Last week we attended the Christmas party for our medical organization with which we are volunteers.  It was a fun mix of Western and Chinese traditions.  We met at a restaurant that serves about 459 different kinds of jao zi–stuffed steamed dumplings and filled up a large meeting room with residents, faculty, nursing staff, administrative, non-medical volunteers and some spouses and kids. 

We sang Christmas songs in English and in Chinese, and had a white elephant gift exchange where bags of snickers bars and a triangular rubix cube made the rounds. 

Some of the residents and volunteers had (sort of) practiced a group dance which theyperformed with great gusto, and the real reason we celebrate Christmas was shared with the group.  

As we have been here just over 6 months now, we realize that we are feeling more as a part of the community here, and are so grateful to be here.  We miss our loved ones overseas, absolutely, but definitely believe we are in the right place at this time. 

Merry Christmas to all of you! 

For a small country, Eritrea has recently been getting a lot of attention in the news – issues surrounding the quality of life of it’s citizens, UN sanctions and the disappearance of it’s national soccer team in Kenya.  On a much more optimistic note, despite it’s reluctant to work with external partners, the government has now been working for years with George Washington University (GWU) and Physicians for Peace (PFP) to address the severe physician shortage in the country. This month, the Orotta School of Medicine graduate it’s first class of 31 physicians and 8 pediatricians.  A result of a collaboration between Physicians or Peace and the George Washington University, the medical school and three residency programs have been established over the last three years to address the severe physician shortage.  Plans are now underway to start an internal medicine program – a challenging and very exciting undertaking that I am leading at GWU.  As I embark on this journey to learn about this country in East Africa I am reminded of the similarities in the region, yet the unique culture, history and challenges of each individual country.

Some background on the country, Eritrea is only slightly larger than Pennsylvania, on the east coast of Africa between Djibouti and Sudan.  Having separated from Ethiopia in 1997, it is a small country with a population of just over 5.5 million, 97% of whom are under the age of 65 years (the median age is 18years and life expectancy is just over 61 years).  20% of the population lives in urban areas (the capital of which is Asmara), therefore, the majority live in rural areas. The fertility rate is 4.7 which is high for western standards but puts it behind many other sub-Saharan African countries.  Interestingly, the rate of HIV infection is just over 1% (much lower than other parts of eastern and southern Africa). That said, they are at risk of other infectious diseases such as the Neglected Tropical Diseases, Hepatitis, Malaria and Typhoid Fever.

Currently, there is only one political party – The People’s Front for Democracy and Justice. The economy of Eritrea is largely based on subsistence farming with 80% of the population involved in farming and herding.  A May 2000 offensive by Ethiopia affected a large portion of land and homes in Eritrea and the government has since been trying to stabilize the economy and make improvements to infrastructure. Unemployment, illiteracy and low skills are challenges that need to be addressed for Eritrea to make economic strides.

With the news of UN sanctions on Eritrea being approved, and given the backdrop of the political and economic challenges within the country, the collaboration between GW, PFP and Eritrea provide a ray of hope for at least better access to care, better health and utlimately a better life.

            Here’s the situation. You’re on duty, assigned to cover the surgery suites. You’re called to the pre-op area and asked to place an A-Line in a patient, who is a known vascularpath, going in for something like a carotid endarterectomy, or a femoral bypass. You put a pressure line together, you break out a sterile field with precision that would make the “Surgeon General” Bow to your presence, and you inject your patient with a small amount of local anesthesia because you’re a really nice clinical specialist. So far so good, right?

            You scrub your patient with iodine solution or chlorhexadine / isopropyl alcohol scrub, complete the sterile field around the intended insertion site and start palpating for the radial arterial pulse. You have a lot of experience, and you’re very confident that you’re doing your absolute very best. Unfortunately your absolute very best isn’t good enough this time. Even though you were able to feel the pulse, and perhaps you even stuck the artery and got a good return flash, you can’t seem to get a guide-wire inside the arterial lumen. How frustrating is that? You try several different “tricks” of the trade, and even try to bleed the catheter in. You fail miserably, and have to admit to the anesthesiologist that you failed miserably. Talk about adding insult to injury.

            In the operating room the anesthesiologist puts the patient to sleep and pops in the A-Line with such ease that it was embarrassing. Then he/she looks down at you and all you can do is hang your head in shame as you walk away from one of the most egotistical specialties in medicine, and you try to figure out why it was so easy for the anesthesiologist when it was so difficult for you in pre-op. Well, as luck would have it, I might have some insight about that. 

