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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

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    Saturday, January 29, 2005

    Never Mind: The British Medical Journal offers an apology to Eli Lilly:

    An article by Jeanne Lenzer in our 1 January issue (BMJ 2005;330:7) reported that the US Food and Drug Administration was to review confidential Eli Lilly documents that had been sent to the BMJ by an anonymous source.

    The article stated that these documents had gone 'missing' during a 1994 product liability suit filed against Eli Lilly.

    That statement has been the subject of a detailed investigation conducted by the BMJ following a complaint by Eli Lilly. That investigation has revealed that all of the documents supplied to the BMJ that were either Eli Lilly documents or were in the hands of Eli Lilly had in fact been disclosed during the suit.

    At the end of the trial, all the documents were preserved by Court Order or were disclosed by Eli Lilly to the plaintiffs' lawyers in related Prozac claims.

    The original article, no longer available online unless you want to pay $8, did make Eli Lilly look pretty bad (a copy of it is here.) Now, how do you get all the newspapers who published the original story to publish this one, too, and with the same amount of sensationalism?

    posted by Sydney on 1/29/2005 11:56:00 PM 0 comments

    Friday, January 28, 2005

    Into the 21st Century: President Bush was in the area yesterday touting computerized medical records. At his press-op was a woman with this tale of wonder:

    It was one of those cryptic messages that physician's offices are famous for: Your blood tests have uncovered a problem; please make an appointment to see the doctor.

    But it would be two weeks before Patty McGinley's doctor -- Dr. Bob Juhasz of the Cleveland Clinic's Willoughby Hills Family Health Center -- would be able to see her.

    A phone call to the office revealed that her cholesterol was the problem. But how high was it? Was McGinley, as she put it, ``a little unhealthy or a lot?''

    Seated next to President Bush at a forum at the Cleveland Clinic on Thursday, McGinley talked about her problem and its resolution.

    ``I'm a worrier,'' the 48-year-old Concord Township woman said. ``I felt pretty helpless and concerned.''

    Then she got an e-mail message from the Cleveland Clinic that included a link to her electronic medical records. In the message were not just her test results, but also charts that showed where her results fell in relation to normal ranges of cholesterol and triglycerides.

    ``I went from feeling helpless to being in complete control,'' she said. ``It really empowered me.''

    Of course, her worry could have been avoided if her doctor had just sent her a note in the mail with her results and the explanation instead of sending the cryptic "call the office" message. You don't need computerized systems to avoid problems like that.

    The Administration has ambitious goals and hopes:

    Dr. David Brailer, Bush's national health information technology coordinator, said the goal in the next 10 years is to have every doctor use a computer to record and read patients' medical records, to order tests, to write prescriptions and to view images, such as X-rays or CT scans.

    The real challenge, Brailer said, is creating connections between different -- sometimes rival -- hospitals, so that if people find themselves in an emergency room in a different city, their medical records will be readily available to doctors who have never seen the patient before.

    That will improve safety, said Dr. Martin Harris, Cleveland Clinic's chief information officer.

    ``A patient will never have to worry about receiving the wrong dose or an inappropriate medication simply because someone couldn't read the handwriting on a piece of paper,'' Harris said.

    No, but a patient will have to worry about typographical errors in their prescription.

    It will be some time before there's a Micro-Soft of EMR, used universally by everyone, large and small. And that's what they're really talking about, isn't it? A system that's used universally so that information can be freely shared electronically? Who's going to develop that? Who's going to pay for it?

    As to empowering the patient, the only advantage my electronic medical record affords my patients is that I can fax their prescriptions over to the drug store so they don't have to spend so much time waiting for it to be filled. The EMR is more an advantage for myself and my staff than it is for my patients. It does improve patient care somewhat, by improving the organization of the chart, but the main advantage is to myself and to my staff. A physician reader who has some experience with electronic records thinks they aren't all that advantageous to physicians, either:

    I was involved with a task force which evaluated computerized records for a large medical group. The bottom line is that computerized records, as currently formulated, will slow down the productivity of MDs. The data entry is slower than handwriting or dictating. The pull downs on some encourage fraud in record keeping. (as a side note I review charts for the state medical board. The state's investigators never believe a chart when it is done with computer records. It has been their experiance that more often than not that computer records are false and do not reflect what occured at the visit.) Interestingly the advocates of computerized record keeping do not suggest that it makes you more efficient. The selling point is that it can improve reimbursement by documentation (see above sidebar) , that it is more readable, or that it is easier to find information. Unless it actually improves efficiency it may remain a geewiz device that is nice to have if you have a lot of excess money in the practice and a minimal patient load. Good Luck with making it work when you are busy. (You might want to try check off sheets for common complaints. that is what the large medical practice ended up doing)

    Although right now it's slowing me down as I enter old patient information (past history, allergies, medications, etc.) in each patient's chart, eventually it will make me more effecient. I won't have to go look for a chart when I have an abnormal lab, I can just pull it up on the computer. The staff won't have to pull charts for the next day and insert paper for the note. I type much faster than I write, and the electronic record I have is designed to use codes for frequently used phrases. For example, if I type amox500, what shows up on the screen is "Amoxicillin 500mg po tid x 10 days. Disp:#30 No refill."

