MedWorm: Internists and Doctors of Medicine

Thoughts on the 4 hour rule and other core measures

Notes from Dr. RW — Fri, 04 Jul 2008 05:24:00 +0100

Bob Wachter’s post on the 4 hour pneumonia rule lists these lessons to apply to future quality measure development:First, results from studies of patients with known diagnoses should be extrapolated cautiously, if at all, to patients who lack a diagnosis.Second, or some measures, “bands” of performance (i.e., 80-100% adherence) may make more sense than “all-or-nothing” expectations.Third, representative end users of quality measures (in this case, ED docs and hospitalists) should participate in measure development.Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. In this case, CMS and the Joint Commission are to be praised for listening to the chorus of criticism: in response, the measure has been revised from a 4-hour to a 6-hour standard. Even though a 6-hour TFAD rule is still not evidence-based, it should cause less harm.Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. The TFAD measure was proposed and endorsed by many of the same people who conducted the foundational studies. None of us can be completely unbiased when evaluating our own research results.These are important lessons for developers of quality measures. But I think there may be an even larger lesson for us “end users.” One of Wachter’s observations is telling:As I’ve discussed previously, the biggest surprise of the last decade in the quality field has been this: public reporting alone (even without pay-for-performance) leads to huge changes in the behavior of providers and healthcare organizations… even though there is virtually no evidence that patients are reading or acting on the reports.In other words, shame and pride are powerful forces for change.The lesson? Shame and pride are about me, us, our institutions. Shame and pride motivate us to play for the test. It’s called performance. I would submit that real quality is something different. Real quality is not about us or our public reports; it’s about the patient. Yes, shame and pride get results, but are they may not be the results we want.The 4 hour pneumonia rule is just one example of the conflict between what performs well and what really works for patients. Last year I commented on the disappointing results for heart failure core measures:The rush by hospitals to get a good report card may have diverted attention from other life saving therapies such as devices and aldosterone receptor antagonists.The first quality measure was the provision of discharge instructions on medications, diet and other aspects of heart failure care. In one study on which this recommendation was based the instructions included a full hour of one-on-one verbal counseling. The intervention was associated with improved outcomes. The “core quality” measure, in contrast, required only that written instructions be given to the patient. It’s one thing to hand patients a ream of paper as they are rushed out the door and quite another to provide detailed counseling. Nominal compliance may earn the hospital a perfect report card while doing little of substance to help patients.DB weighed in here. (Source: Notes from Dr. RW)

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Pulmonary embolism

Medicine and Man — Fri, 04 Jul 2008 00:45:30 +0100

This presentation gives a brief overview of Pulmonary Embolism. It was presented by my co-resident Maria Teresa Bejarano, MD as part of new intern lecture series. | View | Upload your own This presentation can also be downloaded from here. addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F07%2F03%2Fpulmonary-embolism%2F'; addthis_title = 'Pulmonary+Embolism'; addthis_pub = ''; (Source: Medicine and Man)

Upper gastrointestinal bleeding

Medicine and Man — Thu, 03 Jul 2008 12:40:29 +0100

This presentation gives a brief overview on upper gastro-intestinal bleeding which was given by my friend and co-resident Adrian Velasquez, M.D. as part of new intern lecture series. This presentation can also be downloaded from here. addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F07%2F03%2Fupper-gastrointestinal-bleeding%2F'; addthis_title = 'Upper+Gastrointestinal+Bleeding'; addthis_pub = ''; (Source: Medicine and Man)

The four hour antibiotic rule for pneumonia is a sentinel event

Notes from Dr. RW — Thu, 03 Jul 2008 05:07:00 +0100

---in patient safety policy. Bob Wachter, a leader in the field, said so and I agree. Like every sentinel event it deserves a root cause analysis, which Wachter and his colleagues provided in an article in the current issue of Annals of Internal Medicine. Via Kevin MD (Source: Notes from Dr. RW)

Cardiac catheterization in women

Medicine and Man — Thu, 03 Jul 2008 02:19:05 +0100

More conundrums on whether cardiac catheterization is safe for unstable angina (”near heart attack”) or non-ST elevation myocardial infarction (”small heart attacks”). Heart disease is the number one killer of women each year in the United States. Cardiac catheterization is a routine procedure that allows doctors to find potential blockages in coronary arteries in order to help prevent new heart attacks and even death. A recent study finds that high risk women, who do have a heart attack, benefit from this procedure just as much as men. But for some women the procedure may not always be the best option. Reference: JAMA addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F07%2F02%2Fcardiac-catheterization-in-women%2F'; addthis_title = 'Cardiac+Catheterization+in+Women'; addthis_pub = ''; (Source: Medicine and Man)

My paperwork hell

FtM Doctor — Wed, 02 Jul 2008 23:48:24 +0100

I used to be good with paperwork. When I started getting grown up paperwork of my very own when I was 16 I had it all filed carefully. Then the novelty wore off and it all got on top of me. And I realised that so many people are shite with paperwork that you can usually get away with just being rubbish. It just causes hassle. For some reason totally unrelated to common sense I am still working in hospitaltownonsea in exactly the same hospital but I will actually be employed by another hospital down the road. This is logical. Just remind me how. Anyway I have to hunt out the various documents I need to show the trust to allow me to continue to work at the same place I am now. Which obviously I have to take to The Big City on my one morning off. The morning that comes before the ‘late shift’ on admissions, the morning I normally use to look after my own patients because due to rubbish staffing there is no one else to look after my own patients. They want to see proof I’m a doctor, proof I’m registered with the GMC, proof I’m immune against Hep B and other things, my latest CRB form, and also, er… general other bits and bobs. They also wanted my passport. I informed they I was under no obligation to have a passport in the UK, unless I want to travel abroad, that I have lost my passport and if it doesn’t turn up before I decide to go abroad then I would pay for a new one. But they could not just demand that I have a valid UK Passport with two days notice. They looked at my name and picture and recognised I was a white man and told me my driving license would be Ok. I could have said that I don’t drive a car and I am under no obligation to have a driving license either. However I do have a Provisional Driving License for this very reason. Because people keep demanding to see it. Even though I don’t want to drive a car or travel abroad. But some people won’t even let me buy alcohol unless I have one of these docments. Though the more hair I loose and the more expensive wine I am attempting to buy they less they actually care. To find all the stuff they want I have had to spend several hours sorting out the hell that is my pile of unfiled random paperwork. Obviously I haven’t done any filing all year. So do I file my GMC documents under ‘W’ for Work or G for ‘GMC’, and so forth. Anyway I am not contracted to be at work tomorrow so I’m not going to be. I have handed everything over and I’m anxious. I have warned the nurses I won’t be there and that we won’t have any regular cover for our patients. I have given them my mobile number in case things really go tits up and I can at least tell people about my patients. Obviously if something goes wrong it is not my problem. Legally. I am doing my rotated hours. I would spend my free time actually looking after my patients if I wasn’t being summonded half way across the county to give some documents to an organisation that refuses to let me post them. So Not My Problem. Ok. But at least I get to spend two hours on trains reading a nice book. I do wish that wasn’t a treat for me. (Source: FtM Doctor)

