Bringing you up to speed

The MedFriendly blog continues to grow in popularity and I figured that now would be a good time to bring people up to speed about what this blog is all about and where it is going. Basically, I started this blog as a way to share my thoughts on various medical and psychological topics, whether they are funny, sad, bizarre, etc. I often like to discuss some of the strange stories I hear from patients during the week. My posts tend to be very patient-centered. I like to see myself as someone who sticks up for the average Joe and exposes the problems in healthcare when appropriate. However, the positive aspects of healthcare are also discussed here. In an effort to bring diverse opinions to the blog, I arrange for a guest blogger each week. Sometimes, this is someone who runs another blog and sometimes not. For example, this week I expect it to be someone who posted to the blog recently but does not run his own blog.

This raises an important point. Your participation is CRUCIAL to the success of the MedFriendly blog. This means, I want to hear from you and read your comments. If I find them particularly interesting, you may get your very own guest blog entry one day. Also, there have been several times when one of the posts of a reader formed the basis of another blog posting.

If you are new to the blog, please see the index of blog postings to see what has been written so far. As you can see, there are many diverse topics. If you want to get started and have a few laughs, I suggest beginning with the You Can't Make This Stuff Up posts. If you want to subscribe to the posts, just click on the orange button on the main page.

In the future, I may begin a medical news story section each week, but would like to get some feedback from the readers on what they want to see and how they use the blog. Looking forward to hearing from you.

Look before you wipe

Ok, this story is disgusting so be warned. It is a true story though and I figured it would be good to share because it could prevent you from getting very sick. I went to a public restroom the other day (no feet tapping jokes please) to do mother nature's brown bidding. Many people, particularly those in a rush or who read when they are sitting on the pot, may blindly grab at the toilet paper and not look at it before wiping. Well…DON'T DO THAT. I actually like to check out the toilet paper situation before I sit down. After all, there is nothing worse than being on the pot and realizing there is no toilet paper left. Anyway, I looked down at the toilet paper roll and saw that there were brown spots all over it of unmistakable identity. It was pretty nasty as were the thoughts of how that could even happen in the first place. But I could not stop thinking about the body to body transfer of germs that could have happened if I unwittingly wiped myself with soiled toilet paper. I mean, I could have contracted hepatitis or something! I must confess that I am actually laughing while typing this because it is just so bizarre but it is a true story and maybe the weirdness of it will remind you to always…look before you wipe.

Don't let patients step all over you

For the most part, my blog entries are patient-centered. I don't like it when patients do not get treated fairly and if I see something wrong in the health care system, I am going to point it out. But on the flip side, I also do not like when patients try to take advantage of the system. All health care providers know what I am referring to. How many times have you had a patient in your office who you suspected was not as disabled as he/she claimed, asked you to fill out disability paperwork, and you filled it out against your better judgment? What was the real reason why you filled it out? My theory is that some health care providers are afraid to confront patients. When I say "confront" I do not mean yell, scream, make fun of, etc. Confrontation can actually be done in a respectful way and can be used to save you and your patient a lot of unnecessary nonsense.

Let me give you a perfect example. Trust me, this is worth reading. I once evaluated a patient who suffered a mild head injury (possibly a concussion) about two and a half years prior to the evaluation date. The patient always worked in manual labor jobs and reported that several months after the injury that he suddenly developed pain and numbness in both hands. The patient was evaluated by multiple physicians and the most anyone could conclude is that there was a mild cervical strain. No explanation for the hand symptoms though. For years, very physician stated he was disabled and it wasn't until very recently when one said he could go back to work without restrictions. However, others still stated he had some level of disability.

So the guy comes into my office and was very nice. On several self-report scale measures, however, the level of reported symptoms he described was much higher than groups of patients who had suffered much more severe injuries. His workers compensation benefits had been terminated and he was appealing the decision at the time I evaluated him. He was also working with an agency that was trying to get him back to work but every time they tried to help and put him through some work trials, he suddenly became too symptomatic to continue.

My job involves the administration of many objective tests to assess brain functioning but I also like to employ some non-standardized tests as well. The use of such tests can tell you a great deal amount a patient and they were popularized by the famous Russian neurologist, Alexander Luria. One test I like to use is called the pen test. In patient's who are paralyzed on one side of the body, have severe neurological damage in a part of the frontal lobes, or who have significant damage to the hand, the patient will not be able to grip the pen. It will slip out very easily. In just about any other patient, however, there is no way the pen is coming out. Even a five-year-old can grip a pen strongly enough that pulling it out will be very difficult without using significant force. So when I get a person who isn't paralyzed, doesn't have severe frontal lobe damage, and does not have something significantly wrong with the hands that can't hold on to the pen, I know the patient is not trying. Also, it is very easy to detect this while doing the test, because the examiner can feel that the patient is not gripping the pen as strongly as possible.

The first day I saw the patient, the pen came out of BOTH hands extremely easily. "Are you trying your best?" I asked. He said he was. I told him to try again and to imagine that I would give him a million dollars if I could not get the pen out. Same result. I could feel that he was not trying. So he came back for a second visit and we repeated the test. The same exact thing happened over and over and he kept saying he was trying his best.

So when testing was over, I pointed out to him how there were several times on testing where he told me he was trying his best but then when I asked him to try harder that he did much better, even though he originally said he was trying his best. I showed him concrete examples of this by showing him the test results. And then I said, "You know, I am not a physician, but I have done this pen test enough times that I know you were not squeezing the pen your hardest." The patient looked back at me as if I caught him with his hand in the cookie jar. And then I had an idea. I didn't think it would work, but if it did, I knew I would have invaluable information. I said to him, "So let's try this again shall we?" So I walked over to him again, put the pen in his hand, and for each side, I COULD NOT GET THE PEN OUT OF HIS HAND, that's how strong the grip was.

