New (Hopefully) Series: Lonely #greensmoothie Breakfast (#lonelybfast)

January 10th, 2013

You may have noticed my earlier post on my foray into green smoothie land. This is an attempt to meet a personal health goal: eat more vegetables.

I love veggies, and I have no trouble eating them. I do have trouble finding prep time.

So, I’m trying this. It is also a way for me to connect with people who come to me asking about these new fads and trends in nutrition: I say don’t knock it until you’ve tried it. And researched it. Green smoothies is my first trendy nutrition habit to try.

Since I started trying to do this regularly, I have been pretty good about it. I don’t do it everyday, but 3-5 days out of the week I’ve successfully made this breakfast.

I’m going to try to tweet my smoothie recipes and my taste rating under the ‘Lonely’ bfast heading (#lonelybfast) I started writing about my ‘lonely’ meals when I lived apart from my husband and was dining solo. I’m usually eating workday breakfast solo, so it fits.

I can say my experiment is going pretty well so far, and I have been satiated until lunch. That makes me very happy, because I was really worried about getting ravenous in a few hours. I am also drinking 12-16 ounces of coffee, so that may play a role.

Unfortunately it hasn’t worked for my husband, just because he leaves the house so early, he never eats breakfast. To my vast amazement and delight, he actually likes the ones I’ve made for him. He can even tolerate ones that are more savory than I can. I think I’ll have to switch him to a ‘dinner and a smoothie’ plan to get him all the veggies he needs. We already try to have veggies for 1 or 2 side dishes at night, but he ONLY eats veggies at night, and that makes it hard to get his daily servings in.

How should I rate the taste? That’s an interesting question because I know that I may think something tastes really good but someone else (like oh, let’s say my dad) who is used to highly processed fatty/sugary foods will think it sucks. Anyone reading my recipes and ratings should take them with a grain of salt: my 5 stars may not be YOUR 5 stars.

So today I did the following:
1 1/2 cups kale
1/2 cup dandelion greens
1/8 large avocado
1 orange
1 acai/acerola purée smoothie packet (freezer section at Whole Foods)
3/4 cup unsweetened coconut milk beverage
2 tbs dried unsweetened shredded coconut

To be frank, this didn’t taste great. I’d give it 2 stars. I wasn’t looking forward to drinking it. I think it was the dandelions (stronger taste than the red kale), the avocado (I’m developing an aversion to using it in smoothies, not sure why but it’s too creamy I think), the acai/acerola (can’t taste it; frozen blueberries are better) and orange (too citrus, clashed with the avocado).

When I added a half packet of Truvia, it got a lot better, enough to make it a 3.

Tomorrow I probably won’t get to it (7am conference), so we’ll see what my next one will be.

Green Smoothies-OK, I’m curious

December 15th, 2012

I know the wonders of veggies, and I strive to eat as much as I can. Just like the rest of America, I struggle with the time it takes to prepare them. It’s not that I have difficulty with veggies in particular- I have difficulty with preparing my own food period. When you have a 70-80 hour a week job, when are you supposed to find time to cook for yourself?

I worry about my husband in particular. I have to force-feed him veggies. It’s a real struggle.

So I’ve been racking my brains trying to figure out how to incorporate more vegetables into our routine.

One potential answer? Green smoothies. Now before you start laughing, please note I am not a ‘nutrition freak’. I may be the Medical Director of Clinical Nutrition at my hospital, but I’m a Standard American, just like other Standard Americans (to play off the phrase SAD, or Standard American Diet). I eat crap just like the rest of you.

But I am trying very hard to keep my family’s eating habits in line, so as a generally curious person, I was intrigued by the idea of getting all my daily fruits and veggies served straight up in one convenient 16 ounce to-go package that reportedly tastes great.

I’m not a fan of the fact it’s a liquid (liquids generally produce less satiety because they empty out of your stomach more quickly), but I am a fan of how much great green goodness can be packed into just one green smoothie.

I mean, you people have NO CLUE the kinds of faces my husband makes when I serve Kale. It’s painful for both of us.

So, I frantically searched for a place near me that made green smoothies, just so I could give it a try. I do intend to try it at home, but the convenience factor of having someone else make it for me is huge for me right now while I’m drowning in work.

