“Tell me again, Curmudge, why I should become an expert in the diagnosis and treatment of a disease that I presumably have. I’ve heard that a little knowledge is dangerous.”
“Jaded Julie, a little knowledge isn’t dangerous if you discuss it with your physician. Furthermore, it rarely stays little, especially if you have a life-or-death driving force to learn more. There may be a time when your physician will present you with a choice between two apparently equal therapies; you’ll feel better choosing based on understanding instead of just flipping a coin. There might also be instances when treatment decisions involve a trade-off between potential benefits and risks; you’d certainly want to be an informed participant in that discussion.”
“Have there been cases where the patient’s study of diagnosis and treatment made a difference?”
“Read Chapter 5 of Dr. Groopman’s book, Julie (1). A mother’s knowledge—and especially her persistence—saved her daughter’s life. And if you don’t have access to the book, read about Meg Gaines’s experience with ovarian cancer.”
“But, Curmudge, Ms. Gaines’s life was saved by a new procedure performed far from home that wasn’t evidence based.”
“True. But she wouldn’t even have known about the procedure had she not studied her disease and learned of the best medical centers at the forefront of clinical research on ovarian cancer. After her experience she founded the Center for Patient Partnerships in Madison (2). She advises patients to ‘act as if your life depends on it, because it does,’ and to become an active patient ready to make your own way through your disease and its treatment.”
“Okay, Professor, I’m convinced. Teach me more about how to become my own best caregiver.”
“As I promised last week, we’re going to be looking into more technical literature. A Cochrane Review is a scientific investigation into the literature on evidenced-based health care, including randomized controlled trials and sometimes non-randomized observational studies. Individuals without a subscription click on Browse Free Summaries at the bottom of the page and then enter the disease of interest under Search Abstracts and Summaries.”
“Without your instructions, Curmudge, I would have had to follow my nose through these documents like you did.”
“It’s called trial-and-error, Julie, but it’s amazing what one can learn. You next select a title that interests you from those listed under your disease, and out pops a two-page summary. It contains a one-paragraph Summary of the disease, results of completed clinical trials of proposed treatments, and trials that are ongoing. The Main Results section is more technical listing numbers of patients, details of the trials, and some statistics on the results. Findings are summarized in the Authors’ Conclusions. Also given are the dates that the review was published online and when it was last assessed as up to date.”
“Okay, Curmudge, I think my brain is getting better at handling technical information. How can I find a discussion of my disease that is truly comprehensive?”
“Go to http://emedicine.medscape.com/. A page will appear inviting you to Browse by Specialty (within the main categories of Medicine, Surgery, and Pediatrics). Then search under disease categories such as these under Medicine: Emergency Medicine, Hematology, Pulmonology, etc. You should find a very detailed review of your disease, including results of clinical trials. The language will be technical, but the gist of the findings should be evident to the layperson. If I had to select the site that would yield the most information from just three mouse clicks, this would be it.”
“You have been mentioning clinical trials, Curmudge. If I wanted to participate in one, how would I learn more?”
“I’ve found a couple of routes to the same end point, Julie. Start with http://gateway.nlm.nih.gov/. At the home page, NLM Gateway, fill in the box with your request for ‘clinical trials on (your disease)’ and click on Search. Then under Consumer Health Resources click on ClinicalTrials.gov. That will yield a listing of trials that pertain to your disease. This will show for each entry the title, condition (disease), URL, and status (Terminated, Active, Recruiting, Completed). Click on the URL for details, including Purpose, Study Design, Criteria for Inclusion or Exclusion, Locations, and person to contact.”
“What about the second route?”
“That one starts at http://clinicaltrials.gov/. Follow your talented mouse to the same details as above. If you see a trial that is recruiting and interests you, discuss it with your physician. Remember, however, that a trial is just what the name implies. You might be in the population that receives a placebo, or the treatment under study might turn out to be ineffective.”
“I suspect, Curmudge, that our discussion of this topic might turn out to be endless and increasingly technical. This might be a good time to pick up our pieces of new knowledge and go home.”
“You’re right, Jaded Julie, but I hope we can talk more about this next week. Meanwhile, happy googling.”
Affinity’s Kaizen Curmudgeon
(1) Groopman, Jerome. How Doctors Think. (Mariner Books, 2008)
(2) Center for Patient Partnerships: Comforting the afflicted.
http://www.patientpartnerships.org/
Thursday, September 30, 2010
Thursday, September 23, 2010
Evidence-Based Medicine--The Patient's Perspective
“Jaded Julie, how would you feel if you were diagnosed with a serious illness?”
“I’d feel very much alone, Curmudge. Your family and friends can give you food, shelter and care, and they can even assume your debts. But no matter how much people love you, no one can be sick for you.”
“So what would you do?”
“I would have a choice. If I chose to be a totally passive patient, I could take the prescribed medicine, suffer its side effects, and hope and pray for the best. The other option—and that’s what I would select—is to become an expert on my disease and an active participant in my health care team. That way I could take full advantage of personalized care and maybe even help to cure my illness. Hey, the game of life vs. death is one that you can only lose once.”
“Sounds like a plan, Julie. How would you proceed?”
“Well, if I lived near a hospital with a library, like St. E’s or Mercy Medical Center, I’d seek the librarian’s help in learning all I could about my situation. But tell me, Curmudge, what should I do if a city is not nearby or if I were reluctant to share the details of my health with a librarian?”
”In the privacy of your home office, you or a relative or friend should use your computer to google your disease. That will open up a world of medical knowledge.”
“But I don’t want the world. I just want some stuff that I can comprehend.”