            In the operating room the luck of the anesthesiologist is, to their advantage, a little drug induced. No, I don’t mean that the anesthesiologist is doing drugs. What I do mean is the drugs they are using to put the patient to sleep might have a little to do with the performance of the A-Line placement in the operating room.

             When you attempt to place an A-Line into the artery of an awake patient you have some obvious obstacles. For starters your patient is awake, and quite reactive to painful stimuli. In the operating room the patient is nice and asleep. Another obstacle is the reactivity of the arterial wall muscle. Remember arteries are far more active than veins. When you stick a needle through the wall of an artery they tend to spasm. Arterial spasm happens more often that you realize, especially with a vascularpath. When it does it makes a very small arterial inner lumen even smaller. That makes getting even a guide wire inside of it a very difficult task. The secondary effect of arterial spasm is the loss of a palpable pulse. Haven’t you ever wondered why the longer you try to get an A-Line in the harder it is to feel the pulse? It’s not because your fingers are getting tired. Okay, so what does all that have to do with how easy it is for an anesthesiologist in the operating room? Read on…

          General anesthesia is a combination of several different medications. Propofol, and fentanyl are some of the possibilities, and are given by IV. Then there’s anesthesia gas, which is one of several different inhaled medications. Two of the more common are isoflurane and sevoflurane. These drugs to more than make your patient unaware. They relax muscles _{(to include arterial wall muscle)} and they are powerful vasodilators. Yes indeed they make those little radial arteries swell up like sausage in a frying pan, which makes for a much easier target to get a catheter in.

             So the next time you’re anesthesiologist is boasting about his/her skill at placing an A-Line, remember this. Their egotistical skills are merely drug induced. Your skills are purely natural. Keep up the good work, smile, and be safe… 

J. D’Urbano…

Title: Out of hours training for GP registrars

Skinny: Dear Chief Executive letter from Clare Chapman dated 17 December 2009.  It draws attention to PCTs’ responsibility to commission increased GP Out of Hours (OOH) training to reflect the recent extension of training undertaken in GP practices from 12 to 18 months. Following this extension, the capacity for OOH training effectively needs to be increased by 50%, but GP Directors are reporting this increase has not been realised.

Publisher: DH

Size of Publication: 2p.

Published: 17/12/2009

Title: Guide to the implications of the European Working Time Directive for doctors in training

Skinny: Provides clarity on the European Working Time Directive (EWTD) by giving guidance using the views of experts who have already considered most issues arising from the EWTD, implemented in the UK as the Working Time Directive Regulations 1998/the Working Time Regulations (Northern Ireland) 1998 and subsequent amendments. Where a definition already exists by statute or regulation, this is noted; but in other situations a consensus view is given.

The purpose of this document is:

• to address common themes arising
• to provide clarity around frequently asked questions (FAWs) posed by junior doctors
• to signpost to the best sources of information

Publisher: DH

Size of Publication: 41p.

Published: 15/12/2009

I’m really proud that I can organize and run the world’s first university credit course focusing on Web 2.0 and medicine at a medical school. This was the third, and so far most successful, semester with 115 students who filled a survey before and after the course. I hope I can publish the results in a peer-reviewed paper soon with the help of real experts in this field.

In the final lecture, I used Prezi.com again and talked about the future of medicine as well as the results of the surveys. I’ve already got some invitations to do at least a part of the course at other international universities. What is sure is that the next semester will launch in February in Debrecen with assignments and tests because I would like to engage students even more. See you there!

Course material (semester 3)

• Week 1: Web 2.0
• Week 2: Medical Blogosphere
• Week 3: RSS and Twitter
• Week 4: Wikipedia and Medical Wikis
• Week 5: E-patients and doctors in social media
• Week 6: Virtual Reality in Medicine
• Week 7: Social Media in Healthcare
• Week 8: Education 2.0
• Week 9: Google Story and Medical Search Engines
• Week 10: Web 3.0, Web 4.0

1. SI 2009 No. 3086 National Health Service, England. The Royal Wolverhampton Hospitals National Health Service Trust (Establishment) Amendment Order 2009
2. SI 2009 No. 3030 National Health Service, England And Wales. National Health Service, Scotland. Health And Personal Social Services, Northern Ireland
3. Draft Statutory Instruments 2010 No. 000. Health Care And Associated Professions. Doctors
   The General and Specialist Medical Practice (Education, Training and Qualifications) Order 2010

Source : http://www.thaindian.com/newsportal/health1/west-bengal-seeks-medical-colleges-in-public-private-partnership_100284483.html

Kolkata, Dec 4 (IANS) The West Bengal government is in talks with the central government and the Medical Council of India (MCI) to explore the Public-Private-Partnership (PPP) model for developing medical colleges in the state, an official said. The state government will provide the hospital infrastructure including grants for free beds while the private entity will run the college, state Health Minister Surya Kanta Mishra said here Friday.

