Not “Just a Nurse” | Slate

Nurses don't just grease the wheels of medical care, they are the wheels. Virtually nothing happens in a hospital or clinic without the help of a nurse. They are invariably hard-working, dedicated, passionate people who deserve our respect and gratitude. I am grateful every day for the great nurses I'm privileged to work with.

In terms of what was said on that talk show—why are any of us surprised that somebody said something stupid and insensitive on a talk show? If anybody had a nuanced, thoughtful comment that would be more newsworthy.

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Computerized order entry: preventing spoiled doctors? | Edwin Leap

Edwin Leap:

I don’t understand why it’s so much better for me to enter orders than for the secretary, or even nurse in some instances, to enter them. Other people still vastly outnumber doctors in most departments. Further, I still work in two places where I check the box on the form, or tell the nurse/secretary, and they enter it into the computer.

Why was that so bad? Were there that many errors? Were the secretaries that overworked? Is the use of language, as in ‘Mr. Schwartz in room 5 needs CT angio to rule out PE,’ so utterly fraught with confusion and uncertainty? […]

And in an age of nurse empowerment, are nurses so unworthy of our confidence that they can’t do anything until it’s in the computer? I swear, I expect to someday say ‘start CPR’ and be asked, ‘did you put it in the computer yet?’

The answer to the question is not to allow more verbal orders, but to make the process of CPOE quicker and more convenient for physicians, namely by making it mobile and context-sensitive. It would be great working the ER, walk into a patient’s room, assess them, and then pull out my smartphone which would automatically pull up the particular patient (based on the fact that I’m standing in their room) and a menu of relevant orders based on their chief complaint with easy search for any other orders.

There is no reason why physicians can’t enter their own orders; we just need to make it quicker and easier.

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How To Speak Startup, Part Deux | TechCrunch

In a list defining terms frequently used by start-ups:

“We have lots of unstructured big data.” — We have a big pile of shit in a bucket.

Physician notes = unstructured big data

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Dropout Docs: Bay Area Doctors Quit Medicine to Work for Digital Health Startups | KQED

File this under #notSurprisingAtAll.

A particularly damning indictment of clinical medicine:

“I loved working with patients but I looked around me and realized that I didn’t want the jobs of anybody who had ‘succeeded’ as a clinician,” said Rebecca Coelius, who graduated with an MD from UCSF.

I fear more and more medical students and residents are feeling this way. Though there is no shortage of excellent clinical mentors, their career and lifestyle may not be appealing to the current generation of trainees.

Coelius goes on to note:

“Tech culture is very appealing when juxtaposed against the hierarchy and myriad hoops to be jumped through in clinical medicine,” she explained.

What hoops exist?

The most familiar to the public include performing well in an undergraduate program, doing well on the MCAT, applying for and getting into medical school, then completing a residency.

There are many, many less familiar hoops that include the four USMLE licensing exams [1], the process of applying for residency (which includes traveling all around the country), applying for licensure in a given state as a resident then later as a practicing physician [2], becoming credentialed at a hospital (forms for which may be up to 100 pages long and a process that takes months) [3], applying for a myriad of ‘numbers’ such as a National Provider Identifier and DEA number, obtaining malpractice insurance, creating/maintaining an academic portfolio (which can take up entire 3" three-ringed binders, passing medical specialty boards [4], and maintaining board certification through the Maintenance of Certification programs. This is not an exhaustive list but represents only the bare minimum [5].

The medical students detailed in this article who have jumped to startups had to do none of these things and will likely make more money working fewer hours in their positions than they ever would have as doctors.

However, those people as do not get to experience the deep satisfaction of practicing medicine. Helping patients is an indescribable feeling. It’s something I really didn’t even experience as a medical student; you only start to get a real flavor for it as a resident.

I fear two things for this trend:

  1. We are losing very smart people who would make tremendous clinicians and further the practice of medicine itself.
  2. Startups are attracting people with MDs who have never actually practiced medicine and do not truly understand medicine [6].

Both of these issues need to be addressed by (1) trying to tackle all of those ‘hoops’ listed above while ensuring doctors are well-trained and qualified and (2) developing career paths for practicing doctors to work with startups on creating ways to make technology and medicine work in harmony.


  1. There are three parts to the USMLE Step exams (i.e.—Step 1, Step 2, Step 3). However, Step 2 is two parts—a written test and a practical test where you examine and diagnose actor-patients—so there are really four licensing exams that must be complete.  ↩

  2. Some people may go through this process more than just two times. In my case, my residency operates in two states so I will undergo it twice for residency, another time for fellowship (assuming I go to another state for further training), and then again for when I get a ‘permanent’ position somewhere. That means a minimum of 4 times. If should ever switch jobs to something in another state, I will have to go through it all over again.  ↩

  3. A process that is so arduous and time consuming that a startup called CredSimple has just raised $1.5 million to take care of this for physicians.  ↩

