Great site for doctors

For a couple of hundred dollars a year you get Rick and Jerry discussing 40 abstracts each month to do with primary care or emergency medicine, Rick is front line doc and Jerry an academic doc who works in an emergency department as well as being a critical appraiser. As likable as Rick is I get these abstracts to hear Jerry. We need many more docs like Jerry. He does the statistical and methodological stuff. Sounds great but is it?

Here they talk about blood pressure pills

Here they talk about aggressive treatment of CVD in the elderly

Jerry should write a book for us front line docs - please Jerry

If placing these audios from this great site upsets the guys and or gals who own it please let me know and I'll take them down. I have put them here hoping more docs will listen to Rick and Jerry.

What do I want more information on at the moment?

Long acting beta agonists - there is a major push going on with regards these. NMow we are supposed to be using one of them in a similar way to ventolin.

It's getting scary.

Medical research is largely or more and more being funded by drug companies - DCs.
The universities and their professors are becoming largely dependent upon DCs.
So are medical journals.
DCs are not primarily interested in the potential for harm.
They have been known to with hold information.
DCs have no interest in unprofitable treatments.
They have a duty to their shareholders not to patients.
They do what's expected of them.
Their influence is everywhere.
They need new drugs which can be patented.
Lifestyle drugs is the name of the game.
It's in their interest to have as many people as possible taking pills.
They have done great things for us but they should not control research to the extent that they do.


Guidelines are becoming a standard to judge performance and determine pay.
More and more of our top medical scientist are being helped financially by the DCs.
Too many sit on guideline committees while being paid by DCs whose products are under consideration.
Too many of our guideline producers have career conflicts of interest too.
Too many do not see these conflicts of interest as a problem.
Their mistakes and prejudices are becoming enforced on the workforce under the guise of evidence based medicine.
Tops scientists for instance should not be the ones to decide on the validity of research in their field of interest. Do the research have others crunch the numbers.
We need independent critical appraisers arguing the pros and cons of research.
Anyone being paid by a drug company should be excluded from having any a seat on anyy guidelines committee.

Evidence based medicine is a great boon and a potential trap
What is true today may not be tomorrow.
Findings may be plain wrong.
Things can be fudged.
DOEMs become more important than POEMs (disease as opposed to patient orientated evidence)
(what matters is not your cholesterol level for instance but where you have an MI stroke etc or not)
Statistical tricks can be played.
Very few doctors have the ability to sort wheat from chaff.
Critical appraisers with no conflicts of interest are a rare breed.
Once something becomes a truth it's very hard to change

Doctors are losing power to the politicians and managers.
Their livelihoods more and more dependent upon, not patients, but those that pay them and control their right to practice.
Controllers love guidelines - so would I if I was one - they simplify.
It's not their job to determine whether guideline are the truth or not.
Doing so would complicate their lives.
They tell us guidelines are only guidelines yet demand explanation if one steps out of line.
The professional and government bodies are part of this system too. They too use guidelines.
Doctors are controlled beings. If not they will be.
They are becoming less and less able to act out of their own knowledge or even the knowledge of experts that disagree with guidelines.
They are destined to become obedient souls - soldiers - unless things change.

Doctoring is becoming more and more a business rather than a profession. The yard stick - when your doctor is with you are they putting your interest before their own? Are they interested in you or more interested in their computer's requests - thats' where the money is? Ask them what's the evidence? Whats the countering evidence? What's the number needed to treat and harm? Who funded the research? Does he or she know the interaction of all those drugs she or he is offering? If you ask me, you'd get a lot of don't knows! Are you prepared for the discomfort of there being no certainty - only possibilities and probabilities

It's getting scary out there. Not too bad just yet maybe but the future looks grim to me.

Here's some of my stuff on these issues

Tight control of sugar levels in type 2 diabetes. Take a look at this for an example of differences in interpretation of evidence. As good as no benefit over less tight control

Things are not black and white. The more one knows the more Grey they become. Managers and controllers can not handle grey. Individual doctors and patients can but that's too anarchistic for the piper payers. The two people that matter in the moment are being taken bit by bit out of the game. But even for the doctors and their patients the whole business is too time consuming - better just to rely on those guidelines. Mostly they are pretty good but ......

