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Curriculum change might better address the need for PhD level bio molecular medicine, autopsies, bedside teaching
and send the standardized patients packing. Yes, 6 years of medical school, a PhD based on genomic research and clinical correlation. Enough said.
Only the top schools will be able to pull this off. The harder you make it, the more will apply. In this day of poor moral, loss of respect and general indifference, the students with the capacity to become physicians and the surgeons of tomorrow will compete for the privilege.
Thursday, March 26, 2015
Tuesday, February 24, 2015
Curriculum Reform
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When I hear medical school deans rushing to reform
curriculum in order to adapt to the changes in medical practice they see
coming, I fear for the unintended consequences. We don’t have a very good track
record in health care reform. Nearly everything government has done to improve health
care and reduce cost has had the opposite effect.
Yes, the insured fee for service system needs to
change, but preparing our young doctors to work for a salary under
institutional guidelines opens the flood gates for a limitless influx of
unscrupulous health care entrepreneurs. The physician of tomorrow might better
look to organized medicine, group practice and a leadership role healthcare design.
Instead of preparing medical students for electronic
health records and best evidence algorithms, we should focus on genomics,
proteomics, artificial intelligence and the humanities. (public-health poverty
and nutrition)
Should we want to educate our young doctors as a feldsher[1] or
as a scientist trained to lead us into the era of the genome?
I would hope that an evolution of the curriculum could focus
on genomics, humanity and the underlying science of statistics and the computer.
One might also consider extending medical school a year or two longer in order to
explore the clinical applications of genomics and the related science, awarding
a PhD for credible contributions in these applications. Doing so would give the
young physician the credentials to lead the profession as well as patient care and community health.
The Civitas
Hippocratica in Salerno, Italy 900 AD required 5 years of medical school.
The graduate was awarded a ring, a laurel wreath, a book and a kiss. By 1158 UNIBO in Bologna, Italy required 6 years
and until recent times awarded the PhD. Students were protected by law from all
political and religious interference.[2] We
should do so well.
Free enterprise has no place in medical practice; it
has replaced compassion with greed. We sense this intuitively but the
reasons are elusive. Politicians impose a lassie-fare
philosophy with a religious fervor. Health care is not a free market, and with
insurance there is no competition and no restraint; Insured fee for service
effectively creates a monopoly subject only to a token proof of necessity. Our
medical graduates need to stand tall and lead with overwhelming competence.
[1] Feldscher (Gr.) a health care professional who provides
various medical services in the Russian Federation and other countries of the
former Soviet Union, mainly in rural areas.
[2] 1158 Frederick I Barbarossa promulgated a
Constitutio Habita, establishing that every school be established as a
"societas di socii" (group of students) overseen by a master
(dominus) remunerated by the sums paid to him by the students. The Empire
undertook to protect scholars travelling for the purpose of study from the
intrusion of all political authorities
Thursday, January 22, 2015
Peripheral Pulse
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Lifting the right wrist of the patient and palpating the pulse with your 3rd and 4th fingers is the handshake of the physical examination. Lost and forgotten or never learned, buried in the M1 text books, the peripheral pulse should be or is the physician's first encounter with his or her patient. The act of palpating the pulse, tells the physician much about the patient and the patient much about the doctor, opening and sharing the patient's and the physician's personal space in a mutually gentle and informative way.
Unfortunately, a false sense of economy and efficiency relegates this seemingly simple recording of figures to others, to the lowest level of competence. This first level of diagnostic data must not, however, be trusted to others. The same might be said of the blood pressure cuff. Hidden diagnostic nuances are lurking there behind the numbers.
The weak pulse with a slow uptake and a prolonged peak, easily suggests decreased stroke volume, volume depletion, heart failure, aortic stenosis, hypothyroid or congestive heart failure. Whilst the bounding pulse with short peak and steep sides, suggests increased volume, decreased peripheral resistance, fever, hyperthyroid, anemia, bradycardia, aortic regurgitation, patient ducts, A-V fistula or hardening of the arteries with age. The start of your differential diagnosis and knowledge of your patient lies right beneath your fingers.
