This morning (broke my rule about Sunday morning reading, Doh!) I read his latest post, Medical Experts and the American People. This is one time when I think he got it wrong. In the article Dr. Reece basically chastises evidence based medicine (EBM). “I say “presumably” because many patients or doctors do not necessarily buy the experts’ advice [i.e. evidence based recommendations] or follow instructions.” Uh-oh.

He continues the rant by quoting from March 31 Wall Street Journal article “The Rise of Medical Expertocracy”

“For patients and experts alike, there is a subjective core to every medical decision. The truth is that, despite many advances, much of medicine still exists in a gray zone where there is not one right answer. No one can say with certainty who will benefit by taking a certain drug and who will not. Nor can we say with certainty what impact a medical condition will have on someone’s life or how they might experience a treatment’s side effects. The path to maintaining or regaining health is not the same for everyone; our preferences really do matter.”

Dr. Reece finishes by saying “I agree with these observations and conclusions. In the end, there is usually no single right answer to treating an individual, and patients, in conjunction with their doctors, have the right to choose what to do. Despite the rise of medical experts, armed with vast accumulations of data, there still exists no single answer to most medical problems.” 

A couple of comments about this. First and foremost I agree that patients, in conjunction with their physician, have the right to choose their course. But that doesn’t preclude the use of EBM. Second, EBM doesn’t mean letting someone else make a decision for you. It is designed to present you with the latest evidence to give you the information you need to make the best decision possible. Would you really want to do something that has been shown to be detrimental, or miss out on something just because you were too stubborn to look at EBM? If you said yes, it’s an injustice to your patient.

Sometimes there is a single best answer to a medical problem and that’s where EBM shines. I have to laugh when a physician screams that they don’t need EBM telling them what to do and that every single patient is different, only to turn around and write for the exact same medications for the same problems over and over again. How is that different? Did they treat every patient differently? I don’t know. If you use HCTZ for every patient you have with primary HTN, you haven’t exactly gone out of your way to individualize them now have you.

When I used to works nights as a pharmacist in the hospital I could tell you exactly what type of admissions I was going to see and what my technician and I would be doing based on which physicians were in the ED. Prior to starting my shift I’d wander down to the ED and see who was working. That gave me a mental head start for what my night was going to be like. I knew before I started work what medications I’d need on hand, what type of IV load I was going to have, whether or not I’d need to do a lot of vancomycin or gentamycin kinetics, and so on. Why? Because they treated every patient that walked in the door exactly the same way, that’s why. There was no “every patient is different approach”.

Would you want your physician deciding what TB meds to use on you if you had a newly diagnosed case of active TB instead of following the most recent guidelines? You’re a fool if you do. That’s a good way to develop a nice case of multi-drug resistant TB that could make your life miserable down the road.

Ever see a post-op CABG order set? Yeah, those are developed based on EBM and contain about 30 different medications. Any physician that says they’d rather write one of those by hand based on their own ‘opinion’ after consulting with their patient is a liar.

Would you want your physician to think about what to do with you if you were dragged into an ED with sepsis? Heck no. I’d want them start fluids and throw a host of antibiotics at me. Which antibiotics? I’m glad you asked. There are guidelines with laundry lists of recommended antibiotics. They’re based on worst case scenarios and the belief that you’d rather err on the side of overly aggressive than not aggressive enough. Do you know why? Because studies have shown that you need to start fluids and antibiotics ASAP or your chances of survival goes down. Crud, start them in the ambulance if you’ve got me back there. No need to wait for the physician to mull it over with me.

Any pharmacist in the audience know how to treat a 65 year old patient admitted to the hospital with community acquire pneumonia? Of course you do. There are some great guidelines out there put together by the IDSA or other well respected professional organization. And I will guarantee you that those are the exact same guidelines followed by thousands of physicians in the U.S. Does it make them any less of a physician because they peeked at the guidelines for treatment recommendations? Uh, no.

The bottom line is this, EBM is not designed to take your control away. It’s there to make you a better practitioner. Does every patient require the same approach? Probably not, but to believe that every patient is so different that each and every one of them requires a new, unique set of treatment options is preposterous.

During my career I’ve probably interacted with more than a hundred physicians; some good, some bad. With that said, the ones that are the hardest to work with and make things hardest on the pharmacists and nurses are the ones that believe their opinion outweighs the years of research and study done by those before them.