  4. The USMLE licensing exams which are completed in medical school and the first year of residency are only to obtain a medical license. To become “board certified” in a speciality (often a requirement to be hired by a hospital or private practice) you have to complete a residency/fellowship in the speciality (ranging from 3 - 9 years) and pass their exam at the end of your residency/fellowship.  ↩

  5. I’m sure I’ve even missed some ‘hoops’ in this list.  ↩

  6. I would argue that you don’t begin to really practice medicine until your residency and even residency is not truly practicing medicine. A true practitioner of medicine has full responsibility for a patient’s care and deal with the weight of that responsibility.  ↩

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ResearchKit Asthma app developer praises framework in first official blog post | 9 to 5 Mac

I’m very excited about ResearchKit and the potential it has to revolutionize how research is conducted. It is certainly not without its problems, most notably the bias it inherently introduces by only including iOS users. The graph at the bottom of this post highlights another problem—initial excitement but precipitous drop-off in engagement. This developer had a 50% dropoff in less than a month. [1]


  1. This graph doesn’t look too different than such graphs I’ve seen for most apps. People try things out and only a small fraction stay engaged. Unfortunately, that introduces a huge bias when talking about research.  ↩

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Overkill: America's Epidemic of Unnecessary Care | The New Yorker

Atul Gawande writing with his usual, uncommon brilliance about unnecessary medical care:

Well, as a doctor, I am far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years.

We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found.

Much of the debate on unnecessary tests and procedures has focused on our fee-for-service reimbursement system and doctors profiting from “doing more”. The two quotes above highlight what I think is a much more important pressure on physicians—we don’t want to miss something. We truly want to find a cause for our patients’ complaints and treat them. This is done with the notion that we are providing the best care for them. We dramatically underestimate the consequences of overtesting and overdiagnosis. It is a bias and part of the culture of medicine; we feel like we have to do something.

Right now, we’re so wildly over the boundary line in the other direction [of wasteful care] that it’s hard to see how we could accept leaving health care the way it is. Waste is not just consuming a third of health-care spending; it’s costing people’s lives. As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still, when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more—the prospect of doing too little or of doing too much?

This is the ultimate battle, both for doctors and patients. When its your health or your patient’s health on the line, you don’t want to fall on the side of doing too little. This is a struggle I deal with daily in trying to provide the best care for my patients.

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Resident burnout – not fixed | MedRants

Robert Centor:

Burnout generally follows a lack of control. Changing work hour rules, if anything, worsens lack of control.

[...]

The ACGME rules are not helping residents. They are not improving patient safety. They are likely impacting education.

Work hour rules, however, are accomplishing one of their most important goals–giving the public the impression that the ACGME is doing something to keep sleep-deprived residents from harming patients.

As long as they continue to accomplish this goal, I see very little changing.

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Google Glass Is Finally Dead. Ish. | Slate

Will Oremus:

"Moving even more from concept to reality” is a pretty fantastic PR euphemism for discontinuing a product, moving the team to a different division, and going back to the drawing board. While the company promises that there will be future versions of the device, it has offered no timeline.

Some consolation for Google Glass enthusiasts–Tony Fadell, previously at Apple working on the iPod and then started Nest, is reported to be taking over the project.

The most damning part of this announcement is the lack of details or timeline for next steps. If Google didn’t think Glass needed serious work, the next announcement would have been plans for retail sales.

I expect Google Glass to undergo serious changes that will be on a time scale of years not months. I remain bearish on Google Glass, even in medical settings.

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The dumpster fire (part 2) | Controversies in Hospital Infection Prevention

Dr Mike Edmond boldly writing about the crisis in recruiting new ID doctors:

But ethical mentoring now requires that we have frank discussions about the relatively low pay of ID physicians with young physicians who are in the process of career discernment. I tell would-be ID physicians that they need to come to terms with the fact that they will work harder and make less money than their peers who are hospitalists. And the issue isn’t just about money, it’s about how valued you feel.

Many (maybe most) subspecialists maintain their generalist board certifications. Why not trade your overworked, underpaid job for shift work as a hospitalist?

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Should Surgeons Keep Score? | Backchannel

James Somers:

In order for surgeons to improve, they have to know how well they’re doing. In order to know how well they’re doing, they have to know how well their patients are doing. And this turns out to be trickier than you’d think. You need an apparatus that not only keeps meticulous records, but keeps them consistently, and throughout the entire life cycle of the patient.

Great article on the need for performance measurement and feedback. This article focuses on surgeons, but we need this everywhere in medicine. Unfortunately, as stated above, any efforts require meticulous and expansive data. This is one of the promises of electronic medical records, but we are far from that goal right now.

I would love to have a system like this for diagnostic accuracy for myself, especially as I train.

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Don’t Homogenize Health Care | NY Times

Sandeep Jauhar:

We have to get smarter about how we try to improve medical care. I believe the next phase of quality improvement will be a move away from homogenizing care and toward personalizing it, perhaps with the help of genomic research. Neither the old approach, in which seemingly every patient was treated differently, nor the new one, where we try to treat them all the same, has worked well. Medicine needs another way.