Paranoid - yup.

A pile of guidelines from NZGG

NZGG


Population Screening for Colorectal Cancer


Prostate Cancer Screening in New Zealand


A Guideline for the Management of Heart Failure: health professionals guide


Assessment and Management of Cardiovascular Risk


New Zealand Cardiovascular Guidelines Handbook: Developed for Primary Care Practitioners


The Management of People with Atrial Fibrillation and Flutter


Management of Type 2 Diabetes



Guidelines for the Management of Heavy Menstrual Bleeding


Management of Dyspepsia and Heartburn


Depression: information for health practitioners


Guidelines for Medical Practitioners Using Sections 110 and 110A of the Mental Health (Compulsory Assessment and Treatment) Act 1992


Guidelines for the Use of Acetylcholinesterase Inhibitor Drugs in the Treatment of People with Alzheimer's Disease


Diagnosis and Management of Soft Tissue Knee Injuries: Internal Derangements


Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders


New Zealand Acute Low Back Pain Guide, incorporating the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain

Analysis of Chronic Fatigue Syndrome Guidelines

Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation

Diagnosis and Treatment of Adult Asthma

Management of Asthma in Children aged 1-15 years

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006

Guidelines for the Management of Genital Herpes in New Zealand

Hormone Replacement Therapy

How come these have come out black

medical podcasts

There's a lot of them listed here

Here is some others

Mcgaw Hill medical blogs

Johns Hopkins PodMed

JAMA

Great blog site for docs

Things like the following can be found here. Want a refreshing fresher take a peek here. You name it he's got it

Central line placement. See also Central line placement with ultrasound guidance.

Thoracentesis (pleural tap)

Paracentesis (ascites tap)

Arthrocentesis (joint tap)

Arterial line placement is illustrated in The Internet Journal of Health.

Lumbar puncture in eMedicine

Case histories galore, examination how tos - great possie.

What's your doctor up to

When your doctor is listening to your heart, tapping your reflexes and feeling your tummy what's she or he up to. Here you will learn all about it with video and sound tracks - it's kind of cool. Here heart sounds and find out why you are being asked to touch the docs finger and then your nose.

A major rave

The takeover of the medical profession by managers and bureaucrats over the last ten year has been quite extraordinary and shows no signs of slowing up. Why?

The takeover was inevitable and it is going to intensify. Why?

The cost of drugs and surgery are skyrocketing - many thousands of dollars per year per patient for some treatments.

Customer demand is intense. They want the latest and best. They believe in magic bullets.

Doctors are also susceptible to the latest and the best. They need to be able to do something!!

When third parties are paying the bills, the customers don't care and neither do the doctors, someone has to reign in the spend fest.

The third party payers know that zillions of customers are not benefiting much or are being harmed by many treatments. They put out information re harms and it is largely ignored. They are of course suspected of penny pinching.

Doctors become attached to their treatments even when they have been shown to be harmful. They all too often can not or won't let go or change.

Individual doctors can not keep up with the total knowledge and skills base - even specialists have difficulty in their own field.

The knowledge base is highly polluted. Vested interests, bias, egos, unwillingness to speak out, fraud and spun research fool both doctors and customers.

The ability to assess information is not easy and is extraordinarily time consuming. Evidence based medicine has its problems. The more one knows the more grey things become. Neither customers nor doctors like grey. Each person and organisation comes to the party with their particular bias.

The drug and medical technology companies have a duty to their share holders. Benefits are exaggerated and harms put aside. They have huge resources to influence. They have billions of dollars at stake. They do not have your interests at heart.

Many of the guideline bodies have medical advisers who benefit from handsome handouts from the drug and technology companies. They claim these payouts do not influence them.

The major medical journals make their living from drug company adverts and reprints. They, well some of them, admit this is a problem.

More and more research is drug and technology company funded. University departments are all too often dependent on these companies for their survival.

Those that do systematic reviews have their biases and blind spots. Even professional critical appraisers of information can not avoid bias.

