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Gratuitous and grisly x-ray images

June 5th, 2009 by KevinMD in Better Health Network
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A bizarrely morbid slide show of radiology images showing various patients impaled by foreign objects.

If you need more reasons to be wary of nail guns, fishing spears, keys, or knives, look no further.

*This blog post was originally published at KevinMD.com*

The Real Reason Why Doctors Don’t Want To Adopt EMRs, And What To Do About It

June 5th, 2009 by Dr. Val Jones in Opinion
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Have you ever been ignored by someone who was texting or otherwise engaged in a digital conversation? Did you feel that the person was being rude and unresponsive to you? If your answer to both of these questions is “yes” then you will understand the real reason why some doctors don’t want to adopt electronic medical records systems (EMRs).

As sappy as this may sound, most physicians were drawn to medicine because they wanted to help people, save lives, and improve the quality of life for those suffering from disease. Even after we’ve been beaten up by our training programs, and weighed down by debt and the mountains of paperwork required by a broken healthcare system, most of us still retain that do-gooder kernal inside us – we genuinely care about our patients.

And so because we care, we know instinctively that the human side of medicine – the attentive listening, the visual cues, the continued eye contact, and the careful history and physical exam – is critical to our profession. The problem we have with EMRs is that they often interrupt the sensitive and intuitive parts of what we do. EMRs and other digital “tools” designed to make our work more efficient, may do so at the expense of the human connectedness our patients deserve and need.

Most EMRs, as they exist today, are not designed to bring patients into the conversation. In order to maximize efficiency, the physician must type while the patient is talking – usually turning their gaze and even their whole bodies away from the individual or family. Those of us who feel that this behavior is socially inappropriate will take a verbal history from the patient and then type it up from memory later – this creates more work than if we’d simply taken notes during the conversation in a paper-record, and may introduce recollection bias if we do our typing at the end of a long day of seeing many patients.

There is certainly a generation gap in terms of EMR adoption (as my friend Dr. Geeta Nayyar has noted) – our new crop of doctors are very comfortable with EMRs and wireless tools of various kinds, while the “older” doctors are often highly resistant to adopting a digital system. But before we label senior physicians as “obstructing progress” – let’s look beyond the technology issues (yes, it takes time to learn how to do something a different way) and at some of the emotional reasons why physicians don’t like what EMRs do to their patient relationships.

Time and again I’ve heard my peers (who use EMRs in hospitals) say that they feel that they spend most of their time “talking to the computer” rather than the patient. They are wracked with guilt about this, and have actually lost a portion of their “job satisfaction” as a result. They know that the digitization of healthcare has robbed them of the luxury of full history and physical exams, conducted in an uninterrupted face-to-face encounter with their full attention on the patient. They feel like a robot – like a mere collection of algorithms used to process people in an “evidence based” framework. And the patients – they report that their doctors are hurried, uncaring, and potentially replaceable with a robot.

In my opinion, EMR manufacturers must understand the collateral damage that their products can do to the physician-patient relationship and create EMRs that engage patients in the physician encounter. I have seen at least one prototype product that is trying to do this (and there may be many more – it’s difficult to keep up with all the new innovations, so please leave a comment about other products that you know of), Microsoft’s Surface. Surface allows the physician and patient to sit together at a table with a screen embedded in its top. The physician can bring up lab results, radiology images, and medical records to discuss them with the patient so they can see it at the same time. I really like this concept, since it facilitates electronic record keeping while engaging the patient in the encounter.

When EMR vendors and civil servants bemoan the slow technology adoption rates of physicians, I urge them to recognize that there is more at play than just “resistance to change.” There is a resistance to dehumanizing doctor-patient interactions, to turning one’s back on a crying patient to type notes on a laptop, to spending more time “talking to a computer” than talking to a patient. That resistance is actually a good thing – it means we still care, we have hearts, we are human.

Now, to get physicians to adopt EMRs – don’t use a stick (“adopt our EMR or we’ll fine your practices”) use the younger generation of physicians (already comfortable with technology) to teach the older ones how to integrate digital record keeping into their workflow. During that interaction, I believe the senior physicians will be able to teach the junior ones a lot about the art of humanizing their patient interactions, while the younger ones train them about the technical process of incorporating EMRs into their own workflow.

In summary, EMR adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. Senior physicians may understand this risk better than junior ones, and should be admired for their desire to maintain fewer barriers in their relationship with patients. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods.

The Friday Funny: The Alternative To Botox

June 5th, 2009 by Dr. Val Jones in Friday Funny
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Science And The Game Of 20 Questions

June 4th, 2009 by Dr. Val Jones in Quackery Exposed
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An audience member at a recent NYC Skeptics meeting asked me how I handled conflict surrounding strongly held beliefs that are not supported by conclusive evidence. As a dentist, he argued, he often witnessed professionals touting procedure A over procedure B as the “best way” to do X, when in reality there are no controlled clinical trials comparing A and B. “How am I to know what’s right in these circumstances?” He asked.

And this is more-or-less what I said:

The truth is, you probably can’t know which procedure is better. At least, not at this point in history. The beauty of science is that it’s evolving. We are constantly learning more about our bodies and our environment, so that we are getting an ever-clearer degree of resolution on what we see and experience.

