Educate the world, one person at a time.

Today was the Education Council meeting for McMaster’s Family Medicine Teaching Centre and it inspired some thoughts as to how education (both medical and general) has changed over time.  There are a lot of other people that are far more qualified to speak on this topic, but I wanted to put “pen to paper” and just mention a couple of things.

I still have a “certificate” from my elementary school class trip to the Old Britannia Schoolhouse, where we learned how kids were educated and disciplined.  Education as a theme is ageless as people have passed down information from parent to child, teacher to student and possibly as below.

 

In discussion with a colleague of mine, who was telling me about his father who started a charity called Asha Jyoti, which gave a scholarship to a student who was underprivileged and yet showed promise as an excellent student.

It seemed to go well with EveryDayChild‘s motto of Learn, Earn, Return, allowing students with excellent potential the chance to succeed despite unsurmountable odds.

The evolution of education has continued to grow, especially in the way that it is developed.  Child psychology and behaviour has been analyzed in multiple articles and this is being used to avoid the use of discipline involving physical harm to children.  There is good literature that discipline should be focused on being based on what is appropriate for the child’s developmental stage and age.  A 2 year old will not understand a dissertation about why finger painting on the wall is a bad thing.  As such, discipline needs to be based on clear instructions with set rules of punishment and positive reinforcement to allow for rewards for good behaviour.  Interestingly, the use of “Time outs” when used on young children has been shown to be effective in studies and can be used effectively.

It is important to have the goal of discipline be directed at the behaviour and not at the child and that it should taught with respect and patience, not to punish or belittle the child.  As such, it is important for the child to have the punishment be as soon as the behaviour occurs and it needs to be consistent.

There are studies that physical punishment (whether thought to be “minor” or “child abuse”), has been noted to have issues with poor self-esteem, increased risk of drug abuse and depression/anxiety.

Garbage in, even worse out… of your medical record.

There has been a great deal discussed regarding the rise of electronic medical records, which for the remainder of this article will be referred to as EMR.

The spectrum lies in one end stating that they have no need for electronic records as medicine has gotten along famously without it and can continue doing so in the future.  While the competing side of the spectrum states that the future is with the EMR and that we will only be able to move forward, if all physicians decide to move forward and every patient have their medical information readily available.  There are some very intriguing ways that this has been discussed; using a USB device, having it on apps on one’s phone or possibly using a barcode on the health card which links to a cloud storage (patent pending).  All have drawbacks and their own benefits, but come with the same flaw.

What is the information present?  Is it information that the patient ascertained from their physician appointment and scrawled on a piece of paper, or that their family members placed in the notes section of their smartphone?  Is it a typed progress note that their health care provider printed out and gave to them (i.e. complete patient profile)?  This variety changes how likely the information will be helpful and the other side is simply, who reads the information.  When information is given in an unfamiliar format, things can be pushed aside as extraneous.  This will cause confusion and often lead to mistakes.

Don’t get me wrong, I am clearly on the side of the spectrum that states that EMRs are here to stay and that every patient should have their medical records handy for any new physician that they see (whether it’s an emergency room physician, specialist or heaven forbid, walk in clinic physician.  For these physicians, or any health care provider to actually have useful information so that good, sound clinical decision making can occur is critical.

But this is not new, this has been an issue that has been wrestled around with for a while.  The Canadian government attempted to help move EMRs forward using eHealth with …. interesting results.  OntarioMD continues to work forward using Peer Leaders, some of whom I follow on twitter to keep my ear to the ground.  I personally have been a Physician Practice Champion, working with both eHealth and OntarioMD, piloting the Ontario Laboratory Information Service (OLIS) using our EMR, which will likely allow for a smoother roll out.

So what’s the problem?  Unfortunately, the issue as with all things is the bell curve.  Any student will recognize the bell curve, this one is about innovation.

The “laggards” (recently this slide was shown at FM rounds, and I got a kick out the verbiage) will cause significant issues.  Not because things will hinge on their decision of when to come onboard to getting an EMR, but more about what they do when they get there.

The biggest issue with someone that is not fully invested in moving forward with a good EMR is that the information that they put into it, will simply be… garbage!

So what does that mean?  If we take the Complete Patient Profile (CPP) as an example, we will note that there are a few sections where information may duplicate.  If there is no standardized way of displaying data, what will happen is some people might put the fact that a person is a smoker in the “Medical History” or “History of Problems”, while others may place this in “Social History” or “Lifestyle”.  This may seem confusing to think of abstractly, but take this as an example.