    It's true that some templates are more expansive than most people ever are in the office, but it would be a mistake to assume that everyone who uses a template is lying. An auditor should never go into an audit assuming their victim, er client, is guilty. Even when I write my charts by hand, I write the same things over and over and over again when it comes to physical exams. A template just makes the process faster. If I use a template that's just like my repeatedly handwritten exams, then it's really no different, except that it's much faster. And check-off sheets are subject to the same problems as templates - it's easy to mistakenly check off something you didn't actually do. And if you're going fast, you might not even catch it.


    posted by Sydney on 1/28/2005 08:05:00 AM 0 comments

    Wednesday, January 26, 2005

    Distracted by Life: Lots of good blog fodder in the news lately, but, alas, between patient care and getting the electronic medical system up and running this week, little time for blogging it.

    Today, I teach the staff how to use the new computerized medical records. I'm a little worried about their ability to adapt to new technology, or to newness in general. Monday, I introduced them to the new fax/copier/scanner and they were a little freaked just because it doesn't act like the old one. Change is always hard, but add computers to it, especially for folks who came of age before computers were wide spread (or before video games) and its's doubly hard. Yesterday, I overheard the oldest staff member say "computers scare her." We may have a rough couple of weeks, if not months, ahead of us.

    I haven't yet gotten to the point that I can say the system makes my work faster. I began trying it myself on Monday, but abandoned it for my old paper ways after two patients. We were busy and I just couldn't handle the volume and make the switch at the same time. My routine is a well-oiled one, and disrupting it slows me down - a lot. The next day, I used it on six patients before abandoning it. But a lot of that slow down is due to data entry. Once my staff knows how to use it, and once our more complicated and established patients have all of their baseline info entered, it should go much smoother and be at least, if not more, efficient than our current paper system.

    Meanwhile, it's definitely a mistake to expect the computerized system to reduce errors. (Something I've argued all along. Typos are much more common than hand-written errors. And a second party knows when they can't read handwriting (a signal that they should ask for clarification), they don't know if they're reading a numerical typographical error.)

    posted by Sydney on 1/26/2005 08:25:00 AM 0 comments

    Tuesday, January 25, 2005

    Grand Rounds: Is up at A Chance to Cut is a Chance to Cure.

    posted by Sydney on 1/25/2005 03:55:00 PM 0 comments

    Monday, January 24, 2005

    Rise and Fall: Whole body scanning clinics are going bust, not surprisingly. Their appeal was short-lived, being a high cost item of little use. The market was limited and saturated quickly. People who were persuaded by the advertising got the scans in the first year or two, and then had no further need for them, especially if they ended up following a wild diagnostic goose chase for innocuous lumps and calicifications.

    But the funniest part of the article was the claim that radiologists were attracted to the centers not for the easy money, but for the chance to interact with patients:

    The business also appealed to radiologists who normally send reports to doctors but have little contact with patients. At the scanning center, though, Dr. Brant-Zawadzki sat down with patients and discussed their scans. "It was very pleasurable," he said, adding that "it also promoted the value of radiologists to those patients."

    This is closer to the truth:

    Dr. Carl Rosenkrantz, a radiologist in Boca Raton, Fla., said the business had another appeal - it promised radiologists a good living without being on call at a hospital and even without necessarily being present at the scanning center.

    "The goal in life seems to be to try to figure out some way where you don't have to go to the hospital, where you don't have to take calls," Dr. Rosenkrantz said. "Radiologists saw this as a cash business and a way out."

    ....As for Dr. Giannulli, he has moved on to other things. He founded a company, CareTools Inc., which sells software for medical record keeping to doctors' offices. That, he says, is the new frontier in medicine.

    No call, no patients, no hospital. The radiology dream job.

    posted by Sydney on 1/24/2005 08:10:00 AM 0 comments

    Preparedness Watch: When terrorists flew airplanes into the World Trade Center and the Pentagon, there were quite a few lamentations in the media questioning why we were so ill prepared for such a scenario. The common line was if Hollywood could imagine it, why couldn't those responsible for our national defense? And yet, there are those who still haven't absorbed the lessons of that day. They want to shut down research on bioterrorism defense/a>:

    Others argue that the known terrorist groups have little sophistication about biological weapons. Instead, these critics say, the biodefense expansion has been fueled by a scramble for federal money.

    Currently there are four Biosafety Level 4 laboratories nationwide, with six more planned; 50 laboratories operate at Biosafety Level 3, sufficient to work with anthrax, and 19 more are planned at universities and government institutions, according to the Sunshine Project, a Texas group that is tracking the growth.

