Great review of some of the problems with our current peer review system. This system came into being when such reviews were conducted by mailing around paper copies. Today, we have incredible online tools that provide facile publishing outlets and interactive forums. Peer review needs to move into the public, online space. PeerJ Preprints are an example of this at work, but we really need the heavy hitters—New England Journal of Medicine and JAMA—to get onboard.
Collaboration is Sexy | Roni Zeiger →
Roni Zeiger MD:
A new drug often makes waves in the headlines and the stock market when it’s shown to improve relevant outcomes. Somehow it’s not quite as newsworthy when remission rates increase from 55% to 68% in kids with Crohn’s disease… if it happens simply by improved communication among doctors.
In short, we need to invest more in quality improvement and we need to invite all players—doctors, nurses, pharmacists, therapists, administrators, tech people, and especially patients—to join in on the investment.
One Drug, Two Names, Many Problems | NY Times →
One place where we can control this—academic medical centers. Medical educators should never use brand names in their lectures and prohibit the use of brand names on rounds. In my experience, most attendings adhere to this but not as stringently as we all should.
When Memorization Gets in the Way of Learning | The Atlantic →
Ben Orlin:
Memorization is a frontage road: It runs parallel to the best parts of learning, never intersecting. It’s a detour around all the action, a way of knowing without learning, of answering without understanding.
Far too much of medical education relies on memorization (the bulk of the first two years are memorization) [1]. Lack of understanding in medicine is high stakes. Understanding is requisite to account for the variability inherent in practicing human medicine; it is impossible to teach or experience all permutations of disease presentations and management. Without understanding, doctors might miss a unique presentation, new disease, or a novel treatment.
One solution–open-book tests. When practicing medicine in the ‘real-world’ physicians now have the world’s medical knowledge at their fingertips. Why handicap students and not allow them to practice the vital skills of finding, assessing, and applying knowledge [2]? Additionally, this would force professors to write higher-level questions that must pass the Google Test [3]. Students would learn how to focus on important concepts instead of furiously trying to memorize every word [4].
Not mentioned by Mr Orlin, memorization has the further consequence of squashing creativity. If you only know the pieces but don’t understand how they work together, how can you think of new ways for them to work together? Now more than ever, we need creativity in medicine to solve the most vexing medical problems and ways to efficiently deliver those solutions. Memorization won’t get us there.
[via Ryan Madanick MD]
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The Krebs Cycle is the classic example. How many medical students are required to memorize the Krebs Cycle? How many practicing physicians can recite the Krebs Cycle from memory? How many use it in their daily practice? Need more evidence? Just look at the proliferation of flashcards and mnemonics in medical education. ↩
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Javier Benitez MD argues in the this piece that we should be teaching ‘information management’ skills (like finding, assessing, and applying knowledge) in addition to evidence-based medicine. ↩
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Essentially, if a simple Google search can provide an answer within seconds, then it is not a very high level question. ↩
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Some students in my class would simply copy the text from a professor’s PowerPoint slide and paste it into an electronic flashcard, with the prompt for the flascard being the title on that PowerPoint slide. Talk about simple memorization… ↩
Embracing the Millennials’ Mind-Set at Work | NY Times →
Tom Agan:
Social media permeate the personal, academic, political and professional lives of millennials, helping to foster the type of environment where innovation flourishes. So when compared with older generations, millennials learn quickly — and that’s the most important driver of innovation.
Medicine represents a unique environment for this generation to work in. Information is siloed. Common tools–like text messaging–run afoul of HIPAA and other institutional regulations. Innovation moves at a glacial pace owing to bureaucracy and regulation. And let’s not forget the hierarchical structure of medicine itself (something I underestimated until I was in it). We’ve seen some of these forces at work in recent events surrounding 23andMe.
