Sorry for not posting much recently. Between Christmas break and coming to the end of my Internal Medicine rotation I’ve been rather busy and haven’t gotten a chance to post anything. But here’s a link that I think many will like.

It’s At The 20! The 10! Can The Flu Go All The Way?

It’s a great little piece that I heard on the way home from the hospital today that made me chuckle, esp the bit about the flu having a break out season or being a complete bust as well as keeping H1N1 on the bench just in case.

Stolen from Controversies in Hospital Infection Prevention and too good not to pass on. Good follow up to my piece on Paper vs. Computer records.  Enjoy!

When I first heard about the idea of fecal transplants I was in my second year of medical school learning about a horrible condition called Pseudomembranous Colitis in my microbiology course.  This condition is caused by antibiotics wiping out the good bacteria that reside in your intestines and allow the can normally reside in the gut in harmony with all your normal gut flora.  However, when somebody is given a broad spectrum antibiotic (likely during a hospital stay) the majority of your gut flora can be knocked out leaving C. Difficile alone to flourish and take over.  This leads to horrific diarrhea that prevents the individual from being able to take in the  nutrients they require.  Many times the standard treatment of stopping the offending antibiotic and following that with an antibiotic to targe C. Difficile works fine.  However, sometimes that isn’t enough and the individual is left with a continued watery diarrhea and an inability to stomach anything substantial.

The lecture about this condition was being given by the Chair of Infectious Disease at MCV, Dr. Michael Edmond who proclaimed that there is a solution.  It’s a rather unconventional idea but it works wonders.  It’s called Fecal Transplantation.  The reason I’m now writing about this is because it seems to be getting quite a bit of press coverage recently.  There was a very good article in Wired on this topic and also, as I found out on Dr. Edmond’s blog, even Stephen Colbert covered the topic in his cheating death segment.  Enjoy!

As far as my current experience goes, I have to say I prefer EMR.  When it comes to paper charts I run into several problems.  First, when following up on new patients that I haven’t seen before at an outpatient clinic I often have significant difficulty trying to decipher the previous notes.   If the patient is following up on a specific problem, this makes understanding the current treatment plan difficult along with problems determining previously failed treatments.  Fortunately for me, at the clinic I am currently working at, the previous third year student that had been working there has often seen the patients I am following up and and their hand writing is often significantly better than the attending’s.  However, for when that is not the case it becomes a constant struggle and frustration to read many attendings’ notes.

As for the EMR system, handwriting is never a problem.  Each note is typed up and easy to read.  EMR also has the ability to sort notes by the type of visit.  So if I want to specifically see how a patient is doing with their occupational therapist or pulmonologist I can find those specific notes quickly.  Whereas in the paper charts they are typically all mixed together and you have to sort through each note until you find it.

When it comes to documentation of medications, a paper chart is only as good as  the last person filling out the medication list.  Now, I do my very best to make sure all the current medications are up to date in the chart and if the current form is too confusing due to med changes or dosage changes I will replace it so that it is easier to read.  Of course I am only human and when the clinic gets busy it is easy to miss this step.  Compare this to the EMR where, as soon as you put an order in for a new prescription for a patient, it gets recorded in their file for easy recall on their next visit.

Finally, when it comes to access of patient information quickly and efficiently EMR leaves paper charts in the dust.  Picture a doctor’s office where every Physician has a tablet and while talking to the patient can easily put in medication orders or look up recent x-rays or labs and show them right on the tablet to the patient to explain them.  Imagine trying to do that with a paper chart.  In fact, often times we have to access outside records and print them out to put in the chart, if we don’t print them out and include them it’s as if those studies were never done when you come back to the chart later (since by then you will inevitably forget that an outside study was done in the first place).  Also, as an added bonus most tablets are easy to clean by simply wiping them down.  Try that with germ laden paper charts.  The iPAD is already becoming a prominent tool in medicine and tablets in general could help revolutionize patient care at the bedside.

The best and most cost effective treatment would likely be a vaccine.  This has been a long way off for a while with standard vaccine creation methods. However, researchers at Cal Tech recently developed a promising idea that combines gene therapy through a viral vector that inserts a gene for an HIV antibody directly into cells.  These are all very interesting ideas and great news when it comes to the possibility for a cure or prevention of HIV/AIDS.  All of these are still a long way off so currently, the best we have to offer are the current antiretroviral drugs that are very costly but work very well when used correctly.  So for now, in honor of World AIDS day please take a piece of advice from Bono and purchase (RED) products or support the ONE campaign to help provide these drugs to those in need.  Great clip of Bono on The Daily Show here.