This is a perfect example of how respectful confrontation can be helpful. It helped point out to the patient and all his providers that he can do much more than he says he can and that people need to give this guy a motivational push to get him going. He was quite depressed and that was likely contributing to this motivational problem and highlighted the need to treat the depression. Two and half years of being essentially non-responsive to physical therapy and chiropractic care yet no treatment for depression before I see him. Go figure. So we have now identified why treatment of depression is so important and hopefully can get him back to work one day based on the results of the evaluation. The moral of the story: Don't be afraid to confront patients. If done in the right way, it can helpful to everyone involved. Incidentally, this approach will only work if you have a good bedside manner and have established a rapport. Doing so will increases the chances that the patient listens to what you have to say.

Guest blog entry: Confidentiality of records

This week's guest blog entry is from Dr. John Halamka who authors the blog, life as a Healthcare CIO. Dr. Halamka holds numerous titles which include Chief Information Officer and Dean for Technology at Harvard Medical School. He is also practicing Emergency Physician. Please check out his website to learn more about him and his work. His posting, written exclusively for MedFriendly, is below:

Protecting patient privacy is foundational to everything we do in healthcare IT. As CIO of Beth Israel Deaconess Medical Center (BIDMC), I am responsible for the security of 3 million patient records and 146 different clinical information systems. Each of these systems has a different audit trail, different access controls, and different technical protections. I have 4 full time IT security professionals to ensure we are protecting every aspect of our infrastructure - networks, operating systems, applications and databases. Security is a journey and each year we add more and more capabilities.

I believe that patients themselves will soon be the stewards of their own data, making decisions about what data is released, when, and to whom. A very important first step toward patient control of their own records is a national set of security standards which can be used by all vendors, payers, providers, and employers in their electronic health records and personal health record systems. On October 15, 2007, the national Healthcare Information Technology Standards Panel completed a year long consensus effort to specify standards which empower the patient to record their own consent preferences and then apply these preferences electronically over a network or on transportable media (such as CD or thumb drive) to control access to records. This effort is described below

http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/10-23-2007/0004688224&EDATE=

Full details are available at http://www.hitsp.org by clicking on the link labeled

HITSP Security and Privacy Documents HERE

These standards will certainly help me to enhance my own heterogeneous clinical systems at BIDMC.

Over the next year, HITSP will publish additional interoperability specifications for personal health records, quality measurement, and clinical summaries that will enhance safety and ensure that confidentiality is protected for all uses of data.

Halloween poisonings

Halloween is soon upon us and the stories of children being poisoned by crazy loners will surely surface yet again n many households across the county. But have you ever wondered if these stories have any basis to them or if they were just myth? I did and so I did a little research and here is what I found out. Please pass this alonf to your friends and family.

THE FACTS ABOUT HALLOWEEN POISONINGS

One concern many parents have is that some crazed madman will place poison or place hazardous objects such as razor blades in the Halloween candy and randomly hand it out to children. Although one can never rule out the possibility of this happening, it appears very rare indeed. Below is a chronological listing of reported Halloween candy “poisonings” and the facts that surround them. As you will see, the vast majority of cases turn out not to be actual poisonings.

1964: Probably the earliest case associated with an alleged Halloween “poisoning” was when Helen Pfeil, of Greenlawn, New York, handed out arsenic-laced ant poison buttons to trick or treaters. Arsenic is a type of element found inside the earth’s crust, which has been used for centuries as a poison because it is slowly released from the body. As a result, it can quickly become toxic. Ms. Pfeil was handing out the arsenic buttons because she was upset that children who were too old were coming to her house to trick or treat.
The buttons were handed out in a bag that also included dog biscuits and steel wool pads. The buttons were marked “poison” and had a skull and cross-bones on them. Ms. Pfeil reportedly also told the children that the bags she was handing out was meant as a joke. Even though no child was harmed, she was still charged with endangering children, pleaded guilty, and received a suspended sentence.


1970: In Detroit, a 5-year-old boy named Kevin Toston died from a heroin overdose. Heroin is a very powerful illegal drug that is similar to morphine (a pain reliever), but which has no acceptable medical use in the United States. Although it was originally reported that heroin was found sprinkled on the child’s Halloween candy, what actually happened was that the child found his uncle’s secret heroin stash, ingested it, lapsed into a coma, and died. The family then sprinkled heroin on his Halloween candy to protect the uncle! A coma is a state of deep unconsciousness in which there are no voluntary movements, no response to pain, and no speech.

1974: This is the year of the most famous case of Halloween poisoning. In Houston, Texas, Ronald Clark O’Bryan (sometimes referred to as “The Candy Man” and “The Pixie Stick Killer”) killed his son (Timothy) by placing cyanide in a type of candy known as Pixie Sticks. Cyanide is a type of highly toxic chemical compound that contains carbon which is strongly bonded to nitrogen. Carbon and nitrogen are two common types of elements. Cyanide is highly toxic because it interferes with the ability to breathe.

O’Bryan killed his son to collect $20,000 in life insurance. He attempted to cover up the crime by distributing the candy to another one of his children and three other children. He apparently placed the candy in their bags while accompanying them during trick or treating. Fortunately, the other children did not eat the candy. O’Bryan was convicted in May 1975 and was executed via lethal injection on March 31, 1984.

