Adapting Office Workflows to the EMR – or How I Restored Patient Face Time & Got Back the Joy in Medicine

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required.  A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation  (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had become smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

I found myself spending office hours longing for them to be over, and even more sadly, wondering just how many more years I needed to do this before I could retire.

Something had to change. Since the EMR wasn’t going anywhere, it was going to be up to me to make it work.

Renovating the Exam Room was not the anwser

My internist has a patient chair next to the desk in the exam room – I talk with her there, then she leaves the room while I change, then she comes back and does the exam, finally wrapping things up at the desk while I wait in my gown. Then I dress after she leaves.

I thought about pushing for our exams rooms to be renovated, but realized that I probably wouldn’t adopt my internist’s workflow. It just ties up an exam room for too long.

Advance chart prep was not the answer

I tried doing what some of my colleagues do – reviewing the charts of my patients the night before, creating a presumptive note based on her history and the scheduled reason for her visit (when I knew it) , even entering charges and orders for mammograms and birth control pill refills, all of which I could quickly edit and sign tomorrow when I saw the patient, freeing up the encounter itself for more personal interaction.

That idea lasted about a day. While it may work for surgical sub-specialists who hold office hours twice a week to prep charts the night before, it’s impossible for a doc like myself who sees between 15-24 patients a day, 4 days a week.  I had to find a way to get today’s work done today (and not at 4:30 am today, which is when another colleague does his chart prep).

Changing office workflow was the answer

I realized that my private office, which sits between my two exam rooms, is arranged so that I can type and look at my patient at the same time. So I decided to reserve all my electronic charting to my office, and leave the exam room to do what it does best – exams.

My patients now come to see me in my office before and sometimes after they’ve been examined – a workflow previously reserved for new patients. It’s a little more complicated for the office staff, but it’s working really well for me and for my patients. We’re both more relaxed and can both look one another in the eye while we talk and I type.

Its not just the office staff who’ve had to get used to the new workflow. Long-time patients can get thrown, despite my staff explaining that this is the new routine. One patient told me she felt like she was being called to the principal’s office. Another was convinced I had bad news for her. Once I explain my rationale, however, my patients are more than pleased with the new arrangement. Some have remarked on how much they like my office, and how its decor and wall art has allowed them to get a better sense of who I am.

Other pluses –  I’m no longer wasting precious time logging in and out of the EMR, since my office computer isn’t used by anyone but me. I’m physically more comfortable, and so is my patient. Our wrap up after the exam is that much more personal because I am able to enter her mammogram and refills and even her charges while she changes instead of in the exam room. I remember more of the visit later because I’m more fully present with the patient in the exam room. Finally, there’s less down time for me, since I’ve effectively added a third room to office hours and can see a patient in my office while the other two patients are either dressing or undressing in the exam rooms.

But the biggest upside to my new workflow? I’m having fun!  It’s like falling in love with medicine (and my wonderful patients) all over again.

The down side

The down side to my new workflow is that I’ve got to hold everything in memory between the time my patient leaves my office and when she is ready in the exam room, during which I may have seen another patient or two.  It can take me a second or two to ascertain who’s behind door number two, and sometimes I get it wrong. Which has led to an embarrassing moment or two when I opened the door with a comment related to a prior conversation in my office and realize the person behind it is not who I was expecting to see. I’ve since learned to keep my mouth shut until I’m entirely in the exam room.

The good old days 

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done. The entire work of a patient’s encounter took place in one room (or just outside its door), and in one allotted space of time, during which I was hers and hers alone. My chart was there, sure, but it was not the dominant presence in the encounter the way the EMR is now.

Is the IPad the answer?

I find myself thinking a lot about the Ipad these days. While initially skeptical about its place in healthcare, I’m beginning to think that it may ultimately provide the best workflow solution for me. However, I’m worried about my ability to type into it – something that’s not easy to do standing up.  And its compelling interface could be even more of a distraction than the desktop. But its portability could allow me to review a patient’s chart outside the room just like the old days, and things like favorite lists and drop downs in the EMR could minimize typing.

Our EMR vendor at this point only offers a limited version for the Ipad, something that may be useful on call but not robust enough for office hours. So nothing new anytime soon.

