Pharmacogenetics Puzzle | The Scientist →

Nice summary of recent research results showing the questionable utility of screening patients for CYP2C9 and VKORC1 variants when initiating warfarin therapy. This goes along with my previous post about Boston Children’s efforts in pharmacogenomics.

We are in the early stages of making pharmacogenomics clinically useful. There are going to be bumps in the road, one of the biggest being we find out that knowing certain gene variations doesn’t impact clinical care.

The ePrognosis App: How Calculating Life Expectancy Can Influence Healthcare Decision-Making | The Health Care Blog →

Leslie Kernisan MD MPH:

In general, the ePrognosis story illustrates a common challenge in improving healthcare quality: the problems that experts see at the population level (excess cancer screening in frail elders) are experienced very differently by the clinicians and patients on the ground...Although expert guidelines and advice do have an important role to play, it’s usually not nearly enough to counter the habits and attitudes of the people in the trenches.

This is an interesting tale of creating a smartphone app to put evidence-based information in physicians' hands at the point of care (something I've tried to do myself). What I think Dr Kernisan is trying to get at in the quote above is that it's very difficult to persuade experienced clinicians to not rely on their training and experience, to instead use a digital tool for clinical decision support. One reason for this, I believe, is that we overestimate our performance. Decision-support tools are created because there is some population-based evidence for poor performance on some measure (at least that's the general idea). To make their usefulness 'real' for ordinary physicians, they need to see their own performance on those measures and the clinical impact of better performance.

The Pros and Cons of E-Communication | The American Resident Project →

Great topic and initial list of some of the benefits and downsides to communicating with patient through electronic means. I think they missed one major one.

  • Potential for misunderstanding. Written communication is asynchronous and limited in scope and length. This means there is tremendous potential for miscommunication. Verbal cues such as tone are absent. Visual cues, namely body language,  are also absent. A doctor can't see a patient's confused face and know to use less jargon or go deeper. A patient can't hear the seriousness of the doctor's tone. Neither party can easily ask follow-up questions.

Electronic forms of communication will absolutely be part of the future in medicine. However, we must be vigilant for misunderstanding. Many of us are not great communicators in written form; many of us don't read carefully enough. There will always be a place for face-to-face communication between doctor and patient.

We need more residency positions | Med Rants →

Robert Centor MD:

Oops – the author does not know a thing about medical school admission increases – and yet he opines as if he has discovered the answer! Ask any US grad about the increased number of US medical school graduates. Ask the 300+ graduates of last years class who did not get a residency slot!

Pre-Med Students Readjust Concentration Choices | Harvard Crimson →

Setting aside the sanctimonious undertones [1], this article raises an interesting question—will the changes to the MCAT and premed requirements mean more diversity in terms of major for med school applicants? I think it may have a minor impact. The bulk of the MCAT still remains focused on traditional ‘hard’ sciences and most students will still be counseled to choose such a major [2]. Major shifts will require cultural shifts within medicine itself and med school curricula.

[via Wing of Zock]

  1. “While other schools are struggling to figure out which classes provide which competencies, we’re good…It’s what is known colloquially as people skills."  ↩

  2. I don’t mean by premed counselors at undergraduate schools, but rather current physicians and medical professionals who often serve as informal mentors/advisors for med school hopefuls. I would hope that university-based premed counselors do a rigorous job discussing with students the option to choose a non-science major.  ↩

Primary care suffers from guideline overload | KevinMD →

Great insights from Paul Bergl MD, a chief resident and contributor to a NEJM Journal Watch blog. He briefly touches on something I think is critical to achieving his overarching goal of dealing with information overload—research and data evaluation skills. We simply do not provide enough training in med school and residency to empower young physicians to critically evaluate the literature. Without confidence in these skills and little time in the first place to critically read publications, it becomes an impossible task to deal with all of the information.

He also writes:

Our experts in evidence-based medicine need to guide us toward the most relevant and pressing needs, guidelines about guidelines, so to speak. We need our educational and policy leaders to help reign in the proliferation of practice guidelines rather than continuing to disseminate them.

This needs to happen on a local level. Academic medical centers can be the drivers of curating this information for their city, region, or state. Of course, this type of work is not reimbursed, but it should be part of the academic medical center’s mission and their sense of responsibility to the community.

Think you have strep? Answer two questions and check the big data | Vector blog →

Researchers at Boston Children’s Hospital are working on a system that incorporates local microbiology data with two easy questions patients can ask themselves to predict whether or not they should see a doctor.

We need more innovation like this, especially in terms of infectious diseases. Knowing the local burden of a given infection can dramatically improve diagnostic testing performance and inform whether or not such testing should be conducted [1]. Unfortunately, infection data is all too often siloed in hospital and clinic microbiology lab data.