Thank heaven I found a place- awesome organic nursery with a REAL juice bar- these people ROCK! Good Earth Greenhouse and Cafe in River Forest, IL has an unbelievable list of fruit and veggie smoothies.

So, drum roll—–

My first green smoothie!

Brass Monkey with Kale (kale banana hazelnut milk almond butter raw cacao dates)

It’s AWESOME!!

I decided to go all-in and get the Rock Me Amadeus too
Cucumber celery spinach romaine kale arugula cilantro jalapeno parsley

Yeah. I said it. ALL IN.

It’s not exactly awesome, but it’s the real deal green smoothie, and I’m proud of myself for going for it. It’s not bad, it’s just that I, as a card-carrying SAD eater, am not used to savory juices. It has such awesome stuff in it, though, I’ll learn to like it.

I hope to write more about my Green Smoothie experiences.

What’s not so great- this place opens at 9 and closes at 5 which essentially makes it impossible for me to get my daily green smoothie fix.

It’s also 7-8 bucks a smoothie. Wowie that’s pricey but if it is your entire meal then it’s not far off fast food prices for a full meal.

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Doctors, quality guides, and unnecessary tests: Don’t tell me what to do!

April 28th, 2012

Wow.  We REALLY do not like being told what to do.

As a background, quality improvement is a major professional goal of mine.  I have had formal QI training, I’ve taken a lot of classes that explore the issues of quality in medicine, and a significant proportion of my time is spent thinking about how to improve and streamline our delivery of high quality care.

We should all want that, right?  Shouldn’t we all want to improve?

Yeah, you’d think.

Maybe not.  Or at least not in a way that feels like homework/grades/slaps on wrists/cookbooks/“The Man”/you can’t tell me what to do damnit!

An alarmingly large proportion of physicians in the Medscape 2012 annual physician compensation report seemed durn determined to do whatever they ~individually~ feel is best for their patient, ignoring the guidelines that their own professional societies created.  They seem to feel justified, though by stating they don’t think the guidelines are going to do any good/aren’t in their patient’s best interest.

Let’s look at a couple of slides (annotation is mine: locate source URL by clicking on the Medscape link above):

 

I know the challenges to implementing changes that can actually drive improvement.  These challenges plague each step of the process: What is quality of care?  How to you define it? How do you measure it?  How to you balance quality for the patient with quality for the physician and quality for our nation?  How do you pay for it?  How do you convince people less medicine is quality care?

I also know why doctors dislike guidelines: they want to make the decisions for themselves at the bedside, and they don’t want to deny interventions to patients when they think there’s a possible chance it could help.  Evidence-based medicine looks at things on a big scale, and docs want the freedom to think, “what if my patient in front of me really is the one that an Umpteenth Emergency Department CT abdomen Scan shows the as-yet-to-be-diagnosed cancer that caused the last 5 years of his/her abdominal pain?” (Yes I’m being facetious, OK, I’m trying to make a point).

I belong to several professional GI societies, and one of those societies, the American Gastroenterological Association (AGA) has recently joined many other professional societies in the Choosing Wisely campaign [see a JAMA viewpoint article here].  Together they are trying to come up with medical interventions that are IN GENERAL  unnecessary: tests or therapies that add very little to making people better.

For years the AGA, American College of Gastroenterology (ACG), and the American Society for Gastrointestinal Endoscopy (ASGE) have published guidelines that seek to provide the best possible evidence for what has been shown to help people.  DOCTORS WROTE THESE GUIDELINES, along with many other people (and sometimes laypeople).

They are also actively partnering with national non-profit organizations to create and promote better quality in healthcare.

Not that I didn’t know that a lot of doctors don’t like guidelines, or at least don’t like being forced to conform to guidelines.  No American likes being told what to do: patients, physicians alike.  I get it, but C’MON PEOPLE.  You/we are not perfect.  There are truly some things we need to do to get our butts in gear and accept we don’t always provide high quality care, and guidelines can be very helpful tools (when applied correctly) to get better at what we do.

