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Comment Re:Don't use a PPI (Score 3, Informative) 102

  • 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.

Comment Re:you mean capitalism works? (Score 1) 372

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.

Comment Re:That's nice.... (Score 2) 30

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.

Comment Re:Thank you Democrats? (Score 3, Informative) 326

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.

Comment Re:Burnt out doc here: (Score 2) 326

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.

Comment Re:Uneasy About Starting Without a Physician (Score 1) 301

As a physician practicing in a US state (Oregon) where oral contraceptive pills are available behind the counter, I'm all for expanding access to contraception. Nothing quite has made otherwise young, promising women be overwhelmed in my practice than unplanned pregnancy (combined with flaky partners). OCP's are available here without a prescription, but require a consultation from a pharmacist. This isn't free, but where they make sure you don't have any of the various risk factors for having a stroke or blood clot on estrogen-containing contraceptives.

I'm also in favor of expanding access to more effective forms of contraception, like the subdermal implant (sold as Nexplanon in the US), and IUD. I'm pretty puzzled, however, about how one would implement an app to jab the implant in your arm. It's not hard to do (see this video), but clinicians have to get special certification from the manufacturer to do it. (This is to avoid the Norplant debacle of inadequately trained people putting the rods in a little too deep, making eventual removal challenging.) I do love the idea of having etonorgestrel rods and lidocaine hooked up to a smartphone app, however.

Comment Re:War Story on Medical System Security (Score 2) 85

Epic is a big suite of applications that run on top of a big iron server - typically Unix (ours is AIX, I think). There's fine-grained user permissions in the application itself. End users do not have shell access or filesystem access or MUMPS prompt access, and everything has an audit trail. A select group of IT nerds get access to a text-based system running as a (Unix) application (with audit trails), and, at least at our organization, next to no one gets MUMPS prompt access or shell access. We have hot swappable servers located on opposing coasts of North America. I can't speak to the implementation at your daughter's site.

There may be examples out of there of hackers breaking into Epic; I'm not aware of any. Since our implementation was modeled after Epic's recommendations my impression is they've got their heads screwed on straight, security-wise.

Comment Re:There might be a problem with... (Score 1) 265

Good luck getting EMR applications disconnected from the Internet. Every institution I know of has their EMR available behind a firewall, accessible visa Citrix. So we can work on our charts after putting the kids to bed (not uncommon for that to be a 1-2 hour task) and covering our partners during overnight call and answering emergency calls when out of town. And for seeing patients in nursing homes, and home visits (they still happen!). And our EMR's exchange information with one another, so if you go to hospital X in my town and then show up in office Y to follow up with your regular provider we can tell what happened Or, I dunno, I suppose you could keep us (physicians) locked up in the office for 24 hours 2-3 days a week and for 14 hours (instead of 12) on non-call days. I know, boo hoo hoo, but I think this horse has left the barn.

Comment Re:Document2 (Score 1) 265

When I worked as a software engineer, typed my password in for various ssh sessions maybe 10 times a day. Now that I'm working as a physician, every time I walk in and out of a patient room (which can be multiple times for visit, fetching the liquid nitrogen and scalpes and where are we keeping the extra large speculum this week anyway). I get to type in my (Active Directory) password with its enforced mixed capitals and numbers that I'm not allowed to change (too many disparate systems, apparently), maybe 50 times a day.

Which doesn't help with the spear-phishing, right? That just requires that I click on the link in the email addressed from my information security department, complete with their logo, saying they need to verify my information. I don't think my clinician colleagues are falling for that much, but the folks who answer the phone, hired out of high school, it's easy enough for them to fall for it.

Comment Re:Never mind his face, I don't like him. (Score 3, Insightful) 203

Or it means you had diabetes (and there are plenty of thin, otherwise people with diabetes) and didn't work for a company that offered health insurance;

Or it means you had a (now illegal) plan that "covered" well child visits, just not more than 2 in the first two years of life (out of the 9 that are the standard of care);

Or it means you fell off a ladder painting your house and broke your back;

Or it means you have congenital heart disease —

SORRY SUCKERS! You shouldn't have had Pacific Islander grandparents/been a kid/painted your house/been born — not my problem! I'm not saying "Your problem, not mine" isn't a valid viewpoint, but I do think that letting people who have treatable medical problems through no fault of their own drop dead in the streets is a bit more individualistic than all but the most libertarian viewpoints in the US. Not to mention every single other developed nation on the planet, that somehow manage to have popular support for their universal health care systems yet still spend about half of what we do.

