Everyone knows who the first man to land on the moon was (Neil Armstrong). But who was the LAST man to land on the moon? Read below for the answer and look above to enjoy the picture.
Driving on the Moon: Apollo 17 mission commander Eugene A. Cernan makes a short checkout of the Lunar Roving Vehicle during the early part of the first Apollo 17 extravehicular activity at the Taurus-Littrow landing site.
Beautiful video by Hans Roling on the global ascent of health and wealth over the last 200 years. Give people freedom and time and they will create a bright future.
Do Electronic Medical Records (EMR) Make Lying Easier?
Pretend you are a doctor. You examine a patient. You then document your findings on the medical record, or in this case the EMR. If you document that the patient has a “regular [heart] rate and rhythm” and they do not you either: 1) listened but interpreted it incorrectly, 2) listened to to it, heard it correctly but documented it incorrectly or 3) did not listen but documented it as such anyway. The first 2 scenarios signal incompetence, the last dishonesty. Neither is acceptable when taking care of patients.
Recently, I saw a patient that had atrial fibrillation (a. fib.) in his medical history on the EMR. Atrial fibrillation is a condition in which the heart discharges an irregular pattern of beats in an “irregularly irregular” fashion. Before evaluating the patient I read the emergency room doctor’s notes which were written as a standard template physical exam: “normocephalic, atraumatic ….REGULAR RATE AND RHYTHM.” When I hit this part in the record I thought 1) either the A. fib. diagnosis was wrong, 2) the patient was cured of his a. fib, or 3) the examiner was incompetent or dishonest. I ruled out the first 2 options as I found an EKG in his chart with an irregularly irregular pattern and then I checked his pulse myself (I know pretty stupendous for an orthopedic surgeon). That only left incompetence or dishonesty as potential explanations. And it’s impossible for me know which of the 2 it was in this case.
What I do know is that I am seeing this more often. In some respects EMR’s have facilitated a march toward “thorough” yet incompetent/dishonest documentation. Templates which facilitate hitting coding points have replaced reasoned data and conclusions. We stuff charts full of reems of documentation with little in the way of meaning. There are reasons for this.
The economics of note writing and documentation has changed. The cost of putting pen to paper and fully documenting a long physical exam used to be high: much time spent writing out findings. This cost precluded one from writing extraneous information other than what was done. This is no longer so. Long swathes of medical documentation have become cheap, and can be cut and pasted at the click of a mouse. In addition the coding system which captures charges encourages verbose documentation.
The information coded in this documentation has followed suit: as quantity has increased, quality has suffered. Medical charts now explode with cheap documentation. Legible yes, but cheap nonetheless.
It’s fun because it gets you thinking about these large numbers,” Conroy said. Conroy looked up how many cells are in the average human body — 50 trillion or so — and multiplied that by the 6 billion people on Earth. And he came up with about 300 sextillion.
So the number of stars in the universe “is equal to all the cells in the humans on Earth ” a kind of funny coincidence,” Conroy said.
“Did someone predict the crisis before it happened? … If the answer is no, I don’t want to hear what the person says. If the person saw the crisis coming, then I want to hear what they have to say.” - Nassim Taleb, author of The Black Swan, 2010 …
With admirable foresight, Dr. Salameh paid attention to the Lebanese banks’ off-balance sheet items, forbade (in 2004) sub-prime investments, and required a minimum 30% cash reserve at each institution. The result? (In Dr. Salameh’s own words), “Lebanon will not feel the effects of the financial crisis, because we took the necessary measures preemptively” and as they say in Texas, it ain’t braggin’ if it’s true.
In the time since the burst of our bubble, Lebanon’s banking system has been doing super, thanks for asking! The first seven months of 2010 saw “unprecedented growth in lending activity” from a Lebanese system made up of “highly liquid deposit rich banks with low leverage”. Yet, as of this moment Dr. Salameh has garnered scant few American fans for his unmatched success. While Euromoney magazine has been granting him awards since 1996 and The Banker Magazine voted him 2009’s Best Middle Eastern Central Bank Governor, all YouTube yields is 6 results and a search of Google but 17 news items about him. “Everything’s fine” makes for boring press.
The other day I called in a prescription for a patient. It was for colchicine. Originally isolated from plants of the genus colchicum about 190 years ago, colchicine has been used for centuries to combat rheumatoid arthritis and gout. My patient takes the medication as a prophylaxis for gout flares, flares which entail excruciating bouts of disabling knee and ankle pain. The drug works well. And as long has he takes one pill per day he feels great.