That’s okay. I’m happy again. I can wait.
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Pauline Chen,MD wrote about this issue last year in the NY Times. She points out that some docs seem to handle the distraction of the EMR better than others, integrating it more seamlessly into their practice. If you use the EMR and have a workflow that works well for you, tell us about it in the comments. 

Annual Sonogram Screening Prolongs Ovarian Cancer Survival, but Does it Save Lives?

Results from the Kentucky Ovarian Cancer Screening Study at first glance look incredibly promising.  Among the over 37 thousand women who underwent annual pelvic sonograms, the 5-year survival rate for all women with ovarian cancer in the screened group was 75% compared with 54% for unscreened women with ovarian cancer from the same institution treated exactly the same otherwise. The investigators attribute this increased survival to earlier detection – 70% of the screened group were diagnosed at stage I or II, compared with only 27% in the un-screened group. Stage III cancers tended to be earlier (IIIa and IIIB instead of IIIC), and there were no stage IV cancers among women who were screened.

The investigators markedly improved on the positive predictive value of screening by boldly refusing to go where others have always gone before – to the operating room. They stood firm and watched cysts grow to as large as 10 cm before intervening, provided those cysts did not bear the defining characteristics of malignancy – namely solid areas and papillary internal growths. They also were not afraid to tweek their triage algorithm as experience with sonography improved. This is perhaps the biggest contribution from the study – permission to watch and wait.

Following a mean of 5.5 screens in 37,293 women, the authors achieved a specificity of 98.5% and a PPV of 8.9% with 11.1 operations per case of primary invasive epithelial ovarian cancer. This compares with a specificity of 98.4% and 19.5 operations per case of primary invasive epithelial ovarian cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial, in which both ultrasonography and CA 125 were used as first-line tests.

But a closer look reveals important questions that must be answered before we can begin to recommend screening in the general population.

1. Could the results be explained by the healthy volunteer effect? This was not a randomized trial, just a comparison between women in the screening program and the rest of the population who got ovarian cancer in the same time frame outside the program.  We all know that folks who volunteer for studies such as this tend to be healthier in general than the overall population, thus skewing survival statistics in their favor. In this study, however, survival was equivalent between control and screened groups diagnosed in early stages, suggesting that it was indeed the stage shift that led to higher survival in screened groups and not just a healthy volunteer effect.

2.  How about lead time effect? This happens when cancer is identified a little earlier, giving the false impression that folks are living longer when it is really that they have just learned a little earlier about the diagnosis that ultimately will lead to their demise. All screening studies have this potential bias. This is why overall mortality and not just survival time must be the relevant statistic to compare between screened and unscreened groups.

3. Not all cancers were caught by sono. Twelve women developed cancer in the year after a normal screening test, with 7 deaths due to cancer in this group. Such aggressive tumors may never lend themselves to early detection, no matter what modality is used.

4. Major surgery remains the only way to ultimately diagnose ovarian cancer. In the Kentucky trial, 523 women, or about 1.4% of participants  screened ended up in the OR, and 86% of these women did not have cancer.  Until we have a less invasive was to get reliable pathology on ovarian cysts, we are going to be exposing healthy women to unnecessary surgery while chasing the elusive early diagnosis.  While this may be marginally acceptable in high risk women, expanding screening to the general population will lead to millions of avoidable operations, with their consequent risks, costs and mortality.

___________________________________________________________________________

Long-term survival of women with epithelial ovarian cancer detected by ultrasonographic screening. van Nagell JR, Miller RW, DeSimone CP, Ueland FR, Podzielinski I, Goodrich ST, Elder JW, Huang B, Kryscio RJ, Pavlik EJ Obstet Gynecol. 2011 Dec; 118(6):1212-21

Jacobs,I; Menon,U. Can Ovarian Cancer Screening Save Lives? The Question Remains Unanswered. Obstet & Gynecol. 118(6):1209-1211, December 2011.

Night Float Schedule vs Traditional OB Call = Improved Obstetric Outcomes?

As a result of mandatory work hour restrictions, residency programs have moved from the traditional call schedule, where they worked up to 36 hours at a time, to a night float system with distinct day and nightime shifts similar to the ones nurses have worked for years.

