Sunday, October 10, 2004

A New Medical Meme Record... 

...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 relevant to the subject.

Consider this helpful advice (my italics and [comments]):
"Taking care of yourself from a health standpoint is probably the best thing you can do," [whatever that means] said Dr. R. Michael Gallagher, a family physician and dean of the University of Medicine and Dentistry of New Jersey's School of Osteopathic Medicine. [Scary to think of all those years I've recommended flu shots instead.]

"People who are run down, they're overworked, not getting proper rest or proper nutrition, these people increase their risk" of illness, he said. [I thought we were talking about influenza?]

Besides getting enough sleep - at least seven hours a night for adults and more for youngsters - managing stress is important, Gallagher said, because too much can weaken one's immune system. [No RCT's on this, so it is not a given that this results in more influenza.]

How about this from a dietician:
Another new piece of advice is to stop refilling the bottles of water so many of us carry [PubMed = no articles on this that I could find].

The bottles accumulate germs and shouldn't be reused [as if I could give myself the flu] or shared [doh!], said American Dietetic Association spokeswoman Gail Frank, a professor of nutrition at California State University-Long Beach. But don't skip the water, because eight glasses of fluid a day is essential to health, aiding in almost every process in the body. [Their own web site gives conflicting advice: 1) Water: The Drink of Life vs. 2) Too much of a good thing? vs. 3) Bottled water. I guess that's why they call it eatright.org instead of drinkright.org. At least the IOM (Dietary Reference Intakes: Water ...) gives you the basis for a recommendation.]

And, this just in:
People, especially the elderly and those in poor health, also should avoid crowds and people who are coughing or sneezing, said Dr. Michele Bachhuber, an internal medicine specialist at Marshfield Clinic in Marshfield, Wis. [Easier said than done. This is just another form of blaming the patient. Maybe I will start telling my "elderly and those in poor health" to stop attending all those raves.]

"Regular exercise helps boost our immune system, so that's important, too," she said. [Is she saying exercise prevents the flu?]

And one of my favorite medical memes of all time, the "importance of breakfast":
Then there's the role of diet. Frank said it's crucial to eat a healthy and substantial breakfast, about one-fourth of the day's calories. [But whatever you do, please don't go swimming right away unless you want to drown from stomach cramps.]

Variety in the diet is important, but people should emphasize plant foods, including whole grains and at least five servings of fruits and vegetables a day, said Elisa Zied, another American Dietetic Association spokeswoman and a registered dietitian in New York.

She said people can help keep their immune system strong by eating foods rich in vitamins A, C and E: milk, eggs and fish oil; citrus fruits, melons and red peppers; and nuts, spinach, peanut butter and corn oil. [Another party line, but what does this have to do with flu season?]

The article does contain this (CDC - Preventing the Flu) useful link which reminds us:
The single best way to prevent the flu is to get vaccinated each fall.

And under, "Good Health Habits", some practical information:
1. Avoid close contact. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
2. Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
3. Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
4. Clean your hands. Washing your hands often will help protect you from germs.
5. Avoid touching your eyes, nose or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Give the CDC credit for staying out of the: sleep, stress, 8 glasses of water, breakfast and vitamin nonsense. Wishful thinking from advocates should not obscure that fact that there is no excuse for running out of the flu vaccine.

Sunday, September 19, 2004

More on NCEP 

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 

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... 

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 treatment of premature ejaculation.
There are four major recommendations (my italics):
Recommendation 1:

The diagnosis of premature ejaculation (PE) is based on sexual history alone. A detailed sexual history should be obtained from all patients with ejaculatory complaints. (Based on Panel consensus.)

Recommendation 2:

In patients with concomitant PE and erectile dysfunction (ED), the ED should be treated first. (Based on Panel consensus.)

Recommendation 3:

The risks and benefits of all treatment options should be discussed with the patient prior to any intervention. Patient and partner satisfaction is the primary target outcome for the treatment of PE. (Based on Panel consensus.)

Recommendation 4:

Premature ejaculation can be treated effectively with several serotonin reuptake inhibitors (SRIs) or with topical anesthetics. The optimal treatment choice should be based on both physician judgment and patient preference. (Based on Panel consensus and review of data.)

Why couldn't they just say there is insufficient evidence (no good RCT's) to have the basis of a guideline?

I find it particularly ironic when the AUAnet | Clinical Guidelines page has a link ("To learn about how our guidelines are developed, click here.") that gives an error message.

Wednesday, September 01, 2004

More Screening Folly 

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 Hemochromatosis: Translating Screening and Early Case Detection Strategies Into Clinical Practice) got my attention considering the mainstream source.

Considering the U.S. Preventive Services Task Force (USPSTF) and the CDC do not recommend screening, I wondered if anybody did?

A simple Google turned up no shortage of advocacy groups:
1. This one (Hemochromatosis Foundation, Inc.) is apparently having trouble with even more unscrupulous groups.
2. The most emotional award goes to the American Hemochromatosis Society. The physician guideline section even says...
All health care providers including hospitals, doctors, clinics, insurance companies and managed care facilities should screen everyone over the age of 18 years old, male and female, with a iron profile (see section 1.b ) every 1 to 2 years to measure their current iron storage status. Children ages 2-18 years should be monitored every 2-3 years with an iron profile if they have a diagnosed blood relative with hereditary hemochromatosis/iron overload. It should be further noted that “no physician should prescribe iron supplements or vitamins containing iron or vitamin C supplements without first determining the iron storage status of the patient, as otherwise, the physician may be put at risk for medical negligence.” (Victor Herbert, MD JD)

3. I even missed E-Health News : July is Hemochromatosis Screening Awareness Month.

Journal Access #2 

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 data and the popular press spin.

