Old Reflecting Pool

The Reflecting Pool

Musings and meditations on family medicine, education and technology…

(Copied over from Radio Userland servers on 090510…just in time apparently…)

Thursday, September 30, 2004



So Vioxx got pulled off the market today…I’ve already gotten two
mildly panicky calls about “what am I going to be on from here?” 
Most of the people that are on these medicines have been put on them by
specialists – and I find that I must go through a lot of information
about the fact that the cox-2s don’t mean “no ulcers” – just fewer
ulcers.  That otherwise they have relatively fewer
advantages…there’s no real pain benefit – any more than there is with
switching to any of the other classes of NSAIDs.  That’s going to
take a lot of time to give that speech to everyone on Vioxx now…
Speaking of “everyone on Vioxx” – we recently began using an EMR
(really good).  The problem is that we’re using Misys EMR.  I
have to agree with Jacob Reider…this thing is a dog – but I’m an
optimist – and an optimist who also happens to be hamstrung by the
reality that it’s VERY unlikely that we could ever switch to something
else.  I had an idea today to see if we could salvage some of the
negative feelings floating around the group about the troubles with the
EMR by asking if we could get a report on who in our practice was on
Vioxx so that we could be proactive in contact them to manage the
transition.  I’m holding my breath to see if this can actually

10:01:05 PM    

Monday, May 31, 2004



A Study Questions Blood-Test Results on Prostate Cancer.
Significant numbers of older men whose results on a popular screening
test for prostate cancer are normal may nonetheless have cancer. By Gina
Kolata. [New York Times: Health]

While I appreciate this long-overdue, reasonable look at the
dilemma of screening for prostate cancer, I do wish that Ms. Kolata
would have found some rabid PSA screening advocate to respond to some of
this information.  This new information makes things MORE unsure about
the utility of the test, which is what many, especially in the
evidence-based family practice community, have been saying all along…I
look forward to all the reaction.

7:49:47 PM    

Monday, May 17, 2004



Dr. Andrew Weil spoke at
STFM yesterday.  It’s hard to disagree with what he says regarding our
distance from nature and the natural healing process.  His re-framing
of, for instance, the role of antibiotics in infections is this: instead
of antibiotics curing the infection, antibiotics simply reduce the
overwhelming numbers of bacteria so that the body can heal itself.  We
all know this principle – we use it in cancer therapy when we do
“debulking” surgeries to get rid of some of the tumor mass prior to
chemotherapy or radiation.  But what would happen as if we acted like we
believe this principle?’

Dr E.: Ms. J, your cholesterol is too high, which is a risk factor for heart disease…we need to do something about that.

Ms. J: What should I do?

Dr. E. (version A): Here’s a prescription for Lipitor 20 mg.  Take it
every day, and come back in six weeks, so that we can make sure it’s
not injuring your liver or muscles, and we’ll drive up the dose as high
as it takes, addiing another potentially toxic medication if that
doesn’t work.

Dr. E. (version B): Well, you should eat the appropriate foods, get
down to an acceptable weight, and get daily exercise, and your body will
take care of most of the problem.  If it can’t, we can help it along
with a low dose of one of these liver poisons, that has been found to
help in those refractory cases.

Oh wait…we’re supposed to be doing version B anyway, aren’t we…so says the NHLBI
But, often my impression is that sometimes we lose the healthy
lifestyle perspective, and just give the drug in a relentless
single-minded effort to attack that single number (LDL), almost mindless
of the whole patient.

Dr. Weil also makes the point that “integrative medicine” is not
“complementary/alternative medicine”, but includes nutrition,
traditional medicine, holism and CAM.  This perspective may help us
remain a little more open minded about his ideas.