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Hopkins

Ivor Kovic, M.D. — Tue, 01 Jul 2008 15:49:46 +0100

On June 26th, ABC News started airing its six-part series called “Hopkins” which takes an intimate look at the men and women who work at The Johns Hopkins Hospital. Each episode follows a few characters, both healthcare workers and patients, and their stories. The series is greatly produced and is very inspiring to watch. So far, two episodes came out and here are their summaries: Episode 1 Twenty-one years ago Dr. Alfredo Quinones-Hinjosa climbed a 20-foot border fence so he could join other illegal immigrants picking fruit in the lush valleys of central California. Today he is one of the nation’s elite brain surgeons. He tells ABC News about his remarkable journey as viewers watch him try to save a man’s life. Karen Boyle is among the new generation of surgeons. She is the first female attending in urology at Hopkins, and determined to maintain a balance between her family and her job. But what sets her apart from other surgeons is the candid counseling about sexual health and intimacy she offers to her patients. Brian Bethea has made it to the top of one of the most difficult residencies in medicine, cardiothoracic surgery. After nine years of apprenticeship he is ready to join the ranks of the nation’s most illustrious heart and lung surgeons. But the demands of residency have left his family life in shambles. Repairing a ruptured aorta may be easier than saving his marriage. Episode 2 Brenda Thompson is dying from an obscure and always fatal lung disease. After two failed marriages, her third husband seems to be the man of her dreams. But time is running out. Only a lung transplant can save her. And a new lung may not become available in time. When a donor does become available in New England, there is jubilation. But events take an ominous turn when the donor lungs turn out to be damaged. Brian Bethea, the promising cardiothoracic surgeon with marital problems, has been sent to harvest the new lungs that turn out to be damaged. Nothing seems to be going right for him. When Brian returns home, he must explain to his daughters that he and their mother are separating and he has found his own apartment. Mustapha Saheed is in his third year of emergency medicine. At six foot, seven inches tall, this self-described “big black man” cuts a striking figure as he dashes through the ER. Despite the advice of a colleague to not marry the “girlfriend who got you through residency,” Saheed makes plans for the altar. You can watch Hopkins on ABC News website (Source: Ivor Kovic, M.D.)

Neurotoxicity of cefepime

Notes from Dr. RW — Tue, 01 Jul 2008 05:40:00 +0100

All beta lactam antibiotics can cause neurotoxicity, chief among them penicillin and imepenem. A paper showing increased mortality associated with cefepime use suggested neurotoxicity, including encephalopathy and non-convulsive status epilepticus, may be responsible for the increased mortality. Now comes this report suggesting severe neurotoxicity of cefepime in patients with renal failure. I have access only to the abstract, but a review citing this report suggested that cefepime was not renally adjusted and some patients were massively overdosed. (Source: Notes from Dr. RW)

Neuro exam tips

Notes from Dr. RW — Tue, 01 Jul 2008 05:37:00 +0100

---focusing on the cranial nerve and cerebellar exam. From Today’s Hospitalist. (Source: Notes from Dr. RW)

Screening for hepatocellular carcinoma

Notes from Dr. RW — Mon, 30 Jun 2008 11:30:00 +0100

According to this paper we’re not doing a very good job, despite the fact that it may provide the only opportunity for timely liver transplantation. Because many at risk patients are not established with gastroenterologists, the responsibility for screening may often rest with primary care physicians. Editorial comment here. (Source: Notes from Dr. RW)

Acute coronary syndrome guideline review

Notes from Dr. RW — Mon, 30 Jun 2008 11:00:00 +0100

The American Heart Association (AHA) and the American College of Cardiology (ACC) have improved their guideline development process by writing complete guideline revisions and focused updates at more frequent intervals. The acute coronary syndrome updates (STEMI, UA/NSTEMI and PCI) are featured in this Medscape CME offering. Changes from earlier guidelines and points of interest:For STEMI patients an electrocardiographic definition of failed thrombolysis (an indication for rescue PCI) has replaced the angiographic definition. (IIa).Fibrinolytic therapy should be followed by systemic anticoagulation for at least 48 hours or the duration of hospitalization, up to 8 days. Due to the risk of HIT an anticoagulant other than UFH (i.e LMWH or fondaparinux) should be used if anticoagulation persists beyond 48 hours. (I).Clopidogrel (Plavix) is added to ASA in virtually all patients. Minimum duration of treatment (14 days to 1 year) depends on type of ACS and other management strategies. For patients receiving drug eluting stents (DES) it’s 1 year or longer. For all other NSTEMI patients (bare metal stented and unstented) the duration is 1 month or longer. For unstented STEMI patients the minimum duration is 14 days. All clopidogrel recommendations are class I.If warfarin is indicated (e.g., atrial fibrillation) in patients on dual antiplatelet therapy the appropriate INR target is 2-2.5. (IIa).Before implanting a DES the cardiologist should discuss the duration of antiplatelet therapy with the patient and confirm ability to comply. (Can the patient afford Plavix for a year?). (I).If surgery is anticipated in the next year consider avoiding a DES. (I).Polypharmacy works. The more secondary prevention drugs the patient is on, the lower the one year mortality.Was this activity commercially biased? Discussion of the sponsor’s products, Lovenox and Plavix, did not depart from best evidence and was not preferential to evidence based alternatives. The information presented was accurate and, over all, it was a useful exercise.I do have a minor quibble regarding transparency. I wish the presenters had made it clearer that this was not to be considered a comprehensive overview of the guidelines. The coverage of drug therapy was slanted towards antithrombotic therapy. There was some mention of beta blockers and ACE inhibitors but no mention of statins. As with any other CME presentation, the remedy for this type of problem is additional study of primary sources. The original guidelines can be accessed here. (Source: Notes from Dr. RW)

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Taking a step back

Doctor Anonymous — Mon, 30 Jun 2008 01:01:00 +0100

Every so often, one has to take a step back and take a look at the big picture. It's been a little while since my last blog break, and I think I'm at that point right now. First of all, I'm scheduled to take my board exam at the end of July. I can't believe that it's been seven years since I've finished residency. Time flies by when you're having fun. So, I definitely have to focus on that.Secondly, I can not say it enough how much I have been just blown away by Podcamp Ohio this past weekend. I met a lot of great people. There were a handful of people who I only knew through e-mail or blogs or podcasts - to meet them in person was quite a treat.I talked to a lot of people about my blog and about my show - everything from technical questions to lifestyle questions (like why publicly I still identify myself without my real name). And, I have to tell you that they gave me a lot to think about - as far as marketing, identity, and other stuff.So, I've decided that I'm really going to cut down on blogging for a little while (I wasn't blogging that much anyway). I'm not scheduling any shows this month. I'm going to concentrate on my boards. I'm also going to think about if I need to take the blog and the show in a different direction - or to change things around at all.Don't worry, I'm not completely going "off the grid." I will remain very active on Twitter and I will continue to read blogs and occasionally leave a comment. I also shot a bunch of video at Podcamp Ohio this past weekend. I may post them here for you to check out. But, I'll definitely post them on the Podcamp Ohio group site on Viddler. (Source: Doctor Anonymous)

Typhoon frank versus kalibo

Bubbleman — Sun, 29 Jun 2008 19:08:00 +0100

More videos on the recent Typhoon Frank that hit Kalibo:Just talked to my best friend Mark. Still no water and power in Kalibo, and mud is everywhere. Candles are reportedly selling for a ridiculous P60 each, and rice is being sold at double the normal price of P38-42/kilo... if you can find a store, that is. These should tell you that Kalibo urgently needs help.http://rpc.technorati.com/rpc/ping (Source: Bubbleman)

First exam free weekend.

