I think this is a good point: a good primary care clinician should provide a good gatekeeping service for referrals. We should refer you only when it's likely to help, and to a competent specialist. I do think some PCP's refer more than they should because they feel pressed for time and/or think that it's simply easier to send the patient for a specialist to give a more detailed opinion. That opinion can be blinkered, though.

In my mind, competency for specialists includes knowing not just the full range of treatments, but spending time with many patients telling them they should do nothing —no fancy procedures or medications. It's not universal, but there are many specialists out there who are willing to risk making patients unhappy by not waving their magic wand, and who are willing to spend the time (and liability) to do so despite it being to their own economic disadvantage. I'm looking forward to changes in the US health care system that will encourage this, instead of encouraging simply doing as many billable procedures as possible.

It sounds like the GP had Dupuytren's contracture, a common thickening of connective tissue in the palm, with a time course of years that can result in inability fo extend (unbend) one's fingers.

As a primary care physician, I don't think I've yet referred anyone for surgery for this (in 17 years) and instead have people do stretching exercises, but surgery may make sense in severe cases. Collagenase injections (the Xiaflex referred to above)looks like it may be useful for patients who don't do well with stretching, don't want surgery, and don't have severe contractures. It doesn't look totally benign (51% bruising, 37% bleeding, 1% tendon rupture, 0.5% permanent unrelenting pain syndrome) but less invasive than surgery. It looks pretty effective.

That said, I've learned when I do referrals, one needs to be careful of who one refers to. For some specialists, given that they use a hammer a lot, most patients may start looking like a nails. I think pretty much all of these specialists genuinely want to help people, but when you specialize in something there's a risk of tunnel vision. For example, when a patient with annoying (but maybe not disabling) back pain wants to see a specialist —depending on who one sends them to — they've got a good chance of getting surgery done. Most back surgery for common spine conditions isn't clearly better than waiting a year for most patients. It's hard to tell some people you don't want to see a fancy specialist for this: you'd be better off losing weight and exercising more.

That said, though I'm pretty proud of myself for encouraging patients to avoid even seeing a surgeon until I really think it will help, and avoiding brand name medications, and decrying expensive vitamins or supplements with little evidence of effectiveness, this article in the New England Journal of Medicine gave me pause. Sure, Gawande claims with some reasoning that a lot of medical procedures have little benefit, and a lot of money is wasted. But the research leading to those conclusions was somewhat cherry-picked, and there is other research that suggests that higher spending really does improve outcomes. The author notes that "perhaps the most accurate conclusions is that sometimes less is more, sometimes more is more, and often we just don't know." Like a lot of health policy (and a lot of life in general), the issues may be more complex than they first appear.

Face ID seems to work fine in normal daylight in my experience, though bright sunlight is trickier. On the other hand, Touch ID worked for me maybe half the time - no good in the rain, or with sweaty fingers, or gloves on. (When I'm not running in the rain in the not very bright Pacific Northwest, I'm taking pictures of people's moles in a secure app to stick in their medical charts while wearing globes, so I suppose this thing fit my use cases well.) Not having to type my password for Face ID-enabled secure apps 20 times a day has been (effin') worth it.

HPV causes a lot of things (various isotypes are responsible for warts, most head and neck cancer, penile cancer); it is also the (99.7% of the time) cause of cervical cancer. HPV vaccination has been shown to prevent cervical intraepithelial neoplasia (CIN) and carcinoma in situ, the precursor lesions to invasive cervical cancer, in large randomized trials. The current 9-valent HPV vaccine is 97% effective in preventing CIN 2 (moderate) and more severe disease (CIN 3, carcinoma in situ). It also prevents the vaginal equivalent (VIN2/3) - 100% effective, in fact, among HPV naive populations, and 62% among the overall population.