The profession has to a large extent lost the right to call itself a profession. There is just too much evidence that doctors do not have patient interests before there own. Medicine has become a business a very expensive one at that - exponentially growing in cost.

Those that pay the fiddler must feel driven to do something about the above scenarios.

A growing number of potential customers who cannot participate in the latest and greatest bring political pressure to spread the 'benefits'. Yet another reason for external controls.

The result - doctors have become or are becoming pawns of government departments, insurance companies, those they work for and the suppliers of drugs and medical technology.

As guidelines and protocols become rules to be followed one has to ask do the protocol and guideline manufacturers have the patients best interest at heart. To what extent do the above companies influence and control what goes on? As individuals they probably care but they too are subject to external forces and interests. They too may fear stepping out of line.

In the end it seems to me that the doors are now wide open for the drug and technology companies to have their way. Government bodies may do their best to reduce costs and obtain maximum effectiveness but when one looks at the whole statin thing and how this is promoted and its use endlessly extended, it seems we are on a slippery slope and your doctor isn't going to be able to help.

As bad as things may have been when doctors were free to operate from their own assessment of information I see no light the way things are going. When your doctor is a corporal in the medical machinery there's not much he can do. If he or she is top brass there still isn't much they can do. They are caught up in it all.

The end result of where we are going is disempowered patients and doctors with third party payers thinking they are in control whilst being manipulated by the drug and technology companies. What's the solution? I have no idea. It's all too big for anyone to sort out. So things will bumble on until things fall apart and yet another system is promoted.

America performs huge numbers of heart operations for coronary artery disease - billions and billions of dollars are spent - patients know they have benefitted and the demand grows. Yet the stats show they actually obtain little benefit - there are exceptions of course - their results keep the whole thing going. The evidence for benefit is unimpressive. Some people are harmed. Yet both doctors and patients are keen!

Anyone got any solutions??

Be nice to your doctors

It pays to be nice to your doctors and at the same time recognise they are human - that is, they have their bad days, their knowledge and skills are limited and for a successful consultation they need your help or in put. They aren't vets or clairvoyants. The person before you may have been a difficult individual and knocked your doc off his or her perch. Some people reacting out of fear, pain and frustration can be threatening, aggressive and angry - others can be manipulative, dishonest and unpleasant.

You want him or her on your side. He or she wants to be on yours. If this isn't so, then maybe both should call it a day.

Doctors are pattern recognisers. It's their job to hear your story, clarify it, do tests and examination. If all this information produces a pattern they know, they can respond. If there isn't a fit - then they don't know what's wrong with you and so can not respond or treat you.

Many docs have very high IQs are used to knowing their stuff and feel they should know all the time. Not knowing isn't easy for them. Lots of docs are 'helpers'. They need to help. Now if you've seen a specialist and they haven't come up with a diagnosis either, there's a problem. Your doc is having two of his or her buttons pushed. They don't know and feel they can not help.

This makes for a delicate situation. They are a maybe a wee bit reactive and maybe you are too. After all you are unwell, in pain maybe, and you are scared about what might be wrong with you.

The doc may be wondering whether there is something going on in your life you aren't talking about. Maybe you aren't, out of embarrassment, telling him all your symptoms. Maybe your personal life is a bit of a mess and you haven't admitted this to yourself. You could be underplaying your symptoms or overplaying them. Your doc is probably concerned s/he might be missing something.

This is not an easy time for both parties. Your doctor doesn't want to upset you. He or she may be holding back because of uncertainty - what they are thinking might not be right. You could get all miffy and report him or her to the dreaded HDC.

Doc - please give me your honest opinion - don't hold anything back. Give it to me!

Be prepared to hear something you don't want to hear. Don't fight the opinion. Say thanks - let me think about it if it doesn't sit right with you. It takes courage from your doctor to be forthright and honest. Thank him or her for that!

If you don't have an easily diagnosable situation, the best policy is openness and a forthright expression by both parties. Your doctor needs your permission and encouragement. If you don't give it, you may not get to hear what your doctor thinks. It's too easy for both doctor and patients to avoid the difficult conversation and all too often patients ends up on a tread mill of investigations, specialists and treatments that don't serve them well.