Docnotes

Treo 600

Watch - out Bill -- I'm wireless now too. 

After a few months of watching and waiting, I did finally get a treo 600.  It is a useful tool that combines the cellphone and PDA.  It doesn't have any true paging technology (like Motorola's FLEX protocol) so it can't (yet) replace a pager.  It should.  Palm and Motorola had this idea five years ago .. I wonder why it didn't move into these devices.

While I do find the device useful as a PDA (it's got all of the old standbys installed: epocrates, 5mcc, shots) ... and of course a phone ...  the best thing about this device is something that I thought was just a toy beforehand:  Instant Messaging.

Huh?  (you say) ..

For physicians who are not always in the office, this device can significantly improve your life.  Since I work at the Miracle Center 1/2 time ... and I'm at the office 1/2 time, I'm often getting pages from one when I'm at the other.  I can't leave a meeting, or interrupt a patient visit to make a phone call, but I CAN respond to an IM quickly and without too much distraction.

Nurse Kathy and I had several little conversations last week with IM.  It saved me four or five phone calls ... and got her immediate answers to her patient care questions .. so patients got better service.

I'm using chatter - which is a wonderful little program .. and she's using yahoo.  Yeh .. not very secure.  So no PHI.  I've looked into Jabber  -- and we'll probably use that once I can figure out how to install a jabber server.

 

ESF

Since we're on the topic of RSS (see the previos post) ... take a look at John Bristowe's Weblog -- where ther is discussion of how ESF feeds (a superset of RSS) can be used to generate (via newsgator) schedule entries in Outlook automatically.  Not bad.  We'll have to give that a go .. eh Dave?

Yahoo and RSS

Yahoo's RSS aggregator is a wonderful adjunct to my.yahoo.com portal. 

Despite the advertising, my.yahoo remains my home page on most of the computers I use   .. though I recently moved to oddpost for web-based e-mail as it's much faster than Yahoo - and it's MUCH easier to manage my mail.

oh yeah .. back to Yahoo.  It's pretty easy to use ..

The Oncalls physician scheduling system has supported RSS for about 6 months - though most users don't know how to do that. 

1. Log in to Oncalls with your username and password (or use "demo"  "demo" if you don't have an account and you want to play with this)
2. Click on "options"
3. Now RIGHT-click on the orange "XML" icon at the top of the page .. and choose "copy shortcut."
4. Now go to the my.yahoo RSS editing page.  If you don't have a my.yahoo account this won't work.  YOu'll also have to be logged in to Yahoo to make this work.
5. Ok .. we're in Yahoo .. and about 1/3 of the way down the page it says "Add New Source."  In the box there where it says "Enter a keyword, site, or URL"  .. right-click again and choose "Paste"  It should look like lots of gobbeldygook .. but that's ok.  It's your Oncalls username and password in encrypted form. 
6. Click "Search" and Yahoo will go and get the RSS feed from Oncalls, and will include it on your my.yahoo.com home page.

Here's what it looks like:

Pretty cool .. eh?

Technical Pearls

Today's news:

• Chris Cates has released a new version of his wonderful software, Visual RX:
  
• "What’s New?
  
  In the 2004 Updated version of Visual Rx the Confidence Interval (CI) for the calculated Number Needed to Treat (NNT) can be generated by entering the upper and lower CI for the Odds Ratio or Relative Risk on the data entry screen. The CI for the NNT will then be displayed on the second smiley face screen. The rounding is always up to the next integer when calculating NNT (so 3.1 will round up to 4)."
  
• The National Library of Medicine has an excellent palm-based Medline lookup tool.

Lending Library

Starting a lending library at the office ...any other suggestions?  .. I'm light on hypertention, diabetes & smoking cessation. Heavy on parenting.  Leave comments if you have any other suggestions for "must have" lending library books.

