GO VOTE FOR ME!!!
You have to sign up to vote, but so far the top blog in that category only has like 300 votes, we can totally SLAY THEM!!!!!
- Mood:
loved
Here's a note sent today from Dave to his BIDMC doctors (David McDermott, Andrew Wagner, Mee Young Lee, Gretchen Chambers, and Megan Anderson), reprinted with his permission:
I tell people about you everywhere I go, which these days includes conferences and policy meetings. I've begun (unskillfully) doing recorded interviews with Dr. McD and Dr. Wagner to make the world aware of what you offer that's not available everywhere; I hope to do more, when you docs say there's more news to share. (Next time around I'll let YOU talk more...)
Ginny and I are having a fabulous summer, making the most of life. Yesterday we decided that next summer we'll celebrate our tenth wedding anniversary with a trip to Switzerland and Germany, where she went many years ago. Gonna get us some Alps! And on May 31 I got to walk my daughter down the aisle, and next weekend is Mom's 80th birthday party. Needless to say, it is a JOY to be present for these events.
Thanks for making all this possible. You're wonderful. (Pass the word to anyone else who worked on my case - too numerous to recall. And all of Stoneman 7.)
Dave
[From time to time we invite guests to blog about initiatives of interest, and are very pleased to have Anousheh Ansari join us here. – Ed.]
Ever since I was a young girl, it has been a dream of mine to travel into space. In September of 2006, I was fortunate enough to make that dream a reality — I took off from the launch pad in Baikonur bound for the International Space Station and became the world's first private female space tourist. Since then, it's been my mission to help as many people as possible think ambitiously about ways to push the boundaries of exploration, both here on Earth and beyond. As a trustee of the X PRIZE Foundation, and the sponsor of the Ansari X PRIZE, I support Google's goal of opening up space through projects like the Google Lunar X PRIZE, which serve to educate the public about the global benefits of space exploration.
That's why I'm so excited about the release of Moon in Google Earth, which is launching today at the Newseum in Washington D.C. This tool will make it easier for millions of people to learn about space, our moon and some of the most significant and dazzling discoveries humanity has accomplished together. Moon in Google Earth enables you to explore lunar imagery as well as informational content about the Apollo landing sites, panoramic images shot by the Apollo astronauts, narrated tours and much more. I believe that this educational tool is a critical step into the future, a way to both develop the dreams of young people globally, and inspire new audacious goals.
With Google Earth, young explorers around the world can bounce around the galaxy in Sky, fly to Mars and now visit the moon from wherever they may be. To learn more watch the video below or visit the Lat Long Blog. Finally, outer space doesn't seem so far away anymore.
Yvon Le Caer won a couple of medals in 1978 at the FLoride Cycling Masters Championships and then turned his sights towards another challenge - pedaling on water, exploring the ocean via bicycle. After a few years of development the Aquacycle was born and Operation Gulf Stream was launched in 1981 where Yvon pedaled his way across all 63 miles of the Strait of Florida in just under 11 hours time. In 1985, Yvon piloted the Aquacycle across the 75 mile distance of the Western English Channel. Lucky for us, Yvon has documented the development of his machine and these two accomplishments on his website, packed with images and tales from the water. Visit www.yvonlecaer.com for the full story.
Most readers know that I frequently give talks on pharyngitis. Most recently I have focused on morbidity and mortality in pharyngitis patients.
I have collected a number of unfortunate stories about patients having prolonged illness or even death when their initial symptom was pharyngitis. 
I have written and thought about pharyngitis for almost 30 years. My initial approach to pharyngitis came from the emergency department – quick decision making – is it strep or not? My second approach to pharyngitis came from considering a broader differential diagnosis – non-group A beta strep, infectious mono, gonococcus – and considering empiric antibiotic therapy. More recently I have focused on the dangers of considering a sore throat JUST a sore throat. As I spend more time doing inpatient medicine, I see pharyngitis through a different lens – a lens of morbidity and mortality.
In analyzing the patient stories that I use, I find a commonality. Physicians too often consider pharyngitis JUST a sore throat. This error does not exist just for pharyngitis, but perhaps one more easily ignores the patient when approaching pharyngitis. We have guidelines and performance measures that tell us to do a rapid test, treat if positive, and otherwise reassure the patient.