1982: In Detroit, a youth became ill and was taken to the doctor, who misread the lab results and concluded the child had cyanide poisoning. The doctor went public with allegations that someone poisoned the child’s Halloween candy. Further tests to determine what was wrong with the child were inconclusive and later tests of the candy by the Food and Drug Administration were negative (meaning there was no trace of cyanide found).

1988: Maryland Hospital Center discovered a needle in a candy bar when some Halloween candy was X-rayed. The case was never solved.

1990: In Santa Monica, California, a 7-year old girl named Ariel Katz died of heart failure while trick or treating. However, the child had heart problems from birth and the autopsy stated she died of an enlarged heart.

1991: In Washington D.C., a 31-year old man named Kevin Cherry died after eating some of his child’s Halloween candy. As it turns out, he coincidentally died of heart failure, which was unrelated to eating Halloween candy. However, the story was enough to cause widespread panic.

1994: After Halloween, a 3-year-old child in New Britain, Connecticut was diagnosed with cocaine intoxication. However, more than a week later, police stated no traces of cocaine or any other illegal drugs were found in the leftover Halloween candy. The child reportedly had a habit of placing anything in his mouth, so he could have become sick after ingesting some household substance.

1996: In San Jose, California, a 7-year-old named Ferdinand Siquig collapsed after eating candy and cookies he was given while trick or treating. Initial urine analysis showed traces of cocaine, but additional tests performed by other labs came back showing no traces of cocaine.

2000, STORY #1: In Minneapolis, Minnesota, James Joseph Smith was charged with intent to cause death, harm, or illness after handing out candy bars with needles in them. One child was pricked with a needle when biting into a candy bar but no one was seriously injured.

2000: STORY #2: In Hercules, California, some candy bars were made up to look like Snickers bars but were actually marijuana packets. Police traced the “treats” back to the homeowner, who denied any purposeful involvement. The story provided was that a box of what appeared to be Snickers bars were left at a post office without enough postage or an incorrect address. With no way to return the box to the sender, the homeowner (who worked in the post office) took the box home and decided to hand it out as Halloween candy. The homeowner thought he was handing out a treat, but the trick was on him in the end.

2001: In Vancouver, Canada, a 4-year-old named Tiffaney Young died after eating Halloween candy. However, the cause of death was later determined to be a non-contagious bacterial infection. The candy had nothing to do with her death.

IF CHOCOLATE LOOKS GRAY, IS THAT BECAUSE IT IS POISONED?

Most likely not. Chocolate most commonly appears gray when exposed to too much heat or moisture. But a good quote to keep in mind is “When in doubt, throw it out.”

THERE IS WHITE POWDER OUTSIDE MY CANDY BAR. IS THAT POISON?

Most likely not. The white powder that sometimes appears on the surface of candy is usually salt, sugar, or cornstarch that was not completely taken off during manufacturing.

WHAT PRECAUTIONS CAN I TAKE TO PREVENT MY CHILD FROM EATING TAMPERED CANDY?

First, make sure you know where your child will go trick or treating and be sure to avoid dangerous neighborhoods. Make a rule that no candy can be eaten until returning home and inspect the bag for any obvious signs of tampering. You may want to have a rule that you will not eat anything homemade, unwrapped, or which has a torn wrapper. Examine the candy for anything that looks suspicious and when in doubt, throw it out. Although x-rays would detect metal fragments in the candy, it would not detect poisonous liquids, which is why few medical facilities use x-rays with Halloween candy.

WHAT OTHER SAFETY PRECATIONS CAN I TAKE ON HALLOWEEEN?

Besides not eating candy that is homemade, unwrapped, or has a torn wrapper, one of the most important safety precautions is to remind children to look both ways when crossing the street. This is because children are at increased risk of dying in a car accident on Halloween after running across the street to get candy. Other safety precautions include using a flashlight at night (to make it easier to see and easier for drivers to see those with costumes), going out in groups, and avoiding houses that are unlit. Adult supervision is recommended.

Make sure costumes, such as princess outfits or those with capes are not so long that they pose tripping hazards. Avoid masks that obstruct vision. Avoid running to prevent tripping and falling. Motorists should not drive any faster than 5mph in residential neighborhoods on Halloween and should be very alert to the presence of children.

A final precaution has to do with the use of cosmetic contact lenses that some children uses as part of a certain costume to make their eyes appear a certain color. Cosmetic contact lenses, like corrective contact lenses, are medical devices that require a prescription. If cosmetic contact lenses are not used properly, permanent eye damage can result, with the worst case scenario being blindness. A example would be an infection of the cornea leading to blindness. The cornea is the clear covering at the front of the eyeball.

According to an amendment to the Federal Food, Drug, and Cosmetic Act, all contact lenses sold in the U.S. must be fit and dispensed by a professional eye care specialist. Unfortunately, many children are getting contact lenses without a prescription. This makes it less likely the person will get a proper fit and learn how to properly care for the contact lenses. With proper fitting and instructions, contact lenses can be worn safely.

Proofread your dictations!

Ok, I've had it. I am constantly reading notes from nurse practitioners, physicians, and other psychologists that were dictated. To those who are unfamiliar, many health professionals dictate their notes into a recording device. The recording is later translated into a note in the hospital computer system. The health care provider then gets an email to proofread the note, accept it, and finalize it. If it is not finalized, the person who dictated the note can get in trouble.

As you might imagine, the people typing the dictations are not physicians. They have taken some classes about medical terminology but they cannot understand every word spoken, especially with the high number of residents that do not speak English as their primary language of who have a thick accent. So the person preparing the dictation often puts a line like this: _______ to represent words that were not dictated. The person who dictated the note is supposed to go through the note and fill in the blanks.

