What is normal sleep?

As posted on before, it is quite likely that the expectation of 8 hours of uninterrupted sleep was not biologically or historically normal until the industrial revolution imposed it artificially.

This discussion in the BBC's website (h/t Boing Boing) describes further how historical writings, diaries and anthropological study demonstrate that people normally slept in separate four hour blocks often with a few hours of activity in between alone or with others.

I must admit that it makes me wonder about the extent to which industrialization has been all progress!

Misdiagnosis

A contributor to Kevin, M.D. has an interesting post, which also comments on the writings of Dr. Jerome Groopman who has published on the patterns of physician errors in decision-making. I posted on Dr. Groopman's book before, and highly recommend it.

Overall, I agree that correct diagnosis or identification of medical problems is an art as well as a profession. Additionally, I do see that things that can make this more difficult than it already is include inadequate communication and over-reliance on technology.

On the other hand, most of this knowledge should be imparted in medical school and residency training. A great deal of medical education includes learning what lab and imaging studies can do, and what they also cannot do.

I am happy that my teachers imparted several valuable lessons for which I remain grateful and have helped me a great deal:

• "Let the patient talk for at least the first several minutes without interruption." (No one likes to be interrupted, and you'll learn more about what you want to know.)
• "90% of arriving at the correct diagnosis is based on adequate history-taking. Examination and tests rule-out or confirm your impressions." (This is the time-consuming asking of the right questions and paying attention to the answers. This is never wasted time.)
  
• "Ask whether the patient has any questions." (It's polite, and also helps to make sure everyone involved is "on the same page.")
• "Ask the patient what they think is going on: at least half the time they'll be right and save you a lot of trouble." (Yep, pretty much!)
  

For My Military Patients: On Imminent Danger Pay

As one of the very few local docs who sees active duty and military personnel and families, I have gotten some recent concerns or comments about changes in imminent danger pay.

This posting from Kit Up seems to address this nicely, and also provides a useful link and commentary.

(Credit: the graphic is the logo for Danger Close games.)

Interesting Reads

An interesting piece on the evolution of Japanese takes on Western cuisine and apparel. (Wall Street Journal)

The Surgeon General offers a way to create a family medical history; your taxpayer dollars at work! (Health and Human Services, h/t Kevin, M.D.)

Really cool interactive graphic comparing the size and scale of things from quantum foam to the observable universe! Who knew the Grand Canyon is bigger than Rhode Island? 4Chan, h/t Boing Boing. Requires Java)

Just for a hoot, calculate how long it would take for Mitt Romney to make your annual salary. (Slate, scripting required)

Treating Common Warts With Duct Tape

Common skin warts are actually caused by a virus. Your immune system will eventually get rid of the virus and allow your skin to return to normal. The catch is that this can take about a year!

If you don't want to wait that long, there are a number of ways to get rid of them. Freezing them with liquid nitrogen or surgically removing them can be done by me in my office. (Unfortunately, that freezing spray that you can buy over the counter is just not cold enough to get rid of warts, and the acid treatment often fails and is kind of painful.) Aldara (generically known as imiquod) is a prescription cream that can work, and does not sting or burn. However, it is very expensive and not covered by most health insurances.

As an intriguing alternative, duct tape may work (this link is for a technical audience and may require free registration) in getting rid of warts. Yes, duct tape: 101 uses, now 102!

There are only three clinical studies on this, though that's kind of interesting since you could imagine there would be none. The effectiveness is not 100%, but it also doesn't seem to be harmful either. The idea is that covering warts with duct tape causes localized inflammation and irritation, which in turn stimulates an immune system response that helps in getting rid of the warts. This is supposed to be how freezing warts works, too.

The treatment with duct tape in clinical studies is:

1. Cover the wart with a piece of duct tape for seven straight days.
2. Then, remove the tape for 12 hours overnight.
3. Repeat Steps 1 and 2 as needed for up to 6-8 weeks.

Again, there are no wart treatments that are 100% effective. However, this method can be helpful and seems otherwise to have no harmful side-effects unless you are simply allergic to duct tape.

Interesting Reads

Warren Buffet on the risks of bonds assets (ditto from Black Rock): (Bloomberg).

Interesting analysis of the Obama presidency to date,through the lens of the history of modern U.S. Presidents: (Atlantic).

Yves Smith on why the bank bailout sucks: (Naked Capitalism).

Matt Taibbi says "cry me a river" to Wall Street bankers: (Rolling Stone. profanity alert- it's Taibbi)

Could You Pass a U.S. Citizenship Test?

Just for hoots, try passing this 96 question citizenship exam found posted in that hotbed of communist sympathy the Christian Science Monitor.

All applicants for citizenship must pass a Naturalization Test, scoring at least 60% correct. 92% of applicants do so. Have a go at it!

Why Don't You Use a Computer?

I get asked every now and again by patients (usually while I'm writing in their chart) whether I plan to go to a computerized medical record.

I find that to be a really interesting question. Generally, I am a very enthusiastic computer user. I create web content, enjoy computer games, am versed in maintaining and securing wireless networks, and am proficient with several operating systems.

However, I have no plans to adopt "Electronic Medical Records" (EMR) unless they become far more useful than they are at present.

First of all, adopting EMR is shockingly expensive. Start up cost of adding new hardware, licensing software, training staff and doctors in their use and scanning existing paper records to EMR is about $50,000 in itself. This does not include future licensing or upgrades to equipment or software. It also does not include the 10-20% losses in income of the first 1-2 years of adoption due to a decrease in the number of patients that can be seen, as the implementation of EMR slows everything for 1-2 years.

Additionally, there is no widely accepted standard code set or open-source code for EMR. This means it is very easy to sink this kind of time and money into EMR for your office or group or hospital and be absolutely unable to use it to share crucial medical information with neighboring physicians simply because they using one of the other 10-20 most popular EMR platforms being marketed.

It should also be realized that EMR is not new, and has been around for a decade or two. It's intended primary use has never been to enhance the quality or consistency of medical care. Rather, it has been marketed as a way to fully document your visits in such a way as to justify your billing to insurance companies.

Unfortunately, EMR has not been fully re-vamped to optimize patient care and reduction of errors. Instead, features have simply been layered over and added on to the pre-existing systems. As a consequence, studies demonstrate that EMR does not result in improved care and actually results in increased error rates.

All of this may explain why the majority of doctors have not adopted EMR. A regular contributor to Kevin, M.D. nicely sums this up. You might not notice this here in Placerville, since Marshall has implemented an EMR system recently which can make it look like everyone now uses EMR.

I find it interesting that when I answer patient questions by saying that I don't plan to computerize my office the response is usually positive.

Most patients have commented that they find the use of a computer by doctors, nurses and physical therapists to be off-putting insofar as it limits conversation and eye-contact, and seems to take up time that would otherwise be spent examining or communicating with patients. I suspect they have a point here.

I'm sure it's possible to use EMR and not lose this human touch, but the current systems just aren't there yet and aren't likely to be there soon. I myself would rather not risk losing this element of human touch and communication with my patients.