  1. Remember from your basic epidemiology that positive predictive value is dependent on the prevalence of the disease. So, if we know there is a high prevalence of strep throat in the community based on local infection data, the predictive value of simple questions and even rapid strep tests increases.  ↩

Whose Data Is It Anyway? | The Health Care Blog →

Wow, electronic medical record vendors claim ownership of all of the data entered into their systems. It’s like if everything you wrote in Microsoft Word was owned by Microsoft [1]. I have heard of some of the big EMR companies creating ‘exchanges’ where they aggregate data from various hospitals for research. At the time, I thought that was strange and curious how they were able to do it with HIPAA. This is how.

  1. Google claimed similar ownership over data and files when it launched Google Drive. People were not happy at the time, but nobody talks about it anymore.  ↩

Hot Spotting - Innovative Approaches to Caring for the Very Ill | Wing of Zock →

Interview with Jeffrey Brenner MD, executive director of the Camden Coalition of Healthcare Providers and one of the persons behind hotspotting.

Dr Brenner:

Sit down at the foot of the bed, ask patients open-ended questions, and find out what’s going on in these peoples’ lives.

This is something that all physicians at all training levels should do. It’s an important step that we all too often skip in the pursuit of ‘efficiency’. We don’t really know a patient’s disease if we don’t know the patient.

Find out more about the AAMC’s Hot Spotting initiative and get involved.

[via Wing of Zock]

Why it’s the best time to be a healthcare entrepreneur | Rock Health →

Interesting interview with Zen Chu, the founder of HackingMedicine at MIT, about the digital health startup landscape. His reasons for why it’s the most exciting time to be a healthcare entrepreneur are at the bottom. I hope his third reason—“Large entrenched healthcare institutions are having a tough time adapting versus more agile startups”—is actually true, but I don’t know there is much evidence for that.

Health-Care Apps That Doctors Use | WSJ →

Kind of a disappointing list (see my last post) and several of the apps require institutional integration, so if you're hospital's IT department doesn't support it you can't use it (like Epic's iOS apps).

Medical apps needed, and not just for 'hipsters with chronic diseases' | Chicago Tribune →

John Carpenter:

[Dr. Scott Stern] said the growing wealth of medical knowledge doctors are expected to use and apply “is just mind-boggling and impossible to keep in your head. It’s clear that we have to do this better to deliver the kind of care that patients assume they are getting, and that they probably are often not getting.”

Reference apps for physicians are nice; they compose the largest number of physician-centric apps currently on the market. However, we need productivity apps for doctors. Why is there no great electronic prescribing app? Why don’t EMR vendors have simple apps for order entry?

I’m waiting for the day when I can walk into a patient’s hospital room, talk to them, examine them, discuss treatment options, then pull out my phone (PHONE, not tablet or going to a computer) and hit a few buttons to add new orders for the patient. I won’t have to enter login information and wait for the computer. I won’t have to enter the patient’s name; it will already know which patient’s room I’m in through RFID (and will have the consequent benefit of reducing errors). For the most common orders, it will only require a few taps. And it all of this has to be faster than a Google search.

That is what doctors need in terms of medical apps.

[via Wing of Zock]

Imagining the Post-Antibiotics Future | Medium →

Skip to about half way through the article where McKenna [1] discusses how many things we do in medicine depend on antibiotics (transplantation, cancer treatment, ICU care, surgery, safe childbirth, etc) and what the post-antibiotic era will mean for those therapies [2]. That is the truly scary and difficult to convey aspect our current antibiotic situation.

  1. Maryn McKenna is journalist who wrote ‘Superbug’ (an excellent read) and has become a tremendous voice for responsible antibiotic use.  ↩

  2. McKenna also recently wrote a shorter, more focused piece on Wired about the impact of ineffective antibiotics on the practice of medicine.  ↩

The Medical School Class of 2025 | Wing of Zock →

The med school class of 2025 started high school this fall. Interesting thought experiment to predict what will change over the next 8 years before they start their medical education.

In Search of More Primary-Care Doctors | WSJ →

This article points to the well-worn causes for our primary care shortage—too little pay relative to specialists and the hidden-curriculum against primary care. However, they also bring up an infrequently discussed factor—who we select to be doctors.

George Thibault…says that if the U.S. wants to produce more primary-care doctors, especially those who are willing to practice in disadvantaged and underserved areas, medical schools may need to change the way they select students. He says students who have strong ties to their community, want to form long-term relationships and have a commitment to public service are more likely to choose primary care than other students…

…Grades and test scores, [G. Richard Olds, the founding dean at UC-Riverside], can no longer be the exclusive criteria for entry into primary care. “I’d even argue that those with the highest grades and Medical College Admission Test scores may not make the best doctors.” Riverside seeks students with public-service work experience and those from disadvantaged backgrounds who are likely to return to their communities to practice.

Current premed curricula and medical school admissions heavily favor students interested in biology, chemistry, and physics. These disciplines emphasize basic science research and high technology. What medical disciplines tend to feature lab research and/or use of advanced technologies? Subspecialties, not primary care.