Trust Me, I'm a Doctor

A New Medical Meme Record...

2004-10-10T08:21:00.000-05:00

...in one article. I felt the need to post since the same story was in my Sunday paper. This is my previous explanation of medical memes. The headline: "Experts: Good Hygiene Can Ward Off Flu" got my attention in light of the recent flu vaccine shortage. Unfortunately, the "experts" let me down again. Searching PubMed for the credentials of the experts quoted did not yield any publications

More on NCEP

2004-09-19T13:19:00.000-05:00

A reader pointed out a bad link from a previous post and suggested the improvement. Thank you. I think this from the lay press says it better than I could.

Another PSA Without Outcomes

2004-09-19T08:43:00.000-05:00

I wonder if this Private Sector Advocacy’s (PSA) online Health Plan Complaint Form from the American Medical Association (AMA) really works?

If a Tree Falls in the Woods...

2004-09-19T07:57:00.000-05:00

Or, if there is no evidence, then is it a guideline? The American Urological Association (AUA) released a "guideline" on premature ejaculation. At lease they are overt about it when they say:The mission of the committee was to develop recommendations, that are analysis-based or consensus-based, depending on panel processes and available data, for optimal clinical practices in the diagnosis and

More Screening Folly

2004-09-01T13:40:00.000-05:00

I'm pretty busy with sick people so I have a high threshold for screening tests. Unless there is good outcomes data and the interventions are clear, I am wary of the "raise awareness" people. I'm sure they mean well but they don't see their favorite disease screening as displacing something more important. I have to leverage my time. This (Changing the Clinical Management of Hereditary

Journal Access #2

2004-09-01T12:07:00.000-05:00

Bummer dude. Things are getting worse since a previous post. I've been getting JAMA and Archives of XYZ...electronically by way of my medical staff library. However, the institutional license recently changed so I no longer have access. I'm not an AMA member but I get a complementary copy of JAMA for reasons that I don't understand. The reason I care is the frequent mismatch between the actual

Medical School Admissions

2004-08-27T12:39:00.000-05:00

Years ago I served on the admissions committee. The interview always included some form of the question: Why do you want to go to medical school? Most of the answers were neutral and long the lines of: I want to help people... While there are some wrong answers (external motivation, $, etc.) I can only come up with a few right answers after all these years. One is a variation on: Q: Why do

The VA

2004-08-24T20:23:00.000-05:00

Thanks to threemd for pointing this (Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care, The TRIAD Study) out. I review medical records for lawyers and recently had a case that included a VA patient. I was impressed by the chart over the past couple of years. My previous post noted the quality gap. My medical group currently includes a quality audit

Too Aggressive?

2004-07-18T07:16:00.000-05:00

When I first heard about the newest cholesterol guidelines, my first thought was: "It's about time". Unfortunately, they are: 1. Too aggressive (efficacy vs effective?, mortality benefit vs combined endpoint?). 2. Too complicated (my primary prevention patients already think their goal LDL is 70). 3. And, tainted.

Journal Access

2004-07-10T11:06:00.000-05:00

I can't help but wish I had full text access to medical journals. The abstract is helpful but if I really care about something I need the entire article. I can get the real thing from my hospital library but I like the convenience of computer files over traditional paper. This (Wired 12.04: The 2004 Wired Rave Awards) is the right idea.

"We Don't Do Eyes Over the Phone..."

2004-07-07T18:56:00.000-05:00

is what we routinely tell patients but maybe we could. Over the years, I've struggled with the management of acute conjunctivitis. When I'm on call, patients often page me to start Rx eye drops. Sending them to an after hours facility seems excessive. During office hours I have them come in. Neither decision is comfortable for me. At least now for adult patients, I have an option: Rietveld et

Definite Maybe

2004-07-06T16:48:00.000-05:00

Guidelines and evidence are rarely conclusive. I use "do it, don't do it, and be conservative" to guide decisions. Because some questions can't be answered yes or no I've thought about the language for a third choice. From the GRADE Working Group :We suggest using the following categories for recommendations: "Do it" or "don't do it"—indicating a judgment that most well informed people would

Source Data

2004-07-03T09:24:00.000-05:00

Thanks to alert readers for showing me this post's source (bmj.com Isaacs and Fitzgerald 319 (7225): 1618).

