“The extremes inform the mean, not vice-versa” – Timothy Ferriss
To the benefit of society, randomized controlled trials have formed the cornerstone of modern medical information. These types of trials have been instrumental in helping us characterize the best treatments for a number of diseases and conditions, improving healthcare quality overall. To make these studies applicable to the largest possible population, they are designed with very specific inclusion and exclusion criteria, which remove the atypical and extremes in order to formulate the best possible “average patient”.
However, in daily practice, a significant number of patients do not fit the criteria for being average. Despite not having a well-defined best therapy, these patients still need to be treated.
One of the most important parts of being a specialist in any field is knowing what to do when atypical or extreme situations arise. While the focus of most data available will be on the first, second, and third line therapies for the average patient, what really defines the experts among experts is knowing what to do in the most difficult situations.
This type of knowledge comes from three different sources. The first is experience, that for obvious reasons, takes years to develop. The second is by communicating with people with more expertise than yourself, which is made easier in the world of email and social media, but is still often limited to fairly specific questions.
The third option, which I find particularly high yield, is reading quality case reports and series in the literature. This portion of the literature allows you to actively seek out extreme situations and learn from them, which often have been written to summarize whatever data is available for guidance, often drawing on data from the more usual studies. As an added bonus, these articles usually end up being fairly interesting and memorable (or maybe just less likely to put you to sleep at your desk).
So, while it is always going to be important to keep up with the usual landmark trials in medicine, if you really want to separate yourself as an expert, you have to seek out the extremes.
Our medical patients are becoming increasingly complex. Patients come in with multiple preexisting problems and are taking many more medications than ever before. Electronic medical records (EMR) systems are being adopted across the country, with hopes that they will be able to help us organize and sort through the information in the patient’s charts.
The study compared using ICD-9 codes, (a system where each diagnosis is given a specific code [e.g. 714.0 for rheumatoid arthritis]) to the use of free text search to identify adverse events that occurred while the patient was in the hospital. The study showed that free-text search was able to identify more cases of acute renal failure than ICD-9 codes, and that the two methods were similar in identifying the other diagnoses included in their study (venous thromboembolism, pneumonia, sepsis, and postoperative myocardial infarction).
Many of the EMR systems that I have used personally have had limited functionality for searching within a patient chart. The EMR used by the VA in the above study, Computerized Patient Record System (CPRS), has had a search feature for some time.
While free text search will certainly be helpful in identifying adverse events after patients have left the hospital (and thus, help us learn to prevent further complications), it would also be helpful for clinicians currently working with patients in the hospital and clinics.
Why would advanced search function be helpful to clinicians? Because good patient care lies in the details.
We would be able to quickly and easily find (in a chart that might be a few inches thick if printed out):
The details of how a specific diagnosis was treated over time by going specifically to each note where that diagnosis was mentioned (e.g. making it easier to see that my patient with lupus nephritis may have never really gotten a good trial of MMF, before abandoning it as a treatment option) .
Specific details of side effects to medications (e.g. is this antibiotic listed as an allergy because of a rash and shortness of breath, or because of stomach upset?)
Finding the specific details of how a diagnosis may have evolved over time (e.g. such as how a patient with a scleroderma actually presented as a polyarticular inflammatory arthritis).
Details of why certain treatments were chosen at specific times (e.g. finding out that Dr. X chose a certain medication over another because of abnormal liver function tests at the time).
Also, further advanced search might be able to:
Fix our misspellings, or better yet, improve search accuracy by finding those misspellings within the patient record.
Suggest similar or related searches.
Search only records from a certain timeframe, or from certain physicians.
What about the problem of searching outside medical records — the records from another clinic that are scanned into the system? I see no reason that these cannot be searched equally as well as note that are written directly into the EMR sitting in front of you. Evernote, a free online service that I use to scan and organize documents, receipts, etc., offers the capability to search documents that I have scanned, and works extremely well.
Doctors enjoy seeing patients, and many clinicians consider the time they spend with their patients to be the best part of their day.
Unfortunately, for a multitude of reasons, doctors are unable to spend as much time as they would like directly interacting with patients. They can feel rushed to get to the next patient. Documentation, billing, and other paperwork takes up part of this time, and there is little that we can do about this. But what about some of the usual inefficiencies of the hospital, such as trying to locate a patient or trying contact other physicians (for instance, waiting by a phone after paging them, waiting for a callback).
Currently, more and more hospitals are adopting EMRs, and physicians are starting to embrace devices like the iPad, all with hopes that technology will optimize their time spent during the day.
Here are 7 ways that I think that technology could be used in the next few years to improve physician’s use of time in the hospital:
After first arriving at the hospital in the morning, my patient list would come up in order of priority, similar to Gmail priority inbox. With this, I’m able to see the patients that may need my more immediate attention, because of abnormal vital signs, labs, or because the patient’s nurse flagged the patient. Throughout the day, my patient list would be continually updated and prioritized by the system, with different alerts letting me know changes in the patient status, when abnormal vs normal tests have returned, or when a consultant has seen my patient.