“There’s something for everyone out there, Julie, including a lot of sources that one can understand without an MD degree. Your Google search will provide a list of titles followed by a couple of lines describing the contents followed by the URL. Note, however, that the pages of your Google search results will show so-called Sponsored Links; some of these may contain testimonials and ads for non-FDA-approved treatments. Below are a few URLs that should be helpful; they will usually provide an overview of symptoms, diagnosis, and treatment in everyday language.
Mayo Clinic (www.mayoclinic.com)
MedLine Plus (www.nlm.nih.gov/medlineplus)
Merck Manuals (www.merck.com)
Wikipedia (en.wikipedia.org).”
“This sounds pretty useful, Curmudge, but where does evidence-based medicine enter the picture? It’s in our title, but you haven’t mentioned it once.”
“The sites mentioned above contain review articles written, for the most part, in everyday language. Procedures for diagnosis and treatment are evidence based as understood at the time of writing. To learn about new knowledge developed since then we’ll have to look into other—and often more technical—resources. We’ll also have to come back for more discussion next week.”
“So that I don’t go away empty-handed, can you give me a definition of evidence-based medicine?"
“Of course, Julie. Evidence-based medicine is the generally accepted best procedure for the diagnosis or treatment of a specific illness or condition. ‘It requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report (1).’”
“Thanks bunches, Curmudge. It will take me all week to figure out what you just said. But I do understand that I would want to receive the best care available. Presumably that will be evidence based unless my physician and I agree on a good reason to do otherwise.”
Affinity’s Kaizen Curmudgeon
(1) Agrawal, P. and Brown, C. A. An evidence-based approach to acetaminophen overdose. EBMedicine.net, September 2010.
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I’d feel very much alone, Curmudge. Your family and friends can give you food, shelter and care, and they can even assume your debts. But no matter how much people love you, no one can be sick for you.”
“So what would you do?”
“I would have a choice. If I chose to be a totally passive patient, I could take the prescribed medicine, suffer its side effects, and hope and pray for the best. The other option—and that’s what I would select—is to become an expert on my disease and an active participant in my health care team. That way I could take full advantage of personalized care and maybe even help to cure my illness. Hey, the game of life vs. death is one that you can only lose once.”
“Sounds like a plan, Julie. How would you proceed?”
“Well, if I lived near a hospital with a library, like St. E’s or Mercy Medical Center, I’d seek the librarian’s help in learning all I could about my situation. But tell me, Curmudge, what should I do if a city is not nearby or if I were reluctant to share the details of my health with a librarian?”
”In the privacy of your home office, you or a relative or friend should use your computer to google your disease. That will open up a world of medical knowledge.”
“But I don’t want the world. I just want some stuff that I can comprehend.”
“There’s something for everyone out there, Julie, including a lot of sources that one can understand without an MD degree. Your Google search will provide a list of titles followed by a couple of lines describing the contents followed by the URL. Note, however, that the pages of your Google search results will show so-called Sponsored Links; some of these may contain testimonials and ads for non-FDA-approved treatments. Below are a few URLs that should be helpful; they will usually provide an overview of symptoms, diagnosis, and treatment in everyday language.
Mayo Clinic (www.mayoclinic.com)
MedLine Plus (www.nlm.nih.gov/medlineplus)
Merck Manuals (www.merck.com)
Wikipedia (en.wikipedia.org).”
“This sounds pretty useful, Curmudge, but where does evidence-based medicine enter the picture? It’s in our title, but you haven’t mentioned it once.”
“The sites mentioned above contain review articles written, for the most part, in everyday language. Procedures for diagnosis and treatment are evidence based as understood at the time of writing. To learn about new knowledge developed since then we’ll have to look into other—and often more technical—resources. We’ll also have to come back for more discussion next week.”
“So that I don’t go away empty-handed, can you give me a definition of evidence-based medicine?"
“Of course, Julie. Evidence-based medicine is the generally accepted best procedure for the diagnosis or treatment of a specific illness or condition. ‘It requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report (1).’”
“Thanks bunches, Curmudge. It will take me all week to figure out what you just said. But I do understand that I would want to receive the best care available. Presumably that will be evidence based unless my physician and I agree on a good reason to do otherwise.”
Affinity’s Kaizen Curmudgeon
(1) Agrawal, P. and Brown, C. A. An evidence-based approach to acetaminophen overdose. EBMedicine.net, September 2010.
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, September 9, 2010
Amazing Devices 4
“I’ve seen it, Curmudge. I’ve seen how your reading and writing about amazing devices has awakened the long-dormant scientist in you.”
"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“
“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”
“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”
“Even with your hearing problem, Curmudge, you could use one of these.”
“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”
“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”
“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”
“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”
“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”
“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”
“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”
“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”
“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”
“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”
“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”
“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”
“You’ve got that right, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Another handheld ultrasound system is the ACUSON P10.
"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“
“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”
“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”
“Even with your hearing problem, Curmudge, you could use one of these.”
“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”
“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”
“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”
“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”
“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”
“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”
“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”
“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”
“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”
“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”
“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”
“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”
“You’ve got that right, Julie.”
Affinity’s Kaizen Curmudgeon
(1) Another handheld ultrasound system is the ACUSON P10.
Thursday, September 2, 2010
Amazing Devices 3
“You know, Curmudge, the curious thing about you old guys is that you are so easily amazed. I think the reason is that nearly all of today’s wonderful devices were invented after you had completed your education.”
“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”
“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”
“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”
(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”
“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”
Affinity’s Kaizen Curmudgeon
(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html
“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”
“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”
“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”
(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”
“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”
Affinity’s Kaizen Curmudgeon
(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html
Subscribe to:
Posts (Atom)