Alternatives to EBM

2004-06-27T17:13:00.000-05:00

I was cleaning out my office lately and found this list from a few years ago. The source is unknown: 1. Eminence based medicine 2. Vehemence based medicine 3. Eloquence based medicine 4. Providence based medicine 5. Diffidence based medicine 6. Nervousness based medicine 7. Confidence based medicine 8. Opulence based medicine 9. Annoyance based medicine 10. Arrogance based medicine 11.

Simple Breast Cancer Screening Algorithm

2004-06-23T12:50:00.000-05:00

As a family physician, I share many female patients with a gynecologist. Most of the time it works. Sometimes it doesn't. I recently had a 48 year old HMO patient contact my office needing a referral to a breast surgeon for a "second opinion" regarding a "nodule". I asked my staff to get more information. Turns out, it wasn't a lump but rather an abnormal mammogram. I asked her to come in so

Turn Left Right Here

2004-06-22T09:20:00.000-05:00

Or...two wrongs don't make a right but three rights make a left. Wrong side surgery continues to be a problem: Yahoo! News - Doctors Must Double-Check Before Surgery. My hospital committee was recently asked to update our existing policy to meet JCAHO standards (Patient Safety, Universal Protocol for Wrong Site, Wrong Procedure and Wrong Person Surgery). As a family physician, I've always been

Due Remember Me

2004-06-21T21:46:00.000-05:00

I was looking something else up and came across this: The Journal of Urology - Abstract: Volume 170(6, Part 1 of 2) December 2003 p 2356-2358 Salvage of Sildenafil Failures Referred From Primary Care Physicians.The first paragraph has an error that makes for a fun malapropism considering the article is about "inadequate ... education" [my bold].Purpose: Sildenafil citrate is an effective first

House Painter Says: "House Needs Painting"

2004-06-11T12:26:00.000-05:00

Yet another "expert" is describing how they would like the world to be instead of how it is... Sinus headaches are just another medical meme. This (Yahoo! News - Sinus Headaches Often Really Migraines: Study) research only validates something obvious. Which came first? Patients deciding most of the headaches were "sinus" or passive medical providers not taking the time to challenge this

My Mail Bin

2004-06-10T15:58:00.000-05:00

I'm on an electronic medical record (EMR) so most of my day is moving electrons around. Dealing with paper is an ongoing problem. We have a good lab and Xray interface as long as the data is within my integrated health care system. This means I get those reports automatically tagged to the patient account and that makes me spoiled. My patients get Xray results the same day and most lab results

Number Not Needed to Barf

2004-06-10T13:32:00.000-05:00

How fun is this? From today's headlines comes Cheap Drugs Work Against Post-Op Nausea per the NEJM -- A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting. First some facts that this family physician found interesting from the article: 1. Untreated, one third of surgery patients will have post operative nausea, vomiting, or both. 2. The problem is so big

The Enemy is Us

2004-06-08T17:06:00.000-05:00

The PSA issues never seem to go away. Today's Medscape e-mail update says PSA For Prostate Cancer Detection but I'm disappointed when it is only the results of a poll triggered by the recent NEJM -- Prevalence of Prostate Cancer among Men with a Prostate-Specific Antigen Level <=4.0 ng per Milliliter article. Here's the question:Prostate cancer is not rare in men with prostate-specific antigen (

When You Can't Find a Specialist When You Need One

2004-06-06T12:11:00.000-05:00

Yahoo! News - Boston Patients Wait Long Time for Doctors and this Boston.com / Business / Boston found to endure longest wait for doctors (courtesy of Kevin, M.D. - Medical Weblog) validate something that I struggle with on a daily basis. In fact, just this week I got a letter from a local dermatologist announcing the addition of a physician assistant. It says (my italics):When patients call for

Misguided Advocacy

2004-05-25T16:05:00.000-05:00

The American Medical News, May 24/31, 2004 says: 'Network for men' sends patients to the doctor. My thoughts are in [italics]. They say:Spike TV, a men's cable television network, will urge viewers to "check up or check out," as part of a campaign to improve men's health by urging them to go to the doctor annually. An annual checkup ... is the easiest preventive step for all diseases...[Hmmm,

