I swear, that Twitter is ruining your mind. You’re lost the ability to read anything more than 130 characters. You’re chatting and @tting and #ing, but are you…
Hey! Are you reading me, or have I lost you already?
I mean it! Close that damned thing and read a blog!
You don’t know what to read?
Here, let me help you. Read this week’s Grand Rounds over at HealthBusiness Blog. It’s the best of this week’s medical blogosphere. Go on. Read it. Follow every one of those links and learn something besides a Wiener joke.
Talk about eliminating the middle man. Pfizer is now conducting research on their bladder-drug Detrol directly with patients via the internet. (via Pharmalot and the WSJ)
Study participants are being recruited through Internet advertisements and directed to the study’s website, which explains the study and allows enrollment.
Patients who enroll in the study will be required to have blood drawn at a local clinic or during a home visit. Medications will be mailed to participants, something that’s rarely, if ever done in clinical trials. Patients will keep diaries using a mobile phone that has an application specifically designed to track symptoms of overactive bladder. Patients will fill out assessments on a secure website four times throughout the study.
A single study site medical team at UCSF will monitor the trial, which will replicate the original trial done for the drug, which is already FDA-approved
I could not find a copy of the study protocol or informed consent, so what follows is just my take from the study website…
From what I can tell, there will be no face to face contact with study subjects prior to enrollment, and I suppose, no physical examinations, except for subjects in California. I wonder how much work is going to be required of the patient’s own physician – release of records, physical exam, review of the study and approval of patient’s enrollment? And isn’t sending study drug to patients sort of like prescribing medication over the internet without the benefit of a doctor-patient relationship? Just asking – I’m no lawyer, but in general we tend to frown on this sort of thing in the medical circles I travel in…
Head on over to the study website yourself and check it out. The study info video is more like a sales pitch than anything else, with a little cash registers ca-chinking noise every time a study survey is completed, and lots of fun cartoony things explaining the study logistics, making the whole thing look like a real blast and a fun way to make a little extra cash. Only at the very end of the three minute video do they tell you that you may end up getting placebo, and there is nothing of course, about the DRUG you’ll be taking, or it’s possible risks. To get that info, you’ll have to register, and live in a state where the study is being conducted. (I know because I tried to get a look at it, but apparently the study is not being done in New York State).
My Take as As an IRB member
I don’t think I would have approved that recruitment video. Too happy and cutesy, with statements like “You’re probably here because you have symptoms of overactive bladder syndrome, and you want to do something about it” – implying treatment rather than research.
The study intro page states the study is about testing the efficacy of Detrol for reducing incontinence, but the video really has little about actually taking a drug, and more about the fun stuff that will happen over the internet. There isn’t even a picture of a person actually taking a drug – everyone seems to be “receiving” a drug, but not “taking” anything. I swear, by the time I finished watching the video, the medication was the last thing I was thinking about.
Other statements that bothered me – “Lucky you – you’ll be getting three packages!” – implying that participating in the study will make you lucky, as opposed to having an adverse effect of the drug being studied (which would be unlucky…).
Then there is the introduction of the concept of informed consent – “Sound intimidating? Don’t worry – it’s easier than it sounds!”. “They’ll be pop quiz at the end” and a cute pic of a teacher and an apple, as if signing the consent is being a good student, while not signing it means you’ve failed. Informed consent is the cornerstone of clinical research, even when it’s a study of a drug that is already FDA-approved. Let’s treat it with the seriousness it deserves.
The video does do a nice job explaining double-blinding, but not randomization, saying “there is a chance you’ll receive either study drug or a sugar pill”, but that’s not a chance, that’s the study. They also leave randomization to the end – I would have put it earlier on in the video, since for many subjects, the chance of getting a placebo is a game changer.
I like that subjects have access to their study results, and, I assume, lab results along the way. Most studies allow this, but not with the kind of ease the internet provides.
Is this the End of the Multi-center Clinical Trial?
Centralizing the study team will no doubt save tons of money, move things along faster without having to clear dozens of institutions’ IRB and contracts offices, and give much desired consistency and control of the study’s conduct. I do find it hard to imagine some of the clinical trials out there being conducted without a local study doc to handle complications, physical exams, etc. So I expect that this model won’t translate very far in its entirely. But I do see this internet-based approach being used to substitute for a lot of what local study coordinators do, freeing up the study doc up to worry about what’s important – the patient.