More than the cultural and bureaucratic barriers in medicine, I believe we may be putting too much faith in millennials’ capacity to leverage technology for change. While this generation has grown up with these digital tools, by and large most of them do not understand how to create them. Too many of my peers possess a very, very basic technology literacy. Yes, they know how to use Facebook and Instagram, but not much beyond that. They do not understand that today’s smartphones are almost miraculous. They don’t understand how complex something seemingly simple like taking a picture and sharing it with Instagram actually is. It won’t be enough to have millenials simply move up the ranks. They will do a good job with adapting to things like EMR changes or new messaging systems because they’ve moved from MySpace to Facebook to Twitter/Instagram. They will fail at designing the technological tools that could change the health care landscape.
Medical School Expectations | AAFP →
Really nice series on some of the nuts and bolts of medical school. Great short read for premed and med students.
Residency Program Visits: What do you ask the Residents? | Ken Iserson's Global Life →
Talking with residents has been the number one piece of advice I've received during interview season. They are in the position you are applying for and can give the best sense of what life is like for a resident at that particular institution. Also, they are more likely to give 'real' responses rather than sidestep embarrassing aspects of a program. But, what do you ask them? These three questions from Ken Iserson are a good start.
Personally, I do not have set questions to ask the residents. I just try to talk to them to get a sense for who they are and what kind of residents compose a program. Are these people like me in a broad sense? Can I see myself working with them (especially if you talk to interns because they will be your senior residents)? Do they appear happy (without directly asking them)? This requires careful listening but can be much more insightful than asking, 'Why did you choose this program.'
Social Capital Is as Important as Financial Capital in Health Care | Harvard Business Review →
Hopefully it is obvious to anyone that reads this that social media can, should, and will play an important role in building social capital, both for institutions and individuals.
Mobile Health Apps and The Privacy Surrender | Dr Wes →
Surrendering our private data has become commonplace and acceptable when using online services, but are we willing to extend that same access to our medical data? Great piece by Dr Wes.
So much data-gathering, so little doctoring | LA Times →
The refrain—‘I was such a better doctor when I wrote paper notes’—is, by now, trite and cliché. The current problems with EMRs represent design flaws, both with the technological implementation and physicians’ insistence on maintaining traditional habits and note formats from the paper era [1]. Electronic medical records are part of the future, for many reasons. Instead of composing opinion pieces about the virtues of paper or, even worse, actually re-implementing paper charts, let’s agree to work together on creating next generation EMRs.
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We not only need to re-imagine EMR designs and workflows, but also the very notion of notes themselves. Think about the evolution of personal letters from handwritten notes delivered via the US Postal Service to email to text messages. At each step along the way, the typical format and composition changed. Our medical notes need to evolve in a similar fashion and they are, but haphazardly. ↩
Ohio Hospital Puts Docs On The Spot To Lower Costs | NPR →
Lisa Chow:
It’s scary showing doctors data that’s saying they’re not doing as well as they could.
Medicine needs a cultural shift so that physicians welcome quality and cost data as part of their pursuit of better medicine. Incorporating quality improvement education—like the AAMC’s hot spotting initiative—into med school and resident curricula is crucial to bringing about such cultural change. We also need more biostatistics and epidemiology education so that doctors can effectively analyze and incorporate data into their practice.
When 23andMe gives results that no one knows how to manage | Dr Jen Gunter →
But now you have the result and you tested positive. Now you have the result that if you act upon it might cause more harm than good. You just don’t know. What do you do?
Testing of any sort, genetic or otherwise, in medicine is fraught with dangers. Medical students and residents are constantly taught to only order a test when they know what to do with the result--have a plan for if it is positive or negative. Direct-to-consumer genetic testing has always lacked a plan for what do with the result for many of the included tests. This has always been known; it's good to see the FDA's action putting a spotlight on this issue once again.
If Inaccuracy Were Illegal, The Feds Would Have To Regulate Most Health Gadgets | TechCrunch →
Gregory Ferenstein:
But, it’s hard to see a difference between genetics and exercise, especially if a calorie counter leads users to dramatically cut their food intake.