It’s like having a blurry camera lens at a farm.  At first we can only perceive that there are living things moving around on the other side of the lens – but as we begin to focus the camera, we begin to make out that the animals are in the horse or cattle family. With further focus we might be able to differentiate a horse from a cow… and eventually we’ll be able to tell if the horse has a saddle on it, and maybe one day we’ll be able to see what brand of saddle it is. Each scientific conundrum that we approach is often quite blurry at the onset. People get very invested in their theories of the presence or absence of cows, and whether or not the moving objects could in fact be horses. Others say that those looking through the camera contradict one another too much to be trusted – that they must be offering false ideas or willfully misleading people about the picture they’re describing.

In fact, we just have different degrees of clarity on issues at any given point in time. This is not cause for alarm, nor is it a reason to abandon our cameras. No, it just gives us more reason to continue to review, analyze, and revise our understanding of the picture at hand. We should try not to make more out of photo than we can at a given resolution – and understand that contradicting opinions are more likely to be evidence of insufficient information than a fundamental flaw of the scientific method.

***

I have noticed that impatient photo-gazers have a propensity to demand answers before accurate ones are available. And this leads to all manner of passionately held, but misguided beliefs both in the scientific community and beyond. We must somehow find a way to make peace with limited information, eagerly seeking more, without being dogmatic about premature conclusions. My dentist colleague should not feel pressured into choosing sides on an issue that cannot be fully evaluated yet – and will have to wrestle with ambivalence as he waits patiently for more data.

But far more worrisome than living with ambivalence is living with stagnation. I would argue that one of the greatest red flags in the scientific world is an unwillingness to learn – an unyielding commitment to a set of beliefs, despite increasing evidence that they are not accurate. I think of homeopathy and acupuncture as good examples of this phenomenon – since they have not evolved significantly since their inception, their proponents therefore must admit that they have learned almost nothing new since the dawn of their use. The lack of refinement of treatment protocol is evidence of the system’s belief-based (or placebo-based) nature. As John Cage, US composer of avant-garde music, once said,

“I can’t understand why people are frightened of new ideas. I’m frightened of the old ones.”

***

As I mulled over my fuzzy image analogy, an even better one came to mind: the game of 20 questions. For those of you who didn’t play this game growing up, its rules are simple: one person must think of a person, place, or thing and the other(s) have 20 questions that they can ask in order to guess who/what the first person had in mind. The challenge is that the questions have to be asked so that the response is either yes or no. If the questioners can’t devine the name of the person, place or thing within 20 questions, the respondent wins. If the questioners guess the identity of the object within 20 questions they win.

Science is a little bit like 20 questions (of course we have unlimited questions that we can ask) in that we constrain our research to answer a very specific question under a very specific set of circumstances (formulating a “yes” or “no” type question). No one question or answer is likely to unlock the solution to the larger puzzle – it’s the collection of questions, taken in context of one another, that leads to meaningful understanding. When we don’t understand the best path forward, it’s likely that we are early on in the game of 20 questions, with little information to guide us.  Occasionally we get lucky and ask the right question early – but more often than not we’re left to scratch our heads and ponder yet another question to help unlock the “mysteries” that face us.

That is the beauty and the pain of science – it’s slow, it’s methodical, it leaves the honest participant in a state of ambivalence with some degree of frequency, but in the end it yields real answers if we wait for the clarity that can come from careful analysis. Without it we are left with magical beliefs and misguided explanations… we’re left with Jenny McCarthyism.

*This blog post was originally published at Science-Based Medicine*

Reaching Adults – Teens Text Questions About Sex

June 4th, 2009 by Nancy Brown, Ph.D. in Better Health Network
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As if we needed any more indications that the sexuality education we teach in schools might not be working, the latest place for teens to find answers to their questions is via cell phone.

In spite of web sites that allow teens to ask anonymous questions like We’re Talking Teen Health and Go Ask Alice!, teens are still looking for answers to immediate sexuality-related questions, and texting them is the newest way to get answers.

In California, teens can text their sexuality questions to ISIS by texting the word ‘hookup’ to the phone number 365247 which will allow them to sign up for weekly health tips. Each tip contains a prompt to text the word ‘clinic’ plus a zip code to get contact information for two local clinics.

In North Carolina, they can text questions to The Birds and Bees Text Line. Both services provide non-judgmental and medically accurate information within 24 hours to teens with questions.

Neither site provides medical advice, only information from an adult and encouragement to seek medical care. The important part is that these services are another place teens can reach out to adults for information and support.

I worry a little bit about what happens when teens admit they were raped, or are being sexually abused – what do the adults receiving this information do – and are they responsible for reporting what they learn to the authorities, but I guess that is a abridge we cross when we come to it.

For now, I am happy there are more adults willing to provide the information teens need to make good decisions, get medical care, and protect themselves. As always, parents would be the best source of sexuality information, but they might need their own texting site for their questions!

This post, Reaching Adults – Teens Text Questions About Sex, was originally published on Healthine.com by Nancy Brown, Ph.D..