There is still a huge amount of autonomy in the American practice of medicine.  Probably too much autonomy as physicians and patients have been allowed to willy-nilly demand pointless interventions that satisfy our guts (no pun intended) but do little to actually improve health.  We will pass the exhorbitant costs of this wasteful care onto our children who will eventually face a crisis of debt and widespread health disparities.

That is, if we don’t take the bull by the horns and do something about it.

I was recently appointed to the AGA Institute Clinical Practice & Quality Management committee, and I was thrilled to be able to help shape these issues for our field and truly help bring GI into a higher standard of care.

Well, I guess I have my work cut out for me.  I’m going to become “The Man”, so to speak, the “Bad Guidelines Guy”, or umm “Gal”.

So, I guess my challenges in quality improvement are:

  • To try to move that needle on those surveys and convince physicians that being mindful of evidence based medicine can improve population health and individual health
  • To try to understand why so many doctors dismiss the guidelines they created
  • Find out what they think really will help improve patient care
  • To fight with insurance companies, government, and local administrators who apply these guidelines inappropriately (and just fuel those doubting doctor’s fears)
  • To determine what really makes a difference in improving care and decreasing the economic burden of healthcare for my future children

Good luck to us all.

Professional Societies: The Cost of Belonging

November 16th, 2011

What does it cost to belong to professional societies?

I think it is important to belong to one’s professional societies for numerous reasons: ongoing education, networking, leadership roles, and the opportunity to have a voice in how our profession is regulated.  Collective voices (and collective pocket books) are louder than individual voices (and individual pocketbooks).

What will it cost my pocketbook, though, to join all the societies I wish to join?  Let’s see:

  • AGA = Application Fee $40; Annual Dues $395
  • ACG = Application Fee $195 (1st yr dues); Annual Dues $325
  • ASGE = Initiation Fee $100; Annual Dues $350
  • CCFA = Participating Physician $300
  • ACP = Annual Dues < 8 years post training $285
  • AMA= Annual Reg Membership, 1st year in practice $210

Whipping out my calculator, I get a bottom line of $1965.  OUCH.

(I think my application fees for ACG & AGA are waived since I was a member in fellowship.  At least one of the GI societies has a 1st year in practice discount also, I just can’t remember which one).

This is on top of my boards (pray I passed), $2165

Hmm, I think some of those are going to have to wait.

I know there are very good reasons why membership fees exist.  These organizations do a lot for our profession.  The cost of publishing the journals alone must be huge.  However,  I know MY budget and income, and for now I’ll have to pick and choose what professional societies are the most important to me this year.

Maybe next year I can add more letters to the C.V. . . .

 

For older MDs who question [our younger MDs] dedication to medicine, I’m still here

November 9th, 2011

I’m still here and it’s 7:13.   (My office).

I’m still here because I spent 3/4 of my “research” day today taking care of patients.

I’m still here despite a 35-50 minute commute home, more work to do when I get there, as well as a wake-up time of 5:20 a.m.

I’m still here because I went to see an outpatient of mine who was admitted today.  I went after our afternoon conference, around 6 p.m (after calling to talk with another patient about labs).  I did it because it needed to be done.  It couldn’t be done by the housestaff or the hospitalists.  It couldn’t be done by the inpatient GI consult team.  I went because it was appropriate for me to go.

It’s my job.  It’s the right thing to do.  It was what the patient needed.

I have my board exams in 5 days.  Failing that test would be catastrophic and cost thousands of dollars.  I should be studying, but I’M STILL HERE.

I don’t have kids yet because I devoted my entire young life to my career (so I don’t have to pick anyone up from daycare at 6p.m).   I lived  800 miles away from my (now) husband for 4 years for my career.  It was an honor to be accepted to my fellowship, so much so I put up with 48 hour visits and thousands of dollars in plane flights just to stay in that program.  My husband sacrificed as well.

I work between 65 and ~85 hours a week.  In fellowship, my “duty hours” took me well beyond the 80 hour limit.

Can I keep this up forever?  Hell no.  Do I intend to? Uh uh.  I will never shirk my duties to my patients, but I’ll fight tooth and nail for a balanced life so that I can provide the best care to those patients.  My sound mental health allows me to minister to their mental health (and their gut).