This is quite a fascinating piece on Radiolab regarding the origin of the mask that is used in the CPR dummy.  Thought it would be worth posting a link to it,  Death Mask – Radiolab.

The attending whom I worked with last month on my inpatient service showed our team this clip of Ben Goldacre talking about the placebo effect.  It is properly hilarious (be forewarned of the language content, which I think is pretty well negated by the content as well as his accent… everything is funnier and more acceptable with a British accent don’t you think?)  I think the whole placebo effect is a very interesting process and you can read what I believe is the study that Ben Goldacre is referring to here.  It’s a pretty interesting read and it really peaks my curiosity about how powerful the mind can be in controlling physiological responses.

Address Is Approximate from The Theory on Vimeo.

I am in full favor of charging those who end up costing the health system more in the long run.  I see it as very similar to car insurance.  If I were to drive recklessly or get into accidents and have my insurance pay out frequently for car repairs or damages, I would fully expect them to charge me more based on my risk of costing them money.  That is how insurance is supposed to work, at least by my understanding.  So why does it seem like a new idea to charge more to those who’s lifestyle decisions cause their health insurance to pay out more money in their health care costs?  I for one have been paying more for my health insurance simply because I require a certain type of prescription.  Now, am I pleased that I have to pay more on a monthly basis because of a condition that I have no control over and is perfectly well maintained on medication, absolutely not.  But I understand how cost sharing works and know that based on actuarial data, it puts me in a potentially higher cost bracket.  So, for anybody who happens to get upset or outraged that they have to pay more because they smoke, or are obese, I have no pity, as those are conditions that can be changed based on lifestyle choices.  Has Bon Secours gone a bit far in not even hiring smokers?  Well, I think that might be a bit discriminatory as smoking is not illegal.  A health institution can certainly make their property smoke free as it is detrimental to patients to potentially have to walk through a cloud of cigarette smoke, but to outright not hire someone simply because they smoke I think is a bit much.

I feel that I have learned a lot from the team that I have been working on.  I have had the chance to work under two amazing attendings that each have their own style and have individually taught me very different things about medicine.  It has truly been an eye opening experience to learn about the both the joyful and the frustrating aspects of medicine.  On the one hand, I have come to remember why I wanted to go into medicine in the first place by seeing some patients progress from very ill to almost entirely different people by the end of their stay.  On the other, there are some ugly truths in medicine that make me at times question what I’m doing.  For instance, how do I balance trying to do what I feel is the right course of treatment for the patient when the patient has insurance that limits what I am able to do to help?  How do pharmaceutical and insurance companies justify charging those with insurance hundreds to thousands of dollars for a medication that is available as a generic for pennies but because the patient has a certain insurance, is only available to them at the higher price?  I fear that medicine has become too much of a business and has lost its way since my father’s generation of practitioners began working.

My current attending wrote a very interesting piece on some of the aspects that have changed over the years that was published in the Annals of Internal Medicine.  He makes a stark contrast between current working conditions of interns and residents and those when he started practicing.  He states how currently, the most important aspect of your day seems to be making sure you are out of the hospital by a certain time to not violate duty hours.  Compared to before when he was able to take his time with patients, be thorough, and take advantage of teaching moments without worrying about repercussions of staying late.  Part of me wishes that things could be elastic the way he describes, yet I also know how much time could be sucked up at the hospital if there were no time limits.  I hope the system is able to find a happy medium, because constantly handing patients off to the next shift seems to take away a part of the ownership of your patients care.  I worry that when I get to residency that aspect will lead me to not be as focused or thorough with my patients care.  Hopefully, I will keep my current and past attending’s examples of care with me as I move forward in my career and always make sure that I am thorough and put my patient first without also losing site of the fact that I  as an individual need to make sure I have time for myself and my family as well.  Because without those people by my side, I wouldn’t be able to be on the path I’m on in the first place.

One last note, In perusing through archives on the New England Journal of Medicine looking for physician reflections.  I found a wonderful article about how much of an impact one physician had on a family during his internship year.  An impact so strong that the family was grateful for years to follow.  I truly hope to be able to have that kind of impact myself some day.   Unfortunately, the article is only available if you or your institution subscribe to the NEJM.  If you have the ability, it’s a good read.