General Practice

My new computer is a car

2011-05-29T19:04:00.000-05:00

After seven good years my Mini Cooper is gone, replaced by a 2012 Ford Focus.

Good things about the Mini: fun to drive, easy to find parking.
Less than good things about the Mini: premium gas, 21 actual MPG city, run-flat tires (stiff harsh ride and expensive to replace), no spare tire, rear seating a suggestion more than a reality.

Good things about the Focus: regular gas, 28 actual MPG city, computer on wheels, nice ride, more space, parks itself, american made, very competitive pricing.
Less good things about the Focus: sync interface by Microsoft.

When my wife got her Prius in 2004 I was amazed at how easily she could walk up to a locked door, open it, get in and push-button start the car without taking a key out of her pocket. Not only that but her bluetooth phone automagically paired and worked with the handsfree system. At the time there were novel features. Now I can finally do the same and much more. Go Detroit!

Recipe for pain

2011-05-24T22:37:00.000-05:00

Start by overeating. Blend in two glasses of wine. Elevate to 6200 feet above sea level. Put on an elliptical machine for 30 minutes or until done, whichever comes first.

I now have an inkling of what Jon Krakauer was talking about in Into Thin Air.

Back to sea level tomorrow.

Kale

2011-04-24T12:39:00.000-05:00

So this is what bolted in the garden last week. How to cook it. That was the question.

So I checked my favorite recipe sources and the consistent recommendation was Kale with Cannellini in one variation or another. But most called for lacinato kale (also called tuscan, nero, dino or variations of all). But we have red russian kale, which I learned only by googling some images. Apparently we chose it for it's less bitter taste than the more common curly Kale, at least that's what Elaine suspects. It grows earlier in the season also. But I couldn't find specific recipes for russian kale so I did what I've learned to do. Don't look at the specific ingredients, look at them as placeholders for a class of ingredients.

All the recipes for kale with beans called for sautéing veggies in a fat, then adding spice, liquid, and then beans and greens. Most sautéed a few onions, carrots and garlic in olive oil, then added cannellinis, liquid and kale. Others substituted pancetta or sausage fat for olive oil, added some celery or tomatoes to the carrot, or used other beans (navy, great northern, lima, kidney, black) or other greens (spinach, collards, chard, cabbage). The variations are clearly endless, but the overall approach was the same.

And so this is my recipe, based on what I had on hand and in our garden. One chopped carrot, onion and celery stalk sautéed in a little olive and sesame oil until softened. Then 3-4 finely chopped garlic cloves and 1/4 teaspoon of salt for another minute. I then added 3 cups of chicken stock to the mirepoix, bringing it all to a boil before adding 7 cups of washed, de-stemmed and chopped kale. I then simmered for 3 minutes and added a 1/2 can of cannellini that had been puréed with 1 cup stock and then the remaining 1/2 can of cannellini and 1 can of black beans (it was all we had). A little more salt, some pepper, a bit of chopped thyme, rosemary and sage from our garden and the juice of one lemon to add some taste. Served it with some shaved parmesan cheese and olive oil drizzled on top. Would have been better yesterday when it was raining and 58 degrees rather than sunny and 78. But it'll do. It'll definitely do.

Refusing to cry, refusing to laugh

2011-04-03T10:50:00.001-05:00

"My dear Kepler, what would you say of the learned here, who, replete with the pertinacity of the asp, have steadfastly refused to cast a glance through the telescope? What shall we make of this? Shall we laugh, or shall we cry?"

--Letter from Galileo Galilei to Johannes Kepler

Somalis in Minnesota have experienced a higher than predicted rate of measles and resultant excess of preventable deaths in the past year. A similar measles outbreak occurred in 1996-97 in Minnesota in children who were members of a religious group who eschewed immunizations. It also happened in 1977. Same place, same disease, same issue.

California and elsewhere have seen outbreaks of Pertussis (whooping cough) in recent years.

And last but not least Polio continues to win skirmishes in a war thought won 60 years ago.

I personally participated in immunization drives to combat a measles outbreak in Philadelphia in the late 1980's. I've also had the "privilege" of performing a lumbar puncture on a three month old infant with Hemophilus Influenza Type B.

All of which leads me to struggle with how to respond to those who continue to warn of the risks of immunization. Autism! Seizures! ADHD! Asthma! Diabetes! Death! And worst of all Peanut Allergies! OMG!

Are you as non-plussed by the sensationalism, hucksterism, and general snake oil feel to the anti-immunization fringe as I am? Puh-lease save me your "What your doctor doesn't want you to know...", "We have real qualifications too...", "Just buy this..." and especially your "God doesn't want you to vaccinate...".

Yes, Immunizations are risky. We no longer use oral polio vaccine because of the risk of vaccine associated polio. We use inactivated polio instead.

Yes, Immunizations are not perfectly effective. But perfection is the enemy of the good, and immunizations are much more than good enough, measuring higher even than chocolate or Cliff Lee on the goodness scale.

Immunizations are not a choice between disease and no disease; they are a choice between less vaccine preventable disease and complications (with all the costs that come with vaccination) and more vaccine preventable disease and complications (and all the costs that come with no vaccines.) If you wish to save money, vaccinate. If you wish to reduce overall morbidity and mortality, vaccinate. These choices are not imaginary; they are written in the history of those who've made them before us, and those who forget the past...

Lastly, immunization is a social act. The risks of vaccination are borne by those who vaccinate, while the benefits of immunity are received not only by the vaccinated but also by those who aren't, whether they ask for it or not. The least the un-immunized could do is gracefully and thankfully accept that saner, braver folk are not only willing to tolerate their fear but also work to ensure that it doesn't kill the rest of us. But history also tells me that this expectation is too great. Sigh.

Sometimes my patients ask me "Do I have to take this medicine for the rest of my life?" or, in another version "Should I get this immunization?", and my answer to both remains the same. Yes, until we know better, or until something better comes along. Knowing better or identifying something better is often hard, except in the case of immunizations. That one is easy. For most of us anyway. So long as we wear head protection.

We love you Bruiser

2010-05-30T11:55:00.009-05:00

Bruiser died today. Suddenly if not unexpectedly. He's been on medications for his heart for years, and could barely make it around the park without getting short of breath, but he still wagged his tail and pranced for joy until the last, like all good dogs do.

He was 11 years and one month old today. Here's a picture of him with his siblings. You can tell why he was called Bruiser. He's the one with the blue collar.

Like all Scotties he thought he was bigger. Here he's playing (and winning) at Frisbee with his cousin Scout.

But this is how I'll remember him - tail wagging and wanting to play.

Good dog.

Travel and Karma

2010-04-29T11:59:00.005-05:00

I'm waiting for my flight back to PHL from SeaTac after a week in Seattle-Vancouver-Olympia and feel compelled to share the benefits of a week of good karma.

As I learned during a forced layover in Rouen several years ago the travel gods kneecap your best laid plans for a reason. In this instance last minute changes resulted in my 'discovering' the Chucknaut Drive in northwest Washington, the Skagit Valley Tulip Festival, Mallard Ice Cream in Bellingham, the Sunset Inn in Vancouver's Davie Village, Milestones Restaurant in Kitsilano, the Cedarbrook Lodge, and the best meal of the trip - homemade (literally!) pasta with asparagus, fennel, and red onions by none other than Chef Daniel Lipson (husband of noneother than Penn's own Michelle Seelig) who moonlights daytimes as a Physician Assistant at Group Health Puget Sound. If there were ever an argument for slow travel, this trip was it. Get off the interstate peeps!

I was in Vancouver for the Society of Teachers of Family Medicine. As is true of all good meetings I learned more than I thought possible and benefitted repeatedly from serendipity.