1

"Art of Speed Reading People, The: Harness the Power of Personality Type and Create.."
Paul D./Barron-Tieger Tieger;Paperback; $11.87

1

"Changing for Good"
James O. Prochaska;Paperback; $10.36

1

"Siblings Without Rivalry: How to Help Your Children Live Together So You Can Live Too"
Adele Faber;Paperback; $10.40

1

"How to Talk So Kids Will Listen and Listen So Kids Will Talk : 20th Anniversary Edition"
Adele Faber;Paperback; $10.40

1

"Helping Your Child Sleep Through the Night"
Susanna Schevill;Paperback; $10.36 

1

"8 Weeks to Optimum Health"
Andrew Weil M.D.;Paperback; $11.16

1

"Breaking the Antibiotic Habit: A Parent's Guide to Coughs, Colds, Ear Infections, and Sore Throats"
Paul A. Offit;Paperback; $10.36

1

"Caring for Your Baby and Young Child: Birth to Age 5"
American Academy Of Pediatrics;Paperback; $14.00

1

"Solve Your Child's Sleep Problems"
Richard Ferber;Paperback; $11.20

1

"Feed Me! I'm Yours : Revised and Expanded Edition"
Vicki Lansky;Plastic Comb; $9.00

1

"The Pocket Parent"
Gail Reichlin;Paperback; $8.76

1

"Well Child Assessment for Primary Care Providers"
Margaret R. Colyar;Paperback; $42.95

1

"Spontaneous Healing : How to Discover and Embrace Your Body's Natural Ability to Maintain and Heal Itself"
Andrew Weil M.D.;Mass Market Paperback; $7.99

1

"The Schwarzbein Principle: The Truth About Losing Weight, Being Healthy, and Feeling Younger"
Diana Schwarzbein;Paperback; $10.36

1

"The Habit Change Workbook: How to Break Bad Habits and Form Good Ones"
James Claiborn Ph.D.;Paperback; $13.97

1

"No More Amoxicillin: Preventing and Treating Ear and Respiratory Infections Without Antibiotics"
Mary Ann Block;Paperback; $9.60

1

"The South Beach Diet: The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss"
Arthur Agatston;Hardcover; $14.97

1

"500 Low-Carb Recipes: 500 Recipes from Snacks to Dessert, That the Whole Family Will Love"
Dana Carpender;Paperback; $13.97

 

1

"The Myth of Laziness"
Mel Levine;Hardcover; $7.99

 

1

"Allergy Free Naturally: 1,000 Nondrug Solutions for More Than 50 Allergy-Related Problems"
Rick Ansorge;Hardcover; $7.99

 

1

"Your Pregnancy Week by Week"
Glade B. Curtis;Paperback; $4.99

 

Trust

Marcus posted recently about trust.  I think he's talking about it in the context of the physician-patient relationship .. but maybe he's discussing it more globally.

The physician-patient relationship (or the physician-parent relationship) is very tricky .. to some degree because the physician may need to trust the patient much less than the patient needs to trust the physician.   Yet without risking anything, aren't we expecting too much of our patients to trust us .. if we don't invest some trust in them?

The EBM/Malpractice discussion that went on about a month ago seemed to focus on trust. 

• Our trust in evidence-based medicine as a way to deliver good care.
• Our patients' trust in their physicians.

The trouble is that the perceptions and expectations can become cloudy in the context of fear and insecurity. 

Reading Ross' discussion (1st link above) - he puts this very clearly:

How can they possibly determine how to conform to the "standard of care," when they could be dragged into a lawsuit for doing exactly what they've been trained to do? How can a doctor be doing the right thing by keeping up to date with his medical education and respectful of his patient's autonomy, and yet be found wrong by being too curent and not being directive enough?

No kidding.  By presenting choices to our patients, we risk providing a window into the true uncertanties of medicine (of which there are many!) In so doing, we are sharing decisions with them - and trusing them with this vulnerability.

I'm convinced it's better healthcare, but as my legal advisor reminds me, this decision entails risk.  So be it.  Paternalistic physicians who dictate the mythical "standard of care" to their patients are at less risk legally, yet the care they provide can hardly be fulfilling -- or even challenging! 

Informatics Review

The Informatics Review has a new look, and (finally) sports an RSS feed.  Dean has done a great job providing regular updates to the site, and I always find something useful in each issue.

This month he posts a link to the HIMSS Clinical Decision Support Implementers' Workbook.  This is a well-written document that provides a good framework for those who are implementing even rudimentary decision support tools.

 

Fetal Monitoring

Josh Steinberg (scroll down - he's the Mac-user) e-mailed a question to the NE ALSO faculty listserv a while back . and has now answered his own question:

I inquired about online tutorials for fetal heart monitor strips, and now I
have the answer.

Here's one via the University of Nottingham's ob/gyn site in Britain:
http://www.fetal.freeserve.co.uk/  It's nice because it gives a look at overall issues and approaches to fetal monitoring, including but not limited to continuous EFM, also gives practice questions at the end of the module.

