Friday, April 29, 2011

Traveler's wish list

I travel fairly frequently to conferences for our residency program - to help with resident recruitment, to learn, to present, and to support our residents and fellows who are presenting.  In the last five years, I have traveled to such events an average of four times a year.  I have seen a lot of hotels and conference rooms!

This week, I have the privilege of attending another meeting, but my experience, yet again, could be so much better with only a few minor changes by the hotel.

Here are my top gripes of hotels in no particular order - hotel business owners, are you listening?

1. "Nickel and diming"
Conference hotels are not inexpensive.  Even with the "conference rate," one night typically costs in excess of $200.  Yet, if I want WiFi in the quiet privacy of my room, it almost always costs extra.  If I want to use the work-out facility, it also usually costs extra.

2. Exhaust-ed
Why don't most hotel bathrooms have exhaust fans?  A 10-minute shower steams up the entire bathroom and usually the rest of the hotel room to boot.

3. Insufficient work space
I am sharing my room with a colleague to lower the cost to our program.  But there is only one small desk in this room.  Hotel "business centers" typically consist of 2-4 antique computers suitable for little more than printing out boarding passes, with little extra work space.

4.  Mega-air conditioning.
Even the men in short sleeves can be heard complaining about the temperature at these meetings.  Even if it's 90 degrees outside, does it need to be a meat locker inside?

5. Crappy hangers - or not enough hangers.
Eight hangers for two people for five days?  And trying to hang pressed clothes onto a hanger that you can't remove from the closet rod?  Please.

6. Slooooow elevators.
'Nuff said.

But, don't despair conference attendees.  Stay tuned for tips on how to overcome these obstacles and have a great conference experience!

Monday, April 25, 2011

When assumpions become "facts"

The post for this week was supposed to be a rant against rising drug costs.  Here's how far I got before realizing that I should get some specific data to make my points more convincing:

Back rounding with the inpatient resident service recently and, yet, again, I was irritated by the widespread use of Zofran in our hospital.

Let's back up.  Zofran's been around since 1991 in the US.  Researchers developed it to treat chemotherapy-induced nausea and vomiting.  Because Zofran rarely causes any untoward side effects, it became a popular anti-emetic for non-chemo related nausea and vomiting as well.

The older antiemetics, Compazine (prochlorperazine) and Phenergan (promethazine), work great for most nausea and vomiting but didn't perform as well for chemotherapy-related n/v.   They also can also infrequently cause unpleasant extrapyramidal side effects (acute dystonic reactions, akathisia, tardive dyskinesia) along with, rarely, cardiac arrhythmias.

When I was a resident, I remember well the experienced Emergency Department physicians that I rotated with.  "I don't know what's wrong with good old Compazine," one would frequently say.  "Sure, it can rarely cause bad stuff.  But most of the time it doesn't.  And it's a helluva lot cheaper."
So, I e-mailed some of the pharmacists that work at our hospital, asking for the costs of one dose of each of those three medicines.  All I needed to finish off the post was to plug in those costs and let my readers be outraged at the widespread use of the extremely expensive Zofran versus its cheaper counterparts.  Another couple of lines about cost-control in medicine and - voila! - post completed.

Except that my friendly pharmacists e-mailed back to let me know that all three of those meds cost about the same; one IV dose of any of them costs between $1.00 to $1.50.


(Insert picture of me eating humble pie here.)

So much for the rest of that post!

Turns out what I thought was "fact" was totally incorrect.  Yet I have been railing against the spread of Zofran use in our hospital since starting as an attending there nearly three years ago. 

"We, as physicians, are largely responsible for rising health care costs," my diatribe to the residents would begin.  "Why are we using Zofran, an expensive drug for cancer-induced nausea, for an otherwise healthy 25-year-old with viral gastroenteritis?  There are less expensive options that are reasonable to use, yet somehow Zofran has become the de facto antiemetic around here!"

Shame on me, for treating my assumptions as facts.  When Zofran first came out, it probably was more expensive.  But that was several years ago, and I never bothered to update my thinking.  We do that frequently in medicine - tout our biases and thinking as irrefutable facts - but those examples can wait for another day.  For now, I need a glass of milk to wash down this humble pie. 

And one dose of Zofran for the post-pie dyspepsia, please.

Monday, April 18, 2011

Why aren't more docs on Twitter?

I was precepting last week at our busiest outpatient site.  One of the residents there is very interested in all things technology and we got to talking about the iPad.  Knowing that he uses Twitter, I told him about some of the neat ideas I had recently seen there about the use of tablets in patient care. 

The preceptor room is a public place, and it's pretty easy to be overheard.  This resident and I were only about two minutes into this conversation when the comments began to fly from the other residents - and the other preceptor - in the room.

"Twitter?  That's just for celebrities."
"Twitter's a waste of time."
"Twitter's just to make yourself feel important."

Even more discouraging was that my attempts to explain the positives of Twitter - networking, idea sharing, collegial support - were brushed away.

"I have enough things to check every day already with e-mail, Facebook, and texts."
"Twitter is all self-serving.  Does anybody really care what you have to say?"

I have heard these types of comments across all ages and generations.  I have heard them at conferences, among the faculty I work with, in the monthly book group I attend.  Twitter is decidedly not mainstream in medicine, at least not in the circles I travel in.

I have seen and read countless articles, ideas, and opinions that I wouldn't have found without Twitter.  Yes, it takes a little time to find good people to follow, and it then takes a little time to actually follow them.  But the pay-off in new ideas and inspired thinking is marvelous - far better than the same amount of time on Facebook or an RSS reader.