For example I would never have planned 20 minutes in a private informal discussion with Jerome Kassirer, emeritus editor of the New England Journal of Medicine, but that's what happened when he chanced upon me in an out of the way spot we both discovered while waiting for his talk. Was he hoping to nap too? And what a talk! His slides aren't up yet but here's a podcast of his thoughts on industry-medicine relationships. Standing ovation from a full house. At 4:30 in the afternoon! Be still my heart.

The mantra of business travelers is free (fast) wifi and breakfast, but Cedarbrook Lodge (right at SeaTac!) provides the fast free wifi, breakfast of charcuterie, hard boiled eggs, outstanding coffee, oatmeal, juices, bagel, croissant, cheese, yogurt, artisinal bread, in the room you see here. The view out the floor to ceiling windows is even better. Great rates through online booking sites. If you have an early flight out of SeaTac you *can't* stay anyplace else. Did I mention the free all you can eat malted chocolate balls in three different flavors (mint, chocolate, and butterscotch)? Inconceivable!

I met some great new folk, caught up with old friends (Congratulations Mike R.), and remain impressed that our specialty is attracting some enthusiastic and energetic young talent like our own Mario DeMarco who talked about experiential learning in residency properwise. The man haz powerpoint skillz.

And who could ask for more than a dropped ball in the 11th to seal a passable if not winning road trip for the Phillies?

Glad to be coming home. The gate agent is calling...

I have more than enough. Do you? Here's how to tell.

2010-01-31T21:42:00.004-05:00

Kurt Vonnegut first got my attention as a freshman in college. I ran across this when he passed away a few years ago and thought I had lost it. Fortunately a friend's request got me looking again and reminded me how Yossarian and Billy Pilgrim are related.

Adobe Flash and the iPad

2010-01-30T15:54:00.002-05:00

I'm a confirmed MacHead, so everyone who knows this about me has been asking whether (Ha!) or more appropriately when I'll get an iPad.

Watching the introduction this week I noted that the NY times webpage didn't render Flash, prompting instablogs to tout "I can't believe it's not going to use Flash!"

But as a long term MacHead I have the kool aid in my genes. I don't think I have any natural DNA left in fact. So it's natural to me that Apple is again saying "It doesn't work, we're moving on and suggest you do too."

They've said this before. I remember "I can't believe there's no 5 1/4 inch floppy drive!" only to be followed by the hit single "I can't believe there's no floppy drive!" among others.

If Apple's good at anything it's good at making the future.

As my maven John says: Flash sucks and deserves to die. And thanks for pointing out the Daring Fireball treatise that explains exactly how and why Adobe sucks the big one. Adobe installers routinely interrupt me when seeing patients, crash when browsing, and use stupid proprietary installers that were bad when they were state of the art in 1998. And NO I DON'T WANT TO INSTALL YOUR INSANELY ANNOYING AND BUGGY UPDATES NOW.

The Flash install and crash saga is Apple v Adobe, and I know where my money is. (Not really, I bought Apple at $19.50 many years and two splits ago and could probably have retired by now if I hadn't sold it at $24 - on it's way to today's $192 - which is why I don't put money into single stocks anymore. I'm clearly incompetent at the money making part.)

But the money is beside the point. Flash is the past. I'm moving on. If hulu wants me to watch then they're gonna have to get with the program and dump Flash like all right thinking webmasters.

Rob Centor speaks for me today

2010-01-30T08:11:00.001-05:00

Sore throats are easy, right?

Not.

If it were easy anyone could do it.

Official Google Blog: A new approach to China

2010-01-13T09:02:00.000-05:00

Official Google Blog: A new approach to China

In which Google says to China, "Not cool dude." And I thought the Google v. Apple saga was interesting.

Language matters

2009-11-21T10:04:00.002-05:00

And in my final post of a trifecta today, and to reassure those of you who worry that I buy too much into the Two Cultures phenomenon, I give you a prime example of the intersection of humanities and science.

Take medicine as art and distill it into a coding language. Politics as sausage is sterile by comparison.

Coding taxonomies seem dry until you recognize the magnitude of their influence in our current f**ked up healthcare system. John refers to them as deadweight. I prefer to think of them as red matter. I don't have the patience or aptitude to distill our healthcare dreck into a better future state. Thanks to John, I don't have to.

Albert Crewe obit

2009-11-21T09:41:00.003-05:00

From the NYT obit for Albert Crewe, U Chicago Physicist who pushed electron microscopes to show atoms for the first time:

In a public lecture shortly after becoming the director of Argonne, Dr. Crewe bemoaned the growing gulf between scientists and laymen.

“There are too many people behaving like the proverbial ostrich and hoping that science will go away if they bury their heads in the sand,” he said, “and this in spite of the fact that the last few decades have indicated strongly that science will not go away.”

Say hi to Galileo for me Albert. RIP.

That's what I'm talkin about

2009-11-21T09:07:00.003-05:00

I can't believe I missed Robbie Aronowitz' NYT mammogram editorial on Thursday!

THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.
Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s...
...Even though [the screen at 40] consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma...
...You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.

You've heard the rabble and the science. How many times will Galileo be tried before we get it right? Robbie's piece has, sadly, been written before. Different names, same ending.

[disclosure: I'm a proud faculty mate of Robbie's in Penn's Department of Family Medicine and Community Health.]

Has hell frozen over?

2009-11-02T12:02:00.003-05:00

I work with many wonderful orthopedists who continue to see patients without regard to payor. That isn't true for most private orthopedics groups in town who continue to refuse medical assistance patients. Still, I wasn't expecting this... – orthopedists asking for my pay to be raised.

I'm gonna have to send them some link love.

Road trips are underappreciated

2009-10-27T21:02:00.006-05:00

Thanks for all the b-day wishes. I must say it's been a pretty perfect day. And how often can you say that when you start by waking up in a hotel in Poughkeepsie on a cold rainy October day?

Several months ago my oldest drove across country to return to college. On the old Lincoln Highway (US 30). All the way.

I was jealous, but not wanting to spoil his trip with my company (he had a friend to co-pilot) I instead convinced my wife to take a local road trip vacation with two rules: no interstates, no chains. We committed to only one fixed event in the week and have left the rest to whatever strikes our fancy. So last Sunday we packed a small suitcase with two changes of clothes, headed north via the backroads to Princeton where we walked the Delaware and Raritan Canal towpath with friends older than our marriage. I knew about the Erie Canal, but the Delaware and Raritan? Nice. After a Thai dinner we parted ways with our friends and meandered to Milford, PA and the Hotel Fauchére. Eat your heart out Four Seasons.

Monday we toured Grey Towers, the home of Gifford Pinchot, former PA governor and first head of the US Forestry Service. A gorgeous day and a chance for Elaine to talk to someone about American Chestnut blight, which in her book means fun. For my part the grounds were gorgeous, the house more so, and the stories entertaining.

Later we headed a few minutes north to pay our respects to the site of the Woodstock Festival. As we walked up to the roadside monument someone was playing a Janis Joplin tune. Fitting.

From there we wound our way past innumerable Jewish summer campgrounds, across the Shawangunk Mountains, into the Hudson Valley and across the mid-Hudson bridge to Poughkeepsie. And what's there to say about Poughkeepsie? We didn't have reservations anywhere and so settled for a generic local hotel last renovated in the 80's. Sad as it was however the staff was predominantly young can do New Yorkers who were aggressively good at their jobs. Good thing we checked in before the Yankees lose the series.

Today we toured the Hyde Park home of Franklin Roosevelt and just returned from a fantastic dinner at the Culinary Institute of America. We also found a great spot to stay in Rhinecliff; right on the water, impeccable service and decor, and half-price!

The best part however is that by taking the back roads and taking our time it feels like we've gone to the other side of the world and have been gone for a week, even though it's only been two days.

I don't think I'll drive an interstate highway again.

This American Life is My Life as a doctor this week

2009-10-19T11:31:00.002-05:00

TAL is hit or miss, but they've hit close to home (work actually) with their episode Someone Else's Money. The sad part is that the examples of bureaucracy run amok are among the more routine and least outrageous.