Current cervical cancer prevention strategy involves Pap smears and then biopsies and surgical intervention when we find abnormalities. It's not cheap, and involves women (best case) getting an exam they don't like every 3 years from 21-29 years of age, and every 5 years from age 30-65 years of age. In the worst case, in areas and among populations that don't get Pap screening, people either can try to get to "screen and treat" centers (where we use liquid nitrogen to spots that show up on a cervix swabbed with vinegar), or, more often, simply consign a percentage of women to a miserable death. Cervical cancer is common (17.8 per 100k in countries without screening, with 9.8 of those dying), which amounts to about 266,000 deaths per year. In developed countries, cervical cancer is the eleventh most common type of cancer and ninth most common cause of cancer mortality (3.3 per 100k). In the US, that amounts of 13,000 cases per year, and 4100 deaths.

It stands to reason that HPV vaccine, since it prevents in HPV infection, and advanced pre-cancerous lesions, will likely be shown to prevent incident cancer as well when the vaccine has been around long enough. (The vaccine was first licenses in June 2006; most women get colonized with HPV around sexual debut but the cancer doesn't show up until age 35-55, a 20-40 year delay.) The tragedy of the vaccine, if any, is that it is largely available only in developed countries, where most people can get treatment rather than dying from the disease. That's not nothing: ask any woman who has to have repeated colposcopies and LEEP surgery if she would have preferred to have gotten 2 shots around age 11 and skipped all of the attended pain, expense, and risk of later preterm labor.

In fact, with the introduction of widespread HPV vaccination in the United States proposals are already afloat to change Pap screening—one proposal suggests every 10 year screening for vaccinated persons. Despite the expense of the vaccine ($240 for the two shot series) it's likely to be cheaper and less cruel than the current state of the art.

You are free to consider Gardasil to be a "scare tactic." As a family physician who gets to follow up on plenty of abnormal Paps, and not a particular fan of the pharmaceutical companies, my kids are getting vaccinated

I have plenty of apps on my phone that are essentially websites, that, one I verify my identification by other means (like my password and some other factor like my pre-registered IMEI number or out of band code sent to me) let me log in with my fingerprint. Which isn't transmitted; the phone has an API that tells the app my fingerprint was recognized.

This includes my bank, investment firms, and hospital (that's the one keyed to my specific phone).

In my primary care practice in the US, we’ve been asking about firearms since I started (in the Clinton administration). Not by government mandate or guideline, but suggestions from specialty societies, like the American Academy of Pediatrics and the American Academy of Family Physicians. We sit around in meetings and discuss this sort of stuff a couple of times a month and it gets added to the (ever lengthening) questionnaire.

This, in turn, is based on . Here’s your top 10 for 2014:

• 1. Diseases of heart (heart disease)
• 2. Malignant neoplasms (cancer)
• 3. Chronic lower respiratory diseases
• 4. Accidents (unintentional injuries)
• 5. Cerebrovascular diseases (stroke)
• 6. Alzheimer’s disease
• 7. Diabetes mellitus (diabetes)
• 8. Influenza and pneumonia
• 9. Nephritis, nephrotic syndrome and nephrosis (kidney disease)
• 10. Intentional self-harm (suicide)

Out of 199,972 injury deaths during the last reporting year (62.6 per 100k population), 51,966 went by poisoning, 33,736 by motor vehicle accident, and 33,594 by firearms, most of that accidental. (Out of 15.872 homicides, 11,008 were by firearms, so two thirds of firearms deaths are accidents.)

So, we ask if you have a gun, and if you do, we ask if you have it properly locked up so no one accidentally shoots themselves (like your kids), just like we ask about seatbelt and carseats and smoke detectors. If it’s toward the top of the list of preventable deaths, we try to ask you about it to see if we have an opportunity to prevent you from dying—simple as that.

My use case is running for 40 minutes 4 times a week while getting my headphones soaked in a combination of sweat, rain, and lately ash blown in from nearby wildfires. I have blown through 3 prior pairs of Bluetooth wireless headphones, all of which suffered from poor reception while running, and all of which died a salt-encrusted death within several months.

My Powerbeats 3 aren't perfect (the cord sticks a bit on the back of my neck) but they are by far the only wireless headphones that ever really worked for me for running. I spent more than $200 with the other 3, which I suppose made the admittedly stiff price worth my while.