Every day, I come across notes that were finalized but still have blank lines in them. This clearly shows that the person did not actually proofread the note and only finalized it to avoid getting a nasty gram from the hospital. I once heard a health care provider say "I don't have time to read them anymore. I just finalize them and hope they got it right." Excuse me, but… WHAT?! If you don't have the time to proofread the note, it is time to see less patients. The medical record is a crucial piece of information that when it is not proofread and is left with either incomplete or incorrect information, it diminishes the ability of other providers to fully understand the case. This is poor practice.

Are my reports mistake free? No. That's impossible. But when a mistake is found, I know I can tell myself as much as is reasonably possible to prevent one. That is, I write all my own notes and never dictate, I read the report once on the computer, and then I read I again after I print it out on paper. Overkill? Nope. I always find something to correct on both versions I proofread.

My end message: Please take the time to proofread the reports of your patients. It is the final product of the visit and is a permanent record. The patients are relying on you. Don't let them down.

Guest blog entry: Scalpel or Sword

This week's guest blog entry is from the author of the medical blog…Scalpel or Sword. The author of the blog is an ER physician in Texas and I urge you to give it a look. Today's guest entry adds to that of a former guest blog entry about preparing for ER visits. This entry was written exclusive for the MedFriendly with blog and with that, here is the entry:

I’m going to expand on Kim’s excellent suggestions for making your ER visit go more smoothly for you and the staff.

1) In addition to your list of medications and your medical and surgical history, be sure to write down your history of allergic reactions to medications. It really isn’t much help if you tell us that you had a reaction to “some antibiotic.” There are literally thousands of medications out there, and many of them are chemically related; we need to know precisely which ones caused you problems. The specific reaction that occurred is also helpful, with the most important examples being rashes, swelling, difficulty breathing, or fainting. Even medications that caused you unpleasant side effects or that your doctor has recommended you avoid should be included. If a certain blood pressure medication caused your kidneys to fail or your heart to slow down too much, go ahead and list it under allergies although it isn’t really a true allergy.

2) Bring copies of your previous workups with you if you are coming to a different hospital. Discharge summaries, CT or MRI results, lab tests, and procedure reports are particularly helpful. If you bring us this information, you will have a quicker and more cost-effective evaluation.

3) If your doctor tells you to come to the ER to be admitted, understand that
a) he probably hasn’t notified either the ER or the hospital to expect you
b) you are going to have to be triaged and wait in line, depending on the severity of your illness
c) he probably hasn’t told his partner who is on call for him anything about you whatsoever, so
d) you ultimately might not be admitted after all, and
e) this is not the fault of anyone in the ER, it is your own doctor’s fault for misleading you
If your doctor ever tells you to go to the ER, ask him to clarify his intentions or even to make you a "direct admit" so that you can avoid the ER altogether. Ask him to call the ER to let us know you are coming so that we can provide continuity of care.


4) Know exactly why you are coming to the ER and accept the fact that you are going to have to tell at least three different people why you are there. The triage nurse, your ER nurse, and at least one physician will need to hear you tell us why you are seeking medical attention. Don’t expect us to have already “read your chart” - each of us needs to hear you explain your condition directly. Here’s why: when you repeat your story, you are more likely to remember important details, and when different interviewers hear your story, we are more likely to extract subtle but potentially critical bits of information that might be missed if you only tell us one time. Plus, you get to rehearse so that you can get to the point when the physician finally sees you.

Try to be focused and concise. We don’t care what your granddaughter got for her birthday or what your sister’s husband thought might be wrong with you. Just tell us your symptoms. If you have a pain, we need to know exactly where it is located, what it feels like, when it started, how often it happens, what makes it better or worse, and any other symptoms that are associated with it, among other things. Adding extraneous commentary, particularly during the initial phase of your evaluation, makes it more likely we will cut the interview off short and miss some potentially useful information.

5) Be patient. You are likely going to be waiting a long time, particularly if your condition is not life-threatening. If you are not having abdominal pain, chest pain, trouble breathing, neurologic deficit, or a severely traumatic injury, then you are going to have to wait behind those who do have such issues, and it may take hours for you to be seen. Be thankful that you are not as ill or injured as those other folks. Understand that the purpose of the ER is to prevent death or disability, not to promptly treat your stuffy nose or sprained ankle.

If you think that you might have been overlooked or that your condition is becoming more serious, then please let the staff know, but do so in a calm, nonthreatening, nonabusive manner. We do occasionally misinterpret the severity of someone’s condition, and occasionally charts do get lost in the pile. But yelling at the staff simply because you are unsatisfied with the waiting time is not going to help your situation.

Tacky blood donor solicitation technique

So I was going to the post office one day, minding my own business. All I wanted to do was mail a letter, go home, and relax. I pulled into the parking lot of the post office, parked my car, and there it was -- the blood donor mobile. Now, I don't have any problem with donating blood, people who like to donate blood, or people who ask for blood donations. But there is a right way to do it and a wrong way to do it. The right way is with an educational campaign explaining the importance of donating blood for use in medical emergencies that may involve you, a neighbor, or family member. The wrong way is to lay guilt trips on people and almost equate them to murderers.

The blood donor worker at the post office was soliciting people on the way out with this question, "Do you want to save a life today?" Psychologically, this is a classic sales move knows as the foot in the door technique. You start off with a question that you know the person will have to answer a certain way. After all, who is going to say "No, I don't want to save a life." And if you don't want to save a life, one could also argue you chose NOT to save a life, which can at least be considered, say, negligent homicide? I'm being a bit facetious here, but the question asked was exactly how it was posed above and it worked on every single person I saw go through the door. It completely turned me off though. So as I walked out, the person asked me if I wanted to save a life and I turned to her and said "No." The expression on her face was priceless.