For a previous generation of physicians (recent blog post from @skepticscalpal and NY times op-ed from a fellow female doc) who doubt my generation’s motivation and dedication to our jobs,  I say this:

I’m still here.

(and now it’s 7:45, sigh)

Colon cleansing: At best a loss of $100, at worst a loss of life

November 9th, 2011

I have strong opinions about ‘snake oil salesman’ medicine.  My husband and I have vociferous debates about this.   I think he drinks the kool-aid a little too much, and he thinks I place too much weight on evidence-based medicine.

Colon cleansing, or colonics, are a prime example of a much-touted “medical therapy”, purported to cure a variety of gastrointestinal ailments.  From what I’ve read, outpatient hydrotherapy colonics cost about $100/session.  Do-it-yourself kits and extended “spa stays” run the gamut of expense.   I can’t even watch the commercials put on by colon cleansing salesman because they simply make me too angry, and I am afraid I will punch my TV in frustration (I like my TV.  I don’t get paid enough to replace it every time a medical fallacy comes on TV).

I cannot stand to watch overt consumer manipulation and lying.

Colon cleansing promises to cleanse your body of all of the dangerous toxins that have been building up in your system for years, claiming you have industrial/toxic sludge lining the inside of your intestine.  You didn’t even know that you had toxic sludge in your intestine, did you?  Some of them also promise to provide weight loss, improved energy, and “cures” for constipation.

Like the long-standing habit of douching, which falsely claims to provide similar benefits for the female genital region, this practice simply doesn’t do what it says it does.  Not only is ineffective for many of its claimed therapies, it can be a very dangerous thing to do.

A recent article published in The Journal of Family Practice (Mishori et al. August 2011 · Vol. 60, No. 08: 454-457) is an excellent and short report detailing a history of colonics, the process, and the lack of evidence for benefits.  This is a really good summary, and the authors looked very hard for anything to support colonics and hydrotherapy.

They just didn’t find it.

What they did find however, were patients who are seriously harmed from participating in this type of nonsense.

Today, the wildly popular consumer site Angie’s List also published an article about colon cleansing.  (Where I got the JFP source).  I belong to Angie’s List, and you can bet that my Gastroenterology hackles were up when I saw the title.

I have to applaud Angie’s list, though, for being fair and balanced in their opinion.  They reported individual patient experiences (positive) as well as negative aspects such as lack of regulation of centers, deaths [DEATHS] associated with hydrotherapy and colonics, lawsuits against practitioners, and repeated FDA warnings.  Only one state (Florida) requires a license to provide this therapy.   Luckily my own state (Illinois) requires a doctor’s oversight before getting the hydrotherapy procedure.

Western medicine is our worst enemy when is comes to the popularity of treatments such as these.  We have failed our patients in so many ways, and it is only natural that they seek alternative methods for their common problems we cannot “fix” (i put “fix” in quotes because some of my patient’s problems are ones I consider normal annoyances of being human, particularly over-indulgence, and not pathological problems that need a cure).

Complementary and alternative medicines are widely used by Americans and people around the world.  Native medical traditions, including Ayurveda in India and Sri Lanka and traditional Chinese medicine, have been addressing patient illnesses for thousands of years in ways that have not been embraced (and rarely studied) by the West.

I have no beef with these traditions.  I think they can truly provide relief to patients in need who have not found help from the type of medicine I practice.  I even encourage patients to consider alternative therapies when I don’t think these therapies cause harm and when I feel like they can be adjunctive to other things that I prescribed.

Colon cleansing does not fall into this category.   It is simply not physiologic to claim that a person has toxins built up “for years” inside their system that needed to be cleansed by whatever herbal therapy is being advertised that day.  The intestine clears itself of what we eat in a systematic fashion.  (You want less toxins? EAT LESS CRAP).  The time that it takes individuals to do this this is quite variable, but the majority of people will clear within 24-48 hours.  There are some people with severe constipation and motility disorders, though, who take much longer than this and it is this group of people for whom I am willing to admit that hydrotherapy can be a PART of the treatment process.

