Should Twitter be Regulated at Medical Meetings? | 33 charts →

Bryan Vartabedian MD:

We don’t need our meeting dialog subjected to legislation.

Using terms like “regulation” and “legislation” creates a straw man. Of course we don’t want meeting organizers to formally control the use of social media at meetings. However, we should be careful in our use of social media at meetings.

The biggest danger I see is the public broadcasting of non-peer reviewed research that may be deeply flawed.

Scientific meetings are the beginning of the vetting process for research findings. Meeting organizers do a cursory review of research prior to accepting it for presentation at a conference. This review is based on submitted abstracts and mostly involves ensuring the research is relevant to the conference; it does not involve scientific review. Thus, when a researcher stands at the podium promulgating their conclusions, few people have had a chance to critically review their methods and findings.

In contrast, research published in scientific journals has been through a formal peer review process and found fit for public distribution.

We are also in danger of over-simplifying complex research findings in our dash to encapsulate a speaker’s words in pithy 140-character snipits. We tend to broadcast select conclusions that reflect our own biases and may misrepresent the researcher’s own thoughts. 140 characters does not allow for qualification or explanation of a result.

While I agree with Doctor V that “regulation” or “legislation” are wholly unnecessary, I would implore conference attendees to think twice about what they tweet at meetings.

Virtual surgery gets real | Rémi Rousseau →

Researchers in Paris used two synchronized GoPro cameras to capture a total hip replacement from the surgeon’s perspective and then played it back in 3D on an Oculus Rift as a training tool.

When you’re a surgeon in training, you always have a task to do during the surgery; it becomes difficult to see what the main surgeon is doing. Being able to live a surgery in the surgeon’s shoes thanks to the Rift is very useful to replay the surgery in detail, pause, fast forward or backwards. It can also be an inspiring way to share and learn new techniques among surgeons.

Maybe a bit of an overstatement, but viewing complex surgeries from the lead surgeon’s point-of-view has undoubted value for both surgical residents and experienced surgeons learning new techniques.

✚ A tale of two nights—the problem with resident work hours

A few weeks ago, I worked Friday/Saturday overnight shifts on the general inpatient pediatrics team. The two nights were complete opposites.

On Friday night, when I arrived at the hospital my team was just finishing up 3 admissions. I immediately went to work helping out with those admissions. We admitted 4 more patients overnight. We were steadily busy throughout the night without much of a break.

On Saturday night, we had zero admissions [1]. I received a couple of pages regarding minor issues. I relaxed most of the night and got several hours of good sleep.

Due to the resident work hour restrictions, I had to be out of the hospital by noon following each of those nights, regardless of how hard I worked or how much sleep I got.

We restrict resident work hours because work hours are easy to count [2]. They are not indicative of what we are really trying to avoid—fatigue. Unfortunately, fatigue is very difficult to measure and even more difficult to predict. Until we make progress in this area, we will continue to see minimal impact of work hour restrictions on patient safety.

  1. According to the senior residents, busy Friday nights followed by slow Saturday nights are quite common. Their speculation—people take their children to the doctor’s office on Friday before the weekend, the doctor doesn’t feel comfortable with the patient and can’t see them in follow-up the next day, so they send them for admission. On Saturdays, parents tend to try to wait it out until Monday to see their regular doctor. I have no empiric or even much anecdotal evidence to support this theory.  ↩

  2. While easy to count, work hours are by no means an accurate measure. All residency programs I am aware of rely on self-report of work hours.  ↩

Progress notes are a poor tool for doctor-patient collaboration | KevinMD →

Steven Reidbord MD:

[Physicians’ progress notes] assist in performing and archiving medical work, much as a scientist’s laboratory notebook records the design, data, and results of experiments. Progress notes were not designed to be a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts for patients. Yet these notes now serve many masters…

But even in the best-case scenario, progress notes are a poor tool for doctor-patient collaboration. By nature they are shorthand, telegraphing complex medical reasoning in a few words…Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.