While no work restrictions exist for attending physicians, some obstetric attending practices are moving towards a night float system similar to that of the young doctors they supervise, with some not-so-surprising changes in labor management and patient outcomes.

When a 6 person academic OB generalist practice at Northwestern University’s Feinberg College of Medicine changed from a traditional call schedule to a night float system, there were  –

  • Less inductions;
  • More labor augmentation with pitocin;
  • Less manual extractions of placentas;
  • Less episiotomies;
  • Less 3rd and 4th degress lacerations;and
  • Improved neontal unbilical artery pH (A sign of fetal well-being)

Of course, this is just one small study in a single practice, and the results may not be generalizable to other practices in other settings. But it makes sense. If you’re not worried about getting some shut eye, you’re less likely to feel the need to use induction to move deliveries to daytime, more likely to move along a night time stalled labor with a little pitocin, and more likely to wait for the perineum to stretch fully and the placenta to take it’s sweet time to deliver.

__________________________________________________

Type of Attending Obstetrician Call Schedule and Changes in Labor Management and Outcome. Barber, Emma L. MD; Eisenberg, David L. MD; Grobman, William A. MD, MBA. Obstetrics & Gynecology: December 2011 – Volume 118 – Issue 6 – p 1371–1376

Image – Van Gogh’s Starry Night from Wikimedia Commons

Basa Filets with Pine Nut, Parmesan and Basil Pesto Crust

It hasn’t been easy.

I’ve been married for almost a quarter century to a man who eats whatever he wants and is still the same weight he was in high school. That means having to sit next to him at Sunday morning breakfast watching him sop up the yolks of his two sunny-side up eggs with a buttered bagel, while I nibble at an egg white omelet.  On the other hand, it also means feeling like a pig when he refuses to even taste the delicious appetizer I’m eating, because he doesn’t want to “ruin” his dinner.   After said dinner, however, I’ll open the freezer to find that once again, he’s brought home, not one but two half gallons of ice cream (he likes to mix the flavors).  I swear I want to just take those damned ice cream cartons and toss them in the trash. But who am I to tell a guy who rides his bike to work every day and plays tennis at least once a week that he can’t have ice cream?

Not that he purposefully sabotages me or anything.

Because he doesn’t. After all, the poor guy never knows which wife he’s getting when he calls me from work to plan the evening’s meal – the wife who loves Shephard’s Pie as much as he does or the one who’s starting South Beach – again. If I counter with a suggestion for fish for dinner, he may just argue back that he really is in the mood for meat. How could he know that this is not a “what are you in the mood for?” discussion but yet another of many, many make-or-break moments for my diet?  (Unless of course,  I’ve  already broken my diet at lunch and given up for the day, in which case it is a “what are you in the mood for?” discussion…)

Now I’m sure at some point early on, when love was young (and I was much thinner), he must have been a little more clued in to my dietary routine. But now, after so many years of countless diets,  it seems he’s learned to just keep to his own food desires and leave me to handle the weight issues on my own.  It pisses me off sometimes, but mostly I understand.

Why am I telling you this?

I’m telling you all this now so that you can appreciate what it is I am going to tell you next, which is this – His doctor just told him he has 3 months to lower his cholesterol or he has to take a statin.

I won’t say that I’ve been waiting for this moment for 25 years...

But you know, it kind of feels that way. For the first time in our marriage, my husband and I are actually on a shared road diet-wise.

It’s really quite amazing when I think about it. We actually had the same breakfast last weekend – steel cut oatmeal. He called tonight from work to suggest we have tofu for dinner! (Which we did.)   And last night, when I suggested this wonderful fish entree from Kalyn’s Kitchen for dinner, he jumped at the chance to have one of the three fish meals he’s decided to eat a week.  I’ve already lost 5 pounds since his doc gave him the ultimatum – all without feeling at all like I’m dieting.

I finally have a live-in diet buddy. Not a lose weight and starve yourself diet buddy, but a let’s eat healthy and keep eating great food buddy.  Add in the fact that he’s always been my ” Do you wanna’ join me on a bike ride?” buddy, and I have a feeling we’re off on a wonderful journey together.

Oh, and the ice cream in the freezer?