What about the time my patient with AIDS was unable to receive his meds because his employer "forgot" to pay the insurer, leaving my patient at the pharmacy counter with a pharmacist saying "you don't have any coverage."? My patient (now dead) missed several weeks of therapy, a pause that is known to breed resistance, contributing to treatment failure and decline. The employer's penalty? Nothing.

I could go on, but I have patients to see.

The value of art

2009-08-25T09:38:00.002-05:00

Art is essential.

When the Phillies are down and it's the bottom of the ninth inning the jumbotron doesn't light up with a math theorem, but with the Rocky theme. Myth and metaphor communicate in a flash what science can take years to deliver. Our brains, as predictive rather than computing organisms, make connections more quickly (if sometimes errantly) through art than computers can with logic. And our communities, as social organisms filled with social beings, grow stronger with art, especially shared art.

But don't listen to me, read this speech to incoming students at the Boston Conservatory of Music. (tx to Paul Levy's blog pointing it out.)

A Study in Contrasts

2009-01-20T08:49:00.002-05:00

I'm a city boy. Noise and activity. Light and sparkle. But walking across the desert this morning I was struck by its absolute dark and soundless nature. Until, that is, I looked up. I've seen stars before, but this was heaven.

What a beautiful way to start a day of change.

Women's Calendars are from American Greetings; Men's Calendars are from Intel.

2008-12-06T11:45:00.004-05:00

Here's my wife's calendar for the next two weeks. Written on the inside of a greeting card box lid. Graphics are hers. Nice tree.

Here's mine. Requires electricity. Performs better with internet access.

Not sure which is better, but they summarize pretty neatly our respective preferences for organizational activities.

1 down, 6 billion to go

2008-12-06T03:23:00.003-05:00

Ellen Kim got a Mac.

Why I'm a Phillies Fan

2008-12-06T03:05:00.002-05:00

Two degrees

2008-11-30T11:45:00.015-05:00

On reading my Kentucky alumni magazine today I ran across a book review of The Venus Week, written by the older sister of my first 'real' date (to a high school homecoming in the 7th grade - but that's a post for another day...)

It turns out my one time date has made a name for herself by marrying Ted Olson (his fourth wedding, her first.) If you don't know him it's probably because you've blotted the memory from your mind - how he won Bush v Gore in the Supreme Court for Bush? Then was rewarded with an appointment as solicitor general for the US from 2001-2004. In her defense, she met and married him only after he stepped down from the SG post. His third wife (Barbara Olson) was killed on American Airlines Flight 77 when it crashed into the pentagon on 9/11 - his 61st birthday. I suppose that'll rearrange your priorities: his new wife is a registered democrat.

As SG he argued (and lost) an affirmative action case against the University of Michigan, whose president then and now– Mary Sue Coleman – taught me biochemistry and prodded my entry into UK's medical school many years ago.

Which only goes to show, it's not six degrees, it' two. And Kevin Bacon has nothing to do with it.

And as for former dates; no offense Lady, but I'd have to say I've upgraded.

DrRich (the other one) sums it all up

2008-11-24T12:07:00.004-05:00

And nicely, too.

I'm meeting incredible applicants for our residency during this interviewing season which, along with DrRich's advice, gives me hope for the future. I wonder if they feel the same.

NEJM and primary care

2008-11-13T10:47:00.004-05:00

Others have remarked on this NEJM series which appeared yesterday. My response is less prosaic but more concise.

"Duh!"

Less talking, more action.

Facebook finally

2008-11-11T04:33:00.002-05:00

I may be a geek, but being over 40 means I'm slower to some things than others...

News in the post Obama world...

2008-11-07T05:18:00.002-05:00

Kobe Bryant Scores 25 in...

Hilarious!

Redemption

2008-11-05T01:38:00.007-05:00

What a day. Are you inspired? I am.

This is why I like John Faughnan's blog...

2008-11-04T07:47:00.003-05:00

Goldwater for Obama? Try this endorsement on any conservative you know.

...and why my little brother and father should read it. The former wasn't born when Goldwater ran; the latter supported (and I suspect voted for) him.

If not Eternal, at least 28 years!

2008-11-04T07:35:00.002-05:00

It's a great time to be a phillie's fan!

Hope springs...

2008-10-14T07:53:00.004-05:00

Is there anything better than October baseball played during an indian summer?

Two things; the Phillies winning and watching it all with my beautiful wife!

Olympia is a beautiful place

2008-09-27T09:01:00.004-05:00

Sure I like Philadelphia, but Olympia has its charms too. Look west and see the Olympic mountain range. Look east and see Mt. Ranier. North and South aren't too shabby either, as these pics of Budd Inlet and the Washington State Capitol show.

Sure I like Philadelphia, but Olympia Washington is also a beautiful place. Look one way and it's the Olympic Mountain range. Look the other and it's Mount Ranier. Look north and south and here's what you see:

GQ in the house

2008-08-16T08:36:00.005-05:00

My family is far flung. One nephew just climbed Kilamanjaro, while another is living la buena vida in Argentina. I may be old and set in my ways but I still enjoy living vicariously through my gene pool.

Here's Stevie's GQ shot. Handsome huh?

In defense of Family Medicine

2008-07-17T18:52:00.002-05:00

I can't wait to read Bob Centor's reply to this essay in the recent Annals of Family Medicine. His post about it and some provocative comments are here.

As I grow more experienced in what it means to be a family physician in what is an otherwise quaternary-care environment the value of the primary care function grows all the more valuable in my eyes.

It's a good day....

2008-07-16T09:21:00.001-05:00

When a former trainee turns out (because or in spite of your work) so well.

Crisis of the bourgeois

2008-07-14T23:46:00.000-05:00

A year ago I walked right into my local Apple store and picked up an iPhone around 8 pm on release day. No line, no fuss; until I got home and tried to activate it.

Fast forward a year and a week to yesterday. My wife is in the market for the new iPhone but the line was 20 deep at 9 pm last night, and after reading about activation delays she begged off to a later day. Then when we did stop in to pick one up (again no line, no fuss), ATT squelched the deal by invoking BMG, IRU, and FAN. And if you know what those acronyms mean you've spent way too much time on the phone with ATT.

So still no iPhone and all the stores near us are out of stock.

iPocalypse? Hardly.

Catastrophe? Iraq is a catastrophe. Katrina is a catastrophe.

3G iPhone activation problems? Just another...

Again

2008-07-13T17:16:00.001-05:00

Tried to upgrade my wife's phone today. Suffice it to say ATT is still customer service impaired. Deeply.

Geolocate this post

Posted with LifeCast

Why it pays to practice

2008-07-04T17:25:00.003-05:00

You think you can eat a pie? Then listen to the advice of my 5' 11" son and 6'2" brother-in-law, neither one an amateur when it comes to eating: practice, practice, practice. Otherwise you'll suffer the same disgrace they did when losing to the 4' 8" ultrapetit who bested them both for third place while they were daintily cleansing their palate between tastes of their Tastykakes.

Orientation 2008

2008-06-28T10:26:00.005-05:00

Here's this year's new incoming residents in what is becoming a traditional first day shot.

Dragon Boat Champions

2008-06-28T10:05:00.004-05:00

I would be remiss if I did not post a pic of the 2008 Dragon Docs, so here they are. Can you believe this group helped win the 2008 Independence Dragon Boat Regatta Hospital Challenge Cup Championship? We're already plotting our championship defense for 2009.

Getting physical

2008-06-28T09:59:00.003-05:00

My nephew Mike V is off climbing Kilamanjaro. Meanwhile my feet are still hurting from riding my #1 son's folding bicycle last weekend and my wife is out digging in the dirt to lay a foundation for our new patio. Those of you who know her well know that the patio is only her most recent excuse to dig in the dirt.