I do worry, thought, that all this centralization could give too much control of research to a single site. In the case of this study, that site is located at a University which just partnered with Pfizer to the tune of $85 million. I’m not trying to imply anything about this study in particular, just using it as an example to note the potential for conflicts as the relationships between Pharma and Academic Medicine become cozier and cozier. (Pretty much every big center is partnering in a big way with Pharma these days…) Pfizer’s press release states that two institutions IRB’s approved the study, and that made me happy. Given the amounts of money changing hands now between Pharma and Academic Medical Centers, the use of independent IRB’s may become more important over time to avoid any concerns over conflicts in research.
Will Internet-based Research Expand Study Subject Populations?
Despite my reservations about the recruitment video, and the logistics of handling study complications, I think the idea of using the internet to facilitate research is an interesting one, and may expand the population of folks willing to participate in clinical trials. As medicine moves out of the office into the internet and into our patient’s homes, I see no reason why research should not follow. Just so long as we proceed with caution and safeguards.
One final thing
Kelsy, the NP on the the study (see her around 0:25 on the website video), reminds me of Pam from the Office. Uncanny…Especially when she talks. She seems really nice. So does the entire study team. I wish them the best on their project.
An interesting NEJM article on the 40th anniversary of the seminal journal article on DES serves as a potent reminder of the potential effects of exposure to endocrine disruptors during critical times in development.
Beginning in the early 1960′s 1940’s, DES, a synthetic estrogen compound, was given to women in early pregnancy to prevent miscarriages. Females born from these pregnancies had an increased risk of a rare vaginal cancer during childhood, increased rates of uterine malformations that can cause infertility and premature birth, and are at a moderately higher risk for breast cancer. Use of DES in pregnant women stopped in the early 1970’s.
The lessons learned from the DES story are powerful. Endocrine disruptors may cause alterations in the reproductive tract that have severe consequences and form the basis of disease in adults decades later. Endocrine disruptors may come not only from ingested medicines, but potentially also from the environment through food. It is very difficult to recognize a teratogenic consequence of a prenatal exposure when the malformation does not manifest until 20 years later.
I’d actually never made the mental connection between DES and endocrine disruptors, and yet of course, that’s exactly how DES functioned in this case. Remarkable, how a brief drug exposure during early gestation can lead to a cancer arising over a decade later.
An important reminder, indeed, as we begin to awaken to the possible endocrine effects of chemicals such as BPA that we are using on a daily basis without really knowing how they may be affecting us in the long term.
In a large multicenter study enrolling over 70,000 women, annual screening with transvaginal pelvic ultrasound and ca125 blood testing did not reduce deaths from ovarian cancer, and in fact led to an increase in complications due to screening.
Investigators in the NCI-sponsored Prostate, Lung and Ovarian Cancer (PLCO) Screening trial randomly assigned over 78,000 women age 55-64 years of age to either annual screening with transvaginal pelvic sonograms for 4 years plus CA125 testing for 6 years or usual care at 10 study sites across the US., and followed the groups for up to 13 years. Over that time period, ovarian cancer rates in the screened group were 5.7 per 10,000 person-years vs 4.7 per 10,000 persons-years in the usual care group, with 3.1 deaths vs 2.6 deaths per 10,000 person years, respectively. Over 3000 women had false positive screening results, a third of whom had surgery and 15% of those operated on had a complications from their surgery. Deaths from other causes did not differ between the groups.
The investigators concluded that annual screening for ovarian cancer does not reduce mortality, and in fact caused harms among women with fals positive abnormal results.
This is not the first study that failed to find efficacy for ultrasound and ca125 in reducing mortality from ovarian cancer, but it is certainly among (if not ) the largest.
Whether or not more frequent sonogram screening, combining ca125 with other serum markers, or trending ca125 levels over time (rather than just looking for “abnormal” results) will prove to be effective ovarian cancer screening has yet to be determined. Studies continue to be done, although preliminary results to date on these have not been encouraging.