We need to fundamentally re-think clinical documentation.

The current structure serves no one well. Physicians don’t like their EMR generated progress notes because they are junked up with extras for billing purposes and become click-laden nightmares to create. Insurance companies don’t like them because of the amount of unstructured data. Patients don’t like them because they are polluted with medical jargon and difficult to navigate.

In the transition from paper to electronic records, nobody stopped to fundamentally examine the role of doctor’s notes and the myriad of purposes they now serve in modern medicine. EMR designers simply took the SOAP note format and made it electronic instead of trying to re-think how an electronic format could facilitate a new approach to documentation.

All parties are seeking more from our documentation. Without a re-design, all parties will continue to be frustrated.

How to tell someone that she is dying | The New Yorker →

Peter Ubel writing about how doctors trained to treat disease can clash with patients who have different perspectives:

By the end of this particular appointment, the oncologist had done what modern physicians are supposed to do—he informed his patient of her treatment alternatives and he left the final choice up to her. But, in the process, he left the patient little choice but to accept one of these alternatives rather than to leave her cancer untreated.

During my oral exam for my surgery rotation in medical school, I was asked how I would describe the treatment options for breast cancer to a newly diagnosed patient. I started off by saying that the first option would be to do nothing. I was laughed at by the surgical oncologist administering the test.

✚ The First Week

I completed my first week of residency yesterday. 76 hours total.

Like much of my medical training thus far, there were some very tough low moments and some great high moments. I had some tough patients throughout the week and was beginning to become very frustrated. But, then I performed a lumbar puncture on an infant that came back with zero red blood cells [1] which instantly brought me back to center. I can do this.

Compared to such experiences in med school, they are similar but on steroids. I have gone home each day mentally exhausted.

Strangely, the medicine is one of the easiest parts [2]. You learn most of the medicine you need in the third year of med school and refine that in the fourth. What you don’t learn—and what residency is for—is how to be someone’s doctor.

It’s hard to walk into a patient’s room and say, “Good morning. I’m your doctor and I’m going to take care of you today.”

Luckily, I have had a great team to work with and great support from my residency program and hospital. I truly believe I am at one of the best programs in the country for training clinical pediatricians. It’s going to be a tough road but I am incredibly excited for the journey.

  1. Lumbar punctures (or ‘spinal taps’) are a requisite procedure for all pediatricians and performing them without having any red blood cells is a consummate skill.  ↩

  2. By no means do I mean to say I’m an expert clinician or know everything about pediatrics; far from it. The medicine aspect is still difficult, but compared to some other, less familiar skills (like speaking with families or navigating foreign hospital systems) it can seem easier.  ↩

Spit here: can Cue's $199 lab-in-a-box keep you healthy? | The Verge →

Josh Lowensohn writing for The Verge:

“There are over 140 million doctor visits for cold and flu symptoms every year in the US. In more than 31 million of those visits, the patient has flu,” [Cue co-founder, Ayub Khattak] says. “We want to enable people to get this health information in minutes and, if flu is detected, communicate their result to their doctor who can order a prescription to the local pharmacy.”

This sentiment—order a lab test and, if positive, give Drug X—seems to be the prevailing belief in Silicon Valley about how medicine is practiced [1]. Unfortunately, it just isn’t that straightforward, even for something apparently simple like the flu.

The biggest concern with influenza is secondary bacterial infection causing pneumonia. These infections are what made the 1918 influenza pandemic so deadly. A rapid flu test tells you absolutely nothing about such secondary infection.

There is a reason why doctors ask a lot of questions and examine patients. Seemingly innocuous questions like, ‘Have you been feeling short of breath going up stairs,’ can yield lots of information. When it seems like your doctor is making pleasant small-talk, half the time they are gaining valuable information.

Don’t expect to plop down $199 for this box, test your family for flu, and have your doctor call in a prescription for Tamiflu. Coupling a lab-in-a-box system with an app to ask additional questions may prove to be useful for many conditions. However, the most likely scenario—you complete an in-home test, answer lots of question on the app, and still find yourself going to the doctor’s office for a more complete exam.