A great idea except genomic medicine has almost no evidence supporting it. We have excelled at uncovering the genetic components of diseases and physiology. Unfortunately, we have not excelled (so far) at applying that knowledge to changing the practice of medicine.

A quick example, we know that opioids are metabolized with the help of an enzyme encoded by the CYP2D6 gene. We also know that this gene is highly variable in humans. We know how to detect this variability using genetic testing. We do not know what to do with this information [1]. I could have a patient’s CYP2D6 profile in my hands but I would not have a precise estimate of how I should adjust their morphine dosing…because no such studies have been done.

Genomic medicine is likely part of the answer, but we are going to need the translational research first and then guidelines on what to do with that research.


  1. …other than to tell people at the extremes (very poor metabolizers and very rapid metabolizers) they should likely avoid opioids all together.  ↩

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Atul Gawande responding to CIA Torture Report | Twitter

Yesterday morning, Atul Gawande posted a series of 12 tweets detailing and condemning the medical professionals complicit in the CIA’s torture of detainees. The details are appalling and the doctors’ actions reprehensible.

I find it interesting that Gawande used Twitter and a tweetstorm format to publicize this important criticism. While he has over 108,000 followers, he also has access to The New Yorker and The New York Times. With 12 tweets worth of content, clearly he had enough for a longer form [1]. Perhaps this was only the first public debut of his thoughts and we will see more in the next few days in one of those prominent publications.


  1. Maybe we need to hook him up with a tumblr account…  ↩

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How residency programs are training doctors to waste money | Vox

(It’s difficult to link to an article with such a ridiculous title, but here we are.)

An interesting piece written about a new JAMA study that shows residency impacts and continues to impact costs of care for physicians once they are practicing.

I initially read through the Vox article, then read the abstract from the JAMA [1] and came to the conclusion that training in a high-spending region seems to mean that you will have higher costs of care when you go out in practice (regardless of spending patterns in your region).

From the Vox article:

Residents who train in regions with high health care costs (that is, the places that err on the side of more scans and specialists) continue to practice expensive medicine decades beyond graduation — even if they move to low-cost parts of the country.

While proofing my original post, I realized that this is not what the paper says at all [2]. There is never a direct comparison made among residents trained in high-spending areas versus residents trained in low-spending areas. The comparisons (summarized in Table 2) are all made within the training spending levels.

The data (as presented) actually shows the opposite of what Vox concludes. For residents trained in regions with high health costs, their average cost patient expenditure is $9,482 when practicing in a high-spending region versus $7556 when practicing in a low-spending region [3].

The comparison we want to look at is between the high-spending trainees and low-spending trainees and their costs within their specific practice spending strata. So, for a resident trained in a high-spending region who goes to practice in a low-spending region, his average cost is $7,556 (as mentioned above). For a resident trained in a low-spending region who goes to practice in a low-spending region, his average cost is $6,882. This represents a difference of $674—not chump change—but no direct statistical comparison is made, so it is difficult to say if this is a real difference.

This data is correlational and speculative at best. It’s hard to tell the direction of the effect.

Vox concludes:

The JAMA paper suggests a tantalizingly easy way to save money in American health care: train more residents in low-cost areas of the country.

While I don’t think that is a bad idea, I wouldn’t base huge programs to shift residency training to lower-cost regions based on this paper.


  1. I have to jump through about 27 hoops to get a full-text article from JAMA through my institution while at home.  ↩

  2. Which subsequently had to be pulled because it was all sorts of wrong.  ↩

  3. P < 0.001  ↩

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Blood, Simpler | The New Yorker

Theranos and Elizabeth Holmes are utterly fascinating. To develop a diagnostic testing company in complete secrecy over 10 years that is now valued at $9 billion is unreal.

Speaking of Theranos’ valuation:

Investors have valued the company at more than nine billion dollars, comparable to the two major diagnostic labs.

Comparable valuations, but not comparable scale of business:

Quest runs about thirty full-service laboratories around the country; it performs six hundred million tests of all kinds annually—Theranos’s aim is to hit one million blood tests in 2015—and owns four thousand vehicles for picking up samples.

Valuations never make sense to me.

When I first read about Theranos earlier this year, the proposition—hundreds of laboratory tests from a few drops of blood obtained by finger-stick—seemed too good to be true. Conversely, why not? Why do we have to draw so much blood?

I am not a pathologist and definitely not qualified in any way to answer that question. I think the juxtaposition between Theranos’ promise and the eventual reality is what makes it such a fascinating company. As mentioned several times in the article, transparent peer review needs to be conducted before we can fully buy into Theranos’ promise. Comparison to 23 and Me is quite apt; Theranos will undoubtedly go through growing pains which will include government oversight.

I can’t wait to see what happens. I would prefer, both for my patients and myself, easier diagnostic testing, but it has to live up to current standards for accuracy.

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