Friday, August 27, 2004

Medical School Admissions 

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 people go to a stock car race?
A: To see a crash.
In other words, even when I'm having a bad day, at least I don't have what the patient's have. :-)

Another answer is based in childhood. My job could be described as "making messes that other people have to clean up".

The "I like to help people" answer doesn't distinguish between medicine and other service jobs like social work. I think what I do is interpret data and not just generate data.

Sometimes I think the answer is more existential. I often have an office visit to confirm pregnancy and arrange prenatal care. She may have a home pregnancy test that is +, and she may seem pregnant. However, "You are not pregnant until I say you are pregnant." The ability to make a diagnosis is unique.

Tuesday, August 24, 2004

The VA 

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 for HbA1c < one year for my diabetes patients. I hope I can sustain a rate (93%) > = to the VA.

Sunday, July 18, 2004

Too Aggressive? 

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.

Saturday, July 10, 2004

Journal Access 

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.

Wednesday, July 07, 2004

"We Don't Do Eyes Over the Phone..." 

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 al., 10.1136/bmj.38128.631319.AE.

The prevalence of bacterial infection is higher than I expected.

I've already quit seeing uncomplicated dysuria in women in the office. Perhaps I could add adult conjunctivitis?

Tuesday, July 06, 2004

Definite Maybe 

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 make;

"Probably do it" or "probably don't do it"—indicating a judgment that a majority of well informed people would make but a substantial minority would not.

Saturday, July 03, 2004

Source Data 

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

Sunday, June 27, 2004

Alternatives to EBM 

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. Propaganda based medicine

And, my favorite...
12. Webidence based medicine

I figure we could add:
13. Surrogate marker based medicine
14. Pharmaceutical Rep based medicine

Wednesday, June 23, 2004

Simple Breast Cancer Screening Algorithm 

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 we could talk and she agreed.

Here's the actual sequence:
1. My patient can self refer for an annual "well woman" exam. Never mind that this is a political/benefit issue > medical issue. The benefit does not require the patient nor the gyn to let me know she has been in or what they did. Some gyn's keep me in the loop by way of a letter or courtesy copy of any tests but most don't. It sort of works as long as the patient does not have a problem and the tests are normal. In this case, I did not get a letter from the gyn about my patient's clinical breast exam status (lump or no lump?). I was able to obtain a Birads 3 report that included a comparison with three other normal mammograms over the past 8 years.
2. My position is to offer mammograms in women between the ages of 40 and 49 but not recommend them until age 50. I also use the American Academy of Family Physicians Breast Cancer Screening Counseling Tool handout and strive to keep my language neutral. I think of it as seeking her permission but only after she has the necessary information upon which to decide. In this case, she told me the gyn recommended the test just like the other times without any discussion or tools.
3. The patient confirmed at the time of the well woman visit neither of them thought that she had a breast lump.
4. The mammogram report said:
Small density laterally in the left breast. This appears benign but cannot be confirmed on previous studies due to the difference in technique. A repeat left cc view for this region is recommended in six months time. Probably benign, Birads, category 3.
5. The gyn recommended she see a breast surgeon so I got involved when the patient called my office to arrange what I like to call "the hearsay referral". Namely, the specialist tells the patient to tell me.
6. Anyway, she comes to see me and I examine her. We both agree there is not a palpable lump.
7. I go into shared decision making mode. For example: "I would like you to have some additional information, then whatever you chose will be fine with me". We review false positive, false negative and low positive predictive values for Birads 3 mammograms in a screening situation for women under 50. I ask her: "If the surgeon recommends a biopsy, would you have it?" or "Are you comfortable honoring the radiologist's recommendation to repeat an Xray in 6 months?". She surprises me when she states her initial reaction to the gyn's recommendation was to call the gyn and seek a more conservative option. She was told by the gyn's nurse: "We send all abnormal mammogram patients to a surgeon".
8. I'm thinking, must be nice...no time spent explaining anything before or after a test and no tracking/follow-up/reminders.

On that basis, this appears to be the gyn's breast cancer screening algorithm:
1. Recommend mammograms early and often.
2. If normal, done. See #1...
3. If anything but normal, send to a surgeon.

The gyn's system is designed to meet her needs but not mine and certainly not the patient's.

Tuesday, June 22, 2004

Turn Left Right Here 

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 aware of the issue but had not thought much about it.

Until recently, each institution could have their own policy. Naturally, this led to confusion. I think this will help but won't solve the problem until the culture of medicine changes away from provider centered to patient centered.

Monday, June 21, 2004

Due Remember Me 

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 line agent for most causes of erectile dysfunction. Primary care providers (PCPs) write the majority of these prescriptions and most failures of sildenafil therapy are subsequently referred to urologists for alternative therapies. Often it is concluded that the drug is ineffective when in actuality the failure is do to inadequate patient education. We examined patients referred from PCPs who were nonresponders to sildenafil therapy and attempted to convert them to responders through reeducation.
Even the title is fun: Salvage of Sildenafil Failures ...

I think of the word "salvage" in the context of oncology therapy. I'm not sure it applies for Viagra failures according to the MedlinePlus: Medical Dictionary that says:
Main Entry 2: salvage
Function: transitive verb ... to save (an organ, tissue, or patient) by preventive or therapeutic measures. Examples: ... a salvaged cancer patient, or ... salvaged lung tissue.

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