  1. To be fair, this seems to be a common belief among the general public as well.  ↩

In memory of Rebecca Meyer | Kottke →

Jason Kottke:

...Author Elizabeth Stone once wrote that having kids was deciding to "have your heart go walking around outside your body". Steve Jobs put it similarly: your children are "your heart running around outside your body". That's the truest sentiment I've ever read about parenting; it feels exactly like that to me. Reading Eric's writing about Rebecca, a girl so close in age to both my kids, has affected me greatly. That could be me. My kids suffering. My heart, broken and dying. Imagining one of them...I can't even do it, the tears come hard and fast, washing away any such thoughts.

A 'connected' doctor balances his priorities | mHealthNews →

Eric Wicklund:

… [Michael Jordan, MD] feels that mHealth and EHRs are uncomfortable dance partners at present, but will get into rhythm once providers (and EHR vendors) learn how to sort through the data to offer doctors what they need at the point of care.

A little difficult to decipher what exactly ‘providers’ means in that sentence, but the overall message is that people other than doctors need to figure digital workflows and relevant data for doctors.

This is one of my biggest concerns with digital medicine—people without any medical training or experience treating patients are creating the tools doctors rely on everyday. I firmly believe this is why the first few generations of EMRs have been poorly designed for clinical workflows.

We need doctors to lead the user experience design for the next generation of digital medical tools [1]. Doctors with experience and training in the myriad aspects of technology and data need to sit with designers and programmers and work cooperatively to create a great experience for using such tools in any clinical setting. It needs to be magical and delightful.

  1. I am talking specifically about the user experience not the actual user interface, data structures, networking, programming, etc. I’m also talking specifically about the digital medical tools doctors (and other providers) will use; not patient portals, mHealth tools, or the like.  ↩

Clinical Informatics: Prospects for a New Medical Subspecialty | JAMA →

Don Detmer MD and Edward Shortliffe MD PhD:

Clinical informatics is not simply “computers in medicine” but rather is a body of knowledge, methods, and theories that focus on the effective use of information and knowledge to improve the quality, safety, and cost-effectiveness of patient care as well as the health of both individuals and populations.

This is an important paper for anyone interested in the nascent medical subspecialty of clinical informatics.

Doctors flunk quiz on screening-test math | ScienceNews →

This headline depresses me.

It comes from a research letter recently published in JAMA Internal Medicine. In this study, the researchers asked a convenience sample of 61 attendings, residents, and med students the following question:

If a test to detect a disease whose prevalence is 1 out of 1,000 has a false positive rate of 5 percent, what is the chance that a person found to have a positive result actually has the disease?

Depending on how stringently you define a ‘correct answer’ [1], at best, only 40% of the respondents got it right. The most common answer was 95%. [2]

Why do I find these results depressing? Because understanding this concept is fundamental to the practice of medicine. We are talking about test characteristics, more specifically positive predictive value (PPV). PPV is dependent on the prevalence of a disease—the higher the prevalence, the greater the PPV. This is why we gather patients’ histories and physicals. By asking a few questions and examining a patient, we can identify risk factors—that place the patient in a group with higher prevalence of a condition—that allow us to choose appropriate tests with a good chance that a positive result will actually mean the patient has the disease.

I truly believe if we had a better understanding of this concept, we would order fewer diagnostic tests and save both some anguish and money.

  1. That is, if you define having a correct answer as being exactly correct, only 14 (23%) provided such a response. The researchers, in their Methods, have a little bit looser (but, in my opinion, acceptable) definition of the correct response.  ↩

  2. To be fair, this was not the most rigorously conducted study. It wasn’t a random or complete sample, nor was the sample very large. The question they posed was not validated, nor did they pose more than one question about this concept. But, how rigorous of a study do we need? The best data might be on biostats and epi questions from board exams, except reviewing such concepts is a routine part of prep for those exams.  ↩

Nurses Are Not Doctors | NY Times →

Sandeep Jauhar:

And to attract more of the best and brightest in our medical schools [to become primary-care physicians], let’s find a way to increase their pay.