FtM Doctor — Sun, 29 Jun 2008 16:28:46 +0100

And it’s a bit weird. We had the hospital ball last night. Marvellous fun. I always do like that sort of event. I tend to get on with my colleagues quite well and getting to see each other out side of work is nice. When I was a student I was totally different - I didn’t like ‘mainstream’ social events and was a bit of an outsider for these things. Oh and now I get to wear a tux which is always a bonus. And today we went to the zoo. I’m actually scared to get my life back - because life without studying is so unusual for me - I think it’s only been a matter of months that I’ve been without studying in the last 10 or so years. If I get to like not-studying it will be really crushingly disappointing to find that I’ve failed. Which of course I have. (Source: FtM Doctor)

My podcamp ohio experience

Doctor Anonymous — Sun, 29 Jun 2008 12:06:00 +0100

As you can see in the video above, it was late/early again when I recorded this. Why do I do that to myself. And, why do I subject all of you to this? Hehe. Anyway, Podcamp Ohio was a great experience yesterday. I worked the registration desk in the morning and you can see front desk pics here and here. I heard that some of the sessions in the morning were standing room only. It's great that some people took pics during the sessions like here and here. And, as we were sitting at the front desk, we saw that a couple of people were live streaming the sessions on ustream. So, at the front desk, we were able to view a session going on down the hall. Dontcha love technology? Then, I had the idea of "Live Streaming from the Front Desk" - more as a joke than anything else. I mean who would want to see what's going on at the front desk? Apparently, a few people were curious. So, we kind of had a "front desk" podcamp ohio session as we were checking people in. There was such a response to it, that the live stream continued all day and got to stream the lunch line, the afternoon sessions, and the post conference party.I shot a lot of video yesterday - so much so that the battery in the camera almost ran out. I'm really looking forward to putting it together and sharing it with all of you. But, being around a bunch of geeks (and I mean that in a good way) was a really fun experience. I learned a lot this weekend about various technical stuff - I just hope that I remember it all.For my new Podcamp Ohio friends, welcome to my blog! I invite you to take a look around and make yourself at home. I hope you read some of my posts from the past, and take a listen to some archives of my live radio internet radio show. What was your PodCamp Ohio experience like? Leave a comment here - or if you already wrote about it on your blog - leave the link below and I'll check it out! (Source: Doctor Anonymous)

Random notes 16

Bubbleman — Sun, 29 Jun 2008 04:20:00 +0100

Haven't blogged about the devastation that Typhoon Frank brought to Panay Island. Even now, you see mud everywhere. One week after the typhoon, Kalibo still has a lot of problems. YouTube video of mud-soaked Kalibo. You can hear the motorcycle driving through thick mud.And right here in Iloilo, the roads are still coated with a thick film of caked mud that gets into your lungs every time you inhale. Devastation in Jaro. Please don't mind the music - I did not upload this video.I'm just grateful that our house was spared from being overrun by water. But a lot of people I know have had their houses damaged by the flooding.(Here are some more pictures from Kalibo - the mud says it all. It takes someone like Mar Roxas to point to a wall and show how high the water rose.)==I just submitted my first assignment for one of my subjects under the UP Open University, and I hope that I would get a respectable grade. Keeping a regular study time is really daunting especially since I have yet to receive a Course Guide for my other subject. And it's the subject that I don't really understand well - Logic.==This month has been a struggle for me. Joy started her 2-month elective in PGH. I had to transfer to a new apartment because the old one was just too constricting, and I did not want to continue "breaking in" (actually, opening a window and getting in akyat bahay style) just to get some sleep. I have begun seeing what it is like on the production floor, and I seem to be the one of the few that follow the English Only Policy. I am also a little bit taken aback with the added load of study from UPOU, especially since it is not as structured and requires an available internet connection (at least, I think I need one).But I've been through worse. Hope that this is part of an upward trend.http://rpc.technorati.com/rpc/ping (Source: Bubbleman)

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Osteoporosis among americans over 50

Medicine and Man — Sun, 29 Jun 2008 01:16:59 +0100

Some interesting data from the National osteoporosis foundation. Osteoporosis, or porous bone, causes bones to become fragile and weak. A sufferer’s bones can break from a minor fall, or even a sneeze! The disease is a major health threat for an estimated 44 million Americans, or about half of people ages 50 and older. This graph shows the prevalence of osteoporosis and low bone density among Americans over the age of 50 by gender and ethnicity. addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F06%2F28%2Fosteoporosis-among-americans-over-50%2F'; addthis_title = 'Osteoporosis+among+Americans+over+50'; addthis_pub = ''; (Source: Medicine and Man)

Stacking the deck

Notes from Dr. RW — Sat, 28 Jun 2008 21:32:00 +0100

Concerning my post about Rivaroxaban, Retired Doc said:Good point about the dose of enoxaparin.I need to say more about that having made points about stacking the deck in randomized trials. Is that what we have here?Both trials were sponsored by Bayer, which will participate and benefit from the marketing of the product. So, this may be a case of stacking the deck. It's a variant of the straw man fallacy in which the drug is tested against a "claim" that no one in the real world would make for the comparison drug. This has been seen in many other sponsored trials.There's a larger point: I didn't look at the disclosures until I read the comment. I identified the flaw in these trials without knowledge of the funding source. I make it a practice to do this---to examine a paper critically before looking at disclosures. It’s a useful exercise in that it encourages critical examination of studies on their own scientific merits.If authors are open in reporting their methods one can spot flaws without knowledge of financial conflicts. Disclosures create a type of bias on the part of readers. There was a time when scientific papers were evaluated primarily on their own merits. Some industry sponsored papers are scientifically rigorous, some are not. Some nonsponsored papers are rigorous and some are not. Is today's inquisition about conflicts of interest promoting intellectual laziness? (Source: Notes from Dr. RW)

Life record emr

Ivor Kovic, M.D. — Sat, 28 Jun 2008 17:48:03 +0100

Life Record is a web based electronic medical record with some pretty nice features. One of the coolest is the possibility to use your iPhone to pull up a full medical record, make updates and even write prescriptions. Take a look at the video demonstration. (Source: Ivor Kovic, M.D.)

Dr. a show 40: podcamp ohio - jun 27,2008

Doctor Anonymous Live — Sat, 28 Jun 2008 17:00:00 +0100

The kickoff event for PodCamp Ohio which will be June 28 in Columbus. Check out PodcampOhio.com for details. (Source: Doctor Anonymous Live)

Doctors being honest

Ivor Kovic, M.D. — Sat, 28 Jun 2008 16:30:32 +0100

It the last issue of Reader’s Digest two dozen of doctors revealed “41 Secrets Your Doctor Would Never Share“. I recognized myself in quite a few of these thoughts shared by the colleagues. Here are some of their “confessions”: So let me get this straight: You want a referral to three specialists, an MRI, the medication you saw on TV, and an extra hour for this visit. Gotcha. Do you want fries with that? –Douglas Farrago, MD It really bugs me when people come to the ER for fairly trivial things that could be dealt with at home. –ER physician, Colorado Springs, Colorado Sometimes it’s easier for a doctor to write a prescription for a medicine than to explain why the patient doesn’t need it. –Cardiologist, Bangor, Maine Often the biggest names, the department chairmen, are not the best clinicians, because they spend most of their time being administrators. They no longer primarily focus on taking care of patients. –Heart surgeon, New York City (Source: Ivor Kovic, M.D.)

