Docnotes

Physician Fears

Ny Times: Doctors, Too, Have Fears; They Just Go Underground

This is an article about "Medical Student Syndrome" and how it recedes after medical students magically become physicians.

It's an accurate depiction of what happens to students, but the author misses the point in her portrait of physicians. 

Expert Patients

BMJ: Expert Patient

The concept of a well informed patient is welcome, but a new name is needed

Shared decision-making - getting some "push-back" from physicians.  Hmm..

Computerized Guidelines

Family Practice -- Abstracts: Butzlaff et al. 21 (2): 183

Learning with computerized guidelines in general practice?

A randomized controlled trial M Butzlaff, HC Vollmar, B Floer, N Koneczny, J Isfort and S Langea Medical Knowledge Network evidence.de and a Grnemeyer Institute of Microtherapy, Faculty of Medicine, University Witten/Herdecke, Germany E-mail: butzlaff@uni-wh.de

Background. Evidence-based guidelines are seen as an important instrument to transfer scientifically generated knowledge into daily clinical practice and to ensure high standards of clinical care. Despite wide promulgation, clinical guidelines so far have a limited impact on individual professional learning and on changing daily medical practice.

Objectives. Our aims were (i) to study a potential knowledge increase among German GPs after implementation of web- and evidence-based guidelines and (ii) to identify and analyse potential barriers to individual professional learning with computerized guidelines.

Methods. A prospective, randomized controlled trial was conducted including 72 GPs (21% female, 79% male). The intervention group (n = 38) had access to clinical guidelines via the Internet or CD-ROM, the control group had not (n = 34). Both groups received a standardized two-part questionnaire. An increase of knowledge was measured with 25 multiple choice questions related to four different medical topics. In addition, reasons for using or not using computerized guidelines were analysed after access to guidelines was open to all participating physicians.

Results. There was no significant knowledge increase in the intervention group (P = 0.69). Twenty-two (58%) GPs of the intervention group had used the guidelines. Unspecified curiosity (76%) and a specific medical question (38%) were predominant motives for usage among physicians who had used the guidelines. Among ‘non-users’, 78% stated ‘lack of time’ as the main reason for not using guidelines.

Conclusion. An efficient knowledge transfer through computerized guidelines was not achieved. Usage, individual learning and potential implementation depend on adequate incentives and pragmatic aspects of clinical practice: easy and quick access.

Keywords. Clinical practice guidelines, evidence-based medicine, general practice, Internet, randomized controlled trial

I'm not sure what to make of this study.  The results are smilar to other studies that demonstrate how physicians don't change behaviors very well.  Hmm .. regardless of the methods, docs are not likely to embrace new practice patterns.  Duh.  Just becasue it's on the web or on a CD doesn't make it more palatable.  The key (I highlited it iin the above abstract) is that continuing medical education be relevant to a physican's practice. 

CRP is really useful

In Circulation this week, we learn that CRP may soon become a component of the standard set of tools we use to assess cardiac risk.

Our results suggest that CRP enhances global coronary risk as assessed by the FRS, especially in intermediate risk groups. This might have implications for future risk assessment.

Macrolide Resistance

Longtime Docnotes readers know that I am a fanatic about antibiotic overuse.  This relegion applies not only to WHETHER an antibiotic is prescribed, but which one.

I did a research project during my residency in which I demonstrated that physician prescribing practices are influenced by "detailing" as the pharmaceutical industry knows well.  But I detailed generic medications.  So over the course of a winter, I taught my colleagues about erythromycin, TMP/SMX (Bactrim) and amoxicillin.  How to dose them, what they are effective for, etc etc.  ... and through a grant from two local health plans, I purchased samples from the hospital pharmacy of these medications and placed them in the samples cabinet.

The results were that not only did the physicians give out more samples of the generic medications ... but that they wrote more prescriptions for them as well.

Like many of my little adventures (yes .. I'll finish cleaning the basement "real soon now") ... this one was never finished to the degreee that would make it a publication-quality paper  ... but it was a fun and instructive project nonetheless.  A core part of the eduction .. even back then (1996) was that the 1st line treatments for the most common conditions are NOT the higher priced "big guns."  As the physicians built experience with seeing patients get better with inexpensive narrower spectrum agents ... a lifetime of better prescribing practice was (I hope) built.

Fast forward to 2004.

Well established protocols now exist for the treatment of community acquired pneumonia .. and most of them suggest that "a macrolide or doxycycline" be a component of the therapy. (or a newer quinolone .. but don't get me goin about them!)