I’m talking about straight up water hydrotherapy, and NOT herbal oral or rectal colonics.  Herbal colonics should never be done, EVER.  These treatments can put you in the hospital with dehydration, fluid/electrolyte disturbances, and chemical colitis.  Severe electrolyte problems, particularly potassium problems, can kill you.

Hydrotherapy is like an enema on steroids, and it carries a small risk of perforation.  Infections and electrolyte imbalances can result from this type of therapy, too, given the massive amounts of water instilled with force into the colon and the potential for contaminated equipment.  Some people, though, have REALLY severe constipation and this is better to them than drinking liters of Miralax (an over-the-counter, generally safe laxative) or other oral laxatives and standard enemas.  I have had some patients who find them beneficial.

It is not a cure for constipation.  It will not make your colon squeeze more quickly than its squeezes.  But if you find that traditional laxatives do not provide you enough relief, and you are willing to take the risks of hydrotherapy, then you can talk to your doctor about it.

You should NOT do this without talking to your doctor first, particularly if you have had extensive surgery on your bowels.  You probably should not do this at all if you have an inflammatory bowel problem like Ulcerative Colitis or Crohn’s disease due to the risk of causing a flare or a tear in your intestine.

Please be skeptical of any therapy that promises benefits above and beyond what a reasonable doctor can give you.  There are very few “miracle cures” in life.  Do your research before undertaking any therapy, and accept the risks that come with participating in a non-studied, non-standard, and sometimes dangerous practice.

Also bookmark the fantastic website QuackWatch.  Read his take on colon cleansing here.  This website was created by a psychiatrist, Stephen Barrett, with a long career evaluating medical therapies.  With a healthy dose of skepticism and humor, he evaluates various “alternative” therapies.  Read it and form your own opinions.  (He also lived in Chapel Hill, go HEELS!)

Do Physicians Provide Too Much Medical Care?

September 28th, 2011

Today I opened my AGA and AMA E-mail to see the headline:

Survey: Patients may be getting too much medical care

This was a blurb about a study in the Archives of Internal Medicine published online on September 26 which surveyed US doctors regarding the amount and aggressiveness of the care they provide to patients (http://www.nationaljournal.com/healthcare/survey-shows-doctors-admit-to-overtreating-patients-20110926).

The results of the study are no surprise to anyone who practices medicine the US currently.  We all order more tests than we think are necessary, but most of us feel compelled to do so either by our litigious environment, our abject fear of “missing something”, or our overly concerned patients.

That last part is what I’d like to focus on for a bit, simply because I think no one mentions it when this topic is raised.

I just graduated to “attending” level, and finally I provide care directly instead of running everything by a superior.  Even though I have been a practicing physician for 7 years, this new title confers me within an increased responsibility for my patients as well as an increased responsibility for the “health” of our medical center. I want my patients to know they are cared for and listened to.  Providing good customer service is also good business practice.  It’s the right thing to do, and it improves our standing in the community.

However, as one who has studied quality of care in a formal setting, I know that patient perceptions of quality of care do not necessarily echo physician perceptions of quality of care. During my graduate studies in the Gilling’s School of Public Health at UNC Chapel Hill, I took several classes quality of care.  In one class focusing on the research and theoretical basis of the quality of care movement, I was asked to write a short brief about whether patient satisfaction equaled quality of care.  My conclusion was that while patient satisfaction is an important component of high quality medical care, it was not a substitute for other markers of quality of care.  One simple reason is this: often the highest quality care is no “care” (i.e. more tests), and this leaves many patients feeling neglected or ignored.

This directly relates back to headlines I saw last week regarding one physician’s cry for the need to teach financial responsibility to medical residents (http://www.latimes.com/health/boostershots/la-heb-health-care-costs-residents-20110919,0,5453286.story).  I did not read the article, and I probably won’t.  Don’t get to me wrong, I think it’s tragic how little physicians in training are taught about the economics of healthcare in this country.  However, I go to clinic every week, I think about every test I order, and I feel strongly that one of the main barriers impeding my ability to provide cost effective, high-quality care is the patient themselves.

