.  Many others have commented on this already .. and I agree with many of the opinions.  There are a handful of weblogs that I continue to read  (Kevin, Sydney, Dr Bob, Enoch).   And of course I see who's writing what by checking medlogs.com every day.
   
   So the weblog isn't so important for me anymore.  I will still use to to put up links to things that others may not have found yet.

Today's tidbit:  Audio Digest is giving away some free MP3 CME programs.  When I was a resident - I would listen to an Audio Digest tape every day.  I had a 30 minute drive to work .. so .. "Side A" on the way to work and "Side B" on the way home.  This was an extraordinary adjunct to my residency education.  With a 5 minute commute these days ... I don't do this anymore.  Too bad.  I enjoyed it.  Perhaps with the growing presence of MP3 players .. we'll all get in to this ...  and I can do CME on the treadmill at the "Y" ...  and of course it makes an ipod tax deductible now .. doesn't it!?

I think that the next wave in medical blogs will be the merging of traditional medical publishing and weblog-like information sharing.  They won't be called blogs, but they will borrow from the technology and in fact from the techniques quite a bit.  I've already posted (a bit too much) about this in the past.  Here's an abstract overview of what's going to happen:  Both traditional medical publishers and web-based medical publishers will recognize that the way that a weblog communicates and retains information is valuable to physicians.  There are a few principles that we might usefully apply to such communication:

• Editorial Integrity.  the information that is selected for today's "news" must be selected because the editors believe this to be important to me. 
• They need to know who I am - and they need to know what I'm going to consider useful.  Yes - if Yahoo knows what books to show me on their "login" page .. I DO expect the medical publishers to know what kind of physician I am .. and therefore what information I would find most useful.  I'll blab about usefulness later. 
• Integrity also means that the advertising never influences the content.  Never never never.  I understand that advertising may be necessary.  Physicians will tolerate SOME of it - but not much. 
• Usability.  Easier said than done.   Medical information needs to be delivered to me in a form that makes it usable.  Not too many graphics.  Don't make me click a billion times.  Don't make me log in to click-through a big Flash advertisement.  Use words sparingly.
• Usefulness.  I've written about this before - so I won't bore you too much this time.  The key is that the user will get the most value with the least effort. 
• Transparency & Personality.  Perhaps these two are not the same .. but they're related enough that I think they can live in the same paragraph.  Transparency means that the readers know who is speaking to them - and why.  If we're talking about medical information - and perhaps even medical news - there is still an author of the story - and an editor - and if I know a little about them - I am better prepared to judge what it is that I am reading.  "Personality" may be the means to the "transparency" end.   Humor, even in "news" is appropriate and maintains the attention of the reader.  Makes everyone more human.  Sometimes when the author says WHY something is important - or offers an editorial summary - they are providing a framework for the reader.   Ever read Robbins' Pathologic Basis of Human Disease?  No?  Too bad.  It's a wonderful medical textbook - with wry humor sprinkled throughout.  2nd year medical students -- trapped in at their desks for hours at a time will stumble on these gems of humanity and remember that they are human.  Medical news sources should do the same.

Maybe there's more .. but that's all I've got for today.  Experimenting with a wiki for the FMDRL project.  Fun.

Posted by Jacob Reider, MD at 07:34 AM | Permalink

About 8 years ago, as a participant in the cool new thing called a "listserv" where family medicine educators would e-mail each other and talk about medical education ... someone suggested that we should create an online library where we could share digital resources. So I built one And it was hard to manage, moderate, etc.

 People shared viruses in addition to useful resources.

It got messy. So another version was born - which Dave helped to build .. after we built a similar online library for the Crozer-Keystone family medicine residency.

But it still didn't have a team of editors and librarians watching over it. So .. inspired and assisted by Helen Baker and Traci Nolte -- I wrote a grant for STFM to create an infrastructure for the library.

 The grant was funded and now we've started work. In addition to creating a spec for the software ... I've ordered up the servers.

We had a great talk last week with the guys from Heal and will likely staeal lots of their code to creat our version ... None of this is an excuse for the paucity of blog entries lately.

I still have to get my lecture notes and links from the PAFP meeting I spoke at a few weeks ago ... but that may have to wait one more day .. In the meantime ..

here are some interesting "must read" suggestions form the not-so-new thing called "Family-L" -- the listserv for family medicine educators, courtesy of Dan Sontheimer:


John Abrahamson's book, "Overdo$ed Amercia".

Another would be the Future of Family Medicine Project report "The Future of Family Medicine: A Collaborative Project of the Family Medicine Community" in Annals of Family Medicine, Vol. 2, Supplement 1, March/April 2004.

