Category Archives: Tools to Learn by

Who are the stewards of healthcare?

Economist-Healthcare-Spending-Waste-Chart

I met a father yesterday in our ED who didn’t want antibiotics for his child’s otitis media.  He had read that a wait and see approach with appropriate analgesia might be a better option, and I was reminded that better stewardship of our healthcare is everyone’s concern.  It made me so happy to see a parent making such an informed choice, rather than thinking to myself (as I sometimes do) about how bad my Press Gainey score was going to be for being “the idiot doctor who didn’t want to give my child antibiotics for an ear infection”.

Our healthcare system is like recycling, carbon emissions or government spending: everyone agrees we should do more with less and be better stewards in theory, but when it comes to practice it’s always someone else’s problem. Is it because the system is so large we don’t feel that our actions matter, or do we feel entitled to use the resources we have, even if they offer no clear benefit to our patients? I don’t know the answer to this, but I do know that I still do unnecessary tests everyday in the emergency department.  Some are because of my concerns over missing disease in low risk patients, some are because I’m following “standard of care” or “best practice” based on poor evidence, some are because specialists want them or won’t admit or see the patient without them, sometimes its the end of my shift and it’s the path of least resistance.

The list of why unnecessary testing occurs is long and the vigilance required to stay on course and do what I think is right for each individual patient and the healthcare system as a whole is enormous.  In fact I would say a large percentage of my education time and practice is devoted to this one task.  The difficulty is in finding the support and resources to continue the process of informed and judicious use of medical resources against the onslaught of demands made by an avaricious, RVU/procedure driven, and risk averse healthcare industry.

The New York Times posted on a great resource for both patients and doctors that I believe is worth mentioning.  It is a list of the most commonly overused tests in seventeen different medical specialities.  Emergency Medicine is not one of the specialties listed (although it should be), however there are many emergency department relevant tests listed among the various specialty lists. I find this resource particularly helpful in stemming the tide of what other specialists ask of me in my Emergency Department (like PPI for GI bleed or pre-op echoes in cardiac patients) and in making decisions for why I’m admitting a patient.  If my major reason is an expedited workup with one of these unnecessary tests then perhaps I will think twice.

For example here are the top five recommended DON’Ts from the American College of Radiology:

1. Don’t do imaging for uncomplicated headache.

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.

5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

The other seventeen lists are just as good and have a great deal of information relevant to our daily practice.  Of course no list trumps clinical judgement.  The environment we work in, the prevalence of a certain disease in our community, the quality of our tests, and our testing threshold should ultimately determine what we order and what we don’t, but having the support of other specialty societies to NOT do tests is a welcome resource. Along with sites like The NNT and EMLITofNOTE it is another tool to continue improving our daily practice.

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Evernote Meet Google

 

Maybe it’s a hold-over from my childhood days, but September is the month of organization.  You know, the ritual purchasing of three-ring binders, pencil holders, graph paper, all with the hope and optimism that this year things will stay organized.  Inevitably by the end of the year you’re digging around your overstuffed backpack for that piece of paper with the homework assignment on it.

Now instead of three-ring binders I hoard information online: downloading, tagging, and clipping, all in the vain hope that it will stay organized for some future use. And why not.  I spend a lot of time reading and searching online for emergency medicine information for my particular learning needs. Unfortunately, most of it collects digital dust on my hard drive or cloud – the junk drawers of the digital age.

So here is a great new tool that is actually getting me to use the information I’ve already collected.  Evernote meet Google.  Evernote now allows you to simultaneously search Google and your Evernote folder on any web browser.  Want to review subtle ECG findings suggestive of STEMI?  Type STEMI into Google and it gets you 1,700,000 hits, but now it also gives me 3 notes from my Evernote account.  Since I’ve already clipped these to my account the likelihood that they are valuable to me at the moment I want it is high.

Sure enough clicking on the Evernote icon shows me I have an article from Amal Mattu about high risk ECGs, a review of subtle STEMI patterns by Dr Smith from his ECG blog, and a link to another good online ECG education site.

Wow, my preselected information side by side with the power of Google, all at my fingertips on a web browser.  Finally, I’m ready for school (can I redo fifth grade please)?

 

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Notecards in Verse

Inspiration comes from the strangest places.  Yes, I studied English and Philosophy as an undergrad, but I wouldn’t have considered iambic pentameter as a tool for EM education.  Then again, if you asked me whether I preferred a mnemonic to a good limerick for remembering important information I would definitely take the limerick.

Then I stumbled upon a beautifully creative new app from Doormouse mfg, that recreates the beauty and imperfections of an old-fashioned Remington on your iPhone.  Go to their website and check out the creativity of some of the cards in their gallery. Here are some of my favorites to give you an idea of how creative people can be if given the tools to play with.

Once I bought the app for myself, I was addicted, and couldn’t put it down.  I started sending type-writer notes on the app’s “high quality card stock” to people, and was amazed at the responses and positive comments I received.  There is something elusive and fascinating about what sticks in our brains and what passes through unnoticed.

Why my next thought was Emergency Medicine notecards made in this fashion deserve to be in verse I can’t explain. But here we are. This card is based on a study by K. Inaba & Co about chest tube size in trauma.

So here’s the deal.  Each card embodies some key concept from a recent paper in the EM literature I’ve read.  Usually, it will be in verse, but not always (now that I’m a temperamental artist a can’t be bound by such rules)  Click on the card and go to my shared Evernote folder where the reference literature from which the questionable gobbet of educational doggerel was created a gallery of similar cards are available.  I’ll keep adding them as long as the Bard continues to inspire.

Type written cards in verse may not be the answer to all your learning needs, and if you recite them on rounds you may get odd looks, but you can be comforted by the fact that any step closer to the company of William or e.e cummings, and away from Powerpoint is a good one.

PS. if you want to try your hand at a few of these cards yourself just download the app, email your cards to me, and I’ll add them to the collection.  I’m sure a “Selected Works of Poetry in Emergency Medicine” is just a few lyrical verses away.


Tools to Learn by – Readability

I really don’t miss the days of humping to the library in February to photocopy articles, or for that matter watching stacks of unread journals pile up in the front room of my East Village studio apartment (more than six and I can’t open the bathroom door). Honestly, I can’t stand paper clutter anymore, and I’ve gotten obsessive about throwing it in the recycling. My wife on the other hand lives in both worlds, and still like her magazines old school. One afternoon on a caffeine induced paper purge I got carried away and tossed some of her magazines out. Bad idea.

My wife is right, as much as I appreciate the power of digital information, sometimes the simple love of reading gets crushed like some nostalgic flower in the proverbial pavement crack. So over time I’ve found ways to bring that simple joy of reading clean crisp text back into my life. For an EM doc who has to read all the time its a no brainer. I read more, I learn more (and I spend less time looking for the Tylenol). These Tools to Live by posts were started with just that goal in mind . Here is one tool for that will allow you to do the same.

The other day I came across this interesting article on medpagetoday.com  Mostly it’s just a machine for advertising, but I keep it on my radar for articles like the one below.

Can’t see it?  Are you blind?  Oh yes, now I see it buried down there at bottom under all the banners, ads and other crap.  Enter Readability, the little applet that sits on you browser’s bookmarks bar.  Just click it and see below for the world of clean, beautiful undistracted text that is yours for the taking.  Better yet, Readability lets you save that beautifully transformed. You can read it  on your browser later, send it to your Kindle, your iPad, or share it with others, all without the ads.  And its free. Pretty cool.


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