While pay disparities between specialties contribute to the dwindling numbers of med students choosing primary care, they are not the core problem.

The core problem is who we select to become doctors.

The premed curriculum focuses exclusively on basic sciences. Admissions committees emphasize basic science education by favoring applicants majoring in a basic science or those with research experience. [1] These fields focus on using advanced technology to find a single answer to a narrowly-defined question. Is it any wonder that when we select students from these backgrounds—students who spend 4 years doing such work and are deeply interested in it—that they choose to go into subspecialties the focus on a narrow set of problems and employ high-tech tools to find answers?

Certainly the money helps, but I think students are far more interested in happiness and doing work that suits their interests. Our admissions criteria biases our selection of candidates towards those predisposed to enter the ever-growing number of highly technical subspecialties. Until we adjust these criteria, we will continue to have primary care physician shortages, no matter how compensation is adjusted.

An excellent, complementary discussion of how medical education erodes ‘primary care skills’ written by med student Michael Bradfield was recently posted over at KevinMD.

  1. I know, I know…it doesn’t matter what you major in and you don’t have to have research experience. The truth is, you improve your chances of admission if you do.  ↩

Doximity raises $54 million but what value will they add →

On one hand, I’m glad to see these guys continue to raise money and continue their development.

On the other hand, I’m disappointed that we don’t have a better physician-centric social network. While they have been successful at signing up doctors, it seems (at least anecdotally) few are engaging with the network. [1] I have connected with many of my classmates and some physicians I know on the network. I have never interacted with any of them through Doximity.

The article quotes LinkedIn co-founder and Doximity board member [2], Konstantin Guericke:

I think a lot of doctors will have a LinkedIn profile and Doximity profile. But the key is which part is really going to get ingrained in their lives.

The key question is—what value does Doximity provide over other, non-physician centric social networks? More plainly, what is going to make me open up Doximity on my iPhone instead of my favorite Twitter client?

The current answer to that question is: nothing.

In their smartphone app, the news feed features medical journal articles from the likes of NEJM, JAMA, Lancet, etc. It is unclear exactly how these are selected, but quite clear they are not tailored to my interests. [3] Twitter, on the other hand, provides a constant stream of thoughts and articles related to my interests because of the people I’ve chosen to follow. Doximity’s ‘Groups’ feature helps this a little by providing focused streams around topics. Unfortunately, I am a member of only one group and it looks like you can’t add additional groups from the app. [4] A quick perusal of a few groups shows that many of these are dominated by a single person, not robust discussions amongst large groups.

Where Doximity has truly missed a golden opportunity is messaging. Instead of eschewing the most tired of physician tools—the fax machine—they have embraced it as a core component of their messaging platform. The call their messages ‘Fax+Mail’. You can send and receive both email-like messages and faxes. While this may appeal to the current generation of physicians, nobody graduating med school today wants to deal with fax machines (virtual or otherwise).

More specifically, Doximity so far has missed the opportunity to become the de facto text messaging service for physicians, residents, and med students. If they offered a robust messaging service similar to something like Tiger Text, they would not only have more than 40% of physicians sign-up but daily engagement. This would create a ‘halo-effect’ and drive usage of their other services.

Hopefully, this new injection of capital will help them refine their network. I’m cautiously optimistic based on what they done with $27 million so far.

  1. I would like to quote some engagement figures here, but I’ve never seen any from Doximity.  ↩

  2. I don’t know if I consider Doximity and LinkedIn to be direct competitors, but close enough that having their co-founder on my board would seem uncomfortable.  ↩

  3. Even if you find an article in this stream that you want to read, it would take at least 3 taps to get to the full version and you are likely going to hit a paywall (though you can setup a proxy, but most people don’t have access to a proxy and don’t know how to set it up). Also, within an article the sharing button contains only two options—’View in Safari’ and ‘Share email link’. No clear option to share it within Doximity and no sharing options with other apps or saving to read later services.  ↩

  4. In fact, there seems to be a large disconnect between their app and their website. The app seems to be missing some key functionality. ↩

A unique perspective on EHR dissatisfaction | MedCity →

An elegant description not only of what better EMR design should entail, but also what it will accomplish for physicians' practices.