What I do in My Practice
I tell my asymptomatic, low-risk patients who ask me for ovarian cancer screening that annual sonograms are like kissing the Blarney Stone. It makes us all feel lucky for awhile, but actually does nothing to reduce ovarian cancer mortality.
Still, I have not refused occasional screening for anxious women (Often women who have had a friend recently diagnosed with ovarian cancer0), so long as they understand the limitations of screening, but seem to need that negative sonogram to sleep at night. I do respect their anxiety, and if that means an occasional scan in the office and a reassured patient, I don’t see much harm, and they are told up front that their insurance may not cover the scan. I also happen to refer to a great radiologist who does not overcall abnormals, so if I see anything of concern, I refer straight to him. Now that we have this data regarding adverse outcomes due to over-screening, I will share that with my patients, and may be able to stand a bit more firmly in refusing to order ineffective screening to asymptomatic but anxious women.
For women at increased risk (family history of ovarian cancer, BRCA gene mutation carriers), I do offer vaginal sonogram and ca125 screening, but at minimum of twice a year, and urge these women to instead enroll on one of the several ovarian cancer screening trials currently in progress.
The lawyers have been advertising about it for years now, so it’s nice to see the FDA finally begin to address the issue of Yaz and blood clot risks.
The reason is the recent publication of two more studies suggesting that birth control pills containing the progestin drosperineone (Yaz and its generics) may have a higher blood clot risk than other pills.
From the FDA –
Two recent articles in the British Medical Journal have raised the question as to whether there is greater risk of DVT and PE in women taking combination oral contraceptives containing the progestin drospirenone as compared to the risk in women taking oral contraceptives containing the progestin levonorgestrel.1,2 These two new studies reported a two- to three-fold greater risk of venous thromboembolic events or VTEs (VTEs include DVTs and PEs) in women using oral contraceptives containing drospirenone rather than levonorgestrel.
Previously published studies have also addressed the risk of blood clots in women using birth control pills containing drospirenone. These studies had conflicting findings. Two were postmarketing studies required by the FDA or European regulatory agencies. These studies did not report any difference in VTE risk between drospirenone-containing products and products containing levonorgestrel or other progestins.4,5 However, two other publications from 2009 reported a 1.5- to 2-fold higher VTE risk in women who use drospirenone-containing contraceptives as compared to the risk in women who use levonorgestrel-containing contraceptives.6,7 Results of these latter four studies are described in the current labels for all the drospirenone-containing contraceptive products.
If you’re been keeping track, the score is now four studies suggesting a higher clot risk for Yaz vs two studies showing no increased risk.
That was enough to cause the European Medicines Association to issue a statement that drosperinone containing pills have a higher clot risk than levonorgestrel containing pills.
Which led our FDA to issue a statement basically saying that that they are looking into the matter, so stay tuned –
FDA is currently reviewing the two most recent studies and will be looking at all currently available information to assess whether there is a greater risk of VTE in women using oral contraceptives containing drospirenone. Data from an additional, large, FDA-funded, study on hormonal contraceptives is also being finalized and reviewed. This study includes over 800,000 US women and is designed to look at thrombotic and thromboembolic risks including VTE in a number of hormonal contraceptive products; results are expected later this summer. FDA will continue to communicate any new safety information to the public as it becomes available.
Just how high is the blood clot risk from Yaz?
It’s quite small – far, far less than a 1% chance or even a 1 in a thousand chance. According to the US Study, if 100,000 women were to use the pill for a year, clots would occur in 23 Yasmin vs 9.1 levonorgestel containing pill users. In the UK study, corresponding risks were 30.8 for drosperinone vs 12.5 for levonogrestrel-containing pills.
Remember that all estrogen-containing contraceptives carry a clot risk, on the order of a few per 10,000 women per year of use. Risks are highest in the first year of use and in women over 35 who smoke.