There is rather little data to guide us in this choice, and despite ample marketing, and a significant difference in price, my choice predicably remains doxycycline.  Azithromycin seems a popular choice for many other physicians .. and I think that the sense of security they get from the much broader spectrum helps physicians sleep better at night .. knowing that this medication "gets all those bugs."

But the "getting them all" mentality is not consistent with good, thoughtful practice.  We need to treat with as NARROW a spectrum as possible .. and really think hard about what the likely organisms are ... not just shoot from the hip (with a shotgun) and hope that what's there is wiped out.

Challenged this morning by a thoughtful colleage to provide evidence for the long 1/2 - life of azithromycin correlating with clinically important increases in resistance (I often quote studies that demonstrate tissue levels of azithro persisting below MIC even 3 - 4 weeks after treatment is discontinued, which theoretically would account for significant resistance pressure) ... I've come up with a few papers that suggest that such a correlation does in fact exist:

Streptococcus pyogenes resistance to erythromycin in relation to macrolide consumption in Spain (1986–1997)

Juan J. Granizo^a, Lorenzo Aguilar^b,*, Julio Casal^c, Rafael Dal-R^b and Fernando Baquero^d

... From a pharmacodynamic point of view, other factors may have contributed to the selective process. It has been suggested that macrolide agents with low C_max and long half-life (like bd or od macrolides) are likely to produce a longer selective window, which means longer bacterial exposure to resistance-selective concentrations.³² Long-acting agents optimize selective effects.³³ In any case, either directly or indirectly, both bd and od macrolides appear to be the main reason for the increase in erythromycin resistance.

^{Read the whole paper .. as it's a great overview of an issue that is complex .. and quite scary.  The authors are careful to avoid saying that there is clarity of causality (since correlation can never clearly determine causality) .. but this is certainly enough to support the hypothesis that there is a relationship.}

^{There are other reports (here and here) that discuss the correlation between macrolide use and increaseing resistance .. and of course the well known study that demonstrated decreased resistance as macrolide use decreases.}

^{The CDC's report on this highlights an alarming increase:}

azithromycin and clarithromycin, +388%; quinolones, +78%; and amoxicillin/clavulanate, +69%. This increasing use of azithromycin, clarithromycin, and quinolones warrants concern as macrolide- and fluoroquinolone-resistant pneumococci are increasing.

... and this paper sums it up rather well: (my emphasis added)

... Antibiotic use in ambulatory patients is decreasing in the United States. However, physicians are increasingly turning to expensive, broad-spectrum agents, even when there is little clinical rationale for their use.

Infrastructure Project Would Enable Patient-Created EMRs

Health-IT World reports that:

A group housed at Duke University's Fuqua School of Business is moving ahead with an effort to build awareness of health information technology among consumers and then develop an IT infrastructure that would allow patients to create their own electronic medical record (EMR).

The project, called the Health Data Exchange, is being spearheaded by Brian Baum, former chief marketing officer at Cap Gemini Ernst & Young. Baum said he has for many years discussed ways to make health technology a winning business proposition with Kevin Schulman, a doctor who directs Fuqua's Health Sector Management program.

I couldn't find much on the Fuqua website.  It's a good idea ... but I'm not sure the vendors will embrace it.  We'll see.

Rabbit Medicine

Rabbit medicine notes comes up next to "Family Medicine Notes" in a google search.

Topics

I've made an attempt to categorize some of the entries in Docnotes.  I'm not going back 4 years .. (over 1000 posts) .. but I'll try to do this going forward.  See the "topics" menu over there on the left. 

Family Medicine Education

Jan Gottlieb, MPH - developed a set of resources that:

provide a helpful resource for faculty and staff of medical schools who are planning to, or are currently using service-learning to educate medical students and residents about

1. community-oriented primary care
2. Healthy People 2010 objectives
3. Cultural competence.   

The toolkit, which should be applicable to other fields and disciplines as well, is designed to help minimize some of the start-up time involved in developing service-learning programs.  It will also provide examples for tailoring service-learning to fit your timeframe. The toolkit was based on three of the COPC-service-learning programs developed by our Department of Family Medicine in collaboration with community partners, over the last eight years.

Science and Politics

Matthew's The Health Care Blog has some great insight into the discord between GWB's agenda and the scientific community.  I think I'm gonna give Kerry $50 today.