I want a physician that not only has an opinion and years of experience, but one that doesn’t ignore EBM because their ego won’t allow it. We should all have opinions about things, and we should all strive to change practice if we think something is better, but we should not ignore best practice simply for the sake of railing against the system.

Grrr! I knew it. Something totally ridiculous, misleading and meaningless. What was I thinking? Why do I torture myself this way? One can only speculate.

The link led me to the following article: Heart Attack Survivor Says An iPad Helped Save His Life 

“…he remembered having his iPad in his bag. The tablet was a tool he had just gotten and was just beginning to use in his practice of medicine.

In seconds, he brought up the Mayo Clinic’s application to access patient electronic medical records so as to look at McMonigle’s EKG from his past heart scare. The doctors compared it to the new heart rhythms, which confirmed their suspicions that McMonigle was having an acute heart attack.“

I wasn’t surprised, but was certainly disappointed. Based on the stream of Tweets and title of the article I thought for sure the iPad grew legs and pulled the man from a fire. Alas, that wasn’t the case at all. Do I really need to mention that the man had the clinical acumen to diagnose his own heart attack, or that he was standing in a room full of physicians? The iPad had nearly nothing to do with saving the mans life. Why not credit the highly trained healthcare professionals for acting quickly, or the healthcare system that had the foresight to build an EHR that lends itself to mobile access, or the millions of dollars worth of advanced healthcare technology that, oh I don’t know, was used to actually save the man’s life. Sheez.

Here’s an equivalent article for you: Heart Attack Survivor Says BlueTooth Mouse Helped Save His Life 

“…he remembered having his BlueTooth Mouse in his bag. The mouse was a tool he had just gotten and was just beginning to use in his practice of medicine. 

In seconds, he brought up the Mayo Clinic’s application to access patient electronic medical records so as to look at McMonigle’s EKG from his past heart scare. The doctors compared it to the new heart rhythms, which confirmed their suspicions that McMonigle was having an acute heart attack.“

Sounds ridiculous, right? It’s. The. Same. Concept. This is what happens when you get a bunch of people together to write a story armed with IQ’s no bigger than the temperature on a hot summer day in the Central Valley of California. This type of hype irritates me more than you can imagine. Focusing on some small piece of consumer technology – whether Apple, Android or Windows – in a story like this goes off the must-have-been-a-slow-news-day o’meter. And people eat it up.

News worthy would have been if the guy pulled an augmented reality device from his bag, injected a few nanobots into the guy and cleared the blockage and repaired the vessel on the spot. That’s technology worth writing about.

That’s it, no more early Sunday morning reading for me. I’m sleeping in.

Update: Looks like they got it working within 5 minutes of me posting this. It’s a nice format. Check it out for yourself here.

My mother has been doing well since here liver transplant earlier this year, but was recently admitted to a local emergency department with some complications. She was immediately transferred to UCSF where her liver transplant team is. I received the call telling me as much late Thursday night. I couldn’t get any information Thursday night and her life was not in danger so I waited until Friday morning to try to get more details on the situation.

I tried calling my mom’s room directly on Friday morning, but no one answered so I called the nurses station and was told I couldn’t speak with her nurse because they don’t take phone calls between 8:00 – 10:00am. I understand that. It’s prime time for medication distribution on the units and they try to minimize interruptions to prevent medication errors. I get it. Makes sense. However, all I needed to know was what was going on, what they’re doing and what I need to do on my end. I didn’t need her nurse to provide me with the information I needed. They ever so politely told me to call back after 10:00am. Needless to say I was irritated.

Fast forward to 10:00am. I got ahold of the nurse only to be told that she couldn’t tell me anything secondary to patient privacy. Hey, I get it, but I am her son and my name is all over her chart, her durable power of attorney, her medical records, her super secret list of people in the know, etc. Heck, I even set up the password for family members to get updates on her condition when she was there for her transplant. The nurse wouldn’t budge.

My mood went from irritated to pissed. I wanted to reach through the phone and slap the nurse upside the head. I’m several hours away, my mom is in the hospital and I can’t find out what’s going on. After handing up I redialed my mom’s room and eventually reached her. She was tired, in quite a bit of pain and loopy from the meds; not the right person to be giving me information over the phone. While my mom is an intelligent woman she’s not the one that should be answering my questions and being interrogated about tests and procedures. Fortunately she was doing better, but ia am still unclear about the nature of the problem.