The Misuse of Physician Assistants and Nurse Practioners in Modern American Medical Practice

By far, the most popular blog posting I wrote was the series entitled 5 Things I Can't Stand About Going to the Doctor. The series has been posted on numerous medical blogs and has received a fair amount of commentary, particularly on the issue of the misuse of nurse practitioners. In today's posting, I wanted to expand on my thoughts about this topic.

First of all, I want to again clarify that nurse practitioners (and physician assistants) serve a very valuable role in the medical setting. As one anonymous poster correctly pointed out, they improve access to healthcare because there are not enough physicians to see all the patients. If a patient knowingly makes a choice to see a nurse practitioner or a physicians assistant over a physician, that is fine by me. That is the free market at work.

Where I have a problem is when patients are unknowingly and essentially forced to see a physician's assistant or a nurse practitioner. What do I mean by "forced?" Well, take the example of a patient who waits for months for a doctor appointment. The patient shows up and after waiting for a long time because the office is double-booked, is then told that he or she will be seeing the physician assistant or nurse practitioner. I have had patients tell me that they are sometimes told there is no big difference and that it's pretty much the same thing, which is outrageous. I have also had patients tell me that they are told they can reschedule to see the physician if they prefer, but that this will take another few months. So if you are the patient and you have a medical problem, and you waited months for an appointment, what are you going to do? Most people are going to go ahead with the appointment. Sure, the patient could technically leave, but then he/she goes another three months without any medical attention. Therefore, the way I see it, the patient in this scenario is essentially forced to see someone he or she did not plan to see. This is why I use the word "misuse" because it is the responsibility of the physician to make sure this does not happen.

Another thing to keep in mind if you are a physician or nurse practitioner is that many patients have no idea about all of the different medical professions and if you do not tell them who you are they will think you are a doctor, especially if you wear a white lab coat and have a stethoscope. The introduction when meeting the patient should not be "So Jim, what brought you in to see me today?" There NEEDS to be an introduction of who you are. Every week, I wind up needing to correct patients that the person they are calling Dr. Smith is really a physician's assistant or nurse practitioner. Full disclosure is the best policy and would solve all of these problems.

I want to hear from YOU

It’s time for a reader question - how can I make the MedFriendly Blog more useful for you?

Every year I plan to ask readers this question in an effort to keep improving the blog. Here are some areas you might like to comment on:

• Topics - are there topics (specific or general) you’d like covered in the coming months? What would you like to hear about most for the remainder of the year?

• Types of Posts - reader questions, news commentaries, patient-centered guides, guest posts….have your say about what you’d like most/least.

• Posting Frequency - too many posts, not enough, just right?

• Design - if you have design tips, let me know.

• Blog Features - what would make your reader experience better?

• Community - do you feel you connect well with other readers? Are there features that you’d like added to help connect more?

• What Frustrates You about The MedFriendly Blog? What is Best about it?

• Other Ideas and Feedback - anything goes, big or little.

The ‘Rules’ - Any feedback, suggestions, or ideas that you have are welcome. While I can’t promise to respond to each comment or put every suggestion into place I make a commitment to you to read anything you have to say.

All that I ask in return is that you be honest, courteous and constructive with your feedback.

So it’s over to you. Feel free to either leave your feedback in comments below or to share them privately with me via my Contact Page.

Publish or Perish - part 5: Fishing for data

This going to be the last entry for the Publish or Perish blog series…at least for now. I wanted to end off by mentioning a little trick that some researchers like to use to get their studies published. Before I mention that trick though, let me tell you how research is supposed to work. In real research, someone forms a hypothesis (educated guess) about a particular area of interest and then designs a research study to either confirm of disconfirm that hypothesis. For example, let's say a researcher believed that eating pizza for dinner every night will cause cholesterol to be higher compared to people who ate salad for dinner every night. In this case, the researcher would run a study under controlled conditions in which there was a pizza group and a salad group. The researcher would collect cholesterol levels before or after the study and the hypothesis would be confirmed or disconfirmed.

In real life, researchers do not always find the relationships they expect to find. Some will try to publish unexpected findings but others will not even attempt to do this because they assume the editors will not find the results interesting. There are exceptions, but generally, researchers try to publish studies where there are statistically significant findings. In the quest for statistical significance, some researchers collect a bunch of assorted data points and try to find some type of statistically significant relationship between them. This is known as "fishing for data" and there is nothing inherently wrong with it as long as one admits that this is what they are doing. The problem is that many people do not admit it, find some type of significant relationship between two variables (for example, cholesterol levels decrease after drinking a certain juice) and then act like they had hypothesized this all along. They are working backwards rather than forwards but it makes the paper look better and increases the chance of getting it accepted for publication. In the end, this hurts science because the authors are not being honest in how they obtained the data. For example, the more analyses conducted, the more likely that some findings will be detected by chance and do not actually exist. So if you are going to go fishing, please be honest about it and don't pretend that you are doing hypothesis generated research.

Guest blog entry: Dr. Anonymous

It is time for the weekly guest blog series and I am happy to reveal this week's guest blogger, the well known medical blogger, Doctor Anoynmous. He is a family physician in Ohio who has a fascinating blogging website that I urge you to check out by clicking on the link above. As usual, this blog entry was written exclusively for MedFriendly.com. With that, I give you Dr Anonymous…

Family Physician: The Doctor For You

If I were to ask you the definition of a Family Physician, what would you say? Most people would say it is the doctor you go to for your cough and colds. And, this is true, but the specialty of Family Medicine is so much more.