Yet Another Women's Health Issue

2004-05-20T14:10:00.000-05:00

The statin companies must be struggling with this from JAMA. Their comment section says it all: Our systematic review found that pharmacological lipid-lowering therapy, primarily with statin drugs, reduced the risk of CHD events for women with cardiovascular disease. In women without cardiovascular disease, the effect of lipid-lowering therapy was not clear because of the relatively small

Crestor Update

2004-05-18T07:18:00.000-05:00

Back in October I had concerns about using a new drug when we already had options with known benefits (including outcomes) and long term safety. These stories (Yahoo! News - Public Citizen Seeks Cholesterol Drug Ban and Yahoo! News - AstraZeneca Cautions Doctors on High Dose Crestor) just remind me why it is better to be conservative with new interventions and why I hold me too products to a

Family History and Cardiovascular Risk

2004-05-17T21:41:00.000-05:00

I recently calculated the 5 year cardiovascular risk for a middle aged male using the conventional risk factors (sex, age, diabetes, smoking, BP and total chol/HDL). He had some questions about the contribution of weight, exercise and family history. I told him those were already accounted for in the initial risk factors. Besides, I've not have much luck finding any consistent age cut off for

Drug Rep Tales #3

2004-05-14T07:05:00.000-05:00

The Adderall XR folks were in to see me. The idea was to switch everybody over to XR. The studies were either poor quality (unblinded) or RCT's about something irrelevant. The company data relies on the "CGI-P: Conner's Global Index - Parent Version" which is ten questions. I wanted to know about validity. For example, what is the gold standard for ADHD? This month's (May 2004) print version of

Transparency and The Rules

2004-05-13T21:01:00.000-05:00

My initial exposure to the term came from rule #7 from Crossing the Quality Chasm in the context of the The Institute for Healthcare Improvement's "Formulating New Rules to Redesign and Improve Care". I have all ten rules posted in my exam rooms. They are, What Patients Should Expect from Their Health Care:1. Beyond patient visits: You will have the care you need when you need it whenever you

Obesity Surgery

2004-05-06T15:42:00.000-05:00

A recent New York Times - Operation for Obesity Leaves Some in Misery article left me thinking there is a better strategy. To my knowledge the available literature is largely case series and observational in nature. Here is some of the article:In the last year, Dr. Jensen said, he has seen a "tremendous surge" in patients like Ms. Culpepper who have complications from the surgery or have not

Ovary Cancer Screening Hype

2004-05-05T22:24:00.000-05:00

A recent issue of the Family Practice News, April 1 2004 had several articles about ovary cancer screening. First the conservative view: 1. The USPSTF says don't screen the general population and there is insufficient evidence in the high risk population. However, the last update was 1996. 2. The National Cancer Institute (NCI) also says there is insufficient evidence and they go on to say the

Subclinical Hypothyroidism and the ROC Curve

2004-05-04T23:49:00.000-05:00

A recent patient made me rethink some notions about the diagnosis of hypothyroidism. She told me her gyn discovered a TSH of "7" on some screening (?) lab work. This resulted in her previous PCP starting levo-thyroxine. I got involved when she changed PCP's. This young woman told me she could not tell any difference in her well being and she was still struggling with her weight (current BMI = 25

The Expert PCP?

2004-04-25T09:17:00.000-05:00

Been thinking about the recent concept of the Expert Patient. Just as Expert Patients are a threat to PCP's I suppose Expert PCP's are a threat to Non-expert specialists.

Virtual Colonoscopy

2004-04-16T07:22:00.000-05:00

Just when you thought it was safer to go inside. Recent Yahoo! News - Virtual Colonoscopy Method Questioned headlines point out the problems between the ideal and the real world. I was troubled by this comment because it reinforces an ongoing misunderstanding:The American Cancer Society recommends that people over 50 get a conventional colonoscopy every 10 years, calling it the "gold standard"

Considering Medicine Wasn't My Original Career Choice...

2004-04-15T17:17:00.000-05:00

Came across this from The Helix: October 2003 Archives. My highest score: thoracic surgery. My lowest score: family practice. I wonder what this means since I've been happy doing family practice the last 15 years?