These guidelines and performance measures have a major flaw – they ignore that patient. The authors consider pharyngitis as a simple dichotomous problem – strep or not strep. They assume that while not perfect, a rapid test is good enough, afterall little harm is done even if you do not give antibiotics to strep.
In all the sad stories that I share, physicians (or nurse practitioners) follow guidelines. Sometimes they even are nervous and prescribe empiric antibiotics. But in all the stories one can impute a lack of cognition. They either ignore natural history, or are ignorant of the natural history.
They do not seem to understand that sometimes a sore throat is not a simple sore throat. They fail to adequately exam the patient or take a careful history. Sore throat patients apparently do not deserve thought.
While I am talking specifically about sore throat patients, you should extrapolate this screed to all presenting signs and symptoms. Each patient deserves careful consideration. We should always see if the patient’s story and exam fit a common problem as described in the textbook. We should always reconsider the problem when the story does not fit our assumptions.
The rationale behind evidence based medicine and the guideline movement is too improve medical decision making. I fear that too often these guides become cookbook directions for caring for problems. Patient presentations are too often complex and do not fit the directions. We must individualize our clinical thought processes, taking into consideration the evidence, but also the patient.
In my frequent pharyngitis lectures, I emphasize the importance of natural history. I make clear the red flags in pharyngitis patients – reminding the audience and myself when to deviate from “the protocol.”
I fear that guidelines and performance measures encourage us to forget the basic detective approach to pharyngitis. When all the clues are not explained simply, then we should recheck the clues and more important recheck the denouement.
Related Posts
Most readers know that I frequently give talks on pharyngitis. Most recently I have focused on morbidity and mortality in pharyngitis patients.
I have collected a number of unfortunate stories about patients having prolonged illness or even death when their initial symptom was pharyngitis. I have written and thought about pharyngitis for almost 30 years. My initial approach to pharyngitis came from the emergency department – quick decision making – is it strep or not? My second approach to pharyngitis came from considering a broader differential diagnosis – non-group A beta strep, infectious mono, gonococcus – and considering empiric antibiotic therapy. More recently I have focused on the dangers of considering a sore throat JUST a sore throat. As I spend more time doing inpatient medicine, I see pharyngitis through a different lens – a lens of morbidity and mortality.
In analyzing the patient stories that I use, I find a commonality. Physicians too often consider pharyngitis JUST a sore throat. This error does not exist just for pharyngitis, but perhaps one more easily ignores the patient when approaching pharyngitis. We have guidelines and performance measures that tell us to do a rapid test, treat if positive, and otherwise reassure the patient.
These guidelines and performance measures have a major flaw – they ignore that patient. The authors consider pharyngitis as a simple dichotomous problem – strep or not strep. They assume that while not perfect, a rapid test is good enough, afterall little harm is done even if you do not give antibiotics to strep.
In all the sad stories that I share, physicians (or nurse practitioners) follow guidelines. Sometimes they even are nervous and prescribe empiric antibiotics. But in all the stories one can impute a lack of cognition. They either ignore natural history, or are ignorant of the natural history.
They do not seem to understand that sometimes a sore throat is not a simple sore throat. They fail to adequately exam the patient or take a careful history. Sore throat patients apparently do not deserve thought.
While I am talking specifically about sore throat patients, you should extrapolate this screed to all presenting signs and symptoms. Each patient deserves careful consideration. We should always see if the patient’s story and exam fit a common problem as described in the textbook. We should always reconsider the problem when the story does not fit our assumptions.
The rationale behind evidence based medicine and the guideline movement is too improve medical decision making. I fear that too often these guides become cookbook directions for caring for problems. Patient presentations are too often complex and do not fit the directions. We must individualize our clinical thought processes, taking into consideration the evidence, but also the patient.
In my frequent pharyngitis lectures, I emphasize the importance of natural history. I make clear the red flags in pharyngitis patients – reminding the audience and myself when to deviate from “the protocol.”
I fear that guidelines and performance measures encourage us to forget the basic detective approach to pharyngitis. When all the clues are not explained simply, then we should recheck the clues and more important recheck the denouement.
Related Posts
Some sun in the morning, otherwise almost continuous rain all day. Impossible to do anything outside. Notice that hens always eat less in this weather. Top of hay under a few stacks is still dry in spite of the constant rain. Goats show slight tendency to diarrhea from eating wet grass.