“This has been proposed to bring down the investment requirement on the part of the private players and make the whole proposition more attractive to the private sector,” Mishra said while speaking at the fourth CII Health Care East programme. He said the government needed to play a pro-active role in improving the state’s healthcare services.

Ruing that enough land was not available in and around Kolkata for big medical projects, the minister urged the private sector to spread out to the districts in a bigger way. The state’s ruling Left Front has beefed up its initiative to revive the ailing health sector following its string of electoral setbacks over the past one and half years. The shortcomings in the health sector has been a favourite campaign point of the opposition in the state.

As a young man, Samuel Clemens spent two years learning the lay of the Mississippi River to become a licensed riverboat pilot.  No sooner had he completed his apprenticeship than he realized that the topography of the river had changed.  In order to maintain his proficiency as a pilot, he would have to continue to study the waterway, which remained in a constant state of flux.

Rivers are not the only things that change over the course of time.  Medical knowledge also morphs with each new piece of data that is discovered.  Just when we think we’ve got it figured out, voilà—a piece of information gleaned from the latest research hints that we’re probably off the mark; and so we set off, chasing a new lead.

Consider the influenza virus.  These small packets of RNA mutate every year, changing just enough to keep ahead of our immune responses.  We get exposed, we become ill; and, most of the time, we recover.  Yet history has shown that once in a great while a strain of virus surfaces which most of us have not encountered before.  At these times influenza pandemics have the potential to wipe out large segments of the human population.  Those of us who survive carry the immunity to prevent illness when next we are exposed to the same or a similar viral strain.  But just because we survive doesn’t mean that we can become complacent.  It’s only a matter of time until the next mutant arrives on the scene, courtesy of random genetic drift.

Thirty years ago conventional wisdom had it that peptic ulcers were produced by hyperacidity of the stomach, brought on by stress.  Patients were treated with medicines designed to neutralize or decrease the production of gastric acid and advised to seek productive ways to reduce stress in their lives.  Then, in 1979, Dr. Robin Warren, an Australian pathologist, discovered a type of bacteria prevalent in the lining of stomachs of patients who suffered from ulcer disease.  Eventually, Warren and his colleague Dr. Barry J. Marshall were able to prove that Helicobacter pylori was the causative agent of peptic ulcer disease.  Treatment plans were devised to eradicate the organism from the stomach, which led to a cure for this common malady.

So it is with medical science.  Many times what we think we know for certain turns out to be nebulous at best.  Still we beat on against the current of conventional wisdom, ever learning in fits and starts, never quite nailing down the truth.

Thirty years ago when I was a young student of medicine, our professors told us that fifty percent of what we were taught would ultimately turn out to be erroneous.  Their dilemma of course was that they couldn’t tell us which half was wrong.  We were forced to digest as much information as we could, hoping for the best.  The study of medicine, like the study of a river, is a life-long process.

As a riverboat pilot, Samuel Clemens would bark orders from the bridge to periodically sound the depth of the river to avoid running aground.  Soundings were taken by heaving a weighted line over the gunwale of the boat to measure the depth of the water in fathoms, indicated by knots in the line:  two fathoms marked sufficient depth for safe passage.

Like riverboat pilots, we must periodically sound our medical knowledge.  Sometimes we drift into shallow water and come up short; but so far the depth has been sufficient to avoid running aground.

Title: The contribution of medical students to services in pandemic flu

Skinny: Paper providing national guidance about the contribution of medical students (in this case UK wide) but with scope for local interpretation – ‘consistent flexibility’.

Publisher: DH

Size of Publication:11p.