When I called the pharmacist, she alerted me that the drug is still being sold in its current formulation but not for long: the FDA is taking it off the market. Something smelled fishy. A drug that’s been in use for 2000 years in one form or another now off the market? So I did some research.
Turns out that colchicine had been grandfathered in by the FDA approval process. It was never “fully” approved as a stand alone therapy for gout or other afflictions for which it is used. It was, however approved in 1982 in combination with another drug called probenecid. Forget that there was nearly 2000 years worth of emperic evidence (heck, Ben Franklin used the stuff for his gout!).
The explanation is as simple as it is disturbing. A collision of well meaning legislation and the ambition of one pharmaceutical company met head on to create this mess. In 2006 the federal government passed the Unapproved Drugs Initiative, an initiative meant to pass previously “unapproved” but widely used medications through the same screening process that is used to approve new drugs. In conjunction with this a company called URL Pharma created a new formulation of colchicine, performed 2 effectiveness studies and then sued the FDA for exclusive rights to sell the drug. The consequence? A drug that used to cost $.09 per pill shot up quickly to nearly $5 per pill. A drug that has been generic for decades suddenly reverted back to brand name status. Cost increases, access decreases. But what about safety? As a proponent of rigorous science and randomized trials, I personally find it hard to swallow (pun intended) that such a move will drastically improve the safety profile of colchicine. Drastically improve URL’s Pharma’s bottom line? Yes. But increasing the cost of a drug with 100’s of years of use under its belt, by 50x clearly hurts more people than it helps.
So does the FDA help patients or Big Pharma? You decide.
Is it possible to sell a product to a “top down” industry in a “bottom up” fashion? For better or worse we are trying to do just that. It’s not our only tactic mind you, but we feel that this is one of the biggest challenges we face as a start up.
Our goal from the start has been to build a great software product for residents and hospital based medical teams. But there are significant challenges to this. The health care system operates through a series of hierarchies. This makes sense. Health care delivery is complex and risky and hierarchies are good at keeping order and regimenting standards to mitigate risk. Residents (sorry guys) live somewhere at the bottom of the academic medical hierarchy. Ideas/ orders filter through a chain of command starting with the chairmen and eventually make it through to the residents. This is “top down.” This is the culture of medicine.
“Bottom up,” on the other hand is the organic spread of ideas from anywhere in an organization. Bottom up is horizontal. It is when a user finds a product particularly useful and through word of mouth spreads that product on to wide adoption. There is no particular chain of command or authority guiding the decision.
Suffice it to say one of the disadvantages of hierarchical organizations is that they tend to become walled off or “silos.” Those within the “silo” will usually cite this as a necessary constraint because of the nature of their business. For instance health IT departments must necessarily protect personal privacy above all else. This is not wrong. In fact, it is correct. But one cannot deny that such a structure inherently limits an organization’s ability to adopt innovation quickly and adapt to the needs of employees and customers.
Do to our own constraints -time, money, connections, experience- we are attempting to market our product, in part, in a bottom up fashion: get it to enough users and make them happy and hope that they can help spread the word. It would follow that if residents are happier and more productive, their services will run smoother and their attendings will be happier and more productive. And ultimately care will improve. We’ve found so far that residency program directors want their residents’ buy in before trying a product like The List. And residents are excited about moving technology and care forward.
But residents don’t buy things to help “the system.” Remember they are transient and are already “overworked and underpaid.” And program directors are hard to get to. We’re sure we’re in for a grind. But we believe in what we’re doing.
At Touch Consult, we’re developing software for hospital based medical teams. These teams may consist of nurse practitioners, physician assistants, attending physicians and, in academic centers largely residents. Residents are the indispensible, yet under appreciated cog in the machine that is academic medicine. They live in a no man’s land somewhere between trainee and employee. They have multiple bosses, barely sleep, run around all day handling boatloads of data, make critical decisions about life and death and wake up and do it all again the next day. Their number one goal is survival. They have very little control over their lives and they know it. Finally getting a holiday free from call can feel like the granting of a weekend prison furlough: a glorious, albeit brief return to the rhythm of the rest of the world. Dutiful and focused, most residents do what they’re told, suck it up, work for the greater good, over achieve, burn the candle at both ends, gut it out and persevere. They expect to be beaten up, run down, “pimped”, prodded and called upon at any hour. It’s their “rite of passage” - the price they pay for having the privilege of holding lives in their hands. Their job is to do all of the scut that nobody else wants to do, and to do it NOW.
We are designing for the resident in mind. We have an uphill battle. Our user is, for better or worse, not the purchaser of the product that we are selling. Their attention span is necessarily short. They are transient, often moving from one “rotation” to the next every 2 months. And as long as they “fly under the radar,” they and their supervisors are usually pretty happy.