Time Flies

2008-05-04T20:14:00.006-05:00

Here's one of the earliest and most recent pictures of my oldest. His prom was last night and he's flying to college for his freshman advising conference this coming weekend. Enjoy it while you can - it goes by fast!

Evan's new sport

2008-04-26T19:38:00.002-05:00

Every sport has it's own culture, and rowing is no exception. Here's a clip of Evan's latest regatta - the NJ State High School Rowing Championships in Camden on the Cooper River. You can tell from the photos that it's really all about the tents.

His crew placed 5th in their head race to make the final and placed sixth in the final rowing into a vicious head wind. He's rowing fourth from the bow in this boat. Next week is the Philadelphia Scholastic Rowing Championships. Pray for sun!

Mid-Eastern Europe

2008-03-23T06:24:00.042-05:00

Just got home from a week in Berlin, Dresden and Prague (selected pictures here); all an educational counterpoint to the more typical London/Rome/Paris that comes first in most grand tours. What did I learn?

Berlin and Dresden show scars from the war that manifest themselves architecturally, psychically, and culturally in the food, fashion, language and rituals of the street. It's striking to walk Jewish quarters of all three cities emptied of Jews by the holocaust. It's equally striking to note that protestants and Catholics are separated by country borders with the memory of why still fresh in the minds of citizens, despite reasons that are 500+ years old. If you want to learn about war and its aftermath, visit here and watch and listen closely.

Prague is Florence on tourist steroids, but with narrower streets.

Czech restaurants know how to turn a table.

On our trip to Europe in 2002 we got about 1.3 Euros to the dollar. This week it hovered around 0.6 Euros to the dollar - an all time low. Even the Czech crown reached an all time high against the dollar when we were there, promptly dropping a few points after we'd exchanged as many euros/dollars as we were going to. If you want to give your kids a lesson in international monetary exchange, visit Europe when the dollar sucks. My 16 year old was converting the 15.80 Czk to the dollar in split seconds.

When I was a teenager the common street lore was that Levi's jeans could be sold behind the iron curtain for $100 a pair. Now that the iron curtain is down they cost $150. Chuck Taylor tennis shoes that I paid $12 for as a 13 year old cost over $100 on Wenceslas Square.

Fortunately however the cultural hegemony of the west is incomplete: good beer is cheaper than water in Czech restaurants; trains/streetcars/metros are incredibly cheap and follow precise, reliable timetables; and tasty pork knuckles are the cheapest menu item everywhere we go. Even mini-marts have beer that's cheaper than Pepsi. Meanwhile back home in Pennsylvania it's still illegal for one person in one trip to one store to buy three six packs of beer, assuming of course you can find a place to sell it to you.

Learning Czech isn't as hard as it looks.

There is indeed something to the Czech spirit, which I felt most in the museum of communism off Wenceslas Square where film of the 1968 and 1989 protests gave a sense of what it was like to live with no liberty and, perish the thought, no internet. By contrast the Tibetan protests happening this week show how hard it has become to control information.

Despite the 18 years since the fall of the iron curtain there is still a stark contrast between the east and west, most evident in the architecture but also in the day to day lives of the older and younger generations.

Prague/Vienna/Budapest seem to have a New York/Boston/Philadelphia thing going on. Don't make comparisons without knowing the allegiance of the person you're talking to. It could get ugly if you presume Vienna strudel is better than Prague's. (It was explained to me that Vienna just stole it from Prague anyway, like many other things the Hapsburg dynasty mooched.)

And lastly, it can get damn cold in Europe in March. Note to self: it's always easier to take clothes off than to put clothes on that you didn't pack.

#1 desired iPhone apps

2008-02-24T14:05:00.005-05:00

I'm sitting in the mini outside the Moore school at Penn waiting for #2 son to finish crew practice and find myself hoping the iPhone SDK gets out on time and allows me to start using a pharmacy reference on my iPhone. The only thing more pressing and more basic is todo list and notes syncing with my mac.

Soon, please.

iPhone madness

2007-07-01T10:53:00.001-05:00

Bought an iPhone on Friday. It' great. The activation was hell.

Posted my experience at this apple support discussion thread.

Happy New Year

2007-06-20T19:03:00.000-05:00

That's right, new year. Here's the new crowd. We send out the old crowd with a grand soiree tomorrow night.

Am I a Mr. Hollland? If so is this crowd my opus?

Touching Base

2007-06-13T13:18:00.000-05:00

My three month juggernaut of travel is, briefly, halted. I'm home for a month.

But Heather's not - she's in Malawi for a project and is actually taking pictures!

Kent is in Italy, but blogging is the last thing he'd do.

And the kids are at home, having finished another year of school. I left the hous today with a freshman and junior. Now we have a sophomore and senior to deal with.

Where've I been?

Austin, TX - work
Florida - Play (!)
Las Vegas - more work
Gettysburg - ditto
New York - ibid
Kansas City - not enough work so I worked some more.

Hmmmm. Not enough play in there.

P4P again

2007-04-10T05:17:00.000-05:00

A Health Affairs web publication discusses downsides of P4P in urban underserved populations. On target.

"Will Pay-for-Performance and Quality Reporting Affect Health Care Disparities?" (pdf 128k)

How I feel this month

2007-03-24T08:52:00.000-05:00

My residency just matched with six great interns for the coming year, but not all program directors feel the same about their prospects. Many directors have called for reductions in the number of spots available for training in Family Medicine, thereby (so the theory goes) increasing competition for the remaining spots.

I'm all for high quality students entering my specialty, but think reducing the number of training slots is the wrong way to go. The country needs primary care badly. But just as we need to lose weight and fix the mess in Iraq, some things are easier said than done.

I have two different patients in two different hospitals slowly dying of cancer and substance abuse, respectively. My experience with each provides a sobering contrast with our recent successful recruiting year, a contrast echoed by Sandra Miller's excellent essay "Endangered Species" (pdf 40k) from last week's Journal of the American Medical Association.

Get rid of stuff

2007-03-21T15:52:00.000-05:00

Here's why.

The choice

2007-03-20T08:29:00.000-05:00

The first comment is the one that resonates in my household.

Jon Haloto: Macbook it is.

It always snows on St Patrick's Day

2007-03-17T20:07:00.000-05:00

At least it seems that way.

Is the US ready for the Smart Car?

2007-03-16T08:59:00.000-05:00

A co-worker of mine owns Philadelphia's only 'legal' Smart Car. She lives in the city's Art Museum area, driving it around to commute when she's not riding her bicycle. Unfortunately it's been vandalized twice while parked on her street. Clearly not all the attention it garners is positive.

She's reported the latest smashed windshield and driver's window to the police but there have been no leads. Look closely and you'll see that's plastic on the driver's side held in place with duct tape - you'll also see the smashed windshield just below the inspection stickers.

Can you help find out who did it?

Write your play

2007-03-16T08:22:00.001-05:00

Robin is a new co-worker of mine. She enters charge entry data and reconciles payments against charges for our busy residency practice at Penn. But her real ambition in life is to win a Tony for best new play. While talking to her I was reminded of my former life with Actors' Guild of Lexington (as president of their board many moons ago) and also my love affair with Actors Theatre of Louisville, whose Humana Festival of New American Plays continues to feed new material to Broadway and elsewhere. Actors' Guild is easily the more grass roots and exciting to me, in part because of their mission to present compelling modern american theater. Seeing their production of Angels in America is still a highlight of my live performance watching experience.

The discussion with Robin also reminded me of a question I once had during a job interview: "Do you write every day?" The wisdom of this being that if you didn't now you were unlikely to do so. No need to wait for an assignment, a job, or for more time. The barriers (for me anyway) were all internal.

Robin: Write your play. I'll come to see it - even if it's only a reading.