Stated today in letter in D. Tel. That for 1 person using electricity for all purposes, except a periodical coal fire for warming, 1800-2000 units is annual minimum consumption.
12 eggs (1 v. small – it is the mother hen that lays these).
Foreign & General
1. Public Information Leaflet no.3 (evacuation) issued today. Never less than 4 searchlights visible at night from this village. [No reference]
2. News from Danzig seems to indicate that all there expect Danzig to fall into German hands in near future. Daily Telegraph [a]
3. France said to be in favour of acceptance of Russian terms for Anglo-Russian pact, which have not been altered re. The Baltic States. Daily Telegraph [b]
Social
1. One of the editors of Humanité questioned by the Paris police with ref. to spy revelations, but no indication from report whether merely in advisory capacity or under suspicion of complicity. Daily Telegraph [c]
2. Recent W.O. regulation has forbidden army officers to resign their commissions & seemingly steps are being taken to prevent N.C.Ss buying out from the service (present cost £35). Daily Telegraph [d]
[a]
[b]
[c]
[d]
( Seriously, she was really going at that thing )
- Mood:
sleepy - Music:Melissa Etheridge - An Unusual Kiss
I'd like to focus on a few of his points and explore the implications for an academic medical center like BIDMC. With regard to the movement towards capitated (er, now, "global") payment schemes, Gene perceptively notes that:
There needs to be a way to connect patients to primary-care physicians so that payment is made to the organization providing the care. Optimal Accountable Care Organizations will need to have a scale large enough to accept the risk of providing care on a fixed budget and the expertise and infrastructure to manage risk.
This is consistent with the message I sent to our staff a few weeks ago, where I noted:
We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.
If Gene is right about primary care doctors having an ever-increasing role in managing the continuum of care in the future, the structure of the institutional relationship between primary care organizations like those in Atrius Health and the tertiary care organizations exemplified by BIDMC matters a lot. One model, which could be functional but not very interesting, is that the tertiary center would serve as a vendor to the primary care practice. In essence, this is mainly a commercial role, with a focus on the rates charged by the hospital for the services it "sells" to the PCPs.
A more vital role, though, is a true partnership, in which the medical and administrative staff in both organizations constantly seek ways to improve the patient experience. While there will always be the business aspect of who gets what percentage of the global payment, the real time and effort would be spent on improving communication of patients' clinical information, on enhancing modes of treatment based on the latest evidence, on taking steps to reduce the possibility of harm to patients at all stages of their treatment, and on helping staff in both settings redesign their day-to-day work to make it more rewarding and efficient .
In Gene's words, the latter approach reflects a commitment not to focus on "how little we need to change [but] rather [on] how much we could change." That sounds just right, but it is fair to ask tertiary hospitals how good they are at change and how well they have endorsed change in the past. Our place has learned a lot about change during the past few years -- first out of necessity when we had the near-death experience of the post-merger debacle -- later out of choice when we established audacious goals for patient quality and safety and satisfaction, when we committed ourselves to unprecedented levels of transparency of clinical outcomes to hold ourselves accountable, and when we adopted a staff-driven approach to process improvement.
The main thing we have learned about change is to be modest about what you know and what you don't know. We look forward to the opportunity to learn from Gene's group and others in the state as we pursue the creation of accountable care organizations that are truly accountable, truly care, and truly are organized.
The New York Times recently held a brief forum in their opinion section on the subject Should Roadside Memorials Be Banned? While not explicitly touching on the Ghost Bike phenomenon of all white bikes placed at the location of bicycle fatalities, it nonetheless discusses many facets of the argument about memorials in public space, whether for traffic accidents or deliberate violent crimes.
Read more about Ghost Bikes in Urban Velo #11.
August 1st in Ann Arbor, MI brings the Pedal Poker Run presented by Jimmy Rigged. Go to the checkpoints and pick up cards, best hand wins. Within a given time limit you have the chance to throw back a card and get a new one dealt, assuming you can make it to a checkpoint and back in time. Three folks are getting free tattoos from this ride, along with some other prizes in store.
I just found a video for a do it yourself $10 wedding dress made from mens undershirts. And it really is summery and pretty! Rooooose??? http://www.threadbanger.com/tb-projects/e
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