• 1. If I had a nickel for every time I had a heart to heart talk with a patient about improving their diet and exercise regimen to avoid the untoward consequences (reflux, overweight, diabetes, heart disease, feeling like crap in general) I'd have, like, a lot of nickels.
• 2. Interestingly, a response I get that's more common than you'd think is "I'm not switching from Pepsi to water. I hate the taste of water." We call this "pre-contemplative."
• 3. Some folks eat quinoa and twigs and still have risky acid reflux (with risks including esophageal cancer, bleeding, and cooking their esophagus sufficiently in acid it narrows - kind of like ceviche). While H2-blockers are first line, if they don't do the trick, sometimes proton pump inhibitors are the least worst thing.

Epinephrine and naloxone are both typically injected in muscles - no need to hit a vein. You can use epinephrine subcutaneously (just under the skin) but IM seems to work better.

I prescribed a vial and syringes a few hours ago. Not an EpiPen; in my case it was for a similar (but less sexy) scenario, naloxone, to use for opioid toxicity, a popular cause of death among opioid addicts and even those prescribed opiates for legitimate use. (The current recommendation is to prescribe an opiate-antagonist for those using over 50 morphine equivalents a day.) I just hope to heck if my patient ends up over-gorked on their meds they can find the syringe and draw up the medicine. (Injecting it is the easy part; you could do it through your pants blam! into the leg.) You can't keep a regular syringe pre-filled safely - the medicine doesn't stay safe. Luckily, naloxone doesn't need to be dosed carefully. Epinephrine does (too much could fry your heart). I suppose it's not so importnat to be precise as it is for insulin, but most people don't need to draw that up in a hurry.

Blowing my mod points for the opportunity to clarify why we screen for diabetic retinopathy: By the time a diabetic patient has visible diabetic retinopathy, laser photocoagulation treatment cannot always repair the damage. The goal is to find the bleeding before risking significant visual loss, when treatment tends to be more successful. This is why most organizations (like the American Diabetes Association) recommend yearly dilated eye exams for diabetic patients. Unfortunately, screening can be expensive for underinsured or uninsured patients, or those without access to ophthalmologists or optometrists. As a primary care physician I asked if I couldn't get trained myself to save the cost for my uninsured patients, and got basically a bunch of eye-rolling. Somewhat like neuropathy, you don't want to be able to self-diagnose it: you want to prevent it before it becomes noticeable, which is awfully close in many patients to the point of also being irreversible. Diabetic neuropathies tend to be easier and cheaper to diagnose currently and don't need a specialist (and could probably be done by patients themselves with monofilament examinations). The same isn't true for the eyeballs —yet.

Good intentions, maybe, and despite the grief there are some advantages. I can see my patient's clinic charts in the hospital - before, I'd have to wait for Monday and a fax machine. I can see what happened to folks in the emergency department. I can figure out my obstetric patients' prior pregnancy history. I can send records to specialists directly, and send requests with an electronic copy of a chart note and pictures of moles and whatnot at no cost to a patient and sometimes save them a visit to another office.

It's not perfect, but it's not a total disaster either.

I like a conspiracy theory as much as anyone, but I really don't think the NSA convinced Congress to pass the not thoroughly thought out HITECH Act to amass statistics about the home addresses of people with pneumonia or which patients with high blood pressure are smoking. Being able to gather anonymized statistics on public health issues may help, however, to figure out how to improve immunization rates or best help diabetics get their blood sugar under control.

To the grandparent poster, our EMR company actually will pay their own way to have their engineers follow us around and see how we work, and our prior vendor was originally a nice internist who wrote his own code (who then sold the thing to a big conglomerate that also makes microwave ovens and jet engines and curling irons and stuff).

Our current EMR does a lot of stuff well, but I'm hopeful for the day it's more usable by clinicians. The basic process of writing progress notes (in some sense, the evidence of my life's work as a physician) is clunky and hard to correct and even less intuitive for my colleagues who don't happen to have fancy computer science degrees like me. Writing good software is hard, and maybe progress notes have had to wait in line behind revenue cycle and privacy and a bunch of compliance issues.