PROVE-IT (Again)

2004-04-11T10:56:00.000-05:00

I have three reasons to revisit this issue. 1. My post had two errors which I corrected. One is the ARR for the primary endpoint is 3.9%, not 1.9%. The other was regarding figure 3 when I used a 60 instead of a 90 day interval. It is now updated. 2. A nurse and cardiologist recently both disappointed me with their understanding of what the research showed. 3. Medscape sends out an e-mail about

Fun With History #1

2004-04-10T14:43:00.000-05:00

Today's earlier post about prostate cancer screening made me wonder what clinical practice was like before PSA testing was around. Consider this JAMA - Early detection of prostate cancer by routine screening abstract from 1984. It says:In an attempt to detect prostate cancer when the disease was still localized, a free screening clinic was established for men over the age of 45 years. Digital

Fool's Gold Standard

2004-04-10T12:11:00.000-05:00

Am I the only one thinking this is irrational? They say:In men with high PSA levels and negative biopsy results, a test for a protein may reveal undetected cancer, or confirm that the patient does not have the disease. A negative biopsy in an individual with increased serum PSA "raises an important clinical dilemma, namely what to do with the patient at this time," investigators explain.

Vindication

2004-04-06T20:05:00.000-05:00

Nice to see The Onion also picked up on the same theme as yesterday's post from announcements by the National Sleep Foundation.

Experts Agree #1

2004-04-04T17:37:00.000-05:00

There is no end to the "raise awareness" phenomenon by national organizations. The science section of today's paper has an article, Poll Finds Even Babies Don't Get Enough Rest, from the New York Times [registration required] that says: "Infants average almost 90 minutes less sleep a day than the 14-hour minimum doctors recommend...".I'm wary at this point because I'm skeptical that the right

Mountain Sickness

2004-04-03T16:07:00.000-06:00

Ever since attending a Wilderness Medicine conference I've been wondering about my choices for altitude sickness prophylaxis. The speaker was enthusiastic about ginkgo biloba as an alternative to acetazolamide. Today I found a prospective, double blind, randomized, placebo controlled trial with intent to treat analysis: bmj.com Gertsch et al. 328 (7443): 797 The results are: 1. Ginkgo (120 mg

Beyond Tamoxifen?

2004-04-01T15:41:00.000-06:00

One of my breast cancer patients called about the recent NEJM article about Exemestane "better" than Tamoxifen . The information made me wonder about the absolute risk reduction of Tamoxifen therapy. This Lancet abstract is a place to start. Only considering estrogen receptor positive women and 5 year's of therapy: 1. The 10 year survival absolute risk reduction (ARR) for node positive patients

Diseases That You Die Of Trump Those That You Don't

2004-03-11T15:07:00.000-06:00

I have a patient with a 5 year risk for a cardiovascular event of 9%. His blood pressure is well controlled on a thiazide diuretic and beta-blocker. He came in for my opinion about changing his anti-hypertensive regimen. Seems a dermatologist told him the beta-blocker may be causing his "skin lupus" to get worse. It is under control unless he is exposed to a lot of sunshine. Since he is an avid

New Cholesterol Goals? The PROVE IT trial

2004-03-10T12:07:00.000-06:00

Recent information about more aggressive LDL cholesterol goals caught my attention for several reasons: 1. I don't see much drug vs drug literature. 2. Lipitor has less outcomes data than Zocor and Pravachol. I've anticipated a class effect but have been reluctant to initiate therapy with this drug. If I inherit a patient on Lipitor I usually leave them alone. 3. I've not been completely

Believing is Seeing

2004-03-02T07:30:00.000-06:00

I read with interest a recent DB's Medical Rants post about the adoption of evidence-based interventions. The Februrary 17, 2004 Circulation has two articles of interest: 1. Impact of Combination Evidence-Based Medical Therapy on Mortality in Patients With Acute Coronary Syndromes 2. We Must Use the Knowledge That We Have to Treat Patients With Acute Coronary Syndromes It seems to me it isn't

Weight Gain and Breast Cancer

2004-02-27T10:16:00.000-06:00

Interesting abstract today. Too bad the site doesn't allow full text. Here is my best shot at NNT (or harm in this case) given the limited information: 1. Start with 62,756 women then have 1,934 cancers so risk = 1934/62756 = 3.01%. 2. "Weight gain of 21-30 pounds was associated with a rate ratio of 1.4%" with an acceptable CI. So, 3.01 x 1.4 = 4.31% and ARR = 4.31 - 3.01 = 1.3%. Therefore,