The goal should not be to ‘master’ a tool, but to use tools to help providers function at high efficiency. Efficiency does not mean clicking buttons and mouse, it means amplifying strengths.

The Medical Chart: Ground Zero for the Deterioration of Patient Care | The Health Care Blog →

As I have said many, many, many times on this blog—the problem with electronic medical records is not that they are electronic, but that they are poorly designed.

This post from Dr Val seems to tacitly admit this [1], but still laments electronic records and yearns for the return of paper charts. I respectfully disagree with her conclusions.

To her specific complaints:

Medical notes are no longer used for effective communication, but for billing purposes.

Medical records have always been used for billing purposes. [2] The real issue here is that both EMR design and EMR purchasing are conducted by non-physicians.

Few doctors know much about design and even fewer know how to program, so very few have been involved in the actual creation of EMRs. When they are, it generally seems to be quite successful. Unfortunately, we don’t have a stable of brilliant physician-designers. We need to be actively recruiting med students with backgrounds in design and programming to build up these resources.

EMRs are enterprise software. This means, among many other things, that the end-users (i.e.—physicians, nurses, therapists, etc) don’t directly control purchasing. Executives and IT departments with their own interests and motives control those decisions. I have never been privy to such deliberations, but I would surmise that improving billing workflows is a highly prized feature. Usability and communication features are much lower priorities.

No one talks to each other anymore.

I agree; a lot could be accomplished through better face-to-face or verbal communication. However, two things conspire against such communication:

  1. Due to both billing and legal requirements, everything must be charted. While a verbal order may be the clearest method for communicating something, it must also be entered in the chart. Why double your work and do both? [3]
  2. There is a cultural shift away from verbal communication. Just look at the proliferation of online ordering for pizza and take-out food. Although I have no research to back this up [4], I would guess that the current generation of med school graduates feels much more comfortable and amenable to ordering something through a computer interface than picking up a phone.

It’s easy to be mindless with electronic orders.

Again, I agree; it is easy to mindlessly check boxes. Again, I also think this is a design problem.

Somewhere along the line, EMR developers decided that clicking was waaaaay better than typing. In some EMRs, you can write entire notes and complete orders without ever touching the keyboard. This design decision is most likely rooted in programmers desire to produce as much structured data as possible because structured data is a lot easier to deal with than free text. [5] This helps with billing as well.

But, we don’t need to go back to paper records, orders, and prescriptions.

What we need is better free-text recognition and autocompletion. Ever filled out an online form with your address that subsequently analyzed your input and suggested a corrected form that was more complete (e.g.—changing “St.” to “Street” or adding the last four digits of your zip code)? We need systems that can take free-text orders and prescriptions and suggest completed, corrected forms. This would be faster and more accurate.

For example, let’s say you want to write a prescription for amoxicillin. [6] You type:

amox 500 PO BID x 10d

This would translated into a full prescription:

amoxicillin 500 milligrams
Sig: Take one tablet by mouth two times per day for 10 days.
Dispense: #20
Refills: 0

This would be faster than clicking individual boxes and provide more complete, understandable instructions. The full prescription could then be electronically sent and simultaneously dropped into the note.

The current state of electronic medical records is quite frustrating. You don’t have to look very far to find posts similar to Dr Val’s expressing such frustration. But, instead of raging against the EMRs, I think we need to work together to build the next generation of great EMRs that fulfill all of our expectations for technology aiding better patient care.