Another I can't get access to but might be of use.  It is proprietary
software for sale developed at Virginia Commonwealth University's med school
called, "Clinical Simulations of Fetal Heart Rate Patterns in Labor".  One
could spend money to purchase the software.  See about a third
of the way down the page:
http://www.cbil.vcu.edu/resources/projects.html

Finally, there is a dynamite, exhaustive Evidence Based review of electronic
fetal monitoring (144 page .pdf)  with tons of details, definitions, decision guides about when to monitor, when not to, how to respond to various results -- all
linked to quality of evidence and strength of recommendation levels -- at
none other than the British site of the Royal College of Obstetricians and
Gynaecologists (however the Brits spell that).  Nice thing about Brit
websites is that they aren't all trying to make a buck off everything, so I
found lots more accessability than at American websites.  As a poignant
example, one can't get into ACOG's website without being a paying
member and journal subscriber.  I am attaching the PDF RCOG evidence linked
guideline, for what it's worth.  It's only weakness is that it contains no
actual examples of fetal heart tracings.

Since we've not yet convinced Josh to begin a weblog .. I've posted his work product here.  Well done, Josh!

Habits

Busy week - and now I notice I've not posted since last weekend.

Some tips from the week:

a) There's a great review on Lyme disease in The Lancet.  This article is free, but most are not.  Free registration required.

b) Analog and digital don't mix.  I received a fax from a reference lab.  The thoughtful person on the other end had used a "hi-lighter" to draw attention to the abnormal lab values. 

This made the abnormal lab values impossible to read - as the fax machine changed them to very nice darlk black lines.

Motto:  Don't use a hi-lighter when you're going to fax (or scan) something.

c) Seven Habits - corny but useful.

Yeh .. when I finished by residency, one of my mentors gave me Steven Covey's book .. and I read at least some of it and I found it helpful. 

Time for a reminder:

Habit 1: Be Proactive

Are my actions based upon self-chosen values or upon my

moods, feelings, and circumstances? 

 

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Habit 2: Begin With The End In Mind

Have I written a personal mission statement which provides

meaning, purpose, and direction to my life? Do my actions

flow from my mission? 

 

---

 

Habit 3: Put First Things First

Am I able to say no to the unimportant, no matter how

urgent, and yes to the important? 

 

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Habit 4: Think Win-Win

Do I seek mutual benefit in all interdependent relationships? 

 

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Habit 5: Seek First To Understand, Then Seek To Be Understood

Do I avoid autobiographical responses and instead faith-

fully reflect my understanding of the other person before

seeking to be understood? 

 

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Habit 6: Synergize

Do I value different opinions, viewpoints, and perspectives

of others when seeking solutions? 

 

---

 

Habit 7: Sharpen The Saw

Am I engaged in continuous improvement in the physical,

mental, spiritual, and social/emotional dimensions of my life? 

 

Blinking

Salon Reports that Wesley Clark doesn't blink.  Here's the video to prove it.

Hmm.  No blink. 

Why?  maybe ...

• He is under hypnosis
• He has moist eyes
• He's old
• He's thinking:

• Percept Mot Skills. 1975 Oct;41(2):503-6.

  Related Articles, Links

  
  Blinking and thinking.
  
  Holland MK, Tarlow G.
  
  Blinking is related to certain cognitive processes. For example, individuals "punctuate" their speech by blinking between phrases and at the end of sentences. Daydreaming is associated with low rates of blinking. Blinking occurs between fixations and may be timed so as not to interfere with significant visual input. Apparently, blinking occurs at transitions between internal events and is inhibited at other times. In the experiment reported here, blinking was measured while the activity of operational memory was manipulated with mental load kept constant. The rate of blinking was significantly reduced when the cognitive operation of internal counting was being performed. It is inferred that the blink rate is low when information in memory is being operated on. To suspend blinking during certain cognitive activities would be adaptive if blinking disrupts them. Since the blackout period of the blink produces a rapid change in visual level, blinking disrupts those cognitive processes utilizing display areas accessible to visual input. Operational memory and the visual imagination may share components with the visual perceptual system. To protect these vulnerable processes from interference, blinking may be inhibited when they are active.

 

Fortunately, there is no relation to blink rate and neurocognitive impairments in schizophrenia.