See Ya
Us colonials are off to visit our roots. Since I'm english and my wife french, we'll have to ford the channel. Hope to bring rheumatological news from abroad.
Back in two weeks.
June 28, 2008
June 25, 2008
De- Compensation
A recent study might make you think twice about curing your patient's trigger finger. D. Fishbain presented a paper at the 2008 American Pain Society meeting where he found that 5.5% of patients had homicidal feelings towards their physicians. Although I could find little of the actual study, other reports on it have suggested that pain, disability, and compensation are important predictors for this emotion. It's not really that surprising, I guess, after all we are talking about emotions here, not actions. And emotions can run pretty high when we're talking pain, disability and particularly compensation. Patients count on their doctor to help them, and support of their disability claim is often considered part of that help. When it is not forthcoming, for whatever reason, disappointment is natural. Natural, but not necessarily inevitable. Most of the time it's simply a misunderstanding on the patient's part about how the compensation system works (or works against them), and poor communication on the MD's part in explaining that system and his or her own role in it. If everyone knew the rules of the game (and unfortunately, game is an apt description) I think the disappointments, though not necessarily less numerous, would be far less intense and less frequently directed at the treating physician.
June 23, 2008
Mothers In Rheumatology
Rheumatology is putting on a new face, at least in this province. Statistics from our rheumatology association suggest that the average rheumatologist is a fifty-five year old man. (Unpublished statistics would show that he is balding and grey but nonetheless ruggedly handsome) Not for long. Most of the trainees over the last five to ten years have been women and the wave continues to wash away the remnants of maleness in the field. There has to be many reasons for this mad rush to join the poorest paid specialty in internal medicine but I suspect that one important one is that rheumatology actually allows for some semblance of a family life. Call is often from home, not that hectic, and most patients can be handled by the ER staff while you finish up supper and beddy-byes. Men would obviously benefit from these practice bonuses as well, I thrived on them, but I still think that women MD's might take these considerations a little more seriously. In this light, I would like to recommend to the many new female rheumatologists with an interest in doctor-mother issues to visit Mothers In Medicine, a multi-author blog discussing all things related to moms in medicine.
June 17, 2008
Picture This
Pharmaceutical consultation meeting
Pharmaceutical consulting/advisory meetings are a different breed of meeting. MDs are paid for their opinion concerning a product and so the agenda of the meeting has absolutely no pretense of objectivity. For the same reason, the speakers don't have to be impartial at all, and can spew out just about anything that the crowd will take. Because the members are paid, they can usually take a lot. It's at these meetings that members are sometimes put in somewhat awkward spots, being pressed to express an opinion in front of their peers, and before a paying host. Rarely, however, does it get as bizarre as the invitation that I recently received from a pharma company of one of the biologics. In their invitation I was asked to fill a questionnaire about my feelings concerning the efficacy of the major biological anti-rheumatic drugs and their side effect profile. They then asked me to "find a picture from a magazine that I thought symbolized their product, and bring it to the meeting". It might have been worth going to the meeting just to see a dozen adults doing show and tell with their favorite magazine pictures. Hope somebody brought a camera.
June 16, 2008
Compassion in the Corridors
Our hospital is a busy one, apparently the second busiest in this large province. Our emergency is constantly under pressure and for this reason we often have patients on gurneys in the corridor. So often, in fact, that these beds now have permanent curtains. Unlike "those" hospitals, though, we don't have permanent numbers above the beds, simply cardboard and felt pen. This can't be forever, right? All the corridor beds were occupied when I visited a patient last week because of an acute ankle arthritis. A lovely women, but an ugly limb. It was obvious a joint tap would have to be done and I knew it would be difficult. Lots of swelling in a joint that is often tough to aspirate, and the patient was extremely anxious. No matter how much xylocaine you use, a really anxious patient is going to feel pain. As I had guessed, the freezing did nothing and the patient let out a little yelp of pain. What happened next, however, I could not have guessed.
The internist who had called me about the patient was nearby. He dropped what he was doing, came over and started to talk to the patient to distract her while I continued. A couple of minutes only, but for a busy hospitalist, minutes don't come easily . I finished up and while I did my notes, I noticed that an orderly had followed in behind me to help console the still teary women. He stayed a few minutes and then carried on with his many duties. As I left, I went to see that the patient was okay. In front of me, a nurse who was simply passing by gave the patient a little rub on the shoulder as she continued on.
An emergency corridor is a cold and lonely place. It can be much less so though, when those who work there can overcome the daily hassles and hurdles and remember why they chose the helping professions.
June 11, 2008
Have A Seat. The Doctor Will Be With You In An Hour.
I think I have a waiting room wait-time problem. Below are a few of the symptoms.
Luckily there may be some help. Ian Furst, a physician at Wait Time and Delayed Care provides an immense amount of information on all things related to wait times, from the micro level to the grand scheme of things. The only problem with the site is the underlying suggestion that my waiting room grief is likely (all right, definitely) self-inflicted. No more excuses. I'm getting onto this problem... Soon.
June 09, 2008
We'll Try Again In Five Years. Carry On.