Family Medicine physicians specialize in ALL of you. What do I mean by that? Some docs don't have to look at a chart to know your name or know how you're feeling. Family medicine focuses on the physical, mental, and emotional well-being of their patients and families. We know how your family's health history and social situation can affect your health.

Family Medicine physicians receive training to become familiar with the most up to date technologies and treatments. Preventative medicine philosophy is something that is emphasized and is a priority in Family Medicine. Preventing a health problem is definitely better than trying to overcome one.

Family Medicine physicians take the time to synthesize and synergize information from a variety of sources whether it be from you, your family, from the latest medical literature, from the internet, and from other specialists - to give you the best health care possible.

I'm proud to call myself a Family Medicine specialist - a physician who specializes in all of you.

Thanks so much for the opportunity to write a guest blog entry for MedFriendly.com. I invite you to take some time to visit my blog at DoctorAnonymous.com to learn more about me.

Publish or perish - part 4, Politics and publishing

I figured I would continue this blog series with another example of how politics and research often intersect. When I was in graduate school, I attended a local conference for my field in which one of the keynote speakers was a very well-known researcher. He is an elderly gentleman and was reflecting on his personal career during the speech since he had won a lifetime achievement award. One of the topics he discussed was the numerous times where his papers were rejected based on personal politics and not based on the scientific merits of the study. When I say personal politics, I am not referring to whether you are a Republican or a Democrat. Rather, I am referring to the positions one takes on certain issues. For example, there are some people who believe that fibromyalgia is a legitimate diagnosis and others who believe it is really more of a psychiatric problem.

Let's say you did a research study that showed there was a link between a particular blood test finding and fibromyalgia. Well, this would now run counter to the beliefs of those who believe this is impossible and if the paper was sent to one of these people for review, that reviewer may go out of his/her way to poke holes in the study so as to provide grounds to reject it. This is even more likely if the study is going to show findings opposite of something the reviewer has published in the past. Now, just because the paper is rejected from one journal does not mean it won't be accepted somewhere else. It just delays the process significantly because the reviews take months and sometimes up to a year, depending on the journal and the backlog.

There is a saying in research that if you send your study to enough journals, eventually you'll find someone who will publish it. That is probably an exaggeration, but there are now so many journals for every field of science these days that papers of lower quality are more likely to get accepted. Click here for the next post.

Publish or perish - part 3: the problems with blind review

When someone submits a research paper to a peer-reviewed journal, the editor sends the paper to several people in that person's field of interest who have some knowledge of the topic being written about. These people may be members of the editorial board or they may be guest reviewers (people not on the actual editorial board but who have specialized knowledge on a certain subject). The reviewers have usually authored numerous research publications, making them suitable to analyze and criticize submitted manuscripts. I have served as a guest reviewer for the top journals in my field and have found the process very interesting and time consuming -- if you are going to do a good job.

There are two main ways that an article will be reviewed. There is either a blind review or a non-blinded review. In a non-blinded review, the identity of the authors is known to the reviewers. In a blind review, the identity of the authors is kept secret. Blind review is preferable for many reasons. You would be surprised how much of a small world it is when it comes to one's scientific specialty area. Blind review is an attempt to reduce potential bias on the part of the reviewer. That is, articles are supposed to be accepted based on their scientific merits -- not based on who you do or do not know.

So here is the little secret about blind review -- there are plenty of ways around it. Let me give you two of the most common techniques used to get around blind review. Let's say Dr. Smithers is well-known for his research on Alzheimer's disease. He submits a study for publication and while writing it, he lists a disproportionate number of references that he authored. Any reviewer will likely conclude that the article was authored by Dr. Smithers, particularly if the conclusions are described as supporting the prior work of Dr. Smithers. Now, Dr. Smithers is no fool. Dr. Smithers knows Dr. Franklin, the editor of one of the major neurology journals. So before Dr. Smithers sends the article out, he sends an email to Dr. Franklin letting him know to "keep a lookout" for his article. Guess who decides which sub-editors will review the paper? You guessed it -- Dr. Franklin does. And guess what else? Dr. Franklin knows full well which sub-editors will give a very thorough and intense review and which will give a cursory review and likely recommend accepting the paper. If Dr. Franklin feels like doing Dr. Smithers a favor, he will send the paper to the more lenient reviewers. In the end, Dr. Franklin is also within his rights as the main editor to override the recommendations of the reviewers and publish the paper no matter what. It just goes to show you -- whenever there are people, there will be politics. So while blind review is a good idea in theory, there are plenty of loopholes to get around it if you are savvy and political enough. Click here for the next post.

Publish or Perish - part 2

The other day, I began the Publish or Perish blog series. In the next few days, I hope to bring you some examples of the biases and corrupting influences that occur in the name of research. Keep in mind that these examples are not meant to put a black mark on all researchers because many do a fine job indeed. And without research there would be no medical advances. However, that does not mean there are no problems and I want to give you some insights into those.

I once worked with a physician (we'll call him Dr. X) who did research in a specific area and with a specific population. This physician was and still is very ambitious and was set on becoming the top researcher in his field. He had dreams of multi-million dollar grants, articles being published in the New England Journal of Medicine, and the like. One day, the hospital hired another physician who had similar research interests and specialty knowledge in the same area. Dr. X did not take very kindly to this and arranged a meeting in his office. Dr. X informed me that he told the new doctor (I'm cleaning this up): "Do not mess with me and interfere with my research. Get involved in something different or I will destroy you." Having known Dr. X for awhile, I do not doubt that he said these words. The other doctor meekly went away and never interfered with Dr. X's work. Dr. X is now becoming more and more well-known and is meeting his ambitious goals. But at what cost? I think this example shows how power can be corrupting. If this was really all about research and helping patients, there would not be a problem collaborating with another researcher in the same institution. Sometimes, however, egos get in the way. Click here for the next post.