Some of your differential diagnosis might be missed entirely but for the thoughtful palpation of the peripheral pulse. Bisferiens Pulse with a double peak, may be due to aortic regurgitation or regurgitation combined with stenosis or even hypertrophic cardiomyopathy. Pulsus Alterans for example, a normal beat alternating in regular interval with a weaker beat (and an S3), suggests left ventricular failure. While Bigeminal Pulse, a normal beat alternating in shorter interval with a premature contraction of weaker strength, suggests retrograde conduction etc. Intriguingly, Paradoxical Pulse, wherein pulse pressure increases more than 10 mm Hg on expiration, can lead to the early diagnosis of an unsuspected constrictive pericarditis, even tamponade or COPD. The later can be life altering for the patient and greatly enhance the career satisfaction for the physician as it did for me.
Lifting the right wrist of the patient and palpating the pulse with your 3rd and 4th fingers is the handshake of the physical examination. Lost and forgotten or never learned, buried in the M1 text books, the peripheral pulse should be or is the physician's first encounter with his or her patient. The act of palpating the pulse, tells the physician much about the patient and the patient much about the doctor, opening and sharing the patient's and the physician's personal space in a mutually gentle and informative way.
Unfortunately, a false sense of economy and efficiency relegates this seemingly simple recording of figures to others, to the lowest level of competence. This first level of diagnostic data must not, however, be trusted to others. The same might be said of the blood pressure cuff. Hidden diagnostic nuances are lurking there behind the numbers.
The weak pulse with a slow uptake and a prolonged peak, easily suggests decreased stroke volume, volume depletion, heart failure, aortic stenosis, hypothyroid or congestive heart failure. Whilst the bounding pulse with short peak and steep sides, suggests increased volume, decreased peripheral resistance, fever, hyperthyroid, anemia, bradycardia, aortic regurgitation, patient ducts, A-V fistula or hardening of the arteries with age. The start of your differential diagnosis and knowledge of your patient lies right beneath your fingers.
Some of your differential diagnosis might be missed entirely but for the thoughtful palpation of the peripheral pulse. Bisferiens Pulse with a double peak, may be due to aortic regurgitation or regurgitation combined with stenosis or even hypertrophic cardiomyopathy. Pulsus Alterans for example, a normal beat alternating in regular interval with a weaker beat (and an S3), suggests left ventricular failure. While Bigeminal Pulse, a normal beat alternating in shorter interval with a premature contraction of weaker strength, suggests retrograde conduction etc. Intriguingly, Paradoxical Pulse, wherein pulse pressure increases more than 10 mm Hg on expiration, can lead to the early diagnosis of an unsuspected constrictive pericarditis, even tamponade or COPD. The later can be life altering for the patient and greatly enhance the career satisfaction for the physician as it did for me.
Friday, January 9, 2015
La Maladie du Petit Papier
Share Jean-Martin Charcot (1825-1893) at Salpetriere in Paris - a neurologist famous for the beautiful hospital, the Charcot Joint and Charcot Marie Tooth syndrome - may have initiated the term "La maladie du petit papier" observing the triviality and the seeming benefit derived by the patient. The term has become a derogatory one, however, expressing the irritation to the physician from the patient's attempt to organize his or her problems. Does not the phrase, la maladie du petit papier, uttered in contempt, give a false sense of superiority and sophistication, suggesting that one can actually say something in French?
As Koven's Perspective letter in NEJM implies, there may be more to this. "...even when I have no explanation for the headache, upset stomach, or itch - documented on the back of an envelope or punched into a smart phone, a patient feels better just having presented me with his or her recording of it. Perhaps naming our demons and saying their names aloud helps make them less frightening. Perhaps the shorthand of the list somehow abbreviates the anxiety associated with its entries."
Is not the patient, indeed, attempting to build his or her own problem list? Charcot was one of the great physicians of all time, but there was a first - greater yet - Hippocrates, who founded the very science of listening to the patient, observing the environment and documenting the patient's complaints. I rather imagine that Hippocrates would have welcomed la petit papier.
Indeed, is not the petit papier the patient's own problem list? Why not capitalize on the benefit to the patient of reducing their complaints to a problem list - be sure to include them all - and combine them with a check list of past medical illnesses, review of systems etc.? If the problem list has a placating effect on the patient, think what it does for the physician to actually see at a glance the patient's entire struggle with his or her environment and maladies. A problem is not a diagnosis, more likely a symptom, but without the complete problem list, there is no way to know that you've got it right with either the diagnosis or the underlying causes.