It’s GONE.

Basa Filets with Pine Nut, Parmesan and Basil Pesto Crust

Makes 3-4 servings. Adapted from Kalyn, who adapted it from Cooking New American. I encourage you to check out her recipe, which also has great prep pics. Kalyn chops her pine nuts, giving a more even crust. I think I will do that next time; I was just feeling lazy tonight. I wanted to be sure I had enough topping for three filets, so I increased the pesto and decreased the mayo a tad from the original recipe. I also added more garlic.

3 basa or other white fish fillets, about 6 oz. each (You could use flounder, tilapia or cod to name a few)
3 tbsp pine nuts
2 tbsp grated Parmesan Cheese
1/2 tsp finely minced garlic
3 tbsp basil pesto (Made without cheese – see recipe below)
1 tbsp mayonnaise

Preheat oven to 400 F.  Brush casserole dish with olive oil (We used a Le Creuset lasagna pan).  Remove the fish fillets from the refrigerator and let them come to room temperature while the oven heats.

Mix together the pine nuts, Parmesan cheese, garlic, pesto and mayo. Use a rubber scraper to spread the crust mixture evenly over the surface of each fish fillet. Pile it on so all the crust mixture is used.

Bake fish 10-15 minutes, until fish is firm to the touch and crust mixture is starting to lightly brown. If necessary, pop the filets under the broiler for a few minutes to get the crust brown (as we did).

Serve hot. (We served with string beans sauteed in oil and roasted cauliflower, sweet potato and figs.)

Basil Pesto
I decided to make this batch of pesto  without cheese or pine nuts, since I was adding these to the topping later. Turns out it tastes great – my daughter had it on pasta, which she heavily tops with grated parmesan anyway.
  • 2 cups packed fresh basil leaves
  • 2 large garlic cloves, peeled
  • pinch of salt
  • 1/2 cup olive oil
  • (1/4 cup grated Parmesan cheese -optional)

Combine the basil, garlic, and salt in the bowl of food processor and grind till the mixture forms a paste.  While running the food processor, slowly drizzle in the olive oil.  Stores well in the fridge or freezer. Before serving beat in 1/4 cup grated Parmesan or pass the Parmesan at the table.

Grand Rounds Vol 8:No 15 – The Twitter Edition

ONCE UPON  TIME…

Before Facebook and Twitter and Google+, and long before the word “social media” became religion, something called the Medical Blogging made its appearance on the world-wide web.

In those days, there was a small, close-knit community of medical bloggers, who read and commented on one another’s blogs, held long discussions in the comments sections and embedded links to one another’s posts in order to send a message – “I’m reading you and this is what I think about what you wrote”.  In this group, there was no one with a product or a book to sell, no one with ads on their pages, and no one aggregating other blogger’s content (although Kevin was very busy linking away – he was always way ahead of the rest of us at this game).

GRAND ROUNDS IS BORN

At the forefront of this little group of bloggers was Nick Genes, who one day said “Let’s do a medical blog carnival!” For those of you too internet-young to know what a blog carnival is, it is a compilation of posts on a given topic submitted by bloggers and curated by a rotating series of volunteers who post that week’s compilation on their own site. Nick cleverly called his carnival “Grand Rounds” and the rest, as they say, is history.

When Grand Rounds started in September 2004, it was the highlight of the week for all of us. We hung out on our computers on Tuesday mornings with a cup of coffee, checking out the best of what the medical blogsphere had produced that week, linking to it on our own blogs and leaving lots of comments for the host. Hosting and having your blog post cited in Grand Rounds evolved to be a great honor and was the best way to introduce yourself to your fellow medical bloggers and to jumpstart your presence in the online medical community. It was our little home on the internet, and we loved it.

BUT THAT WAS SEVEN YEARS AGO…

Which in internet time is like an entire generation. Since then, the number of doctors engaged in social media has skyrocketed as has the volume and quality of the conversation about healthcare on the internet. Mainstream media healthcare journalists, some of whom are doctors, are creating fabulous content that truthfully is outshining what many of us docs with a busy day job (including myself) can produce on a regular basis. Aggregator sites like Kevin MD, Better Health and even Huff Post are republishing the best of what many bloggers are writing.  More importantly, the concept of the individual blog has been augmented and in some cases, overshadowed by Twitter and to a lesser extent, Facebook, whose continual unending stream demands our constant attention, lest we miss something important that someone said (or re-said, as is mostly the case).