Blog update and Guest blog entry: The Medical Quack

I will return to the "Publish or Perish" blog series tomorrow, but today it is time for the weekly guest blog entry. Before I do so, just a few updates. Remember that I now have an index of blog postings which can always be found to the left of the page. This link allows you to peruse all of our prior entries. If you haven't read the You Can't Make This Stuff Up series, please do so as they are very interesting. Also, one of my old posts has garnered some recent interests. If you have an interest in the topic of ADHD, please share your thoughts at the ADHD for everyone! blog entry.

And now, let's get to the guest blog entry. This weeks guest blog entry was written exclusive for MedFriendly by Barbara Duck, who tongue-in-cheek refers to herself as The Medical Quack. Her entry discusses what she does so without further ado, I turn it over to The Medical Quack…

As a developer and Microsoft partner, I feature new software applications that have a place in health care, and try to give some examples of how software can benefit both physicians and patients alike. This week I featured the new Health Vault from Microsoft which looks to be a good tool for patients to be able to store and share medical records with their physicians. I feel this might turn out to be the best and most functional tool in the PHR (personal health records) area available to all. Health care is something we all need to take an active part in today and with both patients and physicians working to communicate with new and updated technology, we are all working towards a better health care system for all. New technology stands to benefit all and I absolutely try to fill the page with as much beneficial information as possible as well as some posts that are just very interesting. I would urge anyone to take a look at this new and upcoming resource with the Health Vault even if you decide not to participate immediately, at least it will give you an idea of how the world of health care is continuing to evolve.

The Medical Quack website is a mixture of many important and interesting articles as related to Health Care. I focus on many items of interest to include the daily news of what's happening in health care all the way to the other end of the spectrum on dealing with technology. The site also has some valuable and easy to use resources that everyone can use. I also like to have a little fun here and there and have included a humor section for those days when we all need a lift.

Technology is addressed almost every day as it is fast becoming a main stay and sometimes we include some interesting and informative videos from You Tube as they relate to items discussed. Sometimes things may get a little political, but I keep everything open for all to feel free to comment. Medicare and Insurance related stories are covered and sometimes just some good old human related stories are featured at well.

Daily updates on several health topics are listed as well as the latest FDA approvals and related information. If you take a little time to search around there are some helpful links for physicians for billing software, links to live surgeries, and some free clearinghouse services. For patients who visit the site, I have some permanent links to the $4.00 prescription pages offered by a few retailers along with links to other sites such as the Patient's Guide to Valve Surgery.

Daily news posts contain quite a bit of information regarding the latest and greatest medical technology and I like to talk quite extensively about the use of both PDAs and Tablet PCs in health care. If you have any questions related to Tablet PCs and mobility, you might find something of interest here. Tablet PCs are fast becoming the main stay of mobility for physicians and I attempt to provide some examples and perhaps real use scenarios with both the hardware and software itself, again as it relates to health care and paperless is spoken here. Someday in the not too distant future you, the patient, may be handed a tablet to enter your information too, there are some facilities and hospitals doing this today! We provide Tablet PCs from Tablet Kiosk, the best slate tablets available for health care professionals and update material and information as it becomes available. For any physicians who may be reading this , I am also very active in another site called EMR Update. This is what I call the "hard hat" area where the Geeks and Docs come together, sounds unusual, but there's many good discussions and information available here too, and not a bad place to check in and see what the physicians are talking about.

Publish or perish -- part 1

Today, I am beginning a series on the politics of research. I am not certain how many entries this will entail, but there will definitely be a few. One of the reasons I started this blog was to give the average person some realistic insights on how things really work in the medical field. Although my posts tend to focus on the clinical aspects of my job, I have a fair amount of research experience, have published numerous peer-reviewed journal articles, and have presented research all across the county at various conferences.This information is not provided for bravado, but to provide you with the knowledge of where I am coming from in terms of my perspective.

I would say that one of the main things I have observed over the years is that research seems to be more about inflating one's ego and padding one's resume for the purpose of self-promotion. Of course this does not apply to everyone, but it is a general trend I have observed. Although this may seem cynical -- consider the following. The more publications one has, the easier it will be to be move up the ranks in any academic medical institution or university. You start off as an assistant professor (which is what I am), move up to associate professor, and then go up to full professor (also known simply as "professor"). Moving up is largely based on the number of publications you have. To become a full professor is a great honor and is associated with a respectable increase in salary and other perks such as tenure. More publications means that you will be in high demand to give speeches in your area of specialty, which commands thousands of dollars per speech. More publications also means that you may be in demand for various media interviews and also requested to testify as an expert in court, which also commands a hefty fee.

While this all sounds terrific and I certainly would not want to restrict anyone making money off of what they know -- all of these extra publications come at a cost. The main cost I have noted is that there are far too many studies conducted that have no practical applicability. For example, I once reviewed a study where the researchers were trying to show that a memory technique they developed improved memory abilities in patients with a certain neurological disease. How did they prove this? They showed that the patients who were taught the technique could remember one more word from a word list than those who were not taught the technique. Excuse me but….who cares? How does that translate to real life in any way? The study was grant funded and probably cost tens of thousands of dollars. All that money to shows that one group of patients could learn one more word than another. But you see, as long as another publication can be added to the ol' resume, that is really the main thing that matters to some researchers. As for me, my number one priority is to publish and present research that helps patients or the clinicians who treat them. Anything extra that comes after that goal is achieved is fine by me. Click here for the next post.