Don't Eat Your Veggies

2004-02-26T08:55:00.000-06:00

Yet another example of relative risk reduction (RRR) hype (Yahoo! News - Ten Grams of Dietary Fiber Cuts Heart Risk - Study). I understand the lay press enthusiasm but the actual article isn't any better. Let's "do the math": 1. Start with pooled lives = 336,244 and person-years of follow-up = 2,506,581. This means 7.45 years for each person. 2. The number of cardiac events = 5249. So, 5249/

Stupid Specialists Tricks #2

2004-02-26T08:53:00.000-06:00

I have an elderly male, recovering alcoholic patient. He has osteoporosis on his plain films from his most recent fall and long bone fracture a couple of years ago. About a year ago his orthopedist recommended DEXA scan testing. I told him it wouldn't change the treatment options and we agreed to treat him with a Rx biphosphonate instead of doing the test. He was in to see his orthopedist

Breast Cancer and Radiotherapy

2004-02-04T14:36:00.000-06:00

I recently read with interest A Chance to Cut is a Chance to Cure comments about the benefits of radiotherapy over and above breast conservation therapy for early stage breast cancer. I find the decision harder when using absolute risk reduction (ARR) instead of relative risk reduction (RRR). The MSNBC - Radiation after surgery improves survival source is guilty of using RRR to make the benefit

Drug Rep Tales #2

2004-01-14T11:45:00.000-06:00

The rep from AstraZeneca was in yesterday. She said "the FDA allows me to say Atacand is superior to Cozaar". Wow, it's not every day that drugs are compared to each other. Apparently, it requires the submission of two articles before such statements are allowed. She tells me the "CLAIM Studies" prove this. I say "what is the primary endpoint"? She says, "I don't know". Later, the study (J Clin

Give the People What They Want

2004-01-14T06:12:00.000-06:00

The American Academy of Family Physicians this week e-mail newsletter has this link Health Affairs -- Abstracts: Levit et al. 23 (1): 147. They say: "U.S. health care spending climbed to $1.6 trillion in 2002, or $5,440 per person. Health spending rose 8.5 percent in 2001 and 9.3 percent in 2002...". The abstract points out hospital costs account for 1/3 of the rise. Also, the rise is due to

Survey Says

2004-01-13T17:01:00.000-06:00

Got the results of my HMO access audit. I passed. No surprise here since I'm on Same-Day Appointments. The HMO Appointment Standards are (my italics for examples): 1. Emergency ("life or limb") = immediate 2. Urgent ("sick people") = same day or < 24 hours 3. Routine ("chronic illness") = within 7 calendar days 4. Preventive ("wellness") = within 42 calendar days What I struggle with is: 1.

A Modest Proposal #1

2004-01-13T14:39:00.000-06:00

Recall the English physician guilty of murdering patients CNN.com - Britain's 'Dr. Death' found hanged - Jan. 13, 2004. The story goes on to say: LONDON, England (CNN) -- Serial killer Harold Shipman, known as "Dr. Death," has been found dead in his prison cell in northern England, officials say...In July 2003, an inquiry found that Shipman murdered at least 215 patients, mainly elderly women.

The Placebo Effect

2004-01-12T08:07:00.000-06:00

A fascinating link LRB | Carl Elliott : Scrivener's Palsy got me thinking a lot. I plan to read some of the books and post later.

Stupid Specialist Tricks # 1

2004-01-12T07:59:00.000-06:00

I was covering for an associate. His medical assistant told me their patient needed medical clearance before an elective surgery the next day. I found out after 1 PM and was already seeing patients. We told the surgeon's office I would be happy to review the record and make a decision at the end of the day. The surgeon instead called me during a busy time and I was pulled from a room to review

Medical Meme #3 Continued

2004-01-09T08:15:00.000-06:00

Not satisfied with yesterday's post, I was able to find an even better answer. Body weight and risk of oral contraceptive failure makes more sense to me than antibiotic use.