Published: 11/11/2009

The Pediatric Insider © 2009 Roy Benaroch, MD

For Dr. Patty de Urioste (1954-2009), a great pediatrician, partner, and  friend

1. Don’t rush. Even if you’re behind. Even if you’re waaaaay behind. Someone needs your time, and lunch (or dinner, or bedtime) can wait.
2. Have a plan. There is something that needs to be done next, even if the diagnosis is unclear. Decide what to do next, explain it, and do it. Parents need to know there is a plan.
3. Ask for help when you need it. No one knows everything. Call the specialist, call the ER, call the radiologist. Nag them if you have to, politely of course, until they tell you what you need to know. And remember it for next time.
4. Listen to your gut. If the kid looks sick, or the kid looks wrong, do what you need to do. Don’t trust the history or the labs or the x-rays more than you trust your own gut.
5. Help the patient. You might not have all the answers, and parents don’t expect a cure every time. Do what you can to help.
6. Treat your employees like family. Pay well, listen, and make your business a good place to work. They’ve got your back if you’ve got theirs.
7. Don’t miss an opportunity to learn. Every question is a chance to learn something new, and you never know when you’ll need that new tidbit again.
8. Eat lunch. Whatever happens, however late you are, you must eat. And use the bathroom, too.
9. Love books. Order them, buy them, smell them. You’ve seldom seen someone as happy and excited as Patty with a new load of medical textbooks.
10. Don’t complain to patients. They care about you, but they’re there for their own problems. Focus on them.
11. Listen. Someone is trying to tell you something.
12. Wake up early. There’s time to sleep… later. No one regrets not getting enough sleep. Many people regret things they never got to do.

Give away 1000 free iPhones, ask the students to use them for learning, and then be shocked when the feedback is awesome!

Seriously, I think the iPhone/iPod Touch platform is the way forward for medical education and support – it’s such a versatile little thing, powerful, and now almost ubiquitous.  You can even get free tickets to the cinema with an Orange iPhone now.

In Sir William Osler’s farewell address to his medical colleagues in the United States and Canada, L’Envoi, he enumerates his personal goals: to do the day’s work well, to practice the Golden Rule, to cultivate a measure of equanimity that would enable him to bear success with humility.

Over the span of my 30-year career, I have seen several hundred children for suspected abuse. Yet I can’t help but wonder why every time I evaluate such a child, instead of Osler’s measure of equanimity, I’m left with only a hollow feeling deep inside.

Interested readers can now access my latest Humane Medicine column, Evaluating the patient with a measure of equanimity, recently published in the Journal of the American Academy of Physician Assistants.

The year 2009 marked a significant haul of corporate initiatives to move with the sense of budget preservation. There was not much that corporate could do. Most impacted were training budgets and pertinent training initiatives. While I, as a business development professional continuously worked towards helping my healthcare and pharma clients in execution of desired initiatives, even within stringent budget restriction; organizational mid-year plans almost gave no way to training imperitives.

Trainings were largely imparted internally. Worst for corporates that had little internal training infrastructure. Training was barely a part of their year-on plans.

With the advent of 2010 just around the corner, healthcare and pharma companies need to revisit their intermediate plans and re-emphasize on critical training needs. So will they do.

Where is the problem then? Year 2009 plans have been on hold or hibernated. However, these training initiatives have been piling up and as the year 2010 begins, corporates will realize the over-burden of pending critical training tasks. Year 2010 will bring its own wealth of training needs and plans, added with the credited plans of 2009.

How are healthcare/pharma organizations planning to confront this? What mistake did we make in the sluggish year 2009?

With the begining of the economic meltdown, country governances announced practices for restricting funds to be recycled into respective economies.  Even though this proved to be beneficial for economic upliftment of regional economies, it somehow restricted corporate, majorly the SME mind set to roll on with standing plans and needs.

As corporates gear up allocating funds to new plans and needs, there may be several ways corporates can still unwind the pack of hibernated initiatives. With the begining of the new year, and we sincerely hope it to prove prosperous for all, corporates need to refocus on the pending and overloaded last year plans and needs. Partnering with vendors and partners that can help release the addtional task pressure will allow corporates to keep focused on forthcoming needs.

Some intelligent corporates have already understood this method of marking an effective begining of the new year. Such corporates have partnered with preferred vendors during the last months of year 2009 to accomplish left over training tasks. Amongst such corporates are majorly some proactive and foresighted Medical Device Manufacturers, Medical Software providers and Medical Product companies. Good to their foresight that they understand release and launch of newer versions of product during mid-year 2010 and hence the accumulating pressure to achieve associated training demands. It would definitely be a huge relief for such smart corporates to shed of back log of important goals and look forward to newer horizons.

As you plan for 2010,  would you afford overlooking 2009?

In my previous post, I sited a research project that found the average amount of journal reading in 2000 for a practicing internist was around 4 hours per month. This is not an awful lot of reading, given that there are 17,000,000 articles currently available in MedLine. Our field is especially prone to information overload, given the breadth of patients and illnesses we come in contact with. When I graduated from medical school, I did as I was told others did, browsed the medical literature, pulled out articles and put then in a “journal file”, and felt guilty about not doing enough to “keep up”. No wonder the average physicians’ medical knowledge base was directly related to when he or she graduated from residency.