It’s worth noting that the Europeans are stating that the clot risks for Yaz and its generics are similar to those of pills containing desogestrol, which in the United States are marketed as Mircette, Desogen and their generics. So there’s really no reason to be singling out Yaz for blame. It’s also worth noting that norgestimate-containing pills (Ortho-Cyclens and their generics) seem to have evaded much of the scrutiny when it comes to clot risks, although the patch version of norgestimate (Ortho-Evra) did come under fire for possible higher clot risks. One study to date ranks clot risks with norgestimate pills as similar to levonorgestrel. And the Nuvaring seems to have been completely left out of the mix…
The problem, of course, with all the studies comparing clot risks between pills is that no single study included all the pills being marketed, and all to date have had both very low overall clot incidence and methodological issues that make firm conclusions difficult. I hope the study the FDA is awaiting will be more definitive. The fact that they are releasing this communication now, ahead of the results of that study, makes me wonder if they already know the outcome and are preparing us for it…
Links to studies referenced in the FDA communication
Parkin L, Sharples K, Hernandez RK, Jick SS. Risk of venous thromboembolism in users of oral contraceptives containing drospirenone or levonorgestrel: nested case-control study based on UK General Practice Research Database. BMJ 2011; 340:d2139.
Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. BMJ 2011; 340:d2151.
Dinger JC, Heinemann LA, Kühl-Habich D. The safety of a drospirenone-containing oral contraceptive: final results from the European Active Surveillance Study on oral contraceptives based on 142,475 women-years of observation. Contraception 2007; 75:344-54.
These are no ordinary jade plants. They’re my sister Fran’s parting gift to me and each of my sisters, cuttings from the large jade plant in her foyer, potted by her husband Adam, and, when Fran died before being able to finish the pots, decorated by her dear friend Sharon.
The cool part is that the large jade in Fran’s foyer was grown from a cutting from a jade that once grew on Jerry Garcia’s deck in California. You know, this guy –
I swear it’s true. You see, some years back, my brother Joe worked as a landscaper…Wait, I’ll let Joe tell you the story….
The Jerry Jades as told by Joe
I was re-landscaping the deck area of Jerry Garcia”s home in San Anselmo, CA when his girlfriend Manasha told me to toss three potted Jades along with some other plants. I took the Jades home and kept them on my front porch on 4th Street in San Rafael. I also had about 15-20 small terracotta pots running up both sides of my steps out front that were usually planted with annuals for color, but at the time the Jerry Jades were born, the color was not in the pots and the pots just had bare soil.
When we would have wind storms in Marin, the top heavy Jades would blow off the porch ledge and pieces would break off. Jades are basically indestructable so I would just toss the broken pieces and stand the pots back up.
One morning after yet another windstorm had damaged one of the jades, my best friend Tom and I were bullshitting on the porch. Tom hates to waste or throw anything away and he is not one to sit around, so while we were talking, he was breaking the large broken jade limb apart and stuffing the plugs into the empty annual color pots. A little water and lots of neglect later, the jade plugs started sprouting arms of their own. Once in a while, we would casually mention to our friends that the jades were from the larger jade and then it would come out that they used to be on Jerry’s deck. People would get googly eyed and we would give them a cutting.
Tom and I were always more amazed that we had created a jade farm by jamming limbs in dry dirt than the fact that I was working for Jerry and Manasha. Once Jerry died, though, the jades sort took on new meaning.
I have no earthly idea who has the two mother plants at this point, but Frannie acquired one of the Jerry Jades when she mentioned the story to a surgeon friend who was a life long dead head (scary thought…). She begged me to send one for him after he learned of the story and hounded the crap out her for one. I sent her a couple of bare root jades from one of the original color pots via US Postal. Apparently her friend cried when she gave his to him. He then accidentally amputated someone’s head (Just kidding about that part..Dead head, get it?….)
Interestingly, the jades have a similar lineage story to the bootleg tapes the Dead were known for. The tapes were awesome copies, sometimes referred to as first generation sound boards (when the concert was recorded directly from the sound guy’s equipment). However, if you made a tape to tape copy of that tape, it became a “second generation soundboard,” and if you taped that tape, a third generation would be had. You see where I am going with this…
Franny’s plant are true second generation Jerry Jades since they came right from the main plant.That was 20 years ago now, pre-cell phone and pre-email and when I wrote and told my friends that I was working for Jerry (and eventually David Grisman once), I learned that some of my college friends actually thought I was “telling stories” as we now say in the South. I was always known as honest, but I guess I would have wondered about my story too since it was a pretty wild one. What a long strange trip it’s been….