Conclusion: Limited available comparative evidence does not support one monotherapy over another for adults with rheumatoid arthritis. Although combination therapy is more effective for patients whose monotherapy fails, the evidence is insufficient to draw firm conclusions about whether one combination or treatment strategy is better than another or is the best treatment for early rheumatoid arthritis.
This is the unfortunate conclusion of a recent systematic review of DMARD therapy in rheumatoid arthritis, published in the Annals of Internal Medicine. Apparently, a review of the literature was unable to determine whether sulfasalazine was as good as methotrexate, nor whether methotrexate plus a second DMARD is as good as methotrexate with a biologic. I guess it's not that surprising, given the lack of head to head studies between these agents. In fact, you'll never see a study comparing methotrexate and a biologic vs sulfasalazine and a biologic because we've all concluded that in clinical practice, methotrexate is a better drug. They may as well have added gold salts to the study, or blood-letting:
"Because of the lack of head to head studies, we cannot conclude that etanercept is a better treatment option than leeches in the treatment of rheumatoid arthritis. Further studies are encouraged."
I'm not suggesting that the authors should conclude differently in their final opinion, but it should conclude with something like, "There were not enough head to head studies to make this endeavour worthwhile. We'll try again in five years. Carry on".
The results of publishing this kind of non-study is not negligible. When it came out I was in negotiation with the hospital for funds to help us with the administration of biologics. An internist on the hospital board pulled out this study and questioned whether biologics were any better than the other available treatments. I can't but help think that there are government cost-cutter types out there wondering how he/she can use this study to limit access to biologic drugs. In fact, I bet it won't be long before a patient pulls out a copy to challenge my choice of treatment.
June 03, 2008
Top 10 Reasons We See A Doc
I always had the impression that rheumatological, or at least musculoskeletal problems were high on the list of reasons we go to see our doctor, but according to IMS ( a pharmaceutical industry monitoring firm) this isn't so.
Top 10 Diagnoses in Canada- 2007
1) Hypertension
2) Health check-up
3) Diabetes
4) Depression
5) Anxiety
6) URTI
7) Normal pregnancy visit
8) Hyperlipidemia
9) Other ill-defined and unknown causes of morbidity
10) Esophagitis
Number 9 could be our rheumatological ringer. I suspect we might find fibromyalgia here, but no back or neck pain, no tendinitis or bursitis on the list.
Another curious statistic the IMS provides is the percentage of patient visits with drug recommendations based on these 10 diagnoses. 80% of hypertensives get a prescription, 82% with depression, 81% with cholesterol issues but a full 99% of those with ill defined and unknown causes of morbidity. Are they suggesting that the most vague symptoms receive the highest rate of treatment? I gotta see what this is all about.
June 02, 2008
Surely We Can Do Better
But this isn't what usually happens. Several studies including a recent article in The Journal of Bone and Joint Surgery have shown that a minority of these patients get the appropriate treatment. Rozental et al. looked at 298 consecutive radial fractures and found that only 21% had had a bone density six months after their fracture, and only 11% were receiving bisphosphonate treatment. They did a small prospective study as well, asking the orthopods to order a bone density test once the fracture was diagnosed and send it to the family physician, and as a control they simply sent a second group of family physicians a guideline for osteoporosis screening. Those patients who had their bone density ordered directly were much more likely to have them done (93% vs 30%), and to have treatment of their osteoporosis (74% vs 26%). It would seem that this would be a simple solution to the problem, but as we all know, there are no simple solutions. We tried this approach at our hospital. All we asked of the surgeons was to sign the radiology request for the osteodensitometry. The rest was handled by a nurse who arranged follow-up of the results. Greater than half of the orthopods didn't send us a single patient. The others started off well enough but the whole endeavour died out because we didn't have some dedicated person at the fracture clinic to pester the orthopods into signing the request. A second problem that has arisen in our neck of the woods is the lack of family physicians. There's no sense doing a test if no one is around to follow up on it.
The solution must then be some kind of automatic referral from the fracture clinic which does not require the attention, interest, or even the signature of the surgeon, to an osteoporosis clinic which can quickly assess, treat, and send patients back to the primary physician. It seems simple enough- we're going to find out in the next few months.
May 27, 2008
When Do Squeaky Hips Become A Health Concern?
When there's YouTube footage, of course.
Recently the WSJ Health Blog, the rest of the internet universe, and most print sources ran an article about the rather minor problem of squeaky hip joint prosthetics. The odd but no doubt disconcerting side-effect will afflict about 7% of ceramic-on-ceramic prosthetics, and up to 20% of the rest will make other snap, crackle and popping noises. Interestingly, the original study by Jarret et al., was conducted between 2003-2005, and was presented at a meeting in Nov. 2006. An article was published in early 2007 about the findings and a good summary of the study was reported in the American Association of Orthopaedic Surgery. At this point it was still just an orthopaedic nuisance, a pipsqueak of an issue. In January 2008 a YouTube video of an actual patient squeaking along a hallway is posted and soon after (about 27,000 viewings after) it becomes a media superstar. Go figure.
I'm sure you've heard the story and have probably seen the video, but just in case, here it is,
One other thing. They still haven't figured out exactly why this kind of prosthesis squeaks. A possible clue may be found in the French term used for an intra-articular loose body, the souris intra-articulaire, or intra-articular mouse. Just a thought.