In truth, Grand Rounds has dropped a bit off all of our radars. Many, if not most of us have abandoned the old RSS feed to hang out on Twitter, where our online community has grown from a few dozen bloggers to feeds and followers in the hundreds and even thousands. Which begs the question –

WHAT IS THE FUTURE OF GRAND ROUNDS ?

It’s a topic that has garnered much discussion in the past few weeks, as Nick and current Grand Rounds curator Val Jones surveyed the medical blogging community about what they thought Grand Rounds should be.  

I expect Dr Vartebedian, our rapid-rising social media guru, will have something interesting to say and do on the topic next week when he hosts Grand Rounds. And so, I will leave my edition of Grand Rounds more as prelude to his than the definitive word on what the New Grand Rounds format will be.

THIS WEEK’S GRAND ROUNDS EXPERIMENT

Think of this edition more as a little experiment to see if Grand Rounds can make it in the era of the short communiqué (which already this post has far, far exceeded, making me an official blogging dinosaur).

I’ve culled 12 posts well worth your read from submitted links and my wanderings around the internet. Every post is summarized and commented on in 140 characters or less. I’m posting at 7 am and tweeting both the entire set and each post individually throughout the morning, and ask that you re-tweet if you feel about a post the same way I do. If you submitted a post and it wasn’t listed, please don’t be offended – and do submit again next week! 

I actually found the curating a shorter list of posts made hosting a much less laborious and more enjoyable process than previously, and while composing tweets is ever challenging, it’s always fun. 

Perhaps the echo chamber will not only revive but rejuvenate this old dinosaur, so that it will reverberate throughout and beyond our not so little anymore blogging community. Whether or not that happens, dear reader, is up to you.

So Tweet! Tweet! Tweet!

GRAND ROUNDS – THE TWITTER EDITION

Dan Muro at Forbes.com

  • Healthcare Stats for 2012.  Some will astound, some frighten, some anger you (esp no. 11). http://onforb.es/vRqRDs @GrandRounds

Shara Yurkowitz at Plosblogs –

  • “This may hurt a bit” Why some docs fail to live up to their title in a patient’s eyes (and ears). http://bit.ly/vM168E @GrandRounds

Dr Michael Korlwchak at Wired Medical Practice

  • Deep Thoughts from the Meaningful Use Mountaintop. The harsh realities of EMR in practice. http://bit.ly/sKUt5n @GrandRounds

Dr.Bertalan Meskó at Science Roll

  • 12 predictions for HIT, Tech & Innovation in 2012. (He got most of 2011 right.) http://bit.ly/rLB0uh @GrandRounds

Beth L Gainer at Calling the Shots.

  • “Five years ago today, I had to get something off my chest. It was my breasts.” Brutally honest. http://bit.ly/up8V2s @GrandRounds

RL Bates, MD at Suture for a Living

  • @RLBates – Top Eleven of 2011. The years’s best from one of medicine’s best bloggers. http://bit.ly/udij9t @GrandRounds

Jamie Rauscherat Health Jam

Michele R Berman, MD at Celebrity Diagnosis

  • Celebrity Health – 2011. Shamelessly taking advantage of Rich & Famous to teach rest of us about health. @CelebrityDx. http://bit.ly/sLRM93

Dr Elaine Schattnerat Medical Lessons

  • @MedicalLessons – IOM report on environment & breast cancer – great summary of an important report. http://bit.ly/uFjQDP @GrandRounds

Dr Mike Sevilla at Family Medicine Rocks

  • @drmikesevilla – Open Letter to Congress – I Will Stop Taking Medicare. (Cuts delayed – Go Mike!) http://bit.ly/sgo6bm @GrandRounds

Richard Winters, MD at Beyond the Clinical

  • @drwinters. How I lost credibility in 5 mins – Investigating MD Incident Reports.Docs & admins must-read  http://bit.ly/uBwcY3 @GrandRounds

William Dale, MD at WilliamDaleMd

  • A Personal Journey Down the Rabbit Hole – Doc tries to get son’s med record. Powerful. @WilliamDale_md  http://bit.ly/vWVcQIl @GrandRounds

TBTAM 2011 – The Year in Health Blogging (Plus Two Songs)

Asking a blogger to pick her top posts of the year is like asking a mom which of her children she loves best. Because I love them all. Finding out which posts you love most is not possible – my stat counter only reports details on the last few days. So I picked the posts I think reflect what this blog is about (other than the recipes, of course…) and of which I am particularly proud.

