While I squawk about medical weblogs providing trancparency into the practice of medicine, most people at last week's conference agreed that there is such a thing as too much transparency. Where is the line between too much transparency and just enough? I'm not sure. Today's entry may tread the line .... hmmm ..
The New York's department of Professional Misconduct and Physician Discipline is New York's attempt to insure that physicians practicing in this state are well trained and well behaved. Sometimes I help review the cases of physicians who are - for some reason - being scrutinized by this department. While I sometime know why the physician is being reviewed, I usually make an effort to be blind to this - I think that it makes my review more objective.
It's always awkward. I feel uncomfortable challenging another physician's judgement, decksionmaking skill, or personality. The process usually involves reviewing a videotape of the physician interacting with one of the "standardized patients" we have in the medical school. (A "standardized patient" is an actor - someone employed and trained by our faculty to act out a particular problem. We use these "patients" in the training of our students, and it gives us insight into the students' ability to interact with patients, and their physical exam skills.)
After I review the videotape, I usually review a few real charts from the physician's practice, and then there is an interview during which I ask questions about the progress notes and the videotape. This often the most awkward part, but of course reveals the most about their thought processes. Here's the sad news: some physicians simply should not be practicing medicine. They're humans too - so physicians are sometimes in a position that makes them unable to properly do their jobs. The trouble is that their livelihood depends on their practice - and most physicians have enormous debt that remains from medical school and residency - even as many as ten or fifteen years later.
LIke the bus driver who can't see very well - it's a sad situation, but it's clearly unsafe. The tricky ones are where it's not so obvious as the vision impaired bus driver.
Hence the need for reviews such as that described above. In the end - I make no decision, thankfully. Rather - I provide feedback to the State, and they are empowere to take corrective action based on my assessment and several others.
I find the process to be remarkably appropriate. The situations are alwayds delicate, but I think that the process is thorough enough to identify problems if they exist - yet with enough "due process" to provide respect and some presumption of "innocence."
Want to see if a physician in New York has been disciplined in any way? New York has made that easy too ... just go to the New York State Physician Finder and look up the physician. Once you've found the physician, click on "Legal Actions" and you can see any current or previous actions against that physician. Now there's transparency, eh?
I'm experimenting with a reverse-chron medlogs page. It's not quite ready yet. It's supposed to be reading all of the sites on medlogs.com and then putting them in reverse-chronological order -- so the most recent post will appear at the top.
Breastfeeding was inversely associated with reducedrisk of neonatal respiratory tract infections in girls but notin boys. Breastfeeding may confer protection against some community-acquiredinfections as early as the first month of life.
The authors can't come up with a mechanism for why there is this difference - but they suggest that these results be interpreted with some caution. The bottom line is that breasfeeding is good:
Currently, exclusive breastfeeding is recommended for approximatelythe first 6 months of life and breastfeeding with complementarysolid foods for at least the first year of life.28 However,in the United States, most mothers do not breastfeed for thisduration.29 In counseling mothers of newborns about their infantfeeding choices, our data suggest that the protective effectsof breastfeeding start during the first month of life and thateven a short period of exclusive breastfeeding may benefit youngchildren.
An excellent review article on Serum Tumor Markers is in this month's issue of American Family Physician.
"Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumor markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumor markers do not have sufficient sensitivity or specificity for use in screening. Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer. Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses. CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy."
Johnny Damon was badly hurt in Monday night's game in Oakland. Fortunately, he's OK .. but it made me think that there must be a way for the players to communicate with each other in the outfield even if the fans are too loud. ?Little ear-bud radios? Proximity alarms? Hmmm...
We've got tickets to both games in Boston this weekend. I've not been to a playoff game since Game 6 of the World Series, 1975.
It's the time of year that we need to write Dean's letters for the medical students. These letters serve as a summary of the students' medical school careers -- and (we hope) help them get in to the residency of their choice.
It's hard work to write these things .. carefully walking a line of being the student's advocate - while also being honest about students who have not performed so well as they could. Three more to go. I was hoping to finish tonight .. but it's not going to happen.
I enjoyed meeting everyone at Bloggercon - and I think that the "medlical weblogs" session was productive. I've been thinking about a "work product" that we could creat that might summarize some of our discussion - perhaps a "guide to medical weblogging" that might help frame some of the issues that we discussed, and could help claify some of the common "do's and don'ts" of medical weblogging.
Then again ... maybe not. Should there be rules? No .. but guidelines? Perhaps. HIPAA looms large, as do medical ethics. In our enthusiasm to share OUR experiences, we're also share the experiences of our patients and colleagues. Hmm ..
The Author called me yesterday and we talked for a few minutes. He quotes me as saying that .. "one of the problems that I perceive to be a persistent one about how medicine has been practiced in this country is this theme of paternalism."
Yep .. I said that ... more or less ... but I was referring to the old ways of practicing medicine... not what I think/hope usually occurs now. The old "Physician Knows Best" kind of medicine. The sort of medicine that exalted physicians .. and no one challenged them or their confidence.
Things are different now. We do our best to share decision-making with patients -- to be transparent and expose what we know and what we don't know. I think that weblogs are a way to enhance this transparency.
I've noticed this before ... but I think it's noticeable from the notes in Forbes ... 3 of the 5 medical weblog authors featured are 40 years old. And I know that Steve turned 40 just a month or so before I did ... I wonder what's up with all of these 1963 babies and weblogs ...
I was talking with Dave a bit this morning and he reflected that his girlfriend thinks of physicians as uncaring ferrari-driving rich jerks. Man .. I wonder how commonplace this sentiment is. So far from reality.
The day in the office was hectic again .. and ... like the previous few days ... many problems revolved about psychiatric issues. Very challenging stuff. While I do my best to use all of my "15 minute hour" skills ... I often envy the psychiatrists who really do have an hour to spend with their patients.
One bright spot ... I got an e-mail today from a patient I saw on Monday. It's a very long story, but the bottom line is that she's being appropriately withdrawn from steroids, after having been on them for many years - following a misdiagnosis of Addison's disease. Of course, she's on a sloooow taper, but she feels terrible. Her baseline depression is much worse, and she's got so little energy that she can barely function. Taking a suggestion form a colleague, I tried modafinil, and she reports that she's feeling much better in general.
In JAMA this week there is an article on the introduction of cereal into a child's diet.
There's quite a bit of controverys about when is the best time to introducce solids. This paper is interesting in that it demonstrates that a window may exist: kids who are exposed to cereal before 4 months or AFTER 7 months have a higher risk of developing type 1 diabetes later in life.
Wow. While the concept of "too early" introduction being related to problems is nothing new .. this is the 1st discussion of how waiting too long to introduce solids may also be harmful.