Medical History – Tobacco Abuse – 1 pack per day for 14 years.

vs.

Social History – Smoker – 1 ppd – started 1998

 

Both give the same information with different presentations.  To a reader, it might be quite easy to pick up the fact that both are the same, however, the purpose of EMR should not just be a cleaner looking chart, but something that can pull data out and use it in a way that can benefit patients, individually and as a whole.

Other providers may put that a patient who has never smoked a day in his life as a “Smoker” with a negative check box or as a Non-Smoker.  Again, in this instance, both say the same thing.

However, in order for EMRs to be more helpful for a physician and eventually larger entities, this information needs to become standardized, because the information is likely going to be read by automated queries which will be looking for specific phrases and if the information is haphazardly thrown into the system, with abbreviations and with a complete lack of standardization, the EMR will be as worthless as a sticky note that was used to make a quick diagram for a patient.

Information needs to be usable, readable and searchable.  Standardization is the key.  Our office is working on a way within our Family Health Team but there will likely need to be a larger scale approach, and I am afraid when that comes that the steps we make, may end up being extra work.  “All’s well that ends well.” – Shakespeare.  Let’s hope so.

So you want to be a doctor….

The following is all opinion and experience and not based on evidence I have ascertained through literature search.  It is meant to be a general summary and is very over simplified.  As such, I am sure there are individuals will state that it wasn’t how their experience went.

First year plan – one week down.

This first week of posts has allowed for significant educational pearls and I hope to continue for the year.  I am hoping to expand the blog into a couple of avenues, one being a repository for quality, evidence based information based of recent information and for a forum for frequently asked questions.  My overall hope is that it will start the conversation so that medicine does not seem too foreign.  This, luckily, has become quite a bit better with the plethora of patient education data but the way that I look at it, there can never be enough good information on the internet.  After all, I wouldn’t want everyone to freak out about the dangerous dihydrogen monoxide scare.

In case you are wondering, this site is a great example of how information can be twisted.  I will continue to believe this site is a hoax and will enjoy it as such.  Remember that dihydrogen monoxide or H20 or water is only as scary as when it is torrential.  Water is a dangerous force in nature, but it’s safe enough to bathe and drink.

In the end, I am planning on creating more content, hoping to start a weekly or monthly podcast about recent journal articles and creating a section devoted to patient handouts.  The last part is a little selfish as it would allow me to quickly go to a site that I trust (my own) and allow me to print off information for patients.

I want to make sure I acknowledge Essential Evidence Plus/Infopoems as many times I corroborate the information I’ve learned with this site, and usually borrow citations from them.  It is a great site for clinicians and I readily (without compensation) recommend this site.

Another great site to consider is TheNNT.com, which is a fantastic quick hit for evidence based medicine and they can be quite cheeky about it as well.

Hopefully, I’ll be able to stick with my New Years Resolution and keep posting at least 5 days a week, if not daily.

Paying it forward.

Today was a good day. Outside of getting up at 12, which was pretty nice in itself, it was a day of feeling fulfilled. I hesitated initially from making this as my post for the day but realized that it brought me joy helping others and realized that it was just as much a part of medicine as any science I would write about.

First, the science! Happiness is obviously an emotion. It is driven by two main neurotransmitters, Serotonin and Dopamine. When Serotonin is low, it is a common driving force in causing depressive symptoms, noted initially when rats were injected with serotonin and found to be socially isolated and lacking motivation. Doing pleasurable things increases Serotonin and in turn increases the chances people are happy, at least for a short time. This is commonly the surge you see when you’ve “brightened their day”.

Today I was able to help two different people in two very different ways and both had what was palpably a “Serotonin Surge”. I won’t go into all the details but I will use this opportunity and forum to promote my friend’s newly opened physiotherapy clinic, Pro Active Health Group. The website will be up soon and I will post a link when they let me know it is ready. The other was a complete stranger that I was able to change the course of both her day and likely, the whole year by making two very quick emails and one quick phone call.

I do not write this to pat myself on the back but as a challenge to offer any readers to find a way to give someone else their “Serotonin Surge” for the day!

“I am not my disease.”