Looking back on 2011, I’m frustrated to realize that so much of my energy was spent countering Big Pharma marketing, inaccuracies in health reporting and those who would limit reproductive rights for women. I like to think I’m having an impact, limited though it may be, among my small but treasured cadre of readers. A sincere thanks to each and every one of you for your visits, comments, tweets, likes and most importantly, your friendship and encouragement.

I don’t know what the future holds for the individual medical blogger, as the short-form communique grows in dominance and the online medical community becomes larger and more diffuse. As more and more docs enter social media, I hope we continue to be individual voices and not just an echo chamber for the mainstream media and medical marketing machines.

  • How To’s – A Twofer.
  • Mammograms – The controversy led to 4 posts this year (and an exciting research project that I’ll be telling you about soon)
  • Emergency Contraception – Important enough for two posts as the battle for OTC availability for teens wages on.
  • Big Pharma – My favorite whipping boy.
  • Birth Control and Blood Clots – The Patch & Yaz dominated the contraceptive conversation this year.
    • FDA Patch Ruling – The FDA allowed the Patch to stay, but with modified labeling. I put in my two sense and describe the population of women for whom the Patch remains an important contraceptive option.
    • Birth Control & Blood Clots : Visualizing the Risks – Driven by me need to put the risks into perspective for my patients, I pull out my time-honored dot charts and some common sense.
  • Another Death from Cancer – My post about my sister’s death from cancer, while intensely personal, is one that untold millions of us who have had a loved one die of this devastating disease could have written.

And for your musical pleasure –

  • The Healthcare Social Media Anthem – with apologies to the Grateful Dead. Sing along now –  “Set out marketing myself online, A friend on Facebook is a friend of mine…”
  • The Meaningful Use Song – With apologies to Gilbert & Sullivan, the only songwriters with music appropriate to handle the ridiculous complexity of the EMR. 880 views on You Tube!

Art vs. Medicine

 

 

 

 

 

 

 

 

 

 

 

 

I came across this compelling little dyad in a pop-up gallery on 57th St on New Year’s Eve.  Artist Kristian Glynn compares his own financial status –  “Empty”  to that of his surgeon girlfriend – “Loaded”.

I’d love to have bought them both, but I can’t afford it…

Best of luck to Glynn and especially to young gallery owner EA Glitner, whose travels have led him on a world journey to collect art. It’s a lifestyle I envy and which takes a very different kind of courage than it takes to accept the responsibility for another’s life under anesthesia. Both are courageous, though clearly the latter provides a more secure income.

I’ll be Tweeting Grand Rounds on January 3 – Call for Submissions

A New Year calls for a new Grand Rounds.  Let’s see if we can move this blogger-era dinosaur into the new era of social media by integrating it more fully into Twitter.

Submit your post to tbtam@rcn.com by 11:59 pm on Jan 1. Include your twitter @profile name and a shortened url for your post (via bitly.com, tinyurl.com, goo.gl, or whatever url shortener you like).

I’m going to play more of a curating role than previously and will be publishing just 12 submissions – one for each year of this still new-feeling century. I’ll post them here, then tweet the lot as a whole and each one individually. I’ll encourage all of those whose submissions are accepted and those reading to retweet the lot and individual posts as well.

Let’s make a whole lotta’ New Year’s noise in the Tweetspace and see if we can crank up the social media volume on Grand Rounds! (You can start now by tweeting this post – just click on the twitter link down there on the left.)

Teen Mom Kailyn Gets Mirena – Contraceptive Choice or Product Placement?

In this week’s episode of Teen Mom 2, Kailyn heads to her gynecologist for birth control and leaves with a Mirena IUD in her uterus.

