The Pitfalls of Wireless Medicine?

Recently I was at a residency interview where I was asked where I see myself in years from now. I love this question, and a lot of what I spoke of was this new horizon we are seeing with the way medicine is being made more portable or accessible for remote or under served areas. One of the criticisms I received on this topic had to do with how a doctor is only paid for so much of their time and then spends extra unpaid hours doing paperwork. I just nodded consideration, but I didn't understand. The premise of this new digital age of medicine is focused on reducing costs: of course with any new diagnostic or care modality you need to find new ways to secure information but that only creates more jobs while at the same time making the system more amenable to cost cutting and efficiency. Eric Topol is my hero and was heralded as a rockstar of science by GQ magazine- needless to say, the man is "full of win". He's like the Jean Luc Picard of Medicine. And just so that we are all on the same wavelength here, my true feelings about Eric Topol:

+

= awsome

I have links posted on the side to Scripps, etc., and you can read up on him more if you wish on your own. But now to turn to where my interviewer precieved the pitfalls of these new advancements. One of the more fantastic things about this technology is that it can help to eliminate those thousands of dollar per day hospital stays. With remote mointoring and interpretation of data by techs who then send the information to doctors by fax or smart phone- that new "burden" falls on doctors themselves w.r.t charting, and billing for instance. And as she put it, you may only spend 6 hours seeing patients but you'll still have 3 hours of paper work to do afterward. C'est la vie. You can't have the cairrage without the horse to pull it. Of course as the medicine evolves I hope that the renumeration does too but as it stands now, the latter has a lot of catching up to do with the former not to mention security of information concerns.

I'd like to end with an exerpt from an article in The Economist in 2009 talking about health information technology in the form of EHRs and medical software that has vast data gathering potential:

"...Buying a lot of expensive computers is not the answer. As Harvard’s Dr Halamka puts it, “just automating a broken process doesn’t accomplish much.” Indeed, the boffins at the Institute of Medicine reckon that spending on digitisation without connecting it to the organisational culture risks making things worse. Any new HIT systems, they say, must include “cognitive support” that helps doctors and patients make sense of the deluge of medical data that will come their way...One way to do this is to devise software systems that mine data on large numbers of patients with similar illnesses and provide guidance to doctors in real time..."

Here's the link for The Economist: http://www.economist.com/node/13437966
Eric speaking at a convention on consumer electronics:
http://www.westwirelesshealth.org/latest-news/videos-ces-2010.html

The approach to the Thyroid Nodule.

While studying today, my study partner and I came a cross a descrepancy between MTB, UW, Absite Comprehensive Review and Conrad Fischer's disease deck. 2/4 sources say  to do an FNA first while the other 2/4 say to do thyroid panel first. Confounding. Arguemtns for both:

1. MTB and Absite Review: FNA first because it is the most accurate diagnostic modality
2. UW and Disease Deck: thyroid panel first to determine if the nodule is or is not functional and US  to rule out cystic lesion; then do FNA "of all solid lesions that are non-functional and cysts with pathologic features on US".
And here's a confounder for ya: MTB and Disease Deck were written by the same author. Go figure! Looks like this needs a journal review. So, look forward to an addendum.

Addendum:
So, with a solitary thyroid nodule, you want to rule out cancer. Steps to take:
1. biochemical assesment --> TSH, T3/T4: would you do a scintigraphy?
2. thyroid US --> characteristics that would suggest malignancy
*3. FNA: the most important

The article I looked at [link below] went on to say that an FNA must also be done. You can argue about the bearings of the findings on US [findings which are subjective, they are subject to the skill level of the US technician or what have you]: as methods improve the sensitivity and specificity of the test increases, however utility as a guide for biopsy outweighs its value as a sole diagnostic technique. The only way to definitively diagnose a malignancy is by doing the FNA and looking for the cells implicating malignancy.

So why bother doing a thyroid US? Ultra sound can be used to guide the FNA and has been found in some situations to be better guide than palpation. But for the purposes of diagnoses alone it, in my opinion doesn't seem diagnostic. The findings of the FNA are what will determine management as was addressed in the article.

The other item was the scintigraphy; at what point in patient management does one get carried out? Although this imaging is usually not done anymore, it can determine if a nodule is hot, cold or warm. Hot tends to rarely be malignant while a small percentage of cold and warm have that propensity. The third link I have listed talks about the re-emergence of this modality with mangement for multi-nodular goiter as opposed to solitary.

My second source sheds more light on when to do what. It's the "Endocrinology Board Review Manual"- from the horse's mouth. Here is a screen shot of the item- again, the source is the second link: click on image to enlarge.

http://www.ncbi.nlm.nih.gov/pubmed/18305054

http://www.turner-white.com/pdf/brm_Endo_V6P6.pdf
http://www.ncbi.nlm.nih.gov/pubmed/18847633

Compassionate Analysis

Medicine is not stagnant. It is changing and evolving. So too are the systems with which we provide delivery of care. The purpose for this blog was to elaborate on themes that underly my interests in Medicine and it's evolution, as well as cover some interesting topics that I may come across like quality improvement initiatives in health care delivery. Why did I choose to call it "compassionate analysis"? To me, that is what medicine is: combining a compassionate profession with an analytical foundation. More so, it is a life-long journey of learning, and hense why this profession is known as a practice.