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Night before podcamp ohio update

Doctor Anonymous — Sat, 28 Jun 2008 11:01:00 +0100

I really weird thing happened. I shot the video above about six hours ago,. I then went to the video site and hit upload and then collapsed and fell asleep. I was hoping to see the thing uploaded and ready to go when I woke up this morning. But, alas, that is not how things work - apparently. But, I had a great time last night meeting some people the night before the Podcamp Ohio event. Podcamp Ohio hasn't even officially started, and, for me, it's already been a valuable experience. I have never considered myself a "tech guy" and talking with some of these people last night - that definitely re-emphasized that fact. I'm really looking forward to the event later thing morning. It's Podcamp Ohio! (Source: Doctor Anonymous)

Shock in the icu

Medicine and Man — Sat, 28 Jun 2008 05:10:55 +0100

This presentation gives a basic overview of shock in the critical care setting. | View | Upload your own The presentation can also be downloaded from here addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F06%2F28%2Fshock-in-the-icu%2F'; addthis_title = 'Shock+in+the+ICU'; addthis_pub = ''; (Source: Medicine and Man)

An oral anticoagulant in the pipeline

Notes from Dr. RW — Fri, 27 Jun 2008 20:21:00 +0100

Rivaroxaban (Xarelto), an oral direct factor Xa inhibitor, was superior to enoxaparin (Lovenox) for VTE prophylaxis in patients undergoing hip and knee arthroplasty according to two NEJM reports this week. These studies leave questions. First, the investigators may merely have defeated the following straw man: Lovenox is the best agent for VTE prevention when used at less than the recommended dose. That’s right, the lovenox dose for the comparison groups (40 mg daily) was below that which is recommended in the product labeling (30 mg Q 12 hours) for these indications. The bigger question on every one’s mind is whether it will replace warfarin, with the promise of reduced laboratory monitoring. That answer awaits studies on patients with atrial fibrillation and established VTE, early in the game at present. Don’t expect warfarin to disappear from the planet anytime soon. Other blog reactions: Clinical Cases and Images Retired DocImage source: Wikipedia (Source: Notes from Dr. RW)

Joint commission’s 2009 patient safety goals

Notes from Dr. RW — Fri, 27 Jun 2008 18:59:00 +0100

---have just been rolled out (H/T to Wachter’s World). Here’s my take on a few of the hospital goals. (I’m not sure which ones are changed from 2008 but these are some I found interesting). Redundancy: For identifying the correct patient and the correct surgical site. Bar coding is part of this redundancy. It doesn’t replace people. Infection control: Lots of organizational structure and documentation requirements found here. Expect more paper shuffling and longer committee reports. Buried somewhere in all this verbiage are the actual best practice recommendations for prevention of central line and surgical infections. Facility associated infections that result in unexpected death or permanent loss of function are to be handled as sentinel events. Medication reconciliation: At discharge the medication instructions must be both written and verbal (you can’t just hand the patient a piece of paper!). What about in the ER? Say the patient comes in with a laceration. Do you have to do complete med rec? No. It’s not required provided the patient is cognitively intact, not admitted and no changes are made in long term medications. If the patient has changes made in long term medication, is admitted, or is confused a complete medication reconciliation process, to include documentation of name, dose and route, is required. Fall prevention: I was underwhelmed by this section. More paper work, committee reports and raised awareness won’t do it. They’ve taken away restraints and Vail beds. If you want to make patient falls a never event, hire a sitter for every elderly patient. (What hospital can afford that?). Otherwise they’re gonna fall. (Source: Notes from Dr. RW)

Infection control, patient safety and a culture of blame

Notes from Dr. RW — Fri, 27 Jun 2008 04:42:00 +0100

Health care facility related infections have a history of being measured. Recently, certain ones have been shown to be largely preventable. Ergo, when an event occurs it’s an “error” and somebody’s to blame. Therein lie unintended consequences. Those consequences will be magnified come October when Medicare’s no pay policy kicks in. Bob Wachter recently blogged about infection control’s increasing importance in patient safety. He noted: Branding a healthcare-associated infection a “preventable adverse event” meant that failure to adhere to the practices that could decrease the rates of these events could be deemed “medical errors.” Ergo, the failure by a healthcare provider to clean his or her hands wasn’t simply an annoyance to infection control professionals… it was A MEDICAL ERROR! There is a distinction between defining a process breach (failure of hand washing) and a bad outcome as an error. While it could be reasonably argued that failure to wash one’s hands before patient contact is an error it’s quite another thing to label every catheter related infection or episode of ventilator associated pneumonia as error. Wachter seems to make the distinction but a commenter said this: Hospital derived infections are often physician errors and to align incentives and protect patients it may be worth considering that the physicians be responsible also financially for their patients' infections this may be draconian but necessary. With a possible move in the offing to bundle physician fees with hospital DRG payments, it could happen. Why not? The patient safety movement was supposed to move us away from a punitive culture of blame. That, we were told, would promote the transparency and openness necessary for us to confront the system issues important for patient safety. Ironically, our efforts seem to have had the opposite effect. (Source: Notes from Dr. RW)

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Show 40 wrap-up

Doctor Anonymous — Fri, 27 Jun 2008 04:31:00 +0100

A little bit of a different show tonight - for Show Number 40 - in that it was not medically related. But, I did have the crew from Podcamp Ohio on the show. The event will be this weekend in Columbus. We talked about some sessions that will take place. I also asked the people on the call about their specific blogs, podcasts, video podcasts, or whatever new media project that they were working on. (see video post above) It was a little bit of a challenge for me because I'm not that well versed in technical stuff. And, I have never had eight people on the show at the same time. So, trying to balance all of that was a challenge - yet a lot of fun! So, I'll be driving down to Columbus on Friday afternoon/evening (about 3 hours away) and hanging out down there this weekend. If you want to keep track of what I'm doing, you can always check out my twitter feed. Or, if that's not working, I just subscribed to friendfeed. I'll also be shooting video down there and hopefully placing it up on my viddler site. Have a great weekend everybody! (Source: Doctor Anonymous)

We’re under treating mrsa in hospitals

Notes from Dr. RW — Thu, 26 Jun 2008 13:50:00 +0100

This study from Clinical Infectious Diseases demonstrated failure to prescribe an anti-MRSA agent not only empirically on day one but also after confirmatory cultures came back in a concerning number of patients with MRSA infections. Maybe we’ve been over-indoctrinated by “say no to vanco.”Via Medscape. (Source: Notes from Dr. RW)

Dr. a show tonight!

Doctor Anonymous — Thu, 26 Jun 2008 07:01:00 +0100

Thursday, June 26th, 2008 at 9pm Eastern TimeJoin us tonight for The Doctor Anonymous Show number 40. We're going to be talking about Podcamp Ohio on the show. What is this? Well, it a conference, actually called an un-conference, talking about all things new media - whether they be blogs, podcasts, video podcasts, social networking, twitter, and other stuff. Our guests will be conference organizers, people presenting sessions, and of course, taking your phone calls as well.If you do listen live, you can even take part in the chat room. It is truly "The show within the show." You can even call in and say hello. A great opportunity to interact with medbloggers you've only read about. And, you will be able to see me on the live webcam during the show! See you tonight!For first time Blog Talk Radio listeners:*Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.*To get to my show site, click here. As show time gets closer, keep hitting "refresh" on your browser until you see the "Click to Listen" button. Then, of course, press the "Click to Listen" button.*You can also participate in the live chat room before, during, and after the show. Look for the "Chat Available" button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.*You can also call into the show. The number is on my show site. I'll be taking calls beginning at around the bottom of the hour. There is also a "Click To Talk" feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful! (Source: Doctor Anonymous)