Medical Meme #3 Antibiotics and Oral Contraceptives

2004-01-08T07:14:00.000-06:00

This comes up a lot and I've often wondered about the evidence. I was reading the Dec 24, 2003 post from code blog: tales of a nurse and saw the issue again. Turns out, this is an example of using surrogate markers instead of clinical outcomes. While antibiotics can alter hormone levels the rate of unintended pregnancy isn't influenced according to Arch Fam Med -- Burroughs and Chambliss 9 (1):

The Mail Bag

2004-01-05T12:28:00.000-06:00

I get a lot of mail. Most of it is unsolicited. I got to wondering how much are we really talking about? So, I saved one month's (December 2003) worth. Here are the totals: 1. Throwaway journals = 18 pounds 2. Drug company ads = 8 pounds 3. Disease management/practice guidelines = 4 pounds 4. Real journals = 5 pounds 5. Surveys = 2 1/2 pounds 6. CME invitations that were not overtly drug

My Take on This Year's Flu Season

2003-12-22T08:05:00.000-06:00

Headline should read: Flu Season Early This Year. That's it. That's the whole story. Why do we have to explain influenza every year? Every season it's the same articles in the paper. Doesn't anyone remember the principles? This year is unique only because of the hype. For those Peter Senge (the theory and practice of the learning organization and Amazon.com: Books: The Fifth Discipline) fans

Medical Meme #2 Pseudoephedrine and Hypertension

2003-12-17T16:12:00.000-06:00

This comes up a lot. OK to take or not OK? I went to OVID and found little in the way of new information. At least a few years ago, somebody (Journal of Family Practice. 40(1):22-6, 1995 Jan) did get around to measuring the effect. The conclusion was: "At standard doses, pseudoephedrine has no significant effect on systolic or diastolic blood pressure in patients with controlled hypertension".

JAMA Thoughts #1

2003-12-11T12:08:00.000-06:00

I'm reading the 12/3/03 issue over lunch. This is what I'm thinking about each contribution: 1. The first article is comparing calcium blocker (Verapamil) therapy against non-calcium drugs. My initial take is: "seems important since I've used a lot less calcium agents even before and especially after ALLHAT". I'm OK with the data but wonder if another trial that showed no difference would get the

Cookie Doctor

2003-11-27T10:11:00.000-06:00

There was a PCP that cared for a family. They had no insurance so they paid with homemade cookies. One day the PCP was making rounds in the hospital. The PCP ran into the family and asked, "Why are you here"? They said: "Mom's in the hospital". PCP said: "I thought I was mom's doctor". They said: "When mom is sick we see Dr. Specialist". You're the cookie doctor.

Tell Me What I Can Quit Doing #1

2003-11-27T09:48:00.000-06:00

I can't open a medical tabloid without a headline like: PCP's Underdiagnose Insert Your Foundation's Pet Disease Here. Yet, they never tell me which part of my day I can eliminate. This is the first link bmj.com Del Mar and Glasziou 327 (7424): 1117 I've seen that acknowledges the phenomenon. I've quit doing screening rectal exams. Unfortunately, it takes more time to tell the patient why we

Feel My Pain

2003-11-13T08:48:00.000-06:00

While I'm glad I did not make the list at least the author The 10 most overpaid jobs in the U.S. pointed out the discrepancy: "Specialty surgeons may earn $1 million or more, but some young family-practice doctors are hard-pressed to pay off medical-school loans."

Point B Medicine - The VA

2003-10-27T07:18:00.000-06:00

When I trained we used to make fun of the VA. Now they do better then we do. See NEJM -- Medical Care -- Is More Always Better? and NEJM -- Hospital Use and Survival among Veterans Affairs Beneficiaries. Here is something simlar: Ann Intern Med -- Abstracts: Fisher et al. 138 (4): 273 and Ann Intern Med -- Abstracts: Fisher et al. 138 (4): 288 Nobody in the culture I'm in wants to do less.