The entire encounter, obviously edited, ran more like a commercial for Mirena than a contraceptive counseling session. Other contraceptives were mentioned generically only  -“a patch”, “a ring”, “the pill” – but when it came to the IUD, all we hear is the word Mirena – six times, to be exact, during the entire 2 and a half minute encounter with the doc.

DOC: If you don’t like the birth control pill, you do have other options. You know that there’s a birth control patch.
KAILYN: (suspiciously) Yeah
DOC: There’s a once a month vaginal ring. The ring itself is not uncomfortable. (Hands her the ring) They’re one size fits all – Right Isaac? (Baby plays with Nuvaring) They’re cool, right?
KAILYN: I just feel like me putting something in myself is all that much more room for error.
DOC: There’s also the Mirena.
KAILYN: Whaaaat is Mirena?
DOC: The Mirena goes right inside your uterus. They’re THE most effective method of birth control available because it really doesn’t rely on you to do anything or remember to do anything. (Part of a pamphlet shot) That’s what it looks like. It lasts for 5 years. If before 5 years you decide you want to have another child, it’s very easy to remove a Mirena right in the office.
KAILYN: I think I want Mirena.
DOC: If you want to, we can put it in today – and it only takes about a minute to put it in.
KAILYN: Does it hurt?
DOC: It’ll hurt a little tiny bit for a few seconds when it goes in
KAILYN: OK.All right – let’s do it.
DOC: You’re sure?
KAILYN: I’m sure
DOC: I’ll get you set up for it then.
(Staff member, who appears to have been waiting outside the door on cue walks in and offers to take the baby. Kailyn next gets onto table and we cut to Doc doing insertion.)
DOC: All right, if at any point it’s too much, we’ll stop…All right, this is the part that causes the little cramp (Kailyn winces slightly) You’re Mirena is in! You have birth control for FIVE YEARS. You can push yourself up off the edge.
KAILYN: So I’m being protected right now?
DOC: Immediately
KAILYN: I feel better already
DOC: (Smiles) Good. And I will recheck it for you in 6 weeks. Call me in the meantime if you need something before then.
KAILYN: All right, thank you.
(“Protected” stamped across screen. Fade out)

What Kailyn (and MTV’s millions of teen viewers) didn’t hear about Mirena

No one appears to have told Kailyn about anything other than Mirena’s convenience and efficacy and that it pinched a bit going in.

There is no mention that if Kailyn chooses Mirena, she should be prepared for changes in her menstrual cycle, most likely irregular spotting and over time, absence of menses.

Or that Mirena may worsen what appears to be her already pretty bad case of acne, so let’s have a plan for handling that up front.  (Or maybe reconsider Nuvaring – it’s actually pretty darned easy to use and could actually help her skin.)

No one mentioned  that there is another IUD called Paragard that acts a little differently. Or that IUD’s in general carry a small risk of pelvic infection at the time of insertion, should not be used by women who have already had PID, and don’t protect against STD’s, so is her boyfriend still going to use a condom?

All MTV viewers saw was a young woman dismissing every other form of birth control and happily leaving her doctor’s office with Mirena. Best 180 seconds of product marketing Bayer ever got.

Kailyn chose Mirena, but will she continue it?

If Kailyn’s counseling session really went down the way it was edited, I’d have concerns that she was not adequately prepared for the actual experience of having a Mirena, and might end up discontinuing her IUD much sooner than either she or her doctor expect.  She wouldn’t be alone in that regard – Early data suggest that close to 50% of teens will discontinue their IUD in the first 1-2 years of use.

Let’s not set teens up for failure by hyping Mirena on reality TV. Tell them what they need to know in order to make responsible, informed decisions.

It’s called contraceptive choice. Not Contraceptive marketing.

Coffee-Marinated Braised Short Ribs for Christmas Eve

The wonderful thing about braised meat is that it literally cooks itself. The not-so-wonderful thing is that you need to plan ahead for the pr0longed cook time, especially if there is also a pre-braising marinade.

Which means that if you decide at 10 am to make marinated braised short ribs for dinner, then spend the entire marinade time doing last minute Christmas shopping with the kids, you won’t be eating Christmas Eve Dinner till after 10.