Suzanne Koven, M.D. NEJM 2014; 371:2251-2253; 11 Dec; DOI: 10.1056/NEJMp 1411685
As Koven's Perspective letter in NEJM implies, there may be more to this. "...even when I have no explanation for the headache, upset stomach, or itch - documented on the back of an envelope or punched into a smart phone, a patient feels better just having presented me with his or her recording of it. Perhaps naming our demons and saying their names aloud helps make them less frightening. Perhaps the shorthand of the list somehow abbreviates the anxiety associated with its entries."
Is not the patient, indeed, attempting to build his or her own problem list? Charcot was one of the great physicians of all time, but there was a first - greater yet - Hippocrates, who founded the very science of listening to the patient, observing the environment and documenting the patient's complaints. I rather imagine that Hippocrates would have welcomed la petit papier.
Indeed, is not the petit papier the patient's own problem list? Why not capitalize on the benefit to the patient of reducing their complaints to a problem list - be sure to include them all - and combine them with a check list of past medical illnesses, review of systems etc.? If the problem list has a placating effect on the patient, think what it does for the physician to actually see at a glance the patient's entire struggle with his or her environment and maladies. A problem is not a diagnosis, more likely a symptom, but without the complete problem list, there is no way to know that you've got it right with either the diagnosis or the underlying causes.
Suzanne Koven, M.D. NEJM 2014; 371:2251-2253; 11 Dec; DOI: 10.1056/NEJMp 1411685
Saturday, January 3, 2015
(POMR) Problen Oriented Medical Record
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While POMR heads the Syllabus for the teaching of medical
history taking, most first year medical students encounter a source oriented
format or at best a hybrid system without ever learning the problem oriented
system, a system first promoted by Larry Weed at Dartmouth in the early
sixties. In truth, the hybrid system of charting a patient's medical history
and progress, may be superior in that, including the source oriented, or more
traditional, style better identifies the full character of the patient as seen
through the physician's eyes. Tradition since Hippocrates tells us that
"if you just listen," the patient will tell you everything you need
to know. The traditional chief complaint, history of the present illness, past
medical history, social and family history followed by a complete review of
systems constitutes the source oriented medical history. The medical history is
a story, with color, pathos, complication, progression, humanity and hopefully,
with your guidance, a resolution. It is a story worth telling and worth telling
well. Both the patient and physician will likely evolve in so doing.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem.
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem.
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.
Sunday, November 23, 2014
Genomic Screening
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My greatest interest is in the correlation of genomic
information with the medical record both for diagnostic purposes and for the
data mining that will be available from the resulting combined databases, both
clinical and genomic.
The present overly cautious approach to bio-molecular
testing -- that is testing for suspected variants on the basis of clinical
suspicion -- limits the science of data mining. With this limitation, any
additional abnormalities are viewed as incidental to a skewed population of
suspected cases.
Studies based on massive insurance data are flawed from the beginning.
Insurance diagnosis is entered according to the studies the clinician wishes to
do in order to meet the diagnostic requirements for the test -- representing tentative
diagnosis, a speculative or at best a differential diagnosis. Often-times the
insurance clerk picks a diagnosis that approximates the physician’s but which better
meets the requirements for reimbursement.
The screening of all patients -- with their permission -- on
the other hand, will build a correlation between molecular and clinical
findings that is more valid for research and can more cleanly contribute to a
differential diagnosis and differential risk factors.
We have only scratched the surface of the information that
will be forthcoming from molecular biology. We need to open the flood-gate of
genomic information for clinical correlation with statistical analysis on an
ongoing real-time basis. The data from multiple clinics and private practices
could be combined anonymously and indefinitely in a medical school or trusted
institution; its value will grow with time. It’s diagnostic and correlative
legs will reinforce one another with time.
When I sold my practice/clinic there were over fifty
thousand charts, a gold mine for data mining. Most old medical records are
ultimately neglected or lost as were mine. This is front line data, which
differs from the national or regional data collected by institutions. It is
local data and as such more personal and thus more explicit and if analyzed real-time,
more critical.