Smell the Moussaka

2007-03-14T05:57:00.000-05:00

Walking to an early morning meeting yesterday I walked past the spot that sealed the deals - both my marriage and our honeymoon. Walking by one morning in the Fall of 1987 my future wife and I smelled food and walked in to a greek glendi in progress. Being introduced to spanikopita, baklava, and moussaka and shortly thereafter being *forced* to dance. No sitting was allowed. Now that's a culture we just had to explore further.

This is a poor phone cam picture but I couldn't resist. There are too many memories in this town!

Compact Parking - not

2007-03-13T08:43:00.000-05:00

Wish I'd orderded some of the bumper stickers Leo pointed to last month.

Stopping for Life

2007-03-12T08:16:00.001-05:00

Clark DeLeon posted a shot from Fairmount park's Belmont Plateau last
Fall. Ever since I've been telling myself I'd stop along the drive
south on 34th street in front of the Philadelphia Zoo to get a shot
of the boat basin under the Art Museum. Today I brought in my camera
to catch some pictures of my new doctoring class, which meets for the
first time today. Having the camera with me, I stopped for the shot but the light was better for this one - a tunnel of trees waiting for spring. I need a higher resolution camera to catch the details in these branches.

Bruiser

2007-03-11T15:15:00.001-05:00

Test picture. Cute dog, huh?

Spring?

2007-03-11T13:55:00.000-05:00

If daylight savings time starts, baseball is on the radio (Phils give up 4 in the 7th inning to lose the lead - will they get it back?) and the temperature is 45 degrees warmer than five days ago is it spring yet?

Jacob gets it right again

2007-02-04T23:11:00.000-05:00

Why don't the FFM or IHI folks talk this way?

Physician identifiers and Pharma marketing

2007-01-31T21:41:00.000-05:00

After receiving the umpteenth mailing from a prescription benefit manager (PBM) at my home regarding a patient medication issue, I finally took the time to write one of the managers responsible. Getting these at home drives me crazy. The misuse of my DEA makes me crazier!

Some info: I never use my home address in any patient related matters. The only reason the PBM's have it is because they use my DEA registration address. Why? Because that's how they track my prescribing, even for non-DEA schedule medications. Today's mailing was about a beta blocker, and they list my 'prescriber number' which conveniently is identical to my DEA. What a completely wrong and market (not patient) driven problem.

The FDA, DEA and multiple medical organizations have weighed in against this misuse of DEA numbers. There are great alternatives (like the pharma driven National Provider Identifier), but pharma is slow to adopt them. Why change when the old system works fine for them? Who cares if your number is stolen so easily. Narcotic abuse? - not our problem.

I just wish Pharma wasn't so friggen mercenary about this. All their talk about "best for patients" is complete bullsh*t when seen in the light of their marketing behaviors. And to top it all off is the conversation I have with pharmacists who are likewise stuck in the middle between the patient and their PBM - "I'm sorry doctor but the insurer won't pay for the medicine without your DEA number." This for a diphenhydramine prescription - an over the counter anti-histamine. And if I don't cough up my DEA the patient hears "your doctor didn't approve it."

Damn right I don't approve it.

Sigh.

Let the record show...

2007-01-30T12:50:00.000-05:00

That while Prince Charles was in town celebrating the Academy's 150th, I was watching Penn - St Joe at the Palestra. You can take the boy out of Kentucky but you can't take the basketball out of the boy.

Getting meta

2007-01-02T06:39:00.000-05:00

Like Stephen Colbert? I take mine extra medium.

Finishing 06 the right way

2007-01-01T21:16:00.000-05:00

So; Philly gets to keep the picture after the extortion game played by Bob Barchi and Jefferson's board. My town really stepped up to the plate on this one - true philly spirit at work.

My just completed nine day hiatus is just the thing for the mid-year recruiting/accreditation/holiday chaos that is my life in Winter. A few days in North Carolina with family, a few hours struggling to survive my son's driving (on I-95, in the rain, during rush hour, at night), and plenty of time to putter around the house and finish up some BIG work projects.

Not only that: I finished Tony Bourdain's new book The Nasty Bits. His commentary on the various chapters is real whipped cream on a satisfying collection of life's lessons. Sure, it's about the food on the surface, but in the end it's about Tony and his addiction to life. I'm just jealous that he's getting paid for it.

And the iggles pulled it off. Andy Reid's workmanlike affect may not inspire the same kind of loyalty as Knute Rockne, but it'll do, pig.

I even saw Rocky Balboa. What a great bookend to the break for anyone who loves Philadelphia and its spirit - and I do. I even teared up a few times at what is admittedly an average picture. Am I a sucker for sentimentality or what?

Is art important to medicine?

2006-11-11T09:35:00.000-05:00

Art vs. Science, commerce vs. culture; call it what you will, but call it wrong. Jefferson Medical College is selling Thomas Eakins' painting of The Gross Clinic for $68 million dollars to a Wal-Mart heiress who will take it to Arkansas in 2009.

Isn't that a little like selling your soul to the devil? Couldn't Jeff issue bonds in the usual fashion and go into debt like any respectable university?

Says Bob Barchi (University President), "We're not a museum. We're not in the business of art education" and in two sentences betrays his failing grade on his Two Cultures book report , a crushing ignorance of the centrality of art to the human experience, and spins Jefferson's expansion as an Eakins rejection redux.

Heroic myth writ large (Homer) or small (Rocky Balboa, Luke Skywalker) inspires great things in real life, just as Eakins painting of Gross has inspired countless artists, physicians and patients. It is arguably Philadelphia's David. But Philadelphia is not Florence, and the Jefferson Board no Medici.

The sad irony is that Wal-Mart heiress Alice Walton is funding this on the backs of an uninsured and exploited workforce run by a corrupt management culture. She's never been held to account for her drunken driving or vehicular manslaughter of a pedestrian in 1989, but has instead been lauded by those who receive 'her' largess; she is, after all, one of the largest individual sources of contributions to 527 groups.

Since 9/11 I've thought plenty, if shallowly, about the symbolism of our built environment and possessions generally. Can you put a fence around Independence hall without destroying what it stands for? Can destruction of the Buddha's destroy Buddhism? Of course not. Similarly, Jefferson's sale will not destroy the university. But the sale and announcement (Federal holiday Friday afternoon - can you san PR graveyard?) does reveal the price of its values.

As an alum I suppose I thought they were worth more. Sigh.

Philadelphia is beautiful

2006-11-04T10:51:00.000-05:00

Can I say that without invoking sympathetic groans from anyone not familiar with the place I call home?

I've been driving my Mini Cooper on a different path to work every day for the past few weeks in search of my holy grail*, and have been rewarded in every instance with new discoveries about the city that I thought I knew. Wissahickon park's Forbidden Drive is amazing this time of year, as are the trees near Lemon Hill. The centennial exposition residua are still a stately, if a too quiet reminder of what happened here in 1876.

Get off your mental interstate and enjoy the show around you. You won't be sorry.

*Can a person get to work without encountering an intersection with a stop light?

Flu Vaccine distribution

2006-10-11T06:20:00.000-05:00

Breathless posts are flying in from physicians throughout the country to the AAFP 'prez' list (private, moderated) describing broken promises of delivery of flu vaccine.

Post themes:

1. Little guy suffering at the hands of the big guy.

"I paid for 500 doses with a guaranteed delivery of Sept 30 and got 100 on Oct 3 with the balance who knows when. Meanwhile, [fill in bigbox retailer here] is advertising in my town and my patients are all reporting they've gotten their vaccine from them."

2. This one small minimally profitable task is pulled out of our hands by the market in the name of 'public health' while other less profitable (or frankly money losing) but more important public health problems are pushed into physicians offices.