Fran’s Jade plant grew over the years to a beautifully large and healthy bush that sat in her foyer, and from which she and Adam have bestowed cuttings to friends over the years hence. Spreading the Jerry love, so to speak…
I guess you could say that my plant is a 3rd generation Jerry Jade. I plan to keep it alive and growing for many, many years, and eventually, when it’s large enough for cuttings, I’ll spread the love in Fran’s memory.
NPR is running a typical media hype story on oocyte preservation (egg freezing), featuring the standard happy family photo with their “miracle” baby born after thawing and fertilizing a cryopreserved egg.
It’s a heartwarming story and a pretty photo, but far from a complete picture of what women need to know about this still experimental fertility preserving procedure. Nowhere does the article tell women the actual success rates of occyte cryo-preservation.
So before you run out to freeze your eggs, know this – the chance of having a pregnancy after egg freezing is less than a 50/50 shot – at most about 39%, according to the latest data. That’s about the same odds you’d have if you just wait till 40 to try to get pregnant on your own. In addition, while somewhere between 1 and 2 thousand infants have been born using the technology, we do not yet have data on their long term outcomes.
At costs of over $10,00 a freeze cycle, with many women undergoing multiple cycles to get enough eggs to make the odds worth taking, this is one very expensive roll of the dice. Before considering undergoing the procedure, ask the center you are considering using for their numbers, and be sure their oocyte cryo-preservation program is operating under and IRB-approved protocol.
Women making the decision whether or not to freeze their eggs need reliable and honest information, not hype. Save the family photos for Grandma – give women the facts.
An editorial in last week’s NEJM suggests that it’s time we redefine how physicians bill for office visits using E&M (Evaluation and Management) codes, primarily because E&M coding rules have driven the development of an electronic medical record (EMR) built more for the medical coders and bean counters than for clinicians.
The detailed guidelines often cause clinicians to overdocument, making the medical record an ineffective source of communication. To address the elements specified in the guidelines, some clinicians are tempted to engage in extraneous clinical activity to justify using higher code levels and reaping excessive payment. Other clinicians, fearing sanctions for misrepresenting the contents of a medical visit, may downcode their services. Still others blithely ignore the code definitions and guidelines and continue to code according to their own assessment of the value of their E&M services; unless their coding patterns are aberrant, their claims go unchallenged.
It’s the EMR, not E&M, which is the problem
The EMR doesn’t work because it was on the whole designed by non-clinicians.
Yes, current coding rules have driven much of what we document in the EMR, but it’s also meaningful use and PQRS, e-prescribing, patient safety and the desire to create a powerful data repository that has allows us to do things like trend laboratory values, perform clinical research and target health education and marketing.
Changing E&M coding to get documentation right is letting the cart lead the horse. Lets design a electronic note that works clinically, then decide how best to charge for the work of the visit.
The EMR does not cause up-coding
Yes, there are fraudulent docs out there. And yes, the current E&M System is far from perfect. But the latter did not spawn the former. And the former will be the former irrespective of how we define E&M levels of service.
The EMR does not cause E&M upcoding and here’s why – the volume of documentation alone doesn’t drive billing. There’s a little thing called “medical necessity” that ultimately determines the level of billing in E&M. No matter how much I do and document, if it wasn’t necessary at that moment to take care of the patient, I can’t bill for it. CMS knows that, we know that, and our coding reflects that.
I’d argue that it’s learning how to code that allows docs reimbursement to rise, irrespective of EMR use. This is not because docs are gaming the system, but because they’ve finally learned that no matter how well they took care of a complicated patient, if they forgot to document a single element in the review of systems, they don’t get paid. So now that we’ve learned the rules of the game and how to use the EMR to capture every little thing we do so they can’t say we didn’t do it, they want to switch it up again.
Just because it’s documented doesn’t mean we need to see it.
The biggest issue I have with the EMR is not the data it collects, but the data it displays. All I really need to see on a regular basis from my visit notes is my assessment and plan – the rest can be clickable and viewable if I want to find it (or the bean counters want to count it). That’s a quick and easy fix that won’t require a Senate committee and majority vote in Congress.
Exclusively Time-Based Billing is Not the Answer
The authors suggest that time-based billing as a possible alternative to the current E&M system. While we already use time-based billing for visits where counseling and coordination of care dominate, I cannot imagine how I could use it for all my encounters.