This process of learning as we go is the scientific method
and the basis of medical science. The learning process should extend to all
physicians willing to include it in their practice. I feel passionate about
working in a team setting, to bring genetic screening to the medical clinic,
the private practice and the community.
The goal would be the free distribution of a standalone
software application that would securely store the whole genome of patients,
whilst correlating it with that patient’s real-time clinical data. More
relevant, however, the continuing growth in data-mining in the two matched
databases will lead to new insights and certainties not otherwise rapidly
achievable.
As an aside one might observe that evidence based protocols
place more emphasis on treatment than on diagnosis. Missed and wrong diagnoses
remain a major problem, a fact partially borne out by the US’s poor ranking in
the Global Burden of Disease (GBD) studies. A byproduct of this initiative will
lead to enhanced diagnostic decision support and a quantum improvement in
patient care and outcome.
Tuesday, November 11, 2014
Lung-Cancer Screening with Low-Dose CT
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Numerous journals weighed in on the pros and cons of CT screening for lung cancer in high risk patients. The idea of a series of three CT scans seems overly expensive and an over dose of radiation considering the number of false positives. A review in the Resident e-Bulletin of the NEJM
the teaching topic reports the article by M.K. Gould in the November 6th issue: NEJM, 371, 1813-1820 outlines the following.
Lung cancer has an 18% 5 year survival rate and early detection would help. The National Lung Screening Trial (NLST) consisted of 50,000 patients from 33 centers. Low-dose CT was compared with chest X-ray reporting 20% fewer deaths in the CT group, 247 vs. 309 for 2 year follow up. If valid statistically, that would be 3 deaths per 1000 saved.
The screening produced 39% positive reports, 95% of which proved false, however. The author suggested that the resulting additional CT scans and invasive procedures produced few complications: 2% from needle biopsy, 4% by bronchoscopy, and 4% from surgery. 73% of the needle biopsies and bronchoscopies were negative and 24% of the surgeries were benign. Only 1% of these invasive procedures experienced complications, 20% of whom did not have lung cancer. (approximately 0.2% complication rate for non-cancer)
Twenty years ago, our diagnostic routine (Swedish Hospital IM Denver) for 30 and more pack a day smokers with a cough was bronchoscopy, bronchial brushings, culture and chest X-ray. With the low complication rate for bronchoscopy in non malignant patients, why would one choose the overly expensive three CT screening with it's radiation exposure and 95% false positive rate when a low risk and relatively inexpensive bronchoscopy yields more definitive results? It does become a question of sensitivity, however. One would have to re-examine the claimed 20% reduction in 2 year mortality and apply the same if not better trial for the sensitivity of fiber-optic bronchoscopy and bronchial brushings in the early detection of bronchial genic carcinoma. One would be dependent on conventional PA and Lateral for the detection of non bronchial genic CA.
Lung cancer has an 18% 5 year survival rate and early detection would help. The National Lung Screening Trial (NLST) consisted of 50,000 patients from 33 centers. Low-dose CT was compared with chest X-ray reporting 20% fewer deaths in the CT group, 247 vs. 309 for 2 year follow up. If valid statistically, that would be 3 deaths per 1000 saved.
The screening produced 39% positive reports, 95% of which proved false, however. The author suggested that the resulting additional CT scans and invasive procedures produced few complications: 2% from needle biopsy, 4% by bronchoscopy, and 4% from surgery. 73% of the needle biopsies and bronchoscopies were negative and 24% of the surgeries were benign. Only 1% of these invasive procedures experienced complications, 20% of whom did not have lung cancer. (approximately 0.2% complication rate for non-cancer)
Twenty years ago, our diagnostic routine (Swedish Hospital IM Denver) for 30 and more pack a day smokers with a cough was bronchoscopy, bronchial brushings, culture and chest X-ray. With the low complication rate for bronchoscopy in non malignant patients, why would one choose the overly expensive three CT screening with it's radiation exposure and 95% false positive rate when a low risk and relatively inexpensive bronchoscopy yields more definitive results? It does become a question of sensitivity, however. One would have to re-examine the claimed 20% reduction in 2 year mortality and apply the same if not better trial for the sensitivity of fiber-optic bronchoscopy and bronchial brushings in the early detection of bronchial genic carcinoma. One would be dependent on conventional PA and Lateral for the detection of non bronchial genic CA.
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