    In the only major bioterrorist attack in American history - the anthrax-laced letters mailed to news media figures and two senators in fall 2001, killing five people - F.B.I. investigators have focused chiefly on the theory that the anthrax originated not with outside terrorists but within an American biodefense program.

    By the same token, the critics say, the tularemia that sickened the workers in Boston would not have existed if not for bioterror research. Dr. Richard H. Ebright, a molecular biologist at Rutgers University, said the disease "has zero public-health importance." Only about 130 cases a year are reported in the United States.

    The tularemia cases were in three biodefense labworkers who mishandled a specimen. Tularemia in its natural form is not transmissable from person to person. (You get it from rabbits.) Certainly, safety and security at these labs should be high priority. There's no room for shoddy work, but arguing that the whole program should be shut down is an over-reaction born of hysteria. One researcher puts the threat into perspective:

    One scientist who supports the increase in biodefense spending, Dr. Tara O'Toole, does not dismiss the safety issues. In fact, she said, the biodefense expansion has focused attention on long-neglected biosafety rules. But she believes the danger of bioterrorism is so great that the billions of dollars being spent on protections may not be enough.

    "I think bioterrorism is the biggest national security threat of the 21st century," said Dr. O'Toole, director of the Center for Biosecurity of the University of Pittsburgh Medical Center. "So I want a robust biodefense research and development program."

    Dr. O'Toole recently helped organize a bioterror exercise, called Atlantic Storm, in which terrorists attack with smallpox in the United States and four foreign countries, killing more than 87,000 people. Such a potential toll puts the risk of laboratory accidents in a different perspective.

    But is that situation realistic, when nothing remotely approaching such an attack has ever occurred?

    Amazing that a newspaper in the same city where the Twin Towers once stood could print that last line.
    posted by Sydney on 1/24/2005 07:58:00 AM 0 comments

    Sunday, January 23, 2005

    Supply and Demand: A reader sent this link and wondered where all the surplus is:

    States have begun dropping their restrictions on flu shots now that falling demand has led to surpluses, and some health officials want the federal government to take similar action.

    The federal government last month eased its restrictions, imposed when production problems in October cut the flu vaccine supply in half, and allowed shots for adults age 50 and older.

    Since then, at least 17 states have lifted all previous restrictions, according to the Association of State and Territorial Health Officials. The states previously had reserved the vaccine for older adults, infants and people with chronic medical conditions.

    Some health officials say the Centers for Disease Control and Prevention should recommend that restrictions be lifted nationally.

    An article in our local newspaper said that the health department now has about 400 doses of flu vaccine on hand, but just three weeks ago, they still had an answering machine message saying they had none. Evidently, the supply didn't come available until this month, when it's really not all that worthwhile. In this part of the world, flu season usually peaks around January or February. The vaccine works best if given a month or two before flu season. It's too bad the vaccine supply wasn't made available in November or December. The distribution plan moved at a snail's pace, or at least at a bureaucracy's pace.

    posted by Sydney on 1/23/2005 10:21:00 PM 0 comments

    When She Was Well Stricken in Years: Post-menopausal motherhood in Romania:

    The 66-year-old Romanian who last week became the world's oldest known woman to deliver a baby says two abortions in her 20s left her with a life of regret and a yearning for motherhood.

        Adriana Iliescu, a professor of literature here at Romania's largest private university, the Hyperion, gave birth to daughter Eliza Maria after undergoing fertility treatment.

        Mrs. Iliescu, speaking from her bed at Panait Sarbu Hospital, called Eliza Maria a "gift from God."

        She had become pregnant twice in her early 20s during a failed four-year marriage, she said. She aborted both pregnancies, she said, because that was a routine method of birth control at the time in Romania under communist rule.

         She spent most of the rest of her life wishing that she had a child, Mrs. Iliescu said.

        "If there is anything I regret, it is those terminations, not having a baby now," she said.

    ...Mrs. Iliescu gave birth Jan. 16, seven weeks early, after undergoing in-vitro fertilization, for which she paid about $3,900. She originally was carrying triplets, but one died at 10 weeks and another earlier this month. Her doctors decided to induce the delivery of her remaining child.

    People are clucking at the presumed irresponsiblility of having a child so late in life. Motherhood is taxing, no doubt about it, and few are those who can shoulder the burden in the twilight years. But, there are plenty of grandmothers who have taken on the task of raising their grandchildren, even from infancy, and no one clucks at them. Instead, they get only praise. Mrs. Iliescu has her work cut out for her, but it's not an impossible one. And it sounds as if her daughter will be loved and appreciated at least.
    posted by Sydney on 1/23/2005 10:09:00 PM 0 comments

    New Address: Dr. B's Finestkind clinic and fish market has moved.
    posted by Sydney on 1/23/2005 10:08:00 PM 0 comments

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