Point B Medicine - Mammograms

2003-10-24T06:55:00.000-05:00

Check out Yahoo! News - U.S. Doctors Do More Breast Cancer Tests and JAMA -- Smith-Bindman et al. 290 (16): 2129. We do twice the mammograms to get the same outcome. Point A medicine is doing the "right amount". Some mammograms are better than none. Point B medicine is extra ones for no benefit. Point C medicine is so many that we do harm. I don't perceive any forces trying to reduce the number

Colon Cancer Screening

2003-10-20T07:15:00.000-05:00

There is no doubt that dying of colon cancer is bad. Yet, the numbers don't make the screening decision easy for me. I do initiate the subject with all patients at age >= 50. We begin with: Do you want to participate in colon cancer screening or not? Start with the number needed to screen to prevent one death from Lancet, 1996 Nov 30;348(9040):1472-7 using a traditional method (occult blood then

Medical Blogs

2003-10-17T11:44:00.000-05:00

I've been following several for the past few months. Perhaps there are others I've not found. Most spring from the fountain that I call the "bottom of the medical food chain". Medical and surgical subspecialists don't seem to have anything to say.

Tests

2003-10-16T13:34:00.000-05:00

In the past year I recertified my ACLS and declined to renew my family practice boards. One is important and the other isn't. It's only a matter of time until there is a code in my office plus my group practice requires maintenance of ACLS. The physician executive committee struggled with requiring board certification. There isn't any research to support board certification so we fund it but

Outcomes - Clopidogrel (Plavix)

2003-10-13T15:54:00.000-05:00

For combined anti-platelet therapy (aspirin and Plavix) there are two major outcomes studies: 1. CURE Trial, NEJM, Vol 345, No. 7, August 16, 2001, 494-502. This one is relevant for non-ST acute coronary syndromes. The cardiologists in my institution made Plavix a routine discharge Rx. Yet, there isn't a death benefit, only the less powerful "combined endpoint" of death plus non-fatal MI plus

Help, I'm Spending Too Much Time With My Patients!

2003-10-10T06:45:00.000-05:00

I wondered if the "typical" office practice would compare favorably with reality using some national standards. 1. Start with the American Academy of Family Physicians (AAFP) resource FPM Toolbox. 2. Go to Getting Paid - July/August 2002 -- Family Practice Management. Assume a mature practice so the visits are established patients. Apply the benchmark distribution as %: 99211 = 3.64 99212 =

Medical Parable #1 - The Sinking Ship

2003-10-09T07:00:00.000-05:00

My source: Quinn Parables The ship was sinking---and sinking fast. The captain told the passengers and crew, "We've got to get the lifeboats in the water right away." But the hospitals said, “First we need relief from indigent care and specialty hospital competition. Then we'll take care of the lifeboats." Then the government said, "First we need medical errors eliminated and care for the

Weapons Grade Arrogance #3 - ACOG and Pap Smears

2003-10-09T06:42:00.000-05:00

I recall a recent press release that ACOG (American College of OB/Gyn) updated their Pap smear guidelines. Interestingly, the National Guideline Clearinghouse NGC doesn't have any ACOG guidelines (try browsing by organization). So, I go to their web site, American College of Obstetricians and Gynecologists Public Home Page, and find this: Cervical Cancer Screening: Testing Can Start Later and

Collective Medical Nouns

2003-10-08T06:43:00.000-05:00

A shrewdness of apes [cardiologists] A culture of bacteria [infectious disease docs] A sleuth of bears [social workers] A swarm of bees [residents] An obstinacy of buffalo [neurosurgeons] A brace of bucks [physiatrists] A brood of chickens [hospitalists] A clutch of chicks [nurses] A bed of clams [occupational medicine] A cover of coots [interns] A float of crocodiles [urologists] A murder of

Stupid PCP Tricks #2, Ear Temps

2003-10-03T11:22:00.000-05:00

This morning, parents were in with a child. The issue of ear vs oral vs skin vs rectal temps came up. Years ago, I figured out the actual temp reading in my office setting rarely changed the intervention. Yet, we dutifully record ear temps in the chart that are not even compatible with life. The expection that I have with my staff it not to routinely measure temps at all. Then, if I really need

Stupid PCP Tricks #1, Pneumonia Vaccine

2003-10-03T08:15:00.000-05:00

It's that time of year, when some doctor that can't look something up starts allowing/recommending extra Pneumovax just because somebody else does. I've already been asked by two patients this week and a doctor about the interval for repeat vaccination. According to the CDC, no one would ever get more than two and most will only ever have one Recommended Adult Immunization Schedule --- United

Medical Meme #1 Of Breasts, Caffeine and Vit E

2003-10-02T11:59:00.000-05:00

The surgeons and gyns are still telling my patients to avoid Caffeine and Vit E for pain or "fibrocystic" changes. PCP's probably do too, I just wouldn't know. Suspecting there isn't much to support this (pun intended), I did a literature search. My emphasis... For Caffeine: 1. The effect of decreased caffeine consumption on benign proliferative breast disease: a randomized clinical trial.