I sometimes have three rooms going at a time – one patient in the bathroom giving a urine sample, another in my office and a third in the stirrups. I may pop into the exam room to do a pelvic, then while that patient is getting dressed, see another, then see the first patient back in my office for an extended discussion while the second is getting dressed, etc. How am I supposed to accurately measure the time I’ve spent each of them? A stop watch? And what happens to time-based billing when a physician extenders are used in tandem with physician in an office visit to increase practice efficiency?
In a time-based system, what allows physicians to get paid for the extensive out of visit care time that can results from a complicated office visit? There are many complicated patients whose office visits that don’t involve much face time, but spawn large amounts of follow up time for abnormal test results, calls to radiologists and phone calls back to the patient. The current system of basing reimbursement partly on complexity and medical decision making, while not perfect, does give at least some compensation for this kind of time intensive follow up.
Finally, time-based billing could lead us back to the time of the clinically useless short note – “All is well, f/u 1 year”. Some clinicians I knew could amass 10 years work of a patients’ visit notes on a single double sided 5×7 card. While such a note may work in a small town private practice, it is completely useless today.
I say leave the current E&M system alone for now
It’s taken us years to get E&M coding right. Years. This is not simple stuff, folks, trust me – I’m my departments Billing Compliance Leader, and even I get it wrong sometimes. But I’ve been reviewing my colleague’s charts for over a decade now, and I can tell you that overwhelmingly docs are finally getting it right.
Please, don’t change it up on us now, especially while we’re in the midst of learning meaningful use and PQRS and ICD-10. We’ve got other things to do, you know.
I wrote once that not only is Oprah Winfrey not a doctor, she plays a really bad one on TV. From promoting Jenny McCarthy and the anti-vaccine movement, to allowing Suzanne Somers a bully-pulpit for her medical woo, to pushing Prudence Hall and her high-dose hormone treatments without acknowledging their potential risks, to leading the church of the Secret as a way to avoid facing the harsh realities of cancer, Oprah did more harm than good when it comes to health.
And while the publishing industry may be hanging crepe, the medical community is breathing a sigh of relief that Oprah has left the airwaves, at least for now. After all, we “conventional” docs were repeatedly relegated to a seat in the audience by Oprah, who usually presented us as naysayers and officials in the Church of Medicine to Oprah’s self-appointed Galileos of Woo, rather than the health experts we are. Of course, it was all couched in terms of female empowerment, a tactic that Oprah long ago taught marketers can be used to sell anything and everything to women.
My axe to grind against Oprah is not just professional, it’s personal. For I saw my sister, nearing the end her life, turn to the Secret, believing that if she just believed enough in herself, she would be cured. Rather than strengthen her, the Secret drained her, turning her away from the supports around her towards an ever elusive goal that never allowed her the possibility of acceptance and preparation for her departure.
I have to admit that I was surprised when my good friend Linda wrote her own Ode to Oprah Winfrey, in which she thanked the Queen of daytime talk for 25 years of wisdom, excusing Oprah’s medical gaffes as nothing more than misplaced good intentions. Well-intentioned though Oprah may have been at some point, I believe she long ago lost the connection between good intentions and their results. In this regard, one particular lesson Linda learned from Oprah can be applied to Oprah herself, and it is this –
When people show you who they are, believe them.
Well, as far as this doctor is concerned, Oprah long ago showed me who she was, and that is nothing more than the biggest marketing Alpha Girl the media ever created, a woman who refused to use her intelligence to look beyond the marketing messages of her so called medical experts to even try to understand the science behind the issues she was promoting, and who never once considered the potential negative impact of those marketing messages on the health of her viewers. My disappointment in her has been profund, for I really did like her immensely.
Of course, we all know that Oprah isn’t really gone. With the creation of her own network, she will, like the hydra, create ever more marketing opportunities for anyone with a product to sell, relegating to her cadre of producers the authority granted her by her worshipping public.
Happily, so far, when it comes to medical topics, OWN has done pretty well. They purchased the Discovery Channel’s documentary series “Deliver Me“, about three Ob-Gyn docs in urban LA. And Laura Berman’s episode on herpes was spot on, with weblinks to ASHASTD.org, a great resource for health info on herpes and other STD’s. Hmm…maybe OWN’s producers haven’t drunk as much of the Oprah Woo-Aid as I think they may have.