Equating genetics testing for life-threatening medical conditions and personal activity monitors is just plainly wrong. Increasing one’s physical activity or eating healthier is not the same as subjecting someone to the stress of thinking they will develop a disease or, even worse, putting them through needless medical procedures. Those who change their habits due to a physical activity monitor have a feedback loop—as they lose weight, they can adjust their diet and activity accordingly. No such feedback loop exists for the most serious medical conditions tested with these personal genomics companies. Of course their is risk in dramatically changing one’s lifestyle based on an activity monitor, but those risks are smaller, less emotionally taxing, and typically can be avoided.
Note—It is not shocking these personal activity devices are inaccurate. Many, many studies have shown wide variation in the ability of accelerometers to accurately capture such data.
How 23andMe brought down the FDA's wrath | The Verge →
Russell Brandom:
The mere fact that 23andMe was able to operate for six years without marketing approval speaks to how much leeway the FDA was willing to extend at first, especially while many doctor’s groups were skeptical of personal genetics from the beginning…
23andMe didn’t invent the saliva test, after all. All it did was bring such testing outside the doctor’s office and make it available without the headaches of the health-insurance system. It was a consumer-grade version of a professional service: cheaper, easier, and not quite as good. And because the testing could be done in bulk, the service added a lot of genes that would never be tested in a medical lab…But that same fast-and-loose approach can cause problems if a faulty test turns up in an area with real medical complications…And when the bad news does arrive…23andMe didn’t have any counselors on hand to guide users to the medical options available or provide the proper context for understanding the results. Even if the service solves its marketing problems, those issues are likely to remain.
This is probably the best article I’ve read on 23andMe and the FDA’s action. For all intents and purposes, 23andMe seemed more concerned with pursuing its product than dealing with the implications of putting complex medical information into consumers’ hands.
My deadly disease was just a 23andMe bug | @mntmn →
Once the news of the FDA’s action against 23andMe came out, it was only a matter of time before stories of errors using the service surfaced. This particular story is very interesting because of how deep this person went to identify the problem–dowloading the raw 23andMe data, using other pieces of software to parse it, and ultimately discovering he DID have two mutations for limb-girdle muscular dystrophy but they were on two different genes.
Do stories like this put the FDA in the right? Should 23andMe be shutdown for good? Do we need to end the pursuit of direct-to-consumer genomics services? It’s unclear right now. These are complicated issues which require time and thought before settling on a path to find answers.
Bonus—Check out the Hacker New comments for more discussion/entertainment.
Art Makes You Smart | NY Times →
We often say medicine is both science and art; don't forget to study the art part of it...and art in general. One of the best things TEDMED does is incorporate art and medicine.
Flu Drugs Fall in Use for Children | NY Times →
Such a poorly worded headline with emphasis on the wrong finding.
A study published today in Pediatrics showed reduced mortality when neuraminidase-inhibitors (think oseltamivir/Tamiflu) were used in children hospitalized in the ICU with influenza. This is some of the best evidence yet that early intervention with antivirals impacts outcomes for children with influenza. This study also found--which the headline alludes to--that use of neuraminidase-inhibitors has fallen since 2009.
Sorry for the 'flu-heavy' day...
The Quest to End the Flu | The Atlantic →
The mytical ‘universal influenza vaccine’ rears its head once again. I first became interested in influenza during graduate school in 2005. Human cases of avian influenza were being reported and the work on sequencing the 1918 pandemic strain had recently concluded. I remember some talk about a universal flu vaccine back then [1], but have never seen much concrete work [2]. For those not very familiar with influenza and the vaccine difficulties, this article represents an excellent primer.
My experience with AliveCor ECG and Twitter | iDoctr →
Fascinating detailed account of one doctor’s experiences with the AliveCor in his day-to-day life. I especially enjoyed him recounting how he used the AliveCor to monitor a 17 year-old boy while he attempted to stop supraventricular tachycardia with carotid massage in his living room. I think this represented an instance where the AliveCor demonstrated clear utility.