Medical Memes aka "You can't go swimming after lunch..."

2003-10-02T11:20:00.000-05:00

...because you will get stomach cramps and drown. Why do we perpetuate bad medical information? Every time I try and track down the source of something already accepted as fact, I'm disappointed to find the lack of the original reference (the trail just ends) or the quality of the initial work (n=few). I think there is something about early traditional medical education that causes this. Along

Evidenced Based Medicine (EBM)

2003-10-02T06:46:00.000-05:00

Disruptive technology or fad? Religion or cult?

False Positive #1

2003-10-01T16:47:00.000-05:00

True story. 49 year old woman. Earlier this year, we decided after shared decision making and the AAFP handout Breast Cancer Screening Counseling Tools -- American Academy of Family Physicians to wait on a mammogram until age 50. She needed a hysterectomy go I sent her to a gyn. The gyn recommended a mammogram and she agreed. The gyn scheduled the test. No result to me. I'm used to that... The

Weapons Grade Arrogance #2

2003-10-01T16:43:00.000-05:00

True story. 67 year old woman. Recent addition to my managed care panel. Stage II breast cancer 6 years ago. Even survived the stem cell transplant that she did not need. I get interrupted in an exam room to speak with the radiation oncologist. The patient is at the other office for an appointment and there is no authorization for the visit. Turns out, the appointment was made one year ago. The

Take the Crestor Pledge!

2003-10-01T16:41:00.000-05:00

The doctors in my office agreed to refuse to Rx the new statin on the basis there are already competitors with long term safety (Baycol anyone?) and outcomes data (Lipitor?). I was pleased to see the advocacy group had the same conclusion already and felt strongly enough to make the link free Worst Pills, Best Pills News Online - Do Not Use! Rosuvastatin (Crestor) - A New But More Dangerous

Drug Rep Tales #1

2003-09-30T07:21:00.000-05:00

The folks from Boehringer Ingelheim were in this week. They explained their ARB (Micardis) and COX (Mobic) options relative to the competition in the two classes. I told them I considered the ACE's and acetaminophen their competition. They were bewildered.

Weapons Grade Arrogance #1

2003-09-28T12:28:00.000-05:00

True story. Last year the NEJM published an article that concluded: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure” (N Engl J Med 2002; 347:81-88, Jul 11, 2002). So…I thought the hospital quality committee should discuss the implications of this

My Laws of Medicine

2003-09-28T11:45:00.000-05:00

1. New treatments are better than old treatments. 2. Doing something is better than nothing. Since doctors don't know so many things, they resolve their own anxiety by recommending dubious interventions. Why is it so hard to say, "I don't know"? Plus, for some important medical questions, why can't we say, "Nobody knows"? So, applying the Laws of Medicine explains why: Doctor's say "the patient

When emotions trump science #1

2003-09-28T11:08:00.000-05:00

The local paper has the usual emotional appeal for a prostate cancer screening program. They say: 1. "Putting men to the test saves lives". 2. "That's because the earlier prostate cancer is detected, the better our chance at beating it". 3. "A prostate exam, combined with...a PSA...is the most effective method for early detection". 4. "Crucial early detection improves diagnosis and treatment

Nature vs. Nuture

2003-09-27T16:47:00.000-05:00

I was born a skeptic. Then, I graduated from the 21st grade, making me an educated skeptic. Now, years of private practice and Evidence Based Medicine CME make me a trained skeptic.

Competing standards is an oxymoron

2003-09-27T09:58:00.000-05:00

Much of the stress in my professional life is either: 1. Primary care vs. speciality care, or 2. Evidence Based Medicine vs. conventional medicine Dealing with patients is easy. Motivating doctors is hard.