According to the UCSF Medical Center website they “define quality as”:

• Superior care and outcomes
• Outstanding patient safety
• Excellent service and patient satisfaction

I think they nailed the first two things on their list, but failed miserably with the third. This is one time when doing the right thing took a backseat to meeting regulatory compliance. In other words, the patient wasn’t the primary focus of the care, the rules were.

And before you privacy and safety nuts start foaming at the mouth consider this: I am the primary decision maker for my mom’s medical care for the past several years; her medical records say as much, at no point did I ask them to risk her safety and all they had to do was check their records to know that they can tell me anything.

I’ve given UCSF the benefit of the doubt many times because I love the university and the medical center, but not this time. This time they get an epic fail.

Anyway, the ISMP alert shared several examples of oral overdoses with Lugol’s solution secondary to confusion between drops and mL’s. However, mixed in with all the “typical” errors, was the little gem below. Even though the error is more than a decade old, I can’t help but wonder “what the heck were they thinking!”. By the way, my initial read through had me thinking cursive “OS” (oculus sinister, i.e. LEFT eye). With that said, I wouldn’t have actually dispensed it because nothing else on the prescription fits.

One of the errors reported more than a decade ago involved an order to administer 10 drops of Lugol’s solution mixed with "OJ" (orange juice), but nurses misinterpreted "OJ" as OD (right eye). The patient received several doses of Lugol’s solution in his right eye. The error was identified when the patient complained to the physician about how painful the eye drops were.

I have enjoyed compounding throughout various stages of my career. One of the best jobs I ever had was as a compounding pharmacist at a small community pharmacy in San Jose, California. The job was challenging, fun and centered on patient care. For many years I dreamed of having my own compounding pharmacy, but I was never able to make it a reality for numerous reasons. And because of this I was disheartened to read a recent editorial by Dr. Loyd V. Allen, Jr. writing about the lack of compounding content at the recent ASHP Midyear in New Orleans.

In the editorial Dr. Allen writes:

Having just returned from the 2011 ASHP Clinical Midyear Meeting in New Orleans, promoted as the largest gathering of pharmacists in the world, one wonders what the programming committee considers as important topics.

In a year where the number of drugs in short supply exceeds 250, and profiteering rampant among those greedy companies that can purchase and then resell at up to 4000% profit, one wonders why there was no dedicated programming on compounding of drugs in short supply or criteria involved in selecting a compounding pharmacy for outsourcing, both nonsterile and sterile.

Actually, there appeared to be only about 3 posters related to compounding and only one podium presentation. There were untold numbers of sessions on therapeutics, automation, administration and other topics that are covered in detail every year.

With hospitals implementing USP <797> and many actually outsourcing compounding to those pharmacies that can service them, one wonders what is the reason for the lack of programming related to pharmacy compounding. Is it that many pharmacists have not been trained in compounding and realize its importance? Or, they are so busy with distributive, administrative and clinical duties they don’t have time to worry about the drugs that are required for their patients? After all, without the drugs, there is not much need for pharmacists. Or, is it that many consider the highly technical and scientifically based compounding practice can be done by technicians; some of which are good but they do not have the background necessary for formulation, quality assurance, etc. And none have the knowledge base or the responsibility of final approval that a pharmacist has.

It was a very disappointing meeting from the standpoint of educational sessions. There were a significant number of compounding support companies in the exhibit hall and their presence was quite significant. However, to me it seems that there is a disconnect between ASHP programming and the critical needs of patients for their pharmaceuticals.

The profession, she’s a changin’.

The data were on the physician’s external hard drive, officials said. Though the hard drive was encrypted, a piece of paper with the password was nearby and is also missing. The physician notified UCLA the next day and officials began identifying patients affected.”

I am continuously amazed at the number of security breaches involving patient healthcare information caused by careless use of portable storage media like external hard drives, flash drives, and even laptop hard drives. Patient information should never be stored or transported this way. I believe that utilizing cloud computing with simple browser access is a much better solution. 

What makes this particular incident so bad is the cause; reckless behavior by a physician. This wasn’t UCLA’s fault, per se. Sure, the medical center must accept a share of the responsibility, the lion’s share of the blame falls in the lap of the physician. Not only did the physician have sensitive patient information on an external hard drive, but was dumb enough to have the password to access the drive on a piece of paper next to it. Kind of defeats the purpose of encryption and passwords, doesn’t it.