3. Splintering of the medical home.

4. Revisits and rework for flu clinics/visits scheduled and now rescheduled.

5. Conflation of health with consumerism in the market.

6. Does the early push by big box retailers push the vaccine window too early?

CDC Podcasts (including flu vaccination information)
CDC Flu Pages

If choice leaves you unhappy, make your own happiness

2006-10-10T05:26:00.000-05:00

If you haven't figured it out I love TED talks. Great ideas from interesting people. Dan Gilbert's work on happiness was posted just before Barry Schwartz' choice conundrum (see below.) If choice causes problems, then Dan Gilbert explains how we can make ourselves happy with what otherwise seem poor choices. Is this how we rationalize our healthcare mess?

The Choice Backlash

2006-10-10T05:14:00.000-05:00

I've always been vaguely uncomfortable when universal coverage discussions turn to 'patient choice' of coverage, provider and plan. Now I know why. Watch Barry Schwartz' discussion of 'The Paradox of Choice'.

The cost of recruiting

2006-10-04T14:30:00.000-05:00

This summer I attended the AAFP's national conference of residents and students for the umpteenth time with some of our program faculty and residents to kick off the recruiting year. This annual August affair is quite the sight. A fellow faculty mate along for the trip estimates that the 14 programs recruiting resident applicants in our immediate vicinity spent nearly $100,000 for the three day exhibit fest. All that for a chance to meet a handful of students who might want to apply to your residency.

Seems like there should be a less expensive, more direct and targeted way to achieve the end: recruiting medical students to the specialty of family medicine.

Now that recruiting season is really heating up I can't wait to see how this year's version of future family physicians will play out as they walk across the recruiting stage. More later.

Podcasting in healthcare

2006-08-19T08:16:00.000-05:00

A recent dust up with administration at the medical school where I teach tangentially involved this question: do our patients have iPods? I could see innumerable advantages to dissemination of patient information in this way, as do many others, like Kevin Payton at his Health Tech blog and Hans Oh at his eHealth Blog: Podcasting in Healthcare - Revisited 2006.

AAFP is podcasting

2006-08-18T07:47:00.000-05:00

The AAFP announced two podcasts this week. One, a free CME podcast isn't exactly the most riveting audio experience, but the live panel discussion from this years' National Conference is a much better start.

The audio quality could be better, and the range of offerings isn't that great, but I'll always take the 'ship then improve' model over the 'wait until it's perfect and includes the kitchen sink' model (google Microsoft Vista for example of the latter.)

RSS feeds:
In iTunes, select the "advanced" menu, and then choose "open stream" or "Subscribe to Podcast" and past the URL of the RSS feed below. You can also search for the podcast in the iTunes music store podcast section.

AAFP News Now podcast
AAFP Podcasts: Americans in Motion

Flattening Health Care

2006-08-08T11:21:00.000-05:00

Thomas Friedman's The World is Flat posits 10 forces that are flattening the world. Some of these are evident in the US healthcare system, but not enough for my taste.

The first flattener: the fall of the Berlin wall and within six months the shipping of Windows 3.0. It's difficult for those of us who remember the cold war to convey the change embodied by the phrase "I scored some pirated software in China." And we thought only Nixon could go to China. Health care impact: more IMG's are entering medicine in the US than ever before, draining many countries of much needed talent. Meanwhile tele-radiologists and video-intensivists have arrived. Can a Wal-Mart effect be far behind?

Hospitals began outsourcing food services and housekeeping years ago. But will they homesource a call center?

Patients already 'see' their chart online. When will they be able to register themselves, make co-payments online, request referrals and prior-authorization online directly from the insurer?

Inpatient primary care medicine

2006-07-31T10:43:00.000-05:00

I just finished two weeks as attending on our inpatient service, which was notable to me for a couple of recurring themes.

1. I'm getting old. My residents started theophylline on a patient with asthma and not one had ever used it before.

2. If I could get paid a fraction of the hospital costs I could save by providing patients with prescription medicine upon dischargeI 'd be a happy man. We admitted two patient who were recently discharged, only to fail outpatient life because they couldn't afford the medicines that had been prescribed during their previous admissions for asthma and hypertension, respectively.

3. The admission/discharge pace is frantic, with admitted patients rushed from one test to another to shorten their stay. Except of course on the weekends when the cost of staffing radiology for non-emergent cases doesn't make sense. I suppose not everything changes.

4. Scut has changed. In my residency we plated our own strep cultures (and incubated them), ran our own sed rates, spun our own hematocrits, etc. Scut these days is entering orders into a computer, text messaging by computer, checking email at the computer, etc. Lab scut is notable for what CAN'T be done. Indeed, there's not a microscope or lab on the floors at our two main hospitals. God forbid a resident would have to do a gram stain or wright's stain.

Did that sound as crotchety as it reads?

Why doctor's appointments are like airplane seats

2006-07-30T10:48:00.000-05:00

My practice has struggled to balance patient demand for appointments with availability. I've done a lot of traveling lately so have had reason to consider the way that airlines market airline seats, carefully balancing my preferences and willingness to pay against the value in their various seats.

Mid-day flights cost more than early morning flights. Exit row seats cost more than other seats (at least on Northwest.) Frequent fliers get more and earlier choice in seats than non frequent fliers. Want to change flights? That'll be $ please.

Visiting the doctor is at least as expensive as a Southwest roundtrip, and often costs as much as a first class British Airways flat-bed to London. Flyers show up an hour or two early for their trip,queue on command, and print their boarding passes at home.

My QI mavens constantly use the airline quality programs as an example of how medicine should reduce errors. Should we also adopt the pricing and seat controls that airlines use?

Some offices already shunt frequent no-show patients to a special 'alternative probationary' schedule. Isn't this a reverse frequent flier program? Concierge practices charge thousands of dollars to ensure an experience that most of us aspire to provide to our patients anyway. Isn't that a form of 'first class'? Patients in many systems can make appointments online, but I don't know of any that show doctor availability to allow patients a choice of slot. Don't you think my patients would want to know if they're the last slot in a 17 patient session (like yesterday afternoon) vs. first in a 12 patient session (like this morning)? Don't you think they'd pay different for it?

Of course payment is the kicker. We are contracturally forbidden from charging different amounts for the same service to different patients. We are also in the unusual circumstance of not knowing in advance what service will be required before we see a patient. My office visits are one kitchen renovation after another, with the same "Well I didn't know I'd find rotten joists when I agreed to retile your wall" conversations with patients.

Would you fly if you didn't know the fare, didn't know how long it would take to get there, and had no basis to judge the experience of the flight crew or seat comfort on the airplane?

We ask our patients to do that every day.

P4P in primary care

2006-07-15T06:38:00.000-05:00

Family Practice Management has an update article on pay for performance in their July/August 2006 issue, including some interesting statistics and graphs on the rise of P4P programs in primary vs. specialty care and among public and private insurers. There's also a nice checklist for docs to consider before signing up for their local P4P.

I've written before on why performance measures don't work well in primary care; attempts to focus on individual disease markers in patients with multiple comorbid conditions is a byproduct of specialist "disease oriented" rather than "patient oriented" care. The result of this thinking is P4P programs that promote physician behaviors that detract from the demonstrably valuable task of balancing complex competing co-morbidities to achieve improved outcomes. Want more? See Barbara Starfield's editorial in Annals. This unending focus on disease rather than patient is one of the greatest failures of US healthcare.

The New York Times has written about P4P. It's also all over the blogosphere:

Retired doc's thoughts: To see what P4P is really all about, look at the Seattle Blue Shield experience

Roy Poses, a decision analysis maven and fellow generalist: Health Care Renewal: Implementing P4P in the Real World: the Case of Regence BlueShield

KevinMD's thoughts

And even some specialists are aggravated by P4P: Aggravated DocSurg: A(nathe)MA, part the second

Bayes' Theorem in the attention economy

2006-07-14T11:14:00.000-05:00

Nothing like lecturing in the fourth hour of a five hour conference morning on Bayes' theorem in the guise of screening for coronary artery disease to a room of bottom line learners. I've put the pdf of my keynote presentation here. The 2002 ACC guidelines for exercise testing mentioned in the talk are here. My proudest accomplishment in preparing this talk was finally finding a still of Sigourney Weaver floating over Bill Murray from the movie Ghostbusters to illustrate the concept of guidelines. : )

Presentations 101

2006-07-10T11:44:00.000-05:00

I'm a medical school professor, so I give and sit through many lectures. Despite 20 years of trying I still can't get them right, but I'm trying. These three sites might help you with your presentations - they've helped me.