On targets…

FtM Doctor — Wed, 25 Jun 2008 19:28:49 +0100

I’ve been thinking recently about targets. In general in the NHS it’s considered that ‘Targets’ are a bad thing. If for instance you have a pet loving Minister of Health set a target that all hospitals should see all people who have a pet dog at home within 33.3 minutes of arrival, then low and behold it will happen. Because that’s where the money will go. Now this is excellent for the people with dogs but not for the people with exotic fish who will be waiting for 3 hours 59 minutes in A and E with everyone else. Now take MRSA bacteriaemia - this is a bad thing. Of course so the government sets targets that hospitals should try and avoid it. So hospitals discover that if you don’t do blood cultures you can’t find bactaemiaemia - so there’s subtle pressure to avoid blood cultures. One hospital I have heard about on the rumour mill only lets specialist nurses do blood cultures - so of course there’s a pressure to treat empically. Tossers. I don’t know anyone who thinks that having patients waiting on trolleys in A and E for 4 days is a good thing, but it would be good if perhaps that sometimes, if you needed to stay in A and E for 4 hours and 20 minutes because they were too unstable for transfer to MAU then you should do. In general things are better after the four hour wait came into play. Well for the patients, who have minor injuries anyway. I would rather the patients who were coming to medics had things done a bit better at times. But then again things are better in a way. Then there’s a matter of the two week wait for cancer - it’s generally good that patients who have cancer don’t have their operations cancelled numerous times - but it would be nice if the other urgent scans weren’t cancelled for these operations. But what are the alternatives? It would be lovely if doctors just could do thier jobs without any management at all. But that’s not the way any job works - everyone needs some management - unless they’re self employed. And I do wonder if consultants with lots of private work are going to be motivated to try and run an efficient NHS service without any management. You could have ‘outcome based targets’ but I’m not sure if they would work. For instance the targets on treatment of pneumonia in america have led to patients with pneumonia being prioritised over sicker patients. So what’s the answer - I don’t know. I’m not ranty like Dr Crippen so I can’t just declare one way or the other. Obviously if I ran the world then I could run the NHS perfectly. But no one seems willing to give me that job. I gave up on the idea of being prime minister when I was about 11, when I realised no one would give the job to a transsexual, and then again when I was at university when I realised that all students who were involved in student politics were odious creeps. (Source: FtM Doctor)

Debate continues on the value of the hospitalist model

Notes from Dr. RW — Wed, 25 Jun 2008 17:03:00 +0100

Two academic leaders in hospital medicine, Dr. Mark Williams and Dr. Robert Centor (our own DB) debated the model in the current issue of Archives of Internal Medicine. Links to the point-counter point exchange can be found in DB’s post on the topic.In short, Dr. Williams maintains that the model improves outcomes and efficiency, that the evidence is in and the debate is over. DB says “not so fast”, citing mixed evidence and marked variation in the model. As much as I’m excited about the potential for the hospitalist model and as much as I love my hospitalist career (that’s my conflict of interest disclosure) I have to go with DB on this one.For those who can access the articles in the original, many aspects of hospital medicine were covered. I’ll restrict my comments to Dr. Williams’s claim that the model has been proven to improve efficiency and outcomes. From where I sit the evidence is all over the map. It’s mixed at best. I’ve blogged about it many times, most recently here. The most talked about study last year was this one published in NEJM. The conclusion of that largest ever study on hospitalist outcomes and efficiency was underwhelming. There was no improvement in patient outcomes. Hospitalist care was associated with decreased charges per case in comparison with internists but not family practitioners. Although a number of smaller studies showed superior efficiency with the hospitalist model the next largest study, and one with superior design, showed no efficiency or outcome benefits. It was a prospective multicenter study presented at SHM 2005 which you can access in this issue of The Hospitalist. The results:Twelve thousand and onepatients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups.We’re still waiting, by the way, for the one year mortality data. What’s important about that study? It’s the fact that, following some early hype in the blogosphere (here, here, here and here) it got buried. It wasn’t mentioned in Dr. Williams’s article. And because it was never published in a Medline indexed journal it was not included in the systematic review cited by Williams and others who promote the model.This debate will never be settled. There will be few, if any, new studies. With traditional practitioners fleeing hospitals in droves, soon there will be no comparison groups against which to study the model. It’s a moot point. The model is here to stay. We don’t need these metrics to establish our value. (Source: Notes from Dr. RW)

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Can we measure the value (or harm) of cme?

Notes from Dr. RW — Wed, 25 Jun 2008 14:41:00 +0100

In response to one of my posts on the Medscape CME controversy a commenter, Supremacy Claus, said this:This point is missing from the discussion. CME itself is garbage. It does no harm. It has no demonstrable benefit. Demanding an example of a benefit is as valid as demanding an example of harm. I could not name a specific fact of benefit, just as Carroll cannot name an instance of specific harm. CME is an unfunded mandate imposed by the clinician hater lawyer oppressor running the medical licensing boards. There is no evidence of any benefit to any patient from this massive waste of time and paper shuffling. There is no evidence the academic windbags presenting these programs know anything of value to patients. There is no evidence anyone remembers their trite, narrow, useless technical points 5 minutes after walking out. There is certainly no evidence anyone changes any practice after these programs.I do believe a physician’s life long learning produces benefits for patients. These benefits, however, are intangible and cannot be measured in any meaningful way. Moreover, it makes little or no difference whether this learning is “logged in” as accredited CME hours. Learning needs and styles vary from one physician to another. That’s why the responsibility for life long learning should lie with the individual physician, not with government bureaucracy, and that’s what the academic windbags, who think one learning formula fits all, don’t get.I’ve used Up to Date as a point of care look up reference for several years. When Up to Date became a CME provider I was able to log in accredited hours with no extra effort. Was the learning experience suddenly enhanced? No. Did my use of Up to Date change? No. Although I more than satisfy my state’s CME requirement by using Up to Date, for me the most meaningful accredited learning experiences come from meetings such as Bob Wachter’s and Mayo Clinic’s hospital medicine courses, activities which would not exist without industry sponsorship.The academics are clamoring for metrics to gauge CME’s effects on doctors’ “behavior.” There being no meaningful way to measure such an intangible, the best they’re likely to come up with are perfunctory “core quality measures” used today for pay for performance and public reporting, Unfortunately these measures are crude, sometimes non-evidence based and often have produced unintended consequences that far outweigh their benefits. If applied as measuring sticks for CME they are sure to have a dumbing down effect. (Source: Notes from Dr. RW)

Show 40 preview

Doctor Anonymous — Wed, 25 Jun 2008 09:55:00 +0100

This week, The Doctor Anonymous Show is doing something a little bit different - a little different change of pace for the show this week. Don't worry, it's not going to be bad. In fact, I think we're going to have a lot of fun! (See video post above)I'm happy to welcome Podcamp Ohio to the show. What is Podcamp Ohio? Well, the best way I would describe it is that it is a gathering of new media enthusiasts - whether it be blogs, podcasts, video podcasts, social networking, and whatever else comes to mind. Podcamp Ohio will take place this weekend on Saturday, June 28th in Columbus, Ohio.So, I'm hoping to have some of the organizers on the show, to have some people who will be presenting sessions on the show, and to have attendees on the show - just talking about stuff. I think it will be a great time on Thursday, June 26th, 2008 at 9pm Eastern Time. See you for the show! (Source: Doctor Anonymous)

Lost vegas videos

Doctor Anonymous — Tue, 24 Jun 2008 17:43:00 +0100

No, these videos were not lost. I just thought that it made a good title of a post. Anyway, I just saw a couple of videos from Brandice. And, one of them has a layout of her room. Why is it when people go to Vegas - that people want to know what your hotel room was like - interesting. Anyway, here's her room tour below.So, as I have been saying for weeks, I have minutes and minutes of unedited Vegas video from my own trip in May. Finally, I put together my hotel room tour. It's not exciting and the view left a lot to be desired. But, it was fun editing this thing together. Hope you enjoy the video below! (Source: Doctor Anonymous)

Want to ban industry supported cme? evidence please!