For an eye-opening look at the magnitude of data loss and security breaches drop by DataLossDB.org sometime. It’s scary stuff.

Many of my followers were kind enough to tell me I’d been hacked prior to unfollowing me. And of course Twitter followed suite several hours later by sending me an email letting me know they’d reset my password and encouraging me to check my settings for suspicious third party apps. It didn’t really matter by then as I had already changed my password a couple of times. The damage had already been done.

I don’t typically believe in violence to resolve a problem, but this is one of those rare occasions where I think violence is the perfect answer. Just me, a locked room with the person who created the hack inside, a blowtorch, some sharp objects and a long rope with a noose at the end. Sounds fair to me.

There are several definitions for the word opinion. The one I like comes from Merriam-Webster and reads “belief stronger than impression and less strong than positive knowledge”. Opinions are beliefs; something you think. They are not rooted in fact – although facts can play a roll in forming an opinion – nor are they required to be acknowledged by anyone other than the one giving the opinion. You have your opinion and I have mine. What if they’re different? No matter because they’re opinions.

Where we get ourselves in trouble is when we start thinking of one’s opinion as fact, or something close enough to fact that is must be acted upon. I frequently see this when someone with “expert” stamped on the end of their name says something like “you should …” or “why don’t you …”. Instead of evaluating statements like these and thinking them through many people will simply accept  them as fact and act on them. This is a bad thing. Why? Because everyone has an opinion and they don’t often line up with each other. This is especially true in healthcare; pharmacy in particular.

We have a habit of taking an idea, passing it around the table, collecting opinions and making every attempt to act on them all. I see this a lot with automation and technology. Hey, I’m all about functionality, but not at the expense of common sense. When you try to incorporate everyone’s opinion into a product you get the object to the right. I’m sure someone thought this was a good idea; someone must have requested all that functionality, right? Sure. It’s the most functional piece of utility equipment in the history of mankind, but practical it is not. Try putting it in your pocket. This is what many pieces of pharmacy automation and technology turn into once everyone’s opinion is taken into account.

This goes doubly when people start suggesting that something needs to be added secondary to safety; “that should be added because it’s a safety issue”. Ah, the battle cry of those that know their opinion can’t stand up to close scrutiny. I get this one all the time. I suppose walking around in a suite of chainmail armor and driving 25MPH on the freeway would be safer than the way we do things now, but I just don’t see that happening anytime soon. It’s just not practical. And at the most basic level we give up the marginal difference in safety for the efficiency and practicality of wearing jeans and t-shirts while driving 70MPH. It’s a matter of compromise between form, function and usability combined with taking a little responsibility for our actions.

You simply can’t replace human responsibility and accountability with automation and technology. We need people to be responsible for their actions. It’s the only thing that keeps us honest. Without it everyone’s life will be like Phil Connor’s (Bill Murray) in Groundhog Day before he figured it all out.

Ask a nurse how much time they spend documenting and double documenting things to meet some arbitrary rule or regulation. You’ll be surprised by the answer. Now ask a pharmacist or a physician. You’ll get the same ugly responses. I know a lot of my time as a clinician was spent generating documentation to cover my ass rather than helping care for a patient.

Unfortunately the need to comply with government agencies and silly rules inside the walls of healthcare has generated an unwanted side effect – lack of innovation. Why? Because all that innovative energy is spent on regulatory compliance instead of other, more useful things.

I’ve been involved in several conversations over the last month dealing with how to best use pharmacy automation and technology to increase efficiency and solve problems. Would you like to venture a guess as to what most of those conversations centered on? Yep, how to automate some documentation process or create technology to meet some new regulatory compliance. None of the discussions have been about providing better, safer, more complete patient care.

If you don’t think this is a major problem, think again. I was reading a blog by John Halamka last night in which he discusses the ‘Burden of Compliance’. In the blog John states that “[a]s we draft new regulations that impact healthcare IT organizations, we need to keep in mind that every regulation has a cost in dollars, time, and complexity.” Just remember, there is a finite amount of dollars and time floating around in healthcare these days. If a majority of those dollars and time are gobbled up by regulatory compliance, what does that leave for innovation to actually improve medication distribution, safe administration and better patient care? Precious little if you ask me.