  1. In a post-script, she praises one EMR that “was created by physicians for supporting actual thinking and relevant information capture.”  ↩

  2. I just recently heard a story of a rural Kansas doctor working many years ago whose clinic notes consisted only of a ledger with a diagnosis and the charge. It would seem his records were only used for billing purposes!  ↩

  3. A bit of devil’s advocate here. As I said, I think verbal communication is good and face-to-face communication is great. When I start my internship is a couple months, I am going to strive to do as much face-to-face communication as possible.  ↩

  4. Maybe Papa John’s or Domino’s has some figures…  ↩

  5. As a researcher, I have been guilty of this in designing databases and survey forms. Very guilty.  ↩

  6. Many current EMRs have individual entry boxes for each prescription component (conservatively, up to 10 boxes). Many doctors seem to do whatever they can to eschew the carefully designed boxes and cram everything into the only free-text box available (usually the “Sig” box for instructions). ↩

It’s Insanely Easy to Hack Hospital Equipment | Wired →

In hospitals increasingly composed of the Internet of Things, how secure are the ‘things’?

In a study spanning two years, Erven and his team found drug infusion pumps–for delivering morphine drips, chemotherapy and antibiotics–that can be remotely manipulated to change the dosage doled out to patients; Bluetooth-enabled defibrillators that can be manipulated to deliver random shocks to a patient’s heart or prevent a medically needed shock from occurring; X-rays that can be accessed by outsiders lurking on a hospital’s network; temperature settings on refrigerators storing blood and drugs that can be reset, causing spoilage; and digital medical records that can be altered to cause physicians to misdiagnose, prescribe the wrong drugs or administer unwarranted care.

[…]

“There are very few [devices] that are truly firewalled off from the rest of the organization,” he says. “Once you get a foothold into the network … you can scan and find almost all of these devices, and it’s fairly easy to get on these networks.”

Probably even easier now, given the recent revelation of a big Internet Explorer exploit.

They found a number of infusion pumps that have a web administration interface for nurses to change drug dosage levels from their workstations. Some of the systems are not password-protected, while others have hardcoded passwords that are weak and universal to all customers.

So, while these infusion pumps are under physical lock-and-key in the patient’s room, they remain unlocked through their web portals?

And the most damning revelation:

“The vendors don’t have any types of security programs in place, nor is it required as part of pre-market submission to the [Federal Drug Administration],” Erven notes. “There’s no security assessment before it goes to market.”

(h/t Kevin Wang)

Anti-Net-Neutrality “Fast Lanes” Are Bullshit | Marco.org →

Marco Arment:

Everyone in this discussion has been led, most likely by talking-points marketing by the FCC and ISPs, [1] to describe the destruction of net neutrality as allowing ISPs to “create fast lanes”.

This language was carefully constructed to sound like a positive, additive move: It’s building, not destroying or restricting. They want to offer faster service, not reduce the speed or priority of all existing traffic. Who could possibly be against that? They’re building fast lanes, like a highway! Everyone loves fast lanes! U-S-A! U-S-A!

Naturally, this doesn’t reflect reality at all. Only a fool would believe that the ISPs would actually create any new capacity, higher speeds, or consumer value in this process, leaving their existing service untouched…

This is not making anything faster—it’s allowing ISPs to selectively slow down traffic that they don’t strategically or financially benefit from, and only permit traffic from their partners to run at the speeds that everything runs at today.

It is a money grab by the network owners, pure and simple. Like all such money grabs, consumers lose in the end. The Internet will be less free and the barrier to entry for small, disruptive companies will be greater.

Read more about net neutrality in this great Atlantic piece and sign the White House petition to maintain true net neutrality.

  1. FCC = Federal Communications Commission; ISP = Internet Service Providers (Comcast, Time Warner, Verizon, etc)  ↩

Jay Parkinson Reddit AMA | Kevin Wang →

Kevin Wang has put up an excellent selection of excerpts from Jay Parkinson's Reddit AMA today.

I have followed Parkinson's work for many years now and he always has great insights and this list is a greatest hits. Love his thoughts on wearables and consumer health technologies such as a Scanadu; I share his skepticism.