For the most part, physicians are notoriously late adopters of new ideas.  Health systems had to mandate EHRs to get most physicians to use them.  In an age of e-mail and text messages, most of our offices remind people of appointments with a phone call.   Heck, I was a Twitter skeptic a year ago.

Interestingly, though, once docs have these new technologies, they're equally reluctant to change back.  (You should have heard the uproar here the last time the computers went down.  "Write my notes...on paper?!?")  Which leads me to wonder if some of these Twitter bashers would be still so negative if they were actually Twitter users.  So, how about it, Twitter detractors - why not give it a try?

I dare you.

Wednesday, April 13, 2011

Family Medicine - the antidote to the common sense blues

Reading through the responses to my post from yesterday, I realized that Steph and webhill were taking the conversation in a new direction.* I'd like to expand on their very valid points.

These kind responders shared similar stories of supposedly "abnormal" health metrics that initiated some sort of protocol, even when it didn't make an ounce of sense.  Two healthy newborns subjected to unnecessary (and costly) interventions.  Another similar experience to mine regarding "low" blood pressure.

You don't need any medical knowledge, really, to figure out that Steph's baby didn't need to go to the NICU, or that webhill's didn't need formula.  Heck, you don't need a day of medical or nursing school to know that the resident's patient from yesterday's code story was perfectly fine.

So, what is happening in nursing and medical school that strips that common sense away?  Certainly the first two years of medical school focus on learning the minutiae of how the body works - biochemistry, anatomy, etc.  All that time spent memorizing neurotransmitters and cell receptor signals then yields to being ready to respond instantly to your attending's pimping in the third and fourth years about the coagulation cascade or your patient's colonoscopy biopsy results from eight years ago.

The partialists** especially seemed to delight in these details when I was a medical student.  Frankly, it seemed then - and it seems now - that those practitioners best able to see the whole picture were - and are - the family docs.  Perhaps it's because they are the only ones truly taught to think about the patient as a whole being and not a collection of organ systems and biometrics.

Of course, we need our partialists.  They provide important and complimentary skill sets to ours.  But a family doctor should be at the center of every patient's care.

More family medicine as an antidote to the common sense blues?  It couldn't hurt.

* I genuinely appreciate every one of you readers who, at some point, has taken the time to continue the conversation by responding to one of my posts.  You all are the ones who truly keep things interesting around here.  :)
** Please see entry from 3-1-11 for more about the "partialist" label.

Tuesday, April 12, 2011

Shifting the bell curve

The nurse at my doctor's office was checking my blood pressure last week when the following conversation ensued:

Nurse: (trying not to look worried) Um, have you ever had low blood pressure before?
Me:  No.  I've always had normal blood pressure.
Nurse: (now not hiding worry) Well, I'm getting 100/70 for you.
Me:  Yep.  Perfectly normal.

One of the residents today was telling me about a code he attended in the hospital yesterday.  The code was called for hypotension (dangerously low blood pressure).  The resident rushed into the room to find the patient sitting calmly, eating his breakfast.  The nurse informed the resident that the patient's blood pressure was 90/60.

My intention here is not to lambaste nurses.  They are merely following their protocols and experience.  The larger question, I think, is when did reasonable blood pressures become "low"?  Is it just because most of the blood pressures that nurses (and docs, for that matter) see are elevated? 

I can't separate the word "normal" from the picture of a bell curve in my head.  And I have to wonder if the bell curve for "normal" blood pressures isn't starting to shift toward the right.

I don't like the complacency toward a new norm that these events portend.  How can we convince our patients that their blood pressures are too high when the bell curve of normalcy has shifted?  I have started using the word "healthy" to describe desirable blood pressures instead of "normal."

Because, sadly, normal doesn't seem to be healthy anymore.

Wednesday, April 6, 2011

What's on the menu?

Middle-aged guy in the office today: "So, doc, what do you think of those McDonald's fish sandwiches?"

Another mom about her 13-year-son, recovering from vomiting yesterday, about his first meal post-emesis:
Me: "Have you eaten anything today?"
Mom (answering for him): "He kept down some Burger King nuggets at lunch."

I've seen estimates around 25% for the proportion of Americans who eat fast food every day. (1) 

25%.  Every day.


I know that many of my patients are in this group.  I get it - fast food is cheap, effortless, and filling.* Recognizing these enticements, I struggle to give my patients pragmatic advice about eating healthier foods more often.  I know that they need skills and knowledge that are beyond the scope of my time with them to encourage change.

So, please forgive me as I brag about the efforts of two of my resident advisees.  For their residency community medicine project, they have decided to teach middle school students how to cook healthy foods.  In the first lesson, they showed the students how to chop up vegetables.  Future lessons will include easy recipes and a trip to a farmer's market right in their neighborhood.

How cool is that?  With my public health education, I am often tempted to lament health issues from a broad systems perspective.  I mean, 25%!  Every single day!  How do you make any kind-of a meaningful dent in that?

These two residents have decided to start within their own circle of influence** and make a difference with one group of middle-schoolers.  By giving them practical skills to improve their eating habits, I can only imagine how these two residents may have already changed these students' lives for the better.

If only more of us had their simple ambition, how much more could we accomplish?

* Ok, I admit it - I have a total weakness for McDonald's french fries.  But I don't eat them every day...
** Due credit for this concept belongs to Stephen Covey and his 7 Habits of Highly Effective People.