Fast forward 20 years. The Internet was invented by Mr Gore and the personal computer by Mr Gates. Mark Ebell outlines how physicians should use the medical literature. He points out theat the most useful information is relevent, valid and takes little time to access. Computer accessable information is more useful that textbooks (many of which are outdated prior to hitting the shelf). Many physicians now use decision rules to help sort out complex clinical situations. These rules are typically evidence based and often have been validated in “real world” situations. Examples of such rules include the Framingham Cardiac Risk Assessment and the Wells Criteria for suspected pulmonary embolism. Services are now available which aggregate literature and offer clinical “answers to questions” that have been developed using a standardized process. Up-to-date is one such service popular with our residents. If a single journal article is used, it is important to look for those journals that have started to include an assessment of the evidence which supports the recommendations. Then there is searching the 17, 000,000 articles to find the needle in the haystack. What used to be time consuming and complex is now available to anyone on PubMed or Google Scholar.

In short, where previously 15 to 20 clinical questions went unanswered in a typical day, now access to clinical information at the point of service has never been easier. The most important thing is that it’s only going to get easier.

“Did you ever stop to think how doctors and other healthcare professionals learn to do intimate examinations? I’m thinking of vaginal and breast examinations in women, rectal examination in both sexes, and testicular examination in men. In order to be properly trained and competent, these skills must be learned correctly, but it is asking a lot of a patient to agree to additional probing just for the benefit of a fumbling student …” (more)

[Muiris Houston, Irish Times, 8 December]

Live a simple and a temperate life, that you may give all your powers to your profession. Medicine is a jealous mistress; she will be satisfied with no less. 

THAYER WS. OSLER THE TEACHER, IN OSLER AND OTHER PAPERS,  

One of my internal medicine attendings, Dr George Burch,  relayed this aphorism to us while we were in our first pre-clinical year at Tulane. The power of the medical education process is illustrated in the fact that I can still see myself in that auditorium watching this (seemingly very old) man offer this and the advice on how to counteract the siren call of medicine…”get a good book and sit under a tree and read.” 

Although we’d like to believe otherwise, Osler was correct. Being a doctor still entails a lot of study prior to completing training. Although the hours that are required in training for direct patient care are limited to 80 in a week, there is no limit to the amount of study time learners must put in to learn their craft. As a program director, I have tools that I use to assess student’s and resident’s medical knowledge and their ability to synthesize it into patient care. There is no substitute for study and preparation. 

Once out of training, physicians must maintain their clinical skills. They did so traditionally through meeting attendance, journal reading, and informally through conversations in the doctors’ lounge. Now things are more formalized with continuing education credits being offered for using the right tools to look up information regarding patient care, as well as our Board requiring us to take specialized instruction to maintain certification. 

All of this takes time. Internal Medicine specialists, when polled, reported spending about 3.3 hours per week on reading. The part of the evidence based practice incorporated into the new model of care in Family Medicine will require data input and physician and staff education. At this time, none of these efforts result in money into the physicians pocket (back to the mistress…) 

Why put up with it? Aside from the fact that it pays pretty well, I find that it really is an interesting way to spend a day. I get to work with people who occasionally want to be healthier. I get to learn about stuff in the news (and occasionally be in the news). Every now and again though, I pick up a good non-medical book and think about Dr Burch. 

I had a conversation today about a resident not in a family medicine program who wishes she would have chosen our specialty. Selection of a medical specialty often incorporates some of the common pitfalls in clinical medicine identified by Dr Goopman:

Anchoring – medical students tend to fixate on one specialty and do not open to other possibilities as they present

Availability – Students who identify with a resident mentor who was clinically strong will choose that specialty to emulate the resident

Attribution – Students will be offered stereotypes associated with various specialties from fellow students or non-physician teachers in the clinical years and will accept them rather than seek out information independently. They will then enter into the clinical years with this bias.

Fortunately, our specialty has put together a resource for medical students to assist them as they make career choices. They point out that 

“Students who choose family medicine, for instance, do so because:

• They appreciate being an integral part of the nation’s health care system as a primary care physician.
• They enjoy the full spectrum of care in having patients of all ages.
• They find they can relate to people and want to develop long-term relationships with patients.
• They enjoy a mix of seeing patients in community settings, performing procedures in-office, delivering babies, and holding in-depth patient consultations.”

We (and our patients) are fortunate to get folks into the specialty who think this way, especially if the student realizes that Family Medicine is for them early in his or her training…