A tribute to Phil Hendrie

Thanks to all who add their comments to this blog because it helps me develop ideas for additional entries. Yesterday, during my posting about multi-tasking, I had commented about my favorite radio show -- The Phil Hendrie Show. Someone then asked about what is going on with Phil's neurons (brain cells). I have often wondered the same thing. Many of you reading this may have no idea what I am talking about. Phil Hendrie used to have a nationally syndicated radio show from 1999 to 2006. The show became renowned for its unique and controversial guests. But here is the catch…the guests were not real people—they were fictional characters created and voiced by Hendrie himself.

So you may be asking two questions at this point: 1. "So what?!" and 2. "What does this have to do with anything medical?" Starting with question 1, what Phil Hendrie did was carry on long conversations between himself and the fictional character (and sometimes multiple characters in the same skit). In addition, he would seamlessly transition between the multiple voices with the callers he provoked to call in due to the outrageous things his "guests" would say. Listening to it, I always marveled about how on Earth he is able to maintain such mental control as to never make a mistake when performing this feat. I have listened to hundreds of hours of this show and have never heard him make a mistake crossing over voices. Sometimes, he'll laugh in the middle of a character because what he is doing is so outrageously funny, but that just makes it funnier to the listeners who know what is going on.

Now to the medical part. As a neuropsychologist, I marvel about what Phil does because I realize the extraordinary level of frontal lobe functioning required. To those who may be unfamiliar, your frontal lobes play a significant role in higher level cognitive skills known as executive functioning. Examples of executive functioning include multi-tasking, planning, organization, and abstract thinking. The ability to do these activities quickly is another aspect of executive functioning. Phil Hendrie's speeded multi-tasking skills and creativity are second to none. For those who are interested, the man has created over 60 characters which are described here. My personal favorites are Chris Norton, Jay Santos, Herb Sewell, and Ted Bell.

In sum, Phil Hendrie is literally the most ingenious and creative radio personality who ever lived. And Phil, if you ever read this, please send me a coffee mug from Ted's of Beverly Hills, have a "Ted" on me, tell Walter Bellhaven I have some Japanese gardening tips for him, give Jay Santos a tip of the cap (or pith helmet), and tell Chris that all the girls in Syracuse think he is just so darn "sessy." I'd love to hear from any Phil fans or even the man himself.

Multi-tasking: part 2

I wanted to take the opportunity to follow-up on my multi-tasking entry yesterday due to one of the comments I received that suggested multi-tasking decreases the enjoyment of the tasks you are doing. This does not have to be the case. For example, while I am writing this I am downloading music to my ipod and enjoying both activities and enjoying them as much as if I did them separately. Earlier tonight I was on the exercise bike and listening to my favorite talk show (The Phil Hendrie Show). The key to making multi-tasking work is to make sure the tasks you have chosen to multi-task with are compatible. In other words, doing one should not interfere with the other. Therefore, trying to read a novel and watch a movie at the same time would not make sense because one would distract the other. But riding an exercise bike while reading would not be a distraction. So you need to choose carefully. Lastly, if there is something you really enjoy and want to do in peace and quiet without distractions, by all means do so. For me, I never multi-task when watching a movie because I would not enjoy the movie. It all depends on the person though. In the end, the main thing is to enjoy life.

Multi-tasking

While this is a medical website, I do like to offer some self-help information about life on the blog. After all, I am a psychologist. One of the questions I am commonly asked by people who know me is "How do you do everything you do?" In other words, how do I write all the patient reports I do, publish research, exercise, run a website, raise two children, spend time with my wife, do house chores, mow the lawn, watch movies, read books, surf the net, listen to my ipod, etc? The secret is … multi-tasking! There are too many things to do in life that if you try to do them one at a time, it is tough to stay productive. So while I am exercising, I am also watching a TV show I like or reading a book. While I am working on my website I am downloading music to my ipod. While I am mowing the lawn, I am listening to episodes of my favorite talk radio show. Don't get me wrong, I don't multi-task everything. However, if you multi-task a bunch of things in your life, you'll find that you can accomplish a lot more than you would have otherwise. Click here for the next multi-tasking post.

Physicians have it worse than PhDs

People often say to me that they don't know how I went through so much schooling and training to be a neuropsychologist. When I look back, it sure was a lot of schooling beginning with a college degree, graduate degree (PhD), an internship, and a 2-year fellowship. There was lots of training at other sites along the way as well. But what I always tell people is that what I went through in schooling and training is nothing compared to what it must be like to train to be a physician.

The amount of information medical students need to memorize in medical school is simple astounding. The demands on their time are all-encompassing. The competition is incredible. All nighters are common to cram for crucial tests. Double shifts are common to learn the ropes and pay one's dues. If you are lucky, you'll catch some z's on a small cut in a tiny room designed for you on the nit floor. How do I know all this? You witness a lot when you train in medical settings and when you have friends training to be physicians.

The demands on personal time are still great when one earns an MD or DO. For example, physicians are on call for most of their life. For me, there is no such thing as a neuropsychological emergency and I am never on call. For physicians, there are problems patients have with medication side effects, surgeries, and all sorts of emergencies (on non-emergencies being described as emergencies) that rouse them out of bed. Yes, this is the life the physician chose, but sometimes I wonder if you ever truly understood what they were getting into until they actually got into it. By then they have invested so much time and energy, that it is too late (and too expensive) to pull out. Someone has to do it though…I'm just glad it is not me.