Many patients feel that they have diseases.  It has luckily become more common place to think of patients as people who live with disease and not diseased people.  There is a movement to change the nomenclature (or naming) into People First language.  Though, some of the most forward thinking physicians I know do not agree with this, as patients do not recognize this form of speech.

This form of linguistic prescriptivism is meant to stop the dehumanization when discussing people and the diseases they must deal with.  “Diabetics” for “People living with Diabetes”, “Disabled People” for “People with Disabilities” or “Asthmatic” for “Person who has Asthma”.

Some may see this as semantics and cast it aside as another form of political correctness and may state that it is what it is.  I challenge that there are many things that are not as they are in the world and that it is mainly a part of perception.  I will refer people to a great TED talk (found at the bottom of the post), which brings up the great point that things are all about perception.  Some people may think that we live on earth and that we are surrounded by two-thirds water vs. the fact that the we live in a ocean planet on which we live on the earthy part.

It is interesting to me that people who feel that we need to have patient centred care and yet not put the patient first when describing what challenges they have seems counter-intuitive.  Those interested in learning more can consider going to the Disability Is Natural Website.

Enjoy your weekend!

2013 Begins and with it also a new Blog.

Many times I have attempted writing, in many forms.  Writing fiction remains my favourite pastime but I continually state I simply don’t have the time.  However, I constantly advise patients to consider new activities and new exercise regimens and constantly get the comment that there isn’t enough time left in the day to complete such tasks.  As such, I have taken the advice of my lovely wife, and “put pen to paper” figuratively speaking.

I figure making a blog will be a far better way, as compared with keeping a journal for two reasons.  The first being that I plan to use this blog as a way to keep a singular location where I can place all of the interesting evidence based materials which I would like to access at a later time, and in addition, I can refer patients to this site as well.  The second being a form of continuing education.  During my clinic days, I always come across something that I find confusing or vexing and usually I state I don’t have time to look it up.  However, as I have started to take on more and more teaching roles, it only makes sense to continually stay apprised of information that I feel uncomfortable with.

The last point relates to the students/residents that 2013 will bring into my office.  There are three universities that I am affiliated with, McMaster Family Medicine Teaching Program (Assistant Clinical Professor), University of Toronto (FMLE Preceptor) and York University Nurse Practitioner Primary Care Program (Community Preceptor).  With these challenges come significant responsibilities, as well as opportunities and I feel that it will become important to create a very clear agenda for each student/resident.  It will be helpful to have the blog to create an open environment, both in RL (Real Life – the gamer in me comes out) and on the blogosphere/social media.

I am not sure how long I will stick to this blog, but as motivational interviewing is something that I will be speaking on shortly, it’s important that I make a SMART goal.

As my first Clinical Pearl of the year…

Recently I attended a Motivational Interviewing session at Family Medicine Forum and as many people will be creating New Year’s Resolutions this year, I would empower you to make SMART goals.

SMART goals are considered goals that are:

“S”pecific – Vague goals are usually half hearted and very commonly thrown aside quickly or forgotten.  More specific goals will help decide on next steps.

“M”eaningful – Goals that mean more to others and not to the individual usually will only be in play when someone is watching.  When it means more to an individual, it will hold more weight to move forward with the goal.

“A”ssessable – Making a goal that is measurable will allow for a more objective way of looking at it.  There is less feeling of failure when things are not all or nothing.  When you can assess after the time frame set, you will be able to look back and see what has affected your ability to achieve your goal and work towards changing it.

“R”ealistic -Making large jumps too quickly will cause you to fall, as easily evident for any participant of “Wipeout”, the popular ABC show.  Usually small calculated attempts will make far better gains.  “Baby steps” as it were. If a goal is too lofty, there is a lower chance it will be attained.  It’s common to see people make goals that don’t make much sense and usually when I see this in my practice, I ask them if they would like to scale back and very quickly they are willing.  This is usually a sign that it was not a realistic goal and likely not assessable

“T”imed – If a goal does not have a time frame, there is a likelihood that individuals will procrastinate with the changes.  As stated earlier, if there is a measurable outcome, it needs to have an end point to be valid.

An example of a SMART goal would be the one that I made with my wife:

For the next 3 months, we will attempt to work out using Zumba 3 times a week for 20-30 minutes (depending on the session).

Putting on paper does not seem daunting to me, which helps me feel confident that this goal is attainable.  We’ll see after 3 months.

To end the post a quick Calvin and Hobbs.