Notes from Dr. RW — Tue, 24 Jun 2008 15:48:00 +0100

Draconian policy measures have unintended consequences. Proponents of measures against industry supported CME should sustain a burden of proof that such measures would help patients. What is the evidence?This month the Accreditation Council on Continuing Medical Education (ACCME) released a report of a literature review on this subject. Their conclusion:We found no studies that directly addressed the question of whether commercial support produces bias in accredited CME activities.Whether or not the content is biased, do supported activities result in increased prescribing of sponsors’ products? The only two studies that found such an association were based on decades old data reflecting CME activities which predated today’s policies and standards and are not on the table for discussion in today’s debate. And, although there has been limited study regarding the influence on prescribing there are no data concerning the impact on patient outcomes.Via Policy and Medicine. (Source: Notes from Dr. RW)

Cme safe---for now

Notes from Dr. RW — Tue, 24 Jun 2008 01:55:00 +0100

I’m a little late with this, but the AMA proposal to eliminate industry supported CME went down in flames. Pathobilia cited the arguments leveled against the proposal:[T]he report ignores the dramatic difference between certified CME and other non-certified 'education' and thus overlooks the significant advances in the management and resolution of conflicts of interest mandated in the last several years by government, industry and the [ACCME].[T]he report's conclusions are not based on current and scientifically relevant and rigorous evidence in the context of certified CME and do not respect dramatic progress in the past decade.[T]he report lacks a plausible, detailed plan to ensure that the proposed elimination of $1 billion in certified CME funding would improve the quality of certified CME and patient care.The long and the short of it? Proponents could not offer a shred of evidence that this draconian measure would benefit doctors or patients. I guess I won’t cancel my AMA membership just yet. (Source: Notes from Dr. RW)

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More push for open access

Notes from Dr. RW — Mon, 23 Jun 2008 21:38:00 +0100

Articles based on NIH funded research will now be required to be available as open access in Pub Med Central.Via VUMC Reporter. (Source: Notes from Dr. RW)

Diabetic gastroparesis

Notes from Dr. RW — Mon, 23 Jun 2008 21:34:00 +0100

This condition, reviewed in Hospital Physician, is one of the more frustrating disorders to treat. It can sabotage the best laid plans for diabetes control and treatment response is often unrewarding. (Source: Notes from Dr. RW)

In which i bugger up mrcp part 2 (paces)

FtM Doctor — Mon, 23 Jun 2008 20:40:14 +0100

Well I knew it was a bad start yesterday. Yesterday was the first day I wasn’t working or dealing with a dying relative for four weeks. Understandably I was a bit tired. I began to be worried when I woke up after sleeping for 10 hours (yes TEN hours) and felt exhausted. I remembered I might be low testosterone - because I was due an injection two weeks ago and hadn’t had chance to go to my GP since. I noticed my housemate had woken up and quickly asked her to write a private prescription. I then felt exhausted and went back to bed. It took me for ages to find my clothes and my keys- I realised I had no problem solving skills at all. Not a good start for my exam. Never mind - probably just a result of Fortunately the pharmacist accepted the private prescription written on some lined note paper ripped out of a note pad - she’d told me that she’d dispense it if it was written on toilet paper as long as it was by a registered doctor she could find on the GMC’s Online Register. One injection of testosterone later I was still feeling exhausted - but I was considerably more interested in sex. So my exhaustion wasn’t something easily fixable with testosterone. Next step was too look for my suit and have it cleaned - seemed easy enough. Except after a through search of my bedroom floor I couldn’t find it. It didn’t seem to be in my wardrobe either. I found a jacket for which the trousers had worn out and spent a panicked half hour comparing the black trousers I had to the jacket to see which was close enough for a match. Then I finally found the suit - in guess what - a suit carrier in my wardrobe - who would have though - if you know me that the last place I’m likely to find a suit is in a suit carrier. But by this time it was far too late to have it cleaned. Fortunately it was quite clean so I hoped I could get away with it. When I got the date for PACES I was surprised because it was on a Sunday - also because it was about 45 minutes drive from my girlfriends. As getting up at 7.15am on a Sunday wasn’t her idea of fun we decided to book a hotel. Except you can’t book a hotel without a credit card and when I asked her to book a hotel she baulked at the idea of spending £50 on a hotel 45 minutes drive from her house. So we decided to stay at hers. I decided to practice ophthalmoscopy on her - and was struggling a little due to smudge on my opthalmoscope. She decided to clean it using some CD cleaning fluid and afterward I could barely see anything at all. Humm. Balls Anyway. We woke up in time and got to the hospital in plenty of time - half an hour before the report time. For such a big exam it seemed quite a causal affair. The sign to the PACES exam was hand written with a marker pen.. for instance. The exam was in a small day surgery unit in a small DGH, such a normal place - not a grand hall at all. The examiners were just consultants who were doing this in there spare time. We waited around for an hour and ten minutes before we got started - we had to put our name and exam number on the 14 marking sheets which you carry around from station to station and give to the examiner. We chatting at first - but as the time came near we got more nervous. I told myself I was going to fail anyway so there was nothing to be scared of. So this is what happened… Station 4 - ‘Communication Skills and Ethics’ This was where I had to deal with an ‘Actor’ (actually a secretary) angry at the fact her father had been admitted 7 days ago and now had pressure sores and MRSA. It was a bit awkward, at one stage she asked me if the stroke ward had the same number of nurses as a normal ward - I replied that it did. Because it does at the hospital I worked at, and if the nurses had been turning him properly - at this stage I showed her an imaginary turn chart which proved they had been. During the discussion the examiners asked me why I told that the staffing on the stroke ward was the same as ours - I said because it was at our hospital and I would check if I didn’t know. And also why did I pretend to look at imaginary documents? I did point out that I didn’t do that in real life. Station 5 Bits and Bobs The first patient threw me - she had some scars on her legs and was short. And they told me the diagnoses was related to endocrinology. Humm. I struggled a bit and eventually looked at her hands to see if she had a short 4th and 5th metatarsal. She didn’t but the examiner seemed to like that so I mentioned rickets. I asked what the Calcium was (low) and phosphate (low). They asked me if I could measure Vitamin D Directly - and I couldn’t remember if you could - they told me hers was high. I mentioned vitamin D resitant rickets and we moved on to the next patient. They told me he had difficulty swallowing, he had obvious neurofibromas over his arms and he said he daughter had similar problems when I asked. So Neurofibromatosis - but what was the connection was swallowing problems? I couldn’t work it out and blundered about a bit and said there was known to be a link. They asked how I’d manage him and make a diagnosis - again I couldn’t remember. Next patient was a man with lower back pain - the only abnormality I could find was a loss of flextion of the lumbar spine. I wondered if it could be early Ank Spond and talked about that. I couldn’t remember any of the associations or how to manage it. Now the only thing I did really well in any of the examination stations - ophthalmoscopy - the one thing I thought I wouldn’t be good at. This was why I went on the Ealing Neuropaces course. It was obvious optic atropy in a patient in a wheelchair - I thought it could be related to MS. But couldn’t remember the most up to date way to treat a flare up of MS. Station 1 Respiratory and Abdominal I examined the abdomen ok - but finished a little before the allocated time - so probably missed something. The examiner was a bit nasty - I got the impression I didn’t do well. He asked why I thought dilated veins on the upper abdomen were relevant and where the normal anatomical marker of the upper border of the liver was. By this stage I was in too much of a state to actually think of anything but ‘about there’ and point to it. I finally managed to come out with the anatomical landmark The respiratory station was a lady with a chest wall deformity who was recently complaining of fatigue. I found the chest wall deformity easily enough - and presented the case ok. Though I couldn’t think of the term kyphoscolosis - fuck knows why, nerves I think. I couldn’t think why she might be fatigued recently. The examiner asked how I’d manage her - I answered including O2 Sats - he said ‘night or day?’ and I realised they were getting at her having OSA from her chest wall deformity - the bell went and I quickly mentioned the way I’d investigate it. Station 2 History Taking The one station that went really well. It was taking a history from a young girl who had had her first seizure - I did this pretty well, answered all her questions and counselled her on work and driving and stuff. Station 3 Cardiovascular and Neuro The cardio was difficult - the patient had a sternotomy scar and a loud second heart sound - I also thought that she had a disastolic murmur of AI. Except I wasn’t confident enough to say this at first and was rather hesitant about presenting it. Stupidly I only mentioned measuring the BP when I talked about management - there was a really wide pulse pressure. If I’d asked earlier I’d have been more confident about staying there was AI. Neuro - the sort of thing that gives me flashbacks. I examined the upper limbs of the lady - weakness of the elbows and right wrist and absent reflexes and muscle wasting. I thought ‘is this facio-scapular-humeral dystropy’ as I was examining - but when I came to present my findings I forgot about it. And to make it worse I just couldn’t think of a diagnosis that fitting the findings - all the suggestions I could think of were ‘well it could be a parasaggital mengioma but that would be different’. As we left I worked out with the other candidates that it was probably ‘limb girdle muscular dystopy’. Why didn’t I notice this? I don’t think I passed. I don’t think I deserve to have passed. In fact I really don’t think I want to be a member of any Royal College that admits me after that performance. (Source: FtM Doctor)