But we think, since so few people actually “care” about residents and they are so used to bending to the system, that they are ripe for a product that caters directly to them. And maybe, just maybe, if we can make residents’ lives a little easier, we will have won a loyal fan base.
According to a 2007 JAMA study (Klevins RM, JAMA 2007; 298:1763-71), deaths due to MRSA (Methicillin Resistant Staph Aureus) in 2007 exceeded those caused by HIV in the United States.
Staph Aureus is a bacteria that lives, among other places, on our skin. Normally it lives in relative obscurity. Occasionally it circumvents a patient’s immune system- often through surgical incisions- and causes infection. Methicillin, a penicillin relative, was the standard treatment for this bug for years. And it worked quite well until the little pests developed a way around it. MRSA is the result. This “super bug” is resistant to Methicillin and more powerful antibiotics, which in tern breed their own resistance. are necessary to treat it. MRSA is becoming a scourge for hospitals and nursing homes, is driving costs of treating infections up and is scaring the bejeezus out of infectious disease doctors. MRSA really does not discriminate based on age, race or gender. Arguably we are all at greater lifetime risk of being affected by MRSA than many other of the more commonly recognizable diseases.
In this country in which it seems only the politically connected diseases seem to score attention for their cause (if you can get half the NFL to wear pink cleats for a whole month you have some clout), I propose the MRSA movement. If anyone can think of a good ribbon design I think we’d be in business.
However, most important to us at this point is hearing what is NOT working for residents. So far, two issues have come up consistently. The first is that printing of the list, with all its details, takes too many pages. Or, conversely, the print is too small to read if forced to fit on a single page. Therefore, we are designing a new printing format which is much more compressed and wastes less white space. We are hoping to roll this out in the next 1-2 weeks.
Phil keeps us updated on our first test site at the Carolonas Medical Center. When Carolinas agreed to test the List, we assumed that they would dip their feet into the water slowly and try it out on one of the smaller patient services, maybe 8-10 patients. No such luck: they chose to go in head first and use it to organize the trauma list- a list of 50-60 patients at any one time. A trial by fire if there ever was one. So far so good. But there have been some hiccups that we are working out as we speak. Phil highlights a few in his blog post. It’s easy to sing praises about why you think your offering is better than everything else out there. Not so easy to be honest with yourself and move quickly to improve. We’re trying to do the latter and respond as quickly as possible with improvements. Time will tell whether we’ll succeed.
PS thanks to all of my followers. I don’t have a huge following and our little start up barely registers in the big scheme of things but we are passionate about it and appreciate those who have reached out already.
Something big is going on at the center of the galaxy, and astronomers are happy to say they don’t know what it is. A group of scientists working with data from NASA’s Fermi Gamma-Ray Space Telescope said Tuesday that they had discovered two bubbles of energy erupting from the center of the Milky Way galaxy. The bubbles, which will be in a paper to be published Wednesday in The Astrophysical Journal, extend 25,000 light years up and down from each side of the galaxy and contain the energy equivalent to 100,000 supernova explosions.
“They’re big,” said Doug Finkbeiner of the Harvard-Smithsonian Center for Astrophysics, leader of the team that discovered them. The source of the bubbles is a mystery, [but] what it’s apparently not is dark matter, the mysterious something that astronomers say makes up a quarter of the universe and holds galaxies together.
Beautiful picture. I love space because it always delivers perspective. 50,000 light years. And that’s just one galaxy among an unknown multitude. Amazing
![kateoplis:
NYT: Bubbles of Energy are Found in Galaxy
Something big is going on at the center of the galaxy, and astronomers are happy to say they don’t know what it is. A group of scientists working with data from NASA’s Fermi Gamma-Ray Space Telescope said Tuesday that they had discovered two bubbles of energy erupting from the center of the Milky Way galaxy. The bubbles, which will be in a paper to be published Wednesday in The Astrophysical Journal, extend 25,000 light years up and down from each side of the galaxy and contain the energy equivalent to 100,000 supernova explosions.
“They’re big,” said Doug Finkbeiner of the Harvard-Smithsonian Center for Astrophysics, leader of the team that discovered them. The source of the bubbles is a mystery, [but] what it’s apparently not is dark matter, the mysterious something that astronomers say makes up a quarter of the universe and holds galaxies together.
Beautiful picture. I love space because it always delivers perspective. 50,000 light years. And that’s just one galaxy among an unknown multitude. Amazing](http://25.media.tumblr.com/tumblr_lbn8exKZxh1qzprlbo1_400.png)