I would be able to make a video call into the patient’s room as as I’m reviewing their chart. This way, if two or more patients may require more urgent attention, I’m able to visually triage where I’m going to go first. Speaking to them with the video phone, we could discuss the best time to visit in person, or get a sense if I should head to their room immediately. Also, I would be able to easily give them updates on test results quickly and easily throughout the day.
Instead of carrying a pager, I’ll have a smart phone with a fully functional EMR that I can use (for times when I don’t have my iPad or a desktop computer in front of me). Instead of paging, text messages with callback numbers to click on would be preferred for non-urgent issues, as opposed to directly calling physicians throughout the day (which could interrupt time with patients). More urgent issues could be given a different alert on my phone, with direct calls reserved for true emergencies.
If I have have any questions or want to discuss further while I’m reviewing notes from other physicians in the chart, I’m able to click on the name of the person that that wrote the note, bringing up a box that allows me to send a text message to their phone.
When I’m with patients, I’m able to show them their imaging and lab results on the TV in their hospital room, using Airplay on my iPad.
Patients have RFID tags on their wrist bands, which immediately update the EMR if they are somewhere else in the hospital, such as in radiology getting tests done, or just walking around the wards.
When doing my daily notes with voice recognition software, the EMR recognizes the diagnosis and problems of the patient I’m working with, and automatically brings up a number of references that I’m able to click to review, if necessary. Also, physicians are able to easily attach links to relevant journal articles within notes, with highlighting of key points.
Any other ways that we could possibly be using technology to improve time in the hospital? Share your thoughts in the comments…
People say the quantity of medical information doubles every 5 years.
Somehow each of us has to figure out how we organize all of this information that is presented to us.
Every great physician mentor I’ve known has been able to quickly pull excellent journal articles from their personal “archive” of literature that they’ve gathered over the years. Sometimes, these key articles directly changed the management of a patient for the better.
As any physician can attest, keeping up with current medical literature is no small feat. Journals seem to arrive in the mail on an almost continuous basis, and even after learning to quickly discard the “throw away” journals, they quickly pile up in offices, floors, bathrooms, etc.
Finding a way to organize, store, and quickly access the important articles is a critical skill for current physicians.
Enter the world of mobile technology. Only a few years ago, many medical residents were starting to carry around a palm pilot with references for drug prescribing and various medical equations.
Today, access to information on the internet is nearly ubiquitous. Almost everyone has a smart phone in their pocket that can access the internet at any time (either through high-speed 3G/4G networks or local Wi-Fi). We can hardly remember the days we actually had to go in front of a computer to Google something (much less try to remember what life was like before Google existed). The iPad was released in April 2010 (only about 15 months ago as of this writing) and has only further advanced how we access information.
Despite being constantly connected to the internet, only recently has “Cloud Computing” become popular, which is giving us new ways to store and access our own personal files from just about any location on earth.
My personal cloud storage service of choice is Dropbox, which I have been using since September 2008 (when beta invites first started becoming available to the public). With Dropbox, I’m able to keep files synced in a folder on Mac at home with my smartphone and iPad, as well as able to access those files from any computer I happen to be using with an internet connection. There are also ways built in to easily share your files with others.
Ways that I use Dropbox include:
Storing and accessing journal articles from multiple locations
Working on and accessing powerpoint/keynote presentations from multiple locations
Working on papers from multiple locations
Storing copies of a number of documents, including my CV, for access from any location
Storing the multiple login names and passwords for various things using a secure password manager (Personally I use KeePass on my Mac and Android phone; many people seem to prefer 1Password)
***I don’t advocate storing any confidential patient information on Dropbox. Although I think the risk of confidential patient information being lost is likely low, the potential consequences of any breach strongly outweighs any current benefits.***
As always, starting out with a new system for organization is a lot of work and takes a little discipline, but in the end, really makes it worth it when you’re able to find the article you want within seconds. Here’s how I do it:
Step 1: Organize the articles into folders based on diseases as below:
Step 2: Do something about the stack of articles already piled on your floor!
From here, you usually only need to enter the year, volume, and page number to find the article you are looking for:
And this is what comes up:
Now simply download the pdf, then put it in the appropriate folder. Dropbox will sync it and take care of the rest. If accessing these articles requires you to be at your local hospital or university library to access the journals, just login to your Dropbox account on the web and upload the files from that computer.
Step 3: Access your articles:
If you’ve made it with me this far, accessing your files on your desktop/laptop should be fairly straightforward.
For mobile devices (iPhone/iPad and Android), the Dropbox app has a built in pdf reader that works extremely well.
For accessing pdf files on the iPad, I personally use GoodReader. This app gives you the option of downloading a copy of your Dropbox folders, so you have access to them at times when Wi-Fi is not available. It also allows you to annotate your pdfs (highlighting, etc.) for later reference.
Any other ways that you are using cloud computing as a physician? Please, let me know in the comments!
I’ll be speaking on the second day of the conference, from 11:10-11:55am on Recent Advances in Rheumatology for Primary Care Physicians.
After attending this talk, participants should: “Be able to apply recent updates in the diagnosis and treatment of common rheumatologic conditions, including rheumatoid arthritis, gout, and giant cell arteritis.”
I’ll also be helping with the 7:00am morning Joint Injection Skills Course: Elbow, Knee, Shoulder and Wrist, on September 23rd.
Click here or on the above link for registration or more information.