(Click on song title to listen… Sung to the time of A Friend of the Devil)
I got out of residency trailed by massive debt
Figured I would build my practice on the internet
Set out marketing myself online
A friend on Facebook is a friend of mine
If I should start a blog to write
I might just get some Tweets tonight…
Ran into the HIPAA regulations right away
Made me pause before I wrote about my working day
Trying to make my reputation grow
To friend a patient is a big no –no
If I should write a patient piece, I’d better get a signed release ….
Ran into a doctor blogger Vartabedian
He called me unprofessional and a barbarian
Set out blogging but I’ll take my time
I’ll give up Facebook it’s a waste of time
If I should twitter any thought profane
I just might ruin my well–earned name.
Got two reasons why I went into my chosen field
The first one was to cure disease and make the sick ones healed.
The second one’s to make a difference in this world we live
And social media has only marketing to give.
Got a busy practice babe, and not much time to spare.
Should I spend it all online or with the folks I care (about)?
Set out marketing myself online and found the internet a waste of time.
My patients know the kind of doc I am, and social media’s a scam.
I got out of residency trailed by massive debt
Figured I would build my practice on the internet
Set out marketing myself online
A friend on Facebook is a friend of mine
If I should start a blog to write
I might just get some Tweets tonight…
The medical blogosphere and twitterverse are abuzz over Dr Bryan Vartabedian’s blog thrashing of anonymous blogger @Mommy_doctor for a Twitter conversation about a patient suffering from priapism (a prolonged and painful erection). The conversation was pretty much standard fare between colleagues on call dealing with an embarrassing and clinically difficult situation, and Mommy_doctor showed herself to be both funny and sympathetic to her patient’s discomfort.
But was Twitter the appropriate place to have that conversation? Dr V argues that it was not –
…the use of the social space at the comical expense of those we’re called to treat is irresponsible. …This is something I’d expect from a frat house, not a treating physician. Of course this level of dialog could only be sustained by someone hiding conveniently behind the cloak of anonymity. Case in point for putting your name and maskless face behind everything you say.
The 91 and counting comments on Dr V’s blog, as well as Mommy_doctor and Dr V’s subsequent Twitter streams make for interesting reading, as medicalbloggers, patients and readers take sides in the ongoing debate about just what constitutes professional behavior by physicians on the internet, and whether Mommy_doctor was wrong to tweet what she did. (The best tweet prize goes to Scanman, who used the phrase a “Storm in a Tweetcup” to describe the debate.)
For what it’s worth, here’s my two sense
Mommy_doctor’s Twitter conversation, while typical for an OR lounge, was best had offline. In saying this, I subjected it to the elevator test – If it’s not something you’d say in a hospital elevator, it’s probably not appropriate for Twitter’s massively public venue. I also believe it was the subject matter that made this particular tweetversation a more delicate one – who would have cared if Mommy_doctor had written that she was heading down to see a patient with acute cholecystitis in the ER?
As for the cloak of anonymity some argue provides protection for both patient and doc on Twitter, it took me about 5 minutes on the web to figure out who Mommy_doctor is. None of us is anonymous, and that knowledge alone drives our behavior out of the doctor’s lounge and into the public forum.
Which brings me to Movin Meat’s excellent post on guidelines for blogging about clinical medicine, which I strongly urge you to read, in which he gives us these pearls –
Respect their (patient’s) privacy and dignity.
Do not think for a moment that you are anonymous.
Don’t blog or tweet anything that you wouldn’t want you boss/hospital administration to read.
Don’t blog about real patients.
Add some redeeming value.
I do blog about real patients, but only with their expressed permission and offering them the chance to vet what I am writing before I post it. Blog posts about real patients follow the time-honored tradition of the case report in medicine, something I’d hate to see us lose, and for which there are standard guidelines for protecting patient’s rights. Let’s not throw the baby out with the bathwater here.