Comment Re:Under supervision (Score 1) 82

I am interested in this 1 and 1.5 year time for PA and MD programs. Our local PA school provides a 26 month course (done in just over two years), and MD school is 46 months (done in 4 years, but you get two summer breaks the first two years). But at the end of MD school, the shortest available residency is still 3 years (of about 80 hours a week with little vacation), whereas the PA education pathway is not typically associated with residency programs. Those are growing, but are still typically a year long.

I suppose autonomous robot surgeons may arrive someday, but it's hard to believe that day would arrive any time soon. Getting your Google car to avoid knocking over granny in the crosswalk is one thing, but getting a baby with a typically soft skull wedged out of the pelvis during a C-section or figuring out where the heck the bleeding is coming from from a sheared artery somewhere deep inside with no time to spare —that seems well beyond our current robotic capabilities.

Comment Re:Who still uses pagers? (Score 4, Interesting) 307

I'm a doctor, we still use pagers, and they suck. On the plus side, an AA battery lasts a month, and reception is not usually an issue. On the minus side, no one seems to be making pagers anymore, so we get reconditioned units. I long for my old indestructible Motorola pager. Buttons get jammed and latches fall off the "new" ones, the display is less than reliable, and I can customize the beeping to grating, annoying, and nerve-wracking.

We are beginning to investigate smartphone based solutions, which, in order to be compliant with US privacy regulations have expensive recurring monthly charges, and will involve installing and maintaining microcells in our hospitals.

Comment Re:Screw that (pun intended). (Score 4, Interesting) 287

Most vasectomy techniques involve tying (ligating) or fulgurating (burning) both ends. The vas doesn't seem to burst, but there is a complication called "sperm granuloma" where leaking sperm (often happens) can cause inflammation (also often happens) which can cause pain (doesn't happen that often) and in rare circumstances recanalization of the vas.

Granted, it's been a while since I performed a vasectomy but I was trained to ligate and cauterize/fulgurate both ends. Surgical implantation of this switch sounds tricky: the vas is a slippery little thing, the canal narrow, and the human body doesn't always take kindly to the implantation of foreign material.

FWIW, most of the volume of ejaculate isn't sperm, but prostatic fluid. Vasectomized guys are shooting blanks, but it's not easy to distinguish between the blanks and live ammo without a microscope. Check out the grin on this urologist as he explains the same.

Comment Re:We need technology like this... that works. (Score 1) 174

You may wish to pick up the microphone you dropped.

LabCorp, for example, is happy to take your money and have you order (and pay for) your own lab tests. Along with third parties using LabCorp and Quest.) Then you can bring in the results to your family physician, and spend 40 minutes browbeating them if you like about your insignificantly elevated white cell count and the normal thyroid level that the naturopath says is actually abnormal and your asymptomatic but positive rheumatoid factor because your feet are achy.

Your blood tests results aren't like the indicators from your car's OBD 2 port; people are complex meat machines with varying genetics (really amazing the more you think about it), and normal value ranges get interpreted as part of a broader clinical picture.

Not only doctors can give tests, but in my experience the more thoughtful ones order fewer tests and barely any "routine" bloodwork (whatever that is), and instead rely on a fairly complex set of heuristics from clinical experience, lengthy education, and a good understanding of underlying normal and abnormal physiology. The $40 I get for listening to your theories about chronic yeast is supposed to pay for a learned professional opinion, and hopefully you'll let me get in a word edgewise about how Panda Express doesn't really constitute 5 servings of vegetables and walking from your parking spaces isn't going to save you from diabetes and hypertension. Instead of having to order more tests to "prove" your potentially, well, crackpot theory. Not you personally of course. Just that guy who thinks reading the Internet and ordering his own blood tests == 7+ years of training.

On the other hand, there is potentially a fair amount of good you could do, if you had to, reading UpToDate and a few basic med school textbooks, and taking a little more care with the idea that a home pregnancy test is in the same ballpark as diagnosing lupus. Oh, and a statistics course — if I had my way, they'd be teaching that in high school instead of trigonometry.

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