Digg-like open peer-review

Ivor Kovic, M.D. — Mon, 23 Jun 2008 18:00:24 +0100

Medicine 2.0™ is an international conference on Web 2.0 applications in health and medicine, organized and co-sponsored by the Journal of Medical Internet Research, the International Medical Informatics Association, the Centre for Global eHealth Innovation, CHIRAD, and a number of other sponsoring organizations. This conference, to be held in Toronto from 4th to 5th September 2008, is a successor of a highly successful “Mednet 2006: 11th World Congress on Internet in Medicine” Congress. It will be smaller and oriented only on Web 2.0 in medicine. However, these are not the only differences, because the organizing committee decided to completely change the peer review selection process of the submitted papers. Consistent with the Web 2.0 theme of the conference, we are experimenting with a new “Digg”-like open peer-review mechanism, allowing any user to vote for submitted abstracts using a simple thumbs-up/thumbs-down rating system, with the additional ability for anyone to sign up as a peer-reviewer for a submitted abstract. Go ahead and vote for your favorite papers. (Source: Ivor Kovic, M.D.)

Hospital medicine: a mile wide and an inch deep?

Notes from Dr. RW — Mon, 23 Jun 2008 14:13:00 +0100

My last post on the hospitalist as a Swiss Army knife drew this comment:I agree that being a hospitalist is being a Swiss Army knife, but I happen to think these knives are great. I think what you are confusing is being a hospitalist versus being an internist. If we are to argue that hospitalists are a new specialty, which I think they are, then we have to differentiate ourselves from being a hospital-based internist. An internist sees internal medicine problems. A hospitalist manages hospitalized patients, and is a specialist in providing the highest quality care regardless of the diagnosis. An ER doctor specializes in taking care of patients in an emergency setting regardless ofwhether it is medical (MI) or surgical (trauma). Likewise, a hospitalist specializes in caring for hospitalized patients. We should not confuse the concept of the hospitalist, which involves improving the care of all hospitalized patients, from the present reality, which is that we are not adequately staffed to do this. These are 2 separate issues.This comment gets to the heart of some important questions about the hospitalist movement but it makes assumptions about issues that are far from settled. Is hospital medicine a subspecialty of a parent field (such as internal medicine) or, as the commenter suggests, a new specialty altogether? Other new fields in medicine have resolved this question in different ways. Emergency medicine became its own specialty while critical care medicine became a subspecialty of internal medicine. So far the hospitalist work force has been populated mainly by internists, whose training has traditionally focused on hospital medicine. It’s a good fit for them because it provides the best opportunity to practice in the original concept of internal medicine. Internal medicine’s emphasis on in depth care of severely ill patients with complex medical problems also serves hospitals well.Hospitalists who care for patients outside the domain of internal medicine are aligning themselves with other appropriate specialties. Pediatric hospitalists, for example, according to the American Academy of Pediatrics are simply hospital based pediatricians. For surgical patients there are surgical hospitalists.The complexity of the hospital today demands a focused and nuanced approach. I hope hospital medicine doesn’t morph into a single specialty to provide care for all inpatients. If it does it will be a mile wide and only an inch deep. That’s not very promising for career satisfaction and, in my opinion, may not be best for patients. (Source: Notes from Dr. RW)

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Links for 2008-06-22

antifaust — Sun, 22 Jun 2008 08:32:00 +0100

Bookbinding: How to Make a Hardcover Book (tags: diy tutorial) Zoomii.com - The “Real” Online Bookstore (tags: web2.0 books) (Source: antifaust)

The saturday before the storm

FtM Doctor — Sat, 21 Jun 2008 07:58:30 +0100

There are several signs that I’ve noticed that tend to mean I’m working too hard. One is that I look forward to my on calls because they are a nice break from my daily life. And I do love on calls now - once I realised I can deal with the majority of the really sick people that come through the door and that however busy it gets we’ll get through. What cheered me up was doing a Lumbar Puncture and getting the CSF - doesn’t ask - but I really like doing lumbar punctures, I pretty much like all procedures. I like getting people better myself, using my hands, eyes, mind, etc. Yes I diagnosed your meningitis - and then confirmed it myself. So yes, - the funeral - it was excellent - as funerals go. At first my family didn’t want a funeral - just to turn up at the crematorium and watch the coffin go behind a curtain and then go home. My Aunt, Mother and brother aren’t very socially confident and don’t care what neighbours thing. I tried to persuade them that they would need a reception. And then gave up and went back to work. Then I persuaded them to have some sandwiches at the house, and even offered to pay for them myself. I had a few panicked phone calls - when will people turn up, what do they want to do. What will they expect? In the end it was wonderful - we put some old photos of her out and everyone enjoyed looking at her and gossiping. We tried to give the plants and nicknaks away. I was subtly aware that most people knew that I was a transsexual, but didn’t mention it. I was also the only one wearing a suit and felt overdressed. Friday on call was much much more fun! I saw some interesting cases and did an LP - did I mention that? Now today is the day off before PACES tomorrow. I’ve decided to do some housework - I haven’t done any housework for several weeks, thank god for the housemate.. I’ve got to go to the small town where my PACES is being held tonight. (Source: FtM Doctor)