A book by the Harvard Negotiation Team Difficult Conversations: How to Discuss what Matters Most by Douglas Stone, Bruce Patton, Sheila Heen, Roger Fisher Good To Great, by Collins (book, in any chain bookstore, on surprising findings after studying persistently great companies)

The article is in the October 28th, 2004 NEJM by Chris Landrigan, MD et al about work hours in IM interns in the ICU. Prospectively they showed that sleep deprived interns made more mistakes than better rested interns.

Getting to Yes: Negotiating Agreement Without Giving In, by Roger Fisher, William Ury, and Bruce Patton. IOM's Health Professions Education: A Bridge To Quality (part of the Quality Chasm Series).

Chapter 3 "Primary Care :40 Stellar Community Health Centers" in the 2002 IOM Report: "Fostering Rapid Advaces in Health Care"

Health Affairs Web exclusive entitled: "Medicare Spending, The PhysicianWorkforce, And Beneficiaries' Quality Of Care"

The series of articles in NEJM about reforming the VA System via an emphasis on primary care and quality measurement

The Journal, "Health Affairs" Anil's Ghost by Michael Ondatje (author of The English Patient).

Closing the Chart: A Dying Physician Examines Family, Faith, and Medicine By Stephen Hsi

Atul Gawande in his New Yorker article has captured this difference in a much better literary effort. http://newyorker.com/printable/?fact/041206fa_fact

Posted by Jacob Reider, MD at 11:42 AM | Permalink

Here's a little summary of Barbara Starfield's presentation at thei year's WONCA.

 'Grand lady' of public health proclaims: The best care is primary care -- FP Report

 ... For example, in the United States, a "20 percent increase in the number of primary care physicians is associated with a 5 percent decrease in mortality (40 fewer deaths per 100,000)," she said. But the benefit is even greater if the primary care physician is a family physician. Adding one more FP per 10,000 people "is associated with 70 fewer deaths per 100,000, which is a 9 percent reduction in mortality," she said.

This year, we have seven students out of ~125 4th year students who will going into family medicine - the fewest in 15 years. Somehow, they are not getting the message that this is important .. and they are not getting the message that this is good fulfilling work. The message that they hear - from misinformed specialists - is that "family medicine is dying." ugh.

Posted by Jacob Reider, MD at 08:34 AM | Permalink

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!

Posted by Jacob Reider, MD at 08:12 AM | Permalink

From today's Boston Globe .. this interesting article answers the question you've always been afraid to ask:

The answer?

"Probably not, but nobody really knows since burned toast isn't high on the research agenda."

Posted by Jacob Reider, MD at 05:56 PM | Permalink

Discovered today on medlogs: This is very funny (and accurate too!)

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

Academic Medicine Online -- Abstracts: Watkins and Kimberly 79 (5): 432

Internal medicine residents and faculty reported low levels of knowledge about physician-pharmaceutical industry relationships. Some consensus about educational components existed, but optimal educational formats remain uncertain. A six-hour curriculum to address this complex, emotionally charged topic was developed, implemented, and evaluated.

This study confirms what is (for some) self-evident:  marketing works ... and unless you really THINK about the marketing ... the real agenda will be overlooked.  

Posted by Jacob Reider, MD at 11:24 PM | Permalink

Jan Gottlieb, MPH - developed a set of resources that:

provide a helpful resource for faculty and staff of medical schools who are planning to, or are currently using service-learning to educate medical students and residents about

1. community-oriented primary care
2. Healthy People 2010 objectives
3. Cultural competence.   

The toolkit, which should be applicable to other fields and disciplines as well, is designed to help minimize some of the start-up time involved in developing service-learning programs.  It will also provide examples for tailoring service-learning to fit your timeframe. The toolkit was based on three of the COPC-service-learning programs developed by our Department of Family Medicine in collaboration with community partners, over the last eight years.

Posted by Jacob Reider, MD at 02:13 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)

It's the time of year that we need to write Dean's letters for the medical students.  These letters serve as a summary of the students' medical school careers -- and (we hope) help them get in to the residency of their choice. 

It's hard work to write these things .. carefully walking a line of being the student's advocate - while also being honest about students who have not performed so well as they could.  Three more to go.  I was hoping to finish tonight .. but it's not going to happen.

--

I enjoyed meeting everyone at Bloggercon - and I think that the "medlical weblogs" session was productive.  I've been thinking about a "work product" that we could creat that might summarize some of our discussion - perhaps a "guide to medical weblogging" that might help frame some of the issues that we discussed, and could help claify some of the common "do's and don'ts" of medical weblogging. 

Then again ... maybe not.  Should there be rules?  No .. but guidelines?  Perhaps.  HIPAA looms large, as do medical ethics.  In our enthusiasm to share OUR experiences, we're also share the experiences of our patients and colleagues.  Hmm ..

 

Posted by Jacob Reider, MD at 02:42 AM | Permalink | Comments (1)