✚ The fallacy of the 'Smartphone Physical'
Singularity Hub recently featured a post on the ‘Smartphone Physical’, a concept debuted at TEDMED 2013. While I commend the two medical students who conceptualized the Smartphone Physical, I am not as enthusiastic about it’s potential impact on patient care as many of its supporters. The so-called Smartphone Physical involves much more than a smartphone and provides much less information than that collected by a physician during a physical.
A physical is more than measurement—Walk into any doctor’s office for any kind of physical and they will do more than just measure your vital signs and take a look at you through their special scopes. Arguably, the most important part of a physical is taking a detailed history, as it is with any medical encounter. Simply speaking with a patient about what has been going on with them for the past year or more reveals far more than anything displayed on a smartphone. Experienced clinicians know the right questions to ask and how to ask them. Such clinicians are also skilled in the physical exam. While some components of the physical exam include the use of specialized equipment, most of it is accomplished through the clinician’s unaided senses.
The ‘Smartphone Physical’ requires much more than a smartphone—Of the ten components included in the Smartphone Physical, only one does not require an additional piece of equipment. While the creators list “expense” as one of the limitations of the traditional physical exam, I think one look at the Welch Allyn iExaminer puts the ‘Smartphone Physical’ in perspective. It retails at $80 for a piece of molded plastic and they ask for another $30 for the “pro” version of their accompanying app (in-app purchase). Or take the AlivCor Heart Monitor, it retails for $200. Then we have the $7,500 or more you have to shell out for the MobiSante ultrasound device (admittedly much cheaper than most ultrasound machines). All told, putting together a “digital doctor’s bag” with the devices included in the ‘Smartphone Physical’ would cost you over $8,300 (for those devices that are commercially available at this time). Also, be aware that many of these accessories are device specific and may need to be replaced as smartphones change (i.e.–Welch Allyn’s iExaminer only fits the iPhone 4/4S; the AliveCor Heart Monitor has separate cases for the iPhone4/4S and iPhone 5).
The data remains siloed—None of these devices, as far as I can tell, has any sort of integration with common electronic medical records. To be fair, this is not the sole fault of the creators; I am unaware of any EMRs that have data APIs that would allow people to send data from a smartphone app to an EMR. However, this is where there is some true promise. Adding objective data from the physical exam directly to the EMR would be of great benefit. Actual pictures of optic discs and ear drums would be of very beneficial for documenting the acute presentation and progression of disease.
Nothing here is new—With the exception of the NETRA-G and the recently added Biomeme qPCR Molecular Diagnostic, nothing in the ‘Smartphone Physical’ is particularly innovative. We have had electronic devices to take vital signs for a long time, cameras exist for all medical scopes, and we obviously have EKG, spirometry, and ultrasound machines. The common thread among these devices is reduced cost, which I would argue is evolutionary not revolutionary. Non-smartphone based versions of these devices would be low-cost if their manufacturers thought there was a broad-based consumer market to be exploited.
What consistently bothers me most about the ‘Smartphone Physical’ is the hyperbole surrounding it. A quick perusal of the headlines from the ‘Smartphone Physical’ media page gives you a flavor for this. Many times in the media and even on the TEDMED stage, people alluded to a checkup or physical from a smartphone [1]. As I explained above, that couldn’t be further from the truth. No matter how many accessories we connect to a smartphone, the physical will remain the purview of an experienced clinician.
I look forward to seeing these devices evolve, but the true innovation will be integration of objective clinical data with the patient’s subjective experience and augmented with longitudinal data from personal devices, stored in a single electronic record.
[Note–A version of this post appeared on my previous blog.]
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Fast Co Exist, “If we’re able to monitor our vital signs, we may not need doctors for check-ups.” (1) You can already monitor your vital signs at home, without smartphone-based equipment. (2) If all your doctor is doing during a visit is monitoring your vital signs, find a new doctor. ↩