The medical thought police target medscape

Notes from Dr. RW — Fri, 20 Jun 2008 22:46:00 +0100

In my post Tuesday about the growing assault on industry supported CME I briefly mentioned Daniel Carlat’s attack against Medscape. Characterizing Medscape in general as “nothing more than a CME industry voicebox” he cited a drug company supported activity titled Managing Schizophrenia in a Patient with Alcohol Abuse and Hepatic Impairment. Noting that the CME article was sponsored by the makers of one of the drugs in question (Janssen’s Invega) he pointed out that the information presented was (gasp!) favorable to Invega. After quoting at some length from the article and ranting about Medscape’s corruption Carlat made this interesting observation: “Has Janssen--I mean, Medscape--said anything inaccurate in this puff piece? No.” What, then, is Dr. Carlat’s issue? It’s promotional (read: positive towards the drug in question) we’re told. Somehow that makes it irrelevant that the information happens to be true. I left me struggling to find a way to see his argument as anything other than an ad hominem attack.If Carlat’s post was interesting this post at Health Care Renewal by former Duke psychiatry chairman Bernard Carroll was jaw dropping. Full of invective (Medscape’s content is “tacky” and “pedestrian”) and unsubstantiated allegations (“Some items are academic wallpaper, non-promotional pieces designed to create an appearance of commitment to education”), the post offered no examples of inaccurate CME content in Medscape. At the end, though, we got this tease:We will examine that trope in my next posting, which features the poster boy for compromised KOLs in psychiatry, Charles Nemeroff, MD from Emory University’sdepartment of psychiatry. In that example, Medscape joins forces with Nemeroff to promote an entirely new level of sleaze. Stay tuned.The sleaze, we learned in Carroll’s next post, was a Medscape expert interview with Nemeroff. In what reads like an attack piece against Nemeroff Dr. Carroll did cite some objectionable content from the interview. But this whole discussion is about CME. The problem with the example cited is that it’s not a CME offering. It is what it is---an expert interview in which the expert delivers his opinions. It makes no pretense at being anything else. In the comment thread of his follow up post on Medscape CME Dr. Carlat said:But regarding your opinion that most of Medscape's content is "editorially uninfluenced by sponsorship," this is an empirical question. I can't accurately scrutinize their CME offerings in say, cardiology or endocrinology, but on casual inpection they are as saturated with industry sponsorship as the psychiatry section. Hopefully, there's a cardiologist and an endocrinologist out there who has the time to put the "biascope" up to those activities as I have done in psychiatry.If Dr. Carlat will indulge the observations of a non-academic hospitalist I’ll offer my take. First some disclosures. I have no financial ties to the pharmaceutical industry. I have written a few (non industry supported) Roundtable Discussion pieces for Medscape. I have no financial interest (as Dr. Carlat does) in providing industry free CME.Medscape’s content spans multiple levels of scientific objectivity ranging from video rants and blog type entries to peer reviewed journal articles. Most are not offered as CME. The demarcations between these content areas are clear. I have written many blog posts with links to Medscape CME activities in the areas of cardiology, critical care and hospital medicine. These articles, by and large, are accurate and scientifically rigorous. What qualifies me to make that claim? As my readers know I regularly check the content against primary sources and, in most cases, link to those sources.Of course I am judging Medscape’s content on its own merits. Where did we get the mindset that educational content must be judged primarily on the basis of who paid for it? If you can’t understand what’s wrong with that thinking I highly recommend Thomas Stossel’s recent commentary or, better yet, KJ Rothman’s important but long forgotten article on The new McCarthyism in science. (Source: Notes from Dr. RW)

Dr. a show 40: podcamp ohio - jun 27,2008

Doctor Anonymous Live — Fri, 20 Jun 2008 20:45:00 +0100

The kickoff event for PodCamp Ohio which will be June 28 in Columbus. Check out PodcampOhio.com for details. (Source: Doctor Anonymous Live)

Medicine 2.0 : applying what has been learned

Web 2.0 and Medicine — Fri, 20 Jun 2008 16:59:00 +0100

It has been a long time since my last post. I have been busy working in different personal things. But a post by Bertalan Meskó make think about something that I realized long time ago. The key for a development of a culture of Medicine 2.0 is education : Health Digital Literacy.Each one of us can help to make this possible. I am participating in a observership with a group of International Medical Graduates (IMGs) at UCLA. We have developed a web to share our experiences in the process of getting involve in the American Health Care System.In the process I am also teaching my fellows all what I know about Medicine 2.0 .Please Visit us:UCLA International Medical Graduate (IMG) Program. Your feedback is always welcome. (Source: Web 2.0 and Medicine)

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Show 39 wrap-up

Doctor Anonymous — Fri, 20 Jun 2008 04:01:00 +0100

Thanks to Dr. David Loeb from Doctor David's Blog: Musings of a Pediatric Oncologist. (see video post above) The topic of cancer in kids is sometimes an awkward to talk about. Thanks to Dr. David for being up front and honest about talking about these issues. I very much appreciate his candor in talking about this stuff. If you haven't already, check out Show 39 of The Doctor Anonymous Show (and don't forget to rate the show!).Following the interview, I shared some news stories and I'll add those links up on this post a little bit later. Thanks to The Medical Quack for calling into the show and saving me from myself. It's really tough to talk to yourself for 30 minutes to close the show. I really appreciate her promoting the show and talking about the show on her blog. If you haven't check it out yet, I encourage you to click on over to her blog called The Medical Quack.Following the show, I had a request to go over to my Ustream "channel" again and broadcast over there for a bit. I was up there for about 10 minutes talking about the show and hanging out with my blog friends. Thanks so much to those who followed the after show. I'm also thinking about trying out stickam to broadcast something similar. What's interesting about that site is that up to six people with laptop cams (or a video cam in general) can broadcast at the same time - so everybody sees everybody else. So, maybe I'll try that sometime.Finally, I again wanted to thank everybody for your well wishes for my 2nd Blogiversary. I continue to be humbled every day by those who continue to stop by, read my blog, leave comments, listen to the show, call in to the show, and being a part of my blogging life. Thanks to all of you who support me and keep me doing this. I am eternally grateful. Thank you! (Source: Doctor Anonymous)

Dr. a show 39: david loeb - jun 20,2008

Doctor Anonymous Live — Fri, 20 Jun 2008 01:00:00 +0100

Dr. David Loeb who is pediatric cancer doctor joins the show. He is author of Doctor David's Blog (Source: Doctor Anonymous Live)

Funerals..

FtM Doctor — Thu, 19 Jun 2008 23:46:46 +0100

It was the funeral today. Somewhat unconventional as funerals of atheists are apt to be. And then I lost my wallet. I’ll post with an explanation later… if you care. (Source: FtM Doctor)

Sirius satellite radio - doctor radio

Medicine and Man — Thu, 19 Jun 2008 22:37:45 +0100

Doctor radio is new 24 hour channel launched by Sirius Satellite Radio. As per the company: What is Doctor Radio? Here are the symptoms it’s presenting: • World-class Doctors from the NYU Langone Medical Center. • Listeners calling with their medical questions. • Real medical information delivered in a down-to-earth style. • Amazing real-life stories from the ER, operating room and beyond. Wall Street Journal Health Blog has complete coverage. addthis_url = 'http%3A%2F%2Fmedicineandman.com%2Fblog%2F2008%2F06%2F19%2Fsirius-satellite-radio-doctor-radio%2F'; addthis_title = 'SIRIUS+Satellite+Radio+-+Doctor+Radio'; addthis_pub = ''; (Source: Medicine and Man)