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US healthcare

William Cayley: Planning for uncertainty

2 Jul, 15 | by BMJ

bill_cayley_2Martin Marshall could not have said it better in his recent blog—the idea of the 10 minute consultation is a travesty . . . except that sometimes it is not.

With the increasing demands on and increasingly complex expectations of GPs and family physicians, expecting everything to fit into a 10 minute visit is simply crazy. Yet there are times when that 10 minute visit (or less) is what the patient wants. In good generalist primary care or family medicine, when we present ourselves as comprehensive physicians there to stand with our patients in health and in sickness, in prevention and in treatment, it should be no surprise that many a visit goes beyond the stated “chief complaint” to a much longer agenda. On the other hand, sometimes our patients simply want treatment for one narrowly focused concern—a cold, a tick bite, a skin infection. more…

William Cayley: To doctor is to diagnose

16 Jun, 15 | by BMJ

bill_cayley_2I appreciated Richard Smith’s recent discussion of mental models—too often, I think, we simply carry on with practice as usual (or, “life as usual”) without sufficient critical attention to the paradigms on which we rely to organize our thinking and doing.

I would beg to differ with him, however, on the argument that “diagnosis is no longer important because most patients have long term conditions.” To the contrary, it is precisely because our patients have (often multiple) long term conditions that diagnosis has become even more important. more…

William Cayley: Less is more

18 May, 15 | by BMJ

bill_cayley_2Both seasoned clinicians and learners in today’s medical environment receive both explicit and unspoken messages that the best medicine involves advanced technology, the latest medications, and highly specialized care. Evidence based medicine, on the other hand, advocates the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,” and campaigns such as “Choosing Wisely” and The BMJ‘s “Too Much Medicine” are encouraging critical thought as to what amount of “medicine” is appropriate for patients and when. more…

Elizabeth Loder: US medical specialty boards: accountable to whom, for what, and how?

18 May, 15 | by BMJ

elizabeth_loder

Elizabeth Loder examines charges of lax oversight and governance at organizations that assess doctors. 

The medical specialty boards that test and certify US doctors are facing a tough test of their own, with plenty of reasons to worry about the outcome. 24 specialty boards administer the tests doctors must pass in order to say they are “board-certified” in a particular field. The boards are represented by an umbrella organization known as the American Board of Medical Specialties (ABMS)The ABMS and its member boards profess a noble mission to serve the public, improve the quality of healthcare, and ensure that they certify doctors who “demonstrate the knowledge, skills and attitudes essential for excellent patient care.” And yet these organizations are now under siege from disgruntled doctors, who paint a far less favorable picture of their motives. more…

Art Cohen and Selwyn Ray: The lessons of late April in Baltimore

8 May, 15 | by BMJ

art_cohenselwyn_rayAfter years of suffering and resignation about disrespect and mistreatment at the hands of local police, young and older African-American residents of inner city west and east Baltimore, joined by others, came together these past two weeks to say: “we’ve had enough.” The spark for this was the fatal injuring, while in police custody on 12 April, of 25 year old Freddie Gray, who died a week later on 19 April. Gray was a resident of the Sandtown-Winchester neighborhood and also a childhood victim of lead paint poisoning. He was arrested for making eye contact with a policeman and then trying to run away. His death acted as the proverbial straw that broke the camel’s back. more…

John W McEvoy on the Baltimore riots

30 Apr, 15 | by BMJ

john_mcevoyWhen I came to Baltimore from Ireland in 2008 many people said I was crazy. I often heard from friends and colleagues, “Be careful, that’s where they made The Wire.” However, as a young resident physician, an underserved city like Baltimore seemed to me like a great place to train. On my annual trips home this widely held perception of Baltimore as a dangerous place would often come up. However, after getting to know the place better, my typical response became, “It’s not like that; Baltimore is actually a great city.” To this very day, I still believe that Baltimore is a great city. But it also has some flaws. more…

Neal D. Barnard and Angela Eakin: Yes, cholesterol matters

28 Apr, 15 | by BMJ

In February 2015, the US Dietary Guidelines Advisory Committee reported that dietary cholesterol was no longer a “nutrient of concern.” According to the Committee’s report, “available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol….” In the ensuing media tempest, some food writers saw a green light for indulgence in eggs, sausage, and other high cholesterol foods. Others went further, exonerating high blood cholesterol levels, and patients began asking their physicians whether cholesterol matters.  more…

William Cayley: Are you depressed?

27 Apr, 15 | by BMJ

bill_cayley_2“Do you feel down, depressed, or hopeless? Are you bothered by little interest or pleasure in doing things?”

Now that the practice I work for is part of an accountable care organization, one more measure on which our (supposed quality of) patient care is being assessed, is our screening for depression. While that sounds initially good on the face of it (after all, who wants to be depressed?), in reality I fear it not only flies in the face of current best evidence, but also contributes to over-medicalization and “too much medicine.” more…

David Kerr: Dr Uber

23 Apr, 15 | by BMJ

david_kerr_2015picThe hot topic in the technology world at the moment is the so called “sharing economy.” A great deal of money is being made by companies, such as Uber and Airbnb, where the internet is used to match buyers and sellers without the need for the huge upfront costs of purchasing, for example, cars and properties. The question is whether the concept of a sharing economy could also be of value in healthcare? more…

William Cayley: Who are you?

14 Apr, 15 | by BMJ

bill_cayley_2“The Patient” is everywhere. He is in consult notes, she is in hospital admission notes, he is in letters, and she is even in my daily dictations and procedure notes. “The Patient” is that anonymous moniker that gets plopped, intentionally or not, into clinical documentation of our medical care.

This struck me today as I signed a procedure note. For some time, I have been working to deliberately refer to my patients by name when writing or dictating office notes and procedures, yet today I found that once again my dictation was “anonymized” by the transcriptionist, with the patient’s given name removed and replaced with “the patient.” more…

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