Texas’ Other Death Penalty | Texas Observer →

Well-written article from a medical student talking about working in her school's student-run free clinic and the safety net. She provides a nuanced policy discussion vividly detailed by some of her patients' stories.

2013 Medical Education Debt and Tuition Fact Card | AAMC →

Take a look at the second page. The amount of interest (only interest!) paid by graduates over the course of their loans (based on the median debt of $175,000) ranges from $151,000 to $317,000 [1]. Total costs are all in excess of $320,000. These are the figures that med students should think about.

  1. This is only looking at the first 4 sample repayments and ignoring the bottom two sample repayments that include loan forgiveness through public service programs (which often are not an option for most medical students).  ↩

Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics | Pediatrics →

Adam Hersh MD PhD, Mary Anne Jackson MD, and Lauri Hicks DO writing on behalf of the AAP Committee on Infectious Diseases:

A major objective of this clinical report is to provide a framework for clinical decision-making regarding antibiotic use for pediatric URIs. A point of emphasis is the importance of using stringent and validated clinical criteria when diagnosing acute otitis media (AOM), acute bacterial sinusitis, and pharyngitis caused by group A Streptococcus (GAS), as established through clinical guidelines…The careful application of [guidelines and other prescribing interventions] has the potential to mitigate overuse of antibiotics for pediatric URIs.

Why A Patient's Story Matters More Than A Computer Checklist | NPR Shots →

Why does this physician’s EMR contain so many checkboxes? Because checkboxes create discrete data that can then be easily parsed for billing purposes (the main use) and potentially research. We have not figured out how to parse natural language in medical records for these purposes…yet. Hopefully, systems will be designed to accomplish this and physicians can return to more narrative notes.

The other important part:

I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.

EMRs need to be as fast and easy to use as paper, but that doesn’t mean it has to (or should) work like paper. We may have to change the format of our notes (i.e.–blowup the SOAP note) and adjust our workflows.

Darwinian Health IT - Only well-designed EHRs will survive | tdwi →

This is an interesting piece that goes over many of the factors that are responsible for our current electronic medical record (EMR) system mess. However, it misses the most important one–the largest purchasers of EMR systems today are not physicians, but hospitals/large healthcare systems driven by their billing departments and IT departments. Their needs have consistently trumped those of physicians.

They also highlight a disturbing fact for individual physicians or smaller practices:

“The data suggests that it is likely we’ll see a sizable reduction in the number of EHR vendors listed for 2014 edition certification,” predicted Steven Posnack, director of federal policy, and Dustin Charles, a public health analyst, on the ONC’s September 13 blog post

The certification they are talking about here is Meaningful Use Stage 2. What happens to smaller practices who have invested significant amounts of money in recent years implementing an EMR system, only to find out that their system will no longer qualify for Meaningful Use (and the reimbursement that goes along with that qualification)?

✚ Hot spotting as educational tool

The AAMC has a new initiative to teach the next generation of physicians about ‘hot spotting’ and its role in providing high quality care while reducing costs. They have developed a toolkit to assist any medical student, resident, attending, or community physician in conducting their own hot spotting project with a patient from their practice.

I was immediately taken in by hot spotting when I read about in Atul Gawande’s 2011 New Yorker piece [1]. Around the same time, I heard about a research group that was taking a ‘80/20’ approach to prioritizing their initiatives. They were going to look at the 20% of diagnoses that accounted for 80% of their admissions. Electronic medical records enable both strategies and are good examples of using ‘big data’ to direct our efforts.

The initiative and toolkit put together by the AAMC is impressive. Their ‘10 Steps to Hot Spotting’ lays out a framework for comprehensively evaluating a patient who frequents the hospital.

A few thoughts:

  • Absolutely fantastic that their steps include going outside the hospital and clinic. Medical training should include more time for trainees in places providing supportive services (i.e.–nursing homes, physical rehab centers, shelters, mental health centers, etc).
  • Step 2 (essentially identifying the patient) seems like a high bar to pass. Their strategy requires (1) an excellent relationship with a specific care provider in an area likely to see candidate patients and (2) that person to recognize a suitable patient and contact the med student.
  • As written, their 10 steps don’t seem to incorporate identification of a mentor. I think–for med students especially–it would be very beneficial to have a mentor, especially if you can find someone with quality improvement experience/interests.
  • The final step should be presenting all of this at Grand Rounds!! If someone spent the time and effort to put together all of the materials described here, it would make for an amazing presentation. And don’t forget to include the patient (if possible).
  • This would make for a great project to include in quality improvement classes, which should be requisite for med school graduation. I wonder if such a project would count as quality improvement for board certifications now requiring a QI project [2].
Very to excited to see what comes out of this initiative. I think this is an excellent tool for introducing trainees to population-based health without the scary (and often boring) aspects of epidemiology and biostatistics.

  1. Of course, part of that was due to Dr Gawande’s great storytelling.  ↩

  2. For example, the American Board of Pediatrics now requires a pediatrician to complete a quality improvement project as one of four parts to their new Maintenance of Certification. I believe (but don’t know for sure) that other specialties are doing similar things.  ↩

Let’s do a ‘We Do’ | Stanford d.school →

Melissa Pelochino–a Stanford d.school fellow–describes how too often we go from ‘I Do’ (where a teacher models something) to ‘You Do’ (where the student does it independently), skipping the ‘We Do’ (an intermediate step where the teacher and student do something together). I think this is all too frequently true in medical school. In students’ third year, as they rotate from service to service, they may spend a day or two observing the residents and attendings seeing patients. However, within that first week, the med student is typically given a few patients and set loose. They go and see the patients independently and present the patient independently on rounds [1].