Which was fine since we weren’t entertaining anyone but our ourselves.  We had plenty of relaxed family time decorating the tree, wrapping presents, enjoying mulled wine and watching It’s a Wonderful Life on TV before sitting down to what was a delicious and very special meal. So special we may just do it again next year!

COFFEE-BRAISED SHORT RIBS

This recipe is modified from a bison-rib recipe on Epicurious.  I’ve since found another coffee braise that does not call for marinade, and will try that one next time. Serves 4-6.

Marinade
4 cups water
3 cups strong brewed coffee
1/2 cup coarse kosher salt
3 tbsp + 2 tsp packed  brown sugar
1/4 cup pure maple syrup
2 tablespoons chopped fresh rosemary
2 tablespoons + 1 tsp Worcestershire sauce
2 cups ice cubes
4 lbs short ribs

Short Ribs:
1 cup boiling water
1 tbsp instant espresso
4 strips bacon, chopped
2 cups chopped onions
6 garlic cloves, chopped
1/2 tsp red pepper flakes
1 cup low salt chicken broth
1/4 cup Mr TBTAM’s barbecue sauce (you can use tomato paste or chili sauce)
1/4 cup brown sugar
2 tablespoons Dijon mustard
2 tablespoons apple cider vinegar
1 tablespoon soy sauce

Marinade
Stir  water, coffee,  salt and sugar in large bowl until salt and sugar dissolve. Add syrup and remaining marinade ingredients. Stir until ice melts. Add ribs. Place plate atop ribs to keep submerged. Cover and chill 4 to 6 hours. Drain ribs; discard marinade.

Short ribs
Preheat oven to 325°F. In a pyrex measuring cup, stir instant espresso into boiling water and set aside to cool.(Alternatively, use another cup of strong brewed coffee.)

Sauté bacon in heavy heavy ovenproof pot over medium heat until fat starts to render and it begins to brown (be careful – don’t burn it!) Remove  bacon to a plate. Increase heat to medium-high. Sprinkle ribs with salt and pepper.

Working in batches, cook ribs until browned on all sides and transfer to a plate. Add onions, garlic, carrots and red pepper flakes to the pot and cook over medium heat till veggies are soft, about 10 minutes. Add coffee and broth; stir, scraping up browned bits. Add remaining ingredients; bring to boil. Add bacon and ribs, cover, and transfer to oven. Braise until meat is tender, about 2 hours.

Transfer ribs to plate; tent with foil to keep warm. Spoon fat from surface of sauce. Boil sauce until thickened and reduced to your satisfaction (about 2 cups). Pour sauce over ribs.

Serve over homemade mashed potatoes.

The Latke Master’s Latkes

This latke recipe was good enough in 2007  to garner my blog a mention in the New York Times.

Secrets of the latke masters. Happy Hannukah. [The Blog That Ate Manhattan]

I figure that makes it good enough to re-post today.  Happy Hanukkah!

Potato Latkes

3 pounds yukon Gold potatoes
2 eggs, lightly beaten
1 1/2 large onions
A little less than 1/4 cup Motzah Meal
Salt
Pepper
Canola oil for frying

Peel potatoes. Shred using the food processor and remove to a large bowl. Shred the onion the same way and add to the bowl. Open out a large clean dishtowel onto the counter and dump the potato onion mixture on it. Top with a second clean towel and lightly roll to mop up the excess liquid (Don’t overdo it, you need a little of the potato starch and liquid for things to stick together.If you use Russet potatoes, don;t drain them at all, as they have very little water content) Dump back into the bowl and add the eggs and the motzah meal. Season with salt and pepper.

Heat about a 1/2 inch of canola oil in electric frying pan at highest heat (mine goes to 400 degrees Fahrenheit). Scoop some of potato mixture into a large spoon, then put into the oil, flattening with the back of the spoon. Cook until the edges start to crisp and the underside is light brown, then gently flip and cook the other side.

Remove from pan to a cookie sheet lined with paper towels or newspaper. Keep warm in a low oven while cooking the rest of the potato pancakes.

Serve with sour cream and warm homemade applesauce.

BTW,  if you noticed there are two different spellings of Chanukkah on this post, well, that’s just the way it is.