I also think there is much value in the real time tweeting that some docs do – it gives a true sense of what life is really like as a doc. Reading Mommy-Docs tweet stream overall one gets the impression of a very dedicated, busy anesthesologist who on the whole treats her patients with dignity and respect and who I’d trust to put me to sleep any day. It would be great if we could find a way to retain the real world authenticity that tweeting gives medicine, while still protecting patient privacy.
Finally, as a prior anonymous blogger who threw away the Emperor’s cloak of anonomity, the biggest piece of advice I can give to Mommy_doctor is to come out of hiding and take public credit for her tweets and her blog. As a physician, she has lots to share that is meaningful and worth listening to. She also has a job to protect.
UPDATE – Mommy_doctor appears to have taken both her blog and twitter accounts offline. I hope it’s temporary.
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More on the issue from around the web –
Seattle Mamadoc tells us she has taken tweets down in the past to protect patient privacy after being asked privately to do so.
Colin Son argues that Dr V should have approached Mommy_doctor offline
Movin’ Meat doesn’t buy Dr V’s definition of unprofessional
Scepticemia thinks it’s all much ado about nothing, but gives a nice discussion on the issues
Buckeye Surgeon has a nice set of rules for online case blogging
Jeffrey Parks posts his excellent guidelines for medical blogging, and reminds us that op consents should include permission to use images for educational purposes.
Ryan Madenick also makes reference to the elevator comparison
From none other that my sis, Ronnie Polaneczky, in her column at the Philly Daily News, comes this sage advice for Arnold Schwartzenegger and his fellow philandering politicians –
Schwarzenegger is a junkyard dog, but I still winced for him when I heard that son Patrick Schwarzenegger changed his last name to “Shriver” on his Twitter account last week. How much does your kid have to hate you to do that? And how devastating must it feel, as a father, to know you hurt your child that deeply?
That’s why I think these jerks ought to get tattoos of their kids faces – on their penises. It would remind them just who gets screwed when daddy’s wee-wee wanders.
Way to go, sis! Head on over and read her entire column, which includes advice for would-be mistresses as well.
Someone needs to offer my sis a spot on the View …
As a rule, I turn down requests to test new products for the blog, not wanting the place to turn into a free showroom for anyone with something to sell. But when Horman’s New York Deli Pickles offered me free samples for a taste test, well, let’s just say I’ve never met a Dill I didn’t love. And, I reasoned, as long as I’m not prescribing pickles to my patients, the whole thing would be Kosher…
Annie and Marissa agreed to be my impartial tasters, and overall gave the pickles a great big thumbs up.
Bottom Line
Eat the Kosher Dills straight from the jar. Try to stop after three and leave a few for someone else.
The Mustard and Spice Dills are a bit strong straight out of the bottle, but perfect for use in a sandwich.
Pickles are a very low calorie food, but not zero calories as it says on the bottle. More like 8 calories for a medium (65 g) and 16 calories for a large (135 g) pickle.
Horman’s NY Deli pickles are now available from Fresh Direct, which is where I’ll be getting mine. Check their website to find where you might get yours.
Site Jabber, a website funded by the National Science Foundation to help internet users separate the scams and frauds from real content, called and asked me for advice on how to find good medical content on the web. The interview reads like a huge promotion for my blog, something I was not expecting and for which I thank them profusely.
The kernels of advice I gave were pretty simple, though. If you want good health advice
Know who’s funding the site you’re viewing. The “About us” section is a good place to start. If it’s a disease-specific site, it may be an “awareness campaign” funded by Big Pharma, the first step in marketing a new drug.
Avoid any site that is selling a product (ie, bioidentical hormones, vitamins, supplements, cure-alls); and
If you see a big celebrity spokesperson, be wary. With a few notable exceptions (like Gilda’s Club for Ovarian cancer info, or Stand Up to Cancer), only Big Pharma can afford that kind of marketing (eg., Sally Field for Boniva and Bob Dole for Viagra). Check the About Us section of any website to be sure it’s non-commercially funded info before you plunge in.
Watch for site-morph – that’s when a non-profit health site (eg, Livestrong.org) spawns a for-profit site (eg, livestrong.com), or when health experts morph to health celebrities, and a once reliable medical site turns into yet another lifestyle destination site with products to sell you.
Site Jabber is a great resource for web users, and was recently named one of the top 100 websites by PC Magazine. I encourage you to visit them and see for yourself.