I think 3rd year med students, especially those in the first 6 months, would benefit tremendously from more ‘We Do’. Students and residents could see patients together, divvying up with encounter between the two. At times, I’ve had such educational experiences with exceptional residents and it was invaluable.

  1. A bit of an oversimplification. Med students will see and present patients independently, but the responsible resident is also seeing the patients as well. Residents backup the students on rounds and tactfully step in when a student misses something or there is a complicated question.  ↩

Pharmacogenomics - One size doesn’t fit all | Vector →

Nancy Fliesler writing on Boston Children’s Vector blog:

…Manzi and colleagues hope to build a repository and database in order to develop and validate prescribing guidelines that tailor treatments to patients’ genetic makeup. Few such guidelines now exist.

Pharmacogenomics is the future of medicine. I personally can’t wait for the day when I know what the starting dose for a given drug absolutely should be for the particular patient in front of me. Unfortunately, it seems like we have a long road ahead. As I’ve tried to highlight with the quote above, just because we know that a certain gene may increase a patient’s metabolism of a specific drug and we know the patient has that gene, doesn’t mean we know how to adjust the dose accordingly. Educated guesses can be made, but we need much more data on how to incorporate genetic information into actual dosing.

Philadelphia Children's Hospital Bars Herbs And Supplements | NPR →

Elana Gordon writing for The Salt blog on NPR:

Under CHOP’s old policy, dietary supplements were treated as home medications. If a family brought them in, an attending doctor or nurse was obliged to evaluate them as best they could and administer them along with hospital-sanctioned meds during the patient’s admission. If the supplements ran out, the provider would order more through the hospital pharmacy. Now, families are entirely responsible–they have to obtain and administer the unapproved supplements themselves, notify a doctor when that happens, and sign a waiver form. The hospital is also distributing additional explainers to families.

CHOP [1] was one of the first hospitals in the country to begin requiring flu vaccines for its workers. In light of the recent revelations about adulterated supplements and the poor state of supplement oversight, CHOP seems to be at the forefront again.

  1. Children’s Hospital of Philadelphia  ↩

Code Blue | Baylor's Progress Notes →

Donna Huang--a 4th year med student at Baylor--describes learning about ACLS (Advanced Cardiovascular Life Support) and then witnessing it in action. I thought this was a great piece talking about the emotions of responding to a code and the inherent violence of resuscitation.

Can Genomics Blow Up the Clinical Trial? | MIT Tech Review →

Details of what I will call a 'shotgun' approach to incorporating genetics into clinical trials. The work being done here is definitely not 'blowing up the clinical trial' but rather doing a clinical trial on a larger, coordinated scale. The real power of genetics and drug design when we reach the reality of using tumor genetic results to reverse engineer therapies.

Greatly improved new statin guidelines - with one exception | MedRants →

Great summary and commentary from Dr Robert Centor. I didn’t know what to make of the new statin guidelines; it’s not a particular area I’m interested in or have extensive education. However, given its prominence in the news and relevance to family members, I need to know something about it. I think this post from Dr Centor is the best place to start.

Four things we learned at EHI Live | MedCrunch →

Interesting thoughts from MedCrunch on EHI Live–the UK’s national event for health IT. I find point #3–Interoperability is this year’s magic word–particularly interesting. I wonder if we will ever have true interoperability in health care. If we do have true interoperability, will it be as easy for me to change EMRs as it is for me to switch between Chrome, Safari, Firefox, and Opera? That is the EMR future I am looking forward to.

Letting Medical Students Run the Clinic | The Atlantic →

Great examination of the student-run clinic. However, this article makes it seem like the students are running wild with only the distant oversight from the supervising physicians. In all of my experiences [1], there is strict oversight with the supervising physician always going in after the medical student to visit with the patient and conduct their own relevant exam. I am biased (of course) but I believe student-run clinics provide a valuable service to the community and benefit the medical students who participate in them, both in terms of clinical learning and exposure to health disparities.

  1. For anyone interested, the University of Kansas medical students run the JayDoc Free Clinic.  ↩

Graduating Pharmacy Students’ Perspectives on E-Professionalism and Social Media | Am J Pharm Educ →

Conclusion from the abstract:

Many graduating pharmacy students use social media; however, there appears to be a growing awareness of the importance of presenting a more professional image online as they near graduation and begin seeking employment as pharmacists.

Anecdotally, I can say the same for medical students. The vast majority of my classmates seem to change their Facebook name to some weird alias when residency interview season rolls around. However, as someone who has worked hard to cultivate a positive online presence and never been asked about it in an interview, I truly wonder how many programs are looking at candidates online.

Medical School at $278,000 Means Even Bernanke Son Has Debt | Bloomberg →

Janet Lorin writing for Bloomberg:

The median education debt for 2012 medical-school graduates was $170,000, including loans taken out for undergraduate studies and excluding interest. That compares with an average $13,469 in 1978…[or] about $48,000 in today’s dollars.

Educational debt, where med school debt is but one type, is a problem we need to face now. This year, due to the sequestration, all subsidized loans (i.e.—the government pays the interest while in school) for graduate students was cut. This means that medical students in their first year are being charged interest from the day the loan is dispersed. Should medical students start taking part-time jobs or work-study assistance?

We (medical students) understand loans are part of the deal, but the deal has gotten so bad that it is becoming untenable.