Presentation Zen is my latest favorite. Less is more. Make sure to visit the popular posts and presentaiton tips on the links bar.

Guy Kawasaki describes his 10/20/30 rule, which I've never been able to achieve. While he makes reference to venture capital pitches, the rule is applicable to nearly any stand and deliver presentation, especially if you're projecting something. I had a chance to meet Guy at a Lexington, KY computer show back in the 1990's (pre-internet.) I'll never forget that he used a slide carousel and not a computer LCD projector. At the beginning of his talk he noted that he didn't trust computers with something so important, that he was suspicious of slides too (he had overhead transparancies just in case), and that he'd be just as happy giving his presentation with no visuals at all. In that brief encounter he gave me permission to hate technology for it's shortcomings while still loving it for it's promise.

Lastly is Ian Parker's Absolute Powerpoint piece in the May 28, 2001 New Yorker (I link to a web based text version) that should be required reading for all powerpoint users.

Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

2006-07-10T11:30:00.000-05:00

John Faughnan is a family doc who I've been acquainted with since the late 1980's via our common interst in tech. He has the chops, which is why I follow his blog. He's one of my tier one mavens for things medicine and tech.

His take on spam and reputation managment in these days of HIPPA and privacy concerns is more pertinent than anything I've read in the medical journals.

We're going to have to evolve new systems of defense, trust relationships, identity management and reputation management. Developing these systems will be a major social challenge over the next few decades. In the meantime, encourage your parents, and your vulnerable family members, to consult about their financial decisions. From: Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

Future of Family Medicine extended

2006-07-07T07:20:00.000-05:00

I've put a pdf of the Keynote presentation that I gave yesterday at our grand rounds on my file sharing page (download it here - 2.5MB.) It's a long way from my original resident conference I presented in 1988, but in many respects the themes are remarkably similar.

Addendum:
I realized that many links I visited in the talk aren't in the slides. Why would they be? Slides are, after all, so very 1995 : )

Here they are, plus a few extras as your reward for visiting:

A mashup for locating doctors in berkeley.

Ratings of doctors. Not quite digg or slashdot, but the rival doctor shopping networks are fighting it out as you read this.

Another doctor mashup. Want a real 'monetizer' for web sites? Get health system marketing dollars pointed at these mashups, buying preferential placement for their docs and hospitals. Did I say that out loud?

Penn's patient blog site for checking on inpatients

Rob Centor's blog - president of SGIM, faculty at UAB

One of many examples of a personal health record.

An example of a virtual conference that I recently 'attended'. Why doesn't STFM or AAFP do this in addition to their 'regular' conference? Much of the networking value (though not all) without the travel costs.

If you know about 'flash mobs' then you won't be surprised that others are holding what amounts to 'flash conferences'. The prototype is here. This is another idea that medicine needs to adopt. It's certainly more convenient (for me) than the bulletin board next to the registration desk with handwritten notes on it for whomever happens to stop by.

One of many social networking sites that our applicants use to discuss the interviewing process. Yes, I'm reading you!

Graphical browsing - enter a website and see what's connected to it and what it connects to. The underlying concept and code is used by many sites as one example of 'conceptual mapping'. See here for other examples to numerous to list.

The point to this site isn't the story, it's the "big picture" link that allows graphical browsing of the related stories. Let the entire page load then click the 'Big Picture' link in the red bar on the right of the page. Any news story you visit on cnet news can be browsed the same way.

Like graphical browsing? See here and here for more examples. Now imagine this technology used to visualize medical concepts. We're getting close but aren't quite there yet. The Krafty Librarian post from last month talks about this.

Drug Quilt is an example applied to the drug industry. It certainly makes it easier for me to see the relative relationships between companies and products.

The future of lipid therapy

2006-06-22T10:25:00.000-05:00

I'm about to deliver this presentation at the NJAFP annual scientific assembly in Atlantic City. It's a pdf of the keynote file that I used to present. I also have a powerpoint version if you want to email me for it. Feedback is welcome.

Should US Med Students train abroad?

2006-06-19T17:02:00.000-05:00

A recent NEJM podcast notes interest in US students travelling overseas to gain international experience. "In 2003, 1 in 5 US students participated in an international experience" the moderator states.

One of the students interviewed comments on their experience: "The most important question asked in Uganda was whether they had money to pay for medicine. If so, they were given medicine, if not, they weer sent home to die...It Taught me the importance of perspective in global health."

Given the recent spate of articles describing how the US healthcare market is 'stealing' nurses, physicians and other health care workers from developing countries I wonder whether this 'send student doctors back' phenomenon will help stem the tide by opening the minds of medical decision makers to international training.

I know that in the residency that I direct I have little ability to pay for residents to travel or train overseas. Do other payors feel they're getting their money's worth? Anyone up for a cost-benefit analysis of exchange training?

Contextual advertising

2006-06-16T00:01:00.000-05:00

One of the problems facing product manufacturers who want to get their product in front of your eyes is the tension between grabbing your attention by inserting ads in an entertainment experience vs. making the information 'so valuable' that someone actually seeks it out - e.g. 'must watch media' vs. 'must watch ads'.

Of course the 'watch' metaphor in today's attention economy isn't the right verb for the ADHD generation. You know the type; a teenager doing homework while simultaneously holding online chats, playing a MMORPG, talking to someone else on the phone, answering mom who's calling for dinner and playing poker (and winning).

That's why ads in SecondLife (product placements if you will) or other social networking venues work so well. They take advantage of an alreay established social network to interject their product in context; if there is real value in the product there will be real value in the network, with all the viral marketing implications intact.

Call Center homesourcing

2006-06-15T23:53:00.000-05:00

Tom Friedman's book (The World is Flat) includes the forces that are flattening the world. One that stands out to me is homeshoring. We have a small call center in our department that has equipment and people in cubbies. Office Space cubbies. All expensive, all calls tracked relentlessly by a system that tells us everything we could ever want. Unfortunately, we rarely use the call metrics. Instead we continue to ignore them. The result is a continued 15-20% abandoned call rate, in part due to busy Mondays where we don't have staff to cover the phones.

Why don't we contract for our high demand days on some volume/quality basis to qualified and trained folks who work from home? If Jetblue can do it why can't we?

Bibliometric Analysis in promotion decisions

2006-06-11T14:45:00.000-05:00

My chair has challenged me to come up with metrics that go above and beyond publication number or 'impact' as measured by ISI citation index. Promotions here and elsewhere betray their own peculiar mix of culture, politics and tradition. Here are my thoughts.

The basic premise is that academic productivity ought be judged on the basis of defined principles. Boyer's categories of discovery, integration, application and teaching have been quantified by promotions committees in traditional terms such as publication volume, publication influence, patents, grants, courses taught and advising undertaken. The context for these discussions is often one of promotion or tenure in academic environments, concepts themselves with questionable external validity that are increasingly under scrutiny.

While variation in and of itself isn't a problem, not examining the variation is certainly problematic. What I'm most concerned about is decisions where the lack of analysis dampens innovation or worse, hampers scholarship.

Computing and communications advances have created novel means of visualing qualitative and quantitative relationships in real time, which in turn brings variation in promotion and tenure decisions within and between organizations into sharp relief. Unfortunately I don't have answers, but did come up with some questions for myself.