6:17:40 AM    

Saturday, May 15, 2004



Alternative Medicine Outside the Ivory Towers.
The formation of CAM departments has legitimatized “alternative
medicine.” Are the universities now benefiting monetarily from the
promotion of CAM as well?
Medscape General Medicine™ [Medscape PublicHealth Headlines]

This editorial has some good points, I suppose, but they’re lost
in the bluster.  Note that in the specialties he lists as falling prey
to the “chicanery,” gastroenterology is nowhere to be found…

Germane to the issue, however, is the question of “how far out of
our bounds of allopathy can we promote things before we lose the
theoretical underpinnings of our specialty?”  How many people can even
define allopathy (as distinct from homeopathy, naturopathy, osteopathy,
etc.)?  I went to Google for some interesting results…the first of which was this thesis…especially
the part about “administration of highly toxic drugs.”  But more
importantly, allopathy has come to mean different things depending on
which side of the debate you’re on…We (M.D.s and ?osteopaths to some
extent) define it as, essentially, medicine that can be proven to
work…Homeopaths, naturopaths, etc. use the original derivation (from
“opposite”) to set us apart from their more holistic view.  The whole
thing makes me dizzy.

For now, the theoretical underpinnings of family practice –
patient-centered evidence-based care of a bunch of families (my
swiss-cheese definition) – seems enough to give me direction…if it’s
been shown to work, I shouldn’t have a lot of heartburn recommending

7:17:23 PM    

Friday, May 14, 2004



Well, I just got all energized to start weblogging again
after “helping” with Jacob Reider’s talk at STFM on weblogging.  Great
stuff – discussed TypePad (a Radio competitor, so sshh…), FeedDemon, and BlogLet.

Also reminded me of a great list of medical weblogs, MedLogs.

Fun!  Hopefully the fun will inspire me to keep this more regularly….

3:54:43 PM    

Monday, January 05, 2004



The nitty-gritty of marking. Ken Tompkins on North by Northwest explains his
still evolving process for digitally responding to student
writing. It’s a realistic picture, including the frustrations that all
teachers can expect to encounter. “What started out as a way to
eliminate physical papers, to use the speed and ease of the web and to
take advantage of the technology they all have access to has become a
nightmare.” [ebnWL News]

I too have tried to have students email me their write-ups from
the first year clinical diagnosis course I teach.  Fearing the
incompatibilities and difficulty associated with using MS Word and the
“Track Changes” function (which I think is very useful when used
appropriately), I just printed out whatever came to me.  I figured that
I’d at least have a digital and paper record of everything sent to me
(since I’m not very good at logging in assignments).  Even this simple
task was apparently too much – the formats!  the incompatibilities!  the
vast amounts of meaningless gobbledy-gook included in emails because my
email program couldn’t figure out the difference between an attachment
and a really long, comic page swear word.

One day, we’ll agree on a common standard…if only for
individual interpreters that will take whatever’s sent to us and deliver
it in the way WE like it…

10:08:00 PM    

Thursday, January 01, 2004




Humor in Medicine. Humor in medicine is not a specialty in the traditional sense.
Southern Medical Journal [Medscape PublicHealth Headlines]

This is a fun article…a pseudo-scientific/review article about
“types of humor” in medicine.  The “gallows” humor discussion is
particularly appropriate…several times I have tried to tell “funny”
stories about work to people who are not in medicine – it just doesn’t
come across well, especially if the humor is of the “gallows” sort…

5:28:59 PM    

U.S. to Prohibit Supplement Tied to Health Risks.
Ephedra, the herbal supplement that has been linked to heart attack,
stroke and sudden death, will be banned, Bush administration officials
said on Tuesday. [New York Times: Health]

This one got me thinking…again…about the balance between personal
responsibility and need for legislation.  This case is different than
seat belts – people in this country need cars to get around – so you could argue that the effect of this legislation would be to make those cars safer.  But no one needs
to go to the local GNC and buy a dangerous supplement – should we just
publicize the risk and let it go at that?  It’s worked with smoking,
hasn’t it?  Well, maybe that’s a bad example…though there has been a
change in smoking rates with publicity…I often vacillate between
social darwinism and population-based idealism on issues like these.

Happy New Year!

5:03:20 PM    

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John Epling
Last update:
9/30/2004; 10:01:29 PM