Will Google Scholar replace ISI's web of science? Should professors be blogging? The editor of the Scientist thinks so, as does the Unversity of Chicago Law School. How do you cite a blog? Should you be able to tap into the attention filter of mavens? Does doing so alter the nature of their maven role? Are Boyer's categories of scholarship congruent with maven-ness, connecting, or selling? What's the role of personomies in promotion decisions?

If the nature of scholarship is changed by how it's measured, then scholarship in a web 2.0 world has more to do with the new tools to measure it. Visualizing the role of an academic and the relationships in academia over time takes on new meaning when you can do so in real time. Why don't promotion committees use academic tag clouds? Is ISI really a snobbish technorati? Where's my touchgraph ?(You must have java for the touchgraph applet to launch - what's a touchgraph?)

The Krafty Librarian

2006-05-25T10:10:00.000-05:00

Information sciences meets medical search meets web 2.0 at the Krafty Librarian. I don't know what the future of medical education looks like but the future of scholarship will incorporate much of what is discussed here.

Pennsylvania Health Care Reform

2006-05-14T09:37:00.000-05:00

Handing over the reins of my PAFP presidency was painless, though I almost missed the inauguration of my successor. The ceremony (which I mc'd) was to begin at 6 pm and I found myself waking up from a power nap at 5:47 still having to get into my tux and navigate 8 floors in elevators hijacked by teenage band members who acted as if they'd never seen an elevator before.

The big discussion in our house of delegates was about the competing versions of health care reform in play in Pennsylvania. SB 1085 got the most discussion, a full bore universal coverage single payer system that has all the elements to actually work, and therefore all the elements to petrify every stakeholder into opposing it. It's being pushed by a group that includes a lawyer, doctor and businessman (all with progressive leanings) and democratic sponsors in the legislature, making chances of action nearly nil. Reminds me of Star Trek:

Kirk: I take it the odds are against us and the situation is grim.
Picard: You could say that.
Kirk: You know, if Spock were here, he'd say that I was an irrational, illogical human being by taking on a mission like that. Sounds like fun!

Plenty of other blog discussion on SB1085 here and here. A hearing would be nice but seems unlikely at present. Still, the primary is only a few days away and the elections are coming up in November, making for a lame duck sine die session that's already building steam.

Other legislation in play: a Maryland like "make walmart pay their fair share" plan that's pretty white bread to me. A no-brainer "don't let insurers retroactively revoke payment four years after they cut the check", not to mention a few more.

New Mexico - Amazing

2006-05-09T17:55:00.000-05:00

I recently went on a road trip with the family to New Mexico to explore the region. Pueblo indian culture at Bandelier, atomic energy museum at Los Alamos, browsing Santa Fe galleries, driving back roads to Roswell, then a side trip through Hondo Valley to White Sands before circling back to Albuquerque via Tularosa and Carrizozo.

Most amazing aha's? The stunning Hondo Valley drive in the spring. White Sands national monument: we never expected it to be that great. A great 2003 Sangiovese (Sangiovese!) at Tularosa Vineyards. And if you're ever in Carrizozo make sure to get a green chile cheesburger at the Outpost. Honest food, honest setting. Great all around.

Marketing Metrics meets Public Health

2006-05-08T13:25:00.000-05:00

I listened to David Reibstein of the Wharton School* on this Knowledge@Wharton podcast (free registration required) last night while riding home, and it got me thinking about the Press-Ganey surveys we do in our health system. Do we inflate our satisfaction scores by only surveying people bold enough to stay with our practice? I know how to calculate MDRD-GFR. Why don't I know these common marketing metrics? Aren't they a better predictor of what I'm being paid for?

More importantly, how do the metrics like 'market share' relate to similar public health/epidemiology concepts? If patient satisfaction/practice satisfaction is associated with adherence, and adherence with health outcomes, then it would seem we're not paying enough attention to doing right by the patient. Anyone who's navigated my practice's 'automated voice attendant' probably knows what I'm talking about.

*disclaimer-I'm employed by Penn but don't know Dr. Reibstein and am not getting a cut of his book, but would be happy to : )

AAFP now has RSS feeds for news now

2006-05-08T09:39:00.000-05:00

Periodically I send Leigh McKinney (Director, Online and Custom Publishing Division AAFP) an email about AAFP publications and how I'd like to bring them into the 21st century. The academy is already the leader in pushing electronic medical records, and they've won awards for some of their online sites, but as a geek I can't help but consider how the academy can more successfully compete for the attention of its members by using new media tools that take advantage of the social networking that is the strength of the academy.

Today Leigh sent me a message to note that the academy has added an RSS feed to their valuable news service AAFP News Now. wOOTt!

Now how about an AAFP RSS aggregator that pulls feeds of interest to the AAFP into one spot (like David Ross' and Jacob Reider's medlogs.com)?

Contracting resources for residents

2006-05-04T12:32:00.000-05:00

Had a nice chat with my residents this morning about looking for a job. Stark ("what's that?"); restrictive covenants; need for lawyers, etc. This is an area where it's important to personalize the advice to the person involved, hence my inclincation to point residents to resources and have them identify their own learning issues and approach. Guided discussion is one way to do this but it's not as active as it could be and doesn't take advantage of the 'teachable moment' that every resident feels when they first get a glimpse of what life could be after residency.

Here's a collection of articles on contracting from FPM for residents seeking employment. Also contracting services and demystifying contract terms. FPM is a good general resource but [small print lawyer disclaimer language here] "can't substitute for legal counsel."

Why quality measures don't work in primary care

2006-05-04T09:34:00.000-05:00

I've written in my PAFP Keystone Family Physician column about my dissatisfaction with pay for performance measures in primary care. Now Barbara Starfield weighs in. I couldn't agree with her more.

This isn't the first time I've been impressed with her work this week. She presented a plenary at last weeks society of teachers of family medicine meeting that introduced me to the world health chart website and application.

The world health chart is amazing, but clearly in its infancy with regard to the integration of graphic display of quantitative information as it relates to public health. I'm anxious to see local versions of google-map mashups with useful information like the availability of medical assistance dermatology appointments in the Philadelphia area. Alternate mash-ups: physician by appointment availibility, physician by blog, physician by contribution to neighborhood economy, physician by contribution to community health measured by primary care characteristics - availability, comprehensiveness, coordination of care

Anyone up to the task?

Independent Pharmacies still exist

2006-05-04T00:11:00.000-05:00

The version of this pharmacy that still exists here in Philadelphia is Davis Pharmacy on Baltimore Avenue in West Philadelphia. Nice story.

Brain Rain Barrels

2006-05-03T16:00:00.000-05:00

Do you use a mind mapping software program? Inspiration is my current dumping ground, and it's fine for my casual use, but something that makes it easier to group and connect similar ideas would be nice, not to mention something a little prettier to look at. Tinderbox, OmniOutliner and some of the opensource programs at the wiki mind mapping page seem to be candidates. I use Mac OS X and am a casual GTD beginner, using a backpack account for my various lists. Quicksilver is gold. Stickybrain doesn't do it for me.

My typical inspiration use: jotting notes directly into the diagram view using rapidfire mode. Outline view doesn't do it for me.

What do you use? Why?

Albuterol and Pharma

2006-05-02T21:52:00.000-05:00

So why are albuterol inhalers rapidly disappearing from the market? Are CFC's really to blame or is the market transition to HFA inhalers with their higher cost and higher margins to blame. Call me cynical, but this seems to me to be another failing of the current health care system. It takes doing the right thing (eliminating CFC's) and turns it into a profit making - patient hurting debacle.

What am I missing here?

Hello

2006-05-02T20:07:00.000-05:00

No the world doesn't need another doctoring blog, but as you'll see if you read for long it's really for me. A place to brain dump all the otherwise forgotten thoughts that enter my too full head. If I put one more thing in I'll forget how to drive.

OK, I suppose it's also an effort to preserve the patience of my colleagues, who would otherwise have to listen to me rant even more than they already do.