Patients come to me with their concerns and fears.  They are just as heavily entrenched in the structure of our US healthcare model that incentivizes “doing stuff” as we are.  Patients expect this “stuff” to happen in the normal course of seeking care.  Every physician knows that patients believe that if doctors aren’t “doing something”, they are not good doctors.  We subspecialists are particularly used to hearing patients report they felt their previous doctors didn’t listen to them and didn’t do anything about their complaints.

So what am I to do?  Even if I gently counsel patients that I don’t think the tests are necessary, I can see the skepticism plainly on their faces.  They feel bad, and are convinced something dire is wrong.

After their reactions, I generally give in and order the tests if there is any justification for doing so (I put my foot down on testing that carries more than minimal risks and has absolutely no indication).  How can I explain pre-test probability, utility of tests, false positive/negative, medication complications yada yada yada adequately to a normal non-medical individual (particularly in my 40 minute new patient time slot?) Even I have to look up those concepts sometimes, and I have an advanced degree in it!

Hopefully with time I will learn to be a better counselor, and my patients will take my words as reassurance that they will be okay without a blood draw or endoscopy test telling them so.

Until we as a community address our patients’ desire for more aggressive care, as well as our desire to avoid lawsuits against us when we fail to meet their desires, no physician can be the ultimate arbitrar of reducing healthcare costs in this country.  Indeed, I’m not sure how anyone expects to reduce healthcare costs until the American public is willing to accept that “less is more” when it comes to their health.

My Work Apps *In Flux*

September 23rd, 2011

UPDATE: A NEW GI APP YAY!! November 23, 2011

#4 Understanding Gastrointestinal Disorders and Digestive Anatomy

www.understandinggastro.com

So, on my way out the door to Turkey Day! I decided to test out a flyer I got in one of my GI journals for an Applet sponsored by Takeda Pharmaceuticals.  There’s the caveat: this app is sponsored by Big Pharma.  Use this info as you wish.

I was skeptical (cause it’s sponsored by Big Pharma).  But I just spent about five minutes playing around with it and I think it’s really cool!

Essentially this is a quick atlas/anatomy app that you can use during clinic with your patients to help them visualize their disease.  The drawings seem to be mostly Lippincott drawings, and the flyer has copywrite info from Wolters Kluwer Health/Lippincott Williams & Wilkins.

The cool thing is that if you click on a disease picture, you see the disease drawing, but you can toggle “view normal” to see normal anatomy, and “view disease” to go back to the diseased anatomy.

You can click “information” for a quick, patient-centered summary of the disease process with references to the literature.

While Takeda’s name is on the home page, it isn’t shown anywhere else that I can see, which is nice.

I think it’s a great app, and I can envision many uses.  I used to have pictures and models of GI anatomy at my former hospital, but I don’t have any in my rooms here at Loyola (it’s a multi-specialty clinic so the “flavor of the day” changes).

As for the pharma sponsorship, I’m not surprised that it took Big Pharma money to make this quality of a web app.  I discussed a similar concept with one of my attending mentors, Doug Drossman, who is a legendary gastroenterologist specializing in functional and motility diseases.  Though the enthusiasm for the concept was there, finding the money to make the app was not.  I certainly can’t pay out of pocket for a hot-shot Apple App programmer, and there is very little money to go around for good educational apps that do not generate income.

So, I guess I’ll take what I can get.  I don’t even know what Takeda makes, and luckily I can’t tell by using their app.  I can barely tell Takeda sponsored it.

 

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{ORIGINAL POST}

Now we get to practice with Dragon naturally speaking.

My Hospital (Loyola University Chicago) has a wonderful tool to help doctors with their productivity.  I was super excited to learn that we were able to use Dragon NaturallySpeaking to record our clinic notes, procedure notes, and other documents associated with my day-to-day activities.  So I’ll practice a little bit here at the office, and write my first blog post using Dragon.

A couple of days ago, I be-moaned the limitations of my iPhone 3GS’s folder system.  I found that I could only put 12 applications in one folder.  Considering that I have several work applications, this was quite frustrating to me.  Indeed, I had only recently discovered how to use the folder function at all.  Yes, I know, I am and odd early-adopter and late-figure-outerer.

I got a Twitter message from @gastromom about sharing.  So here you go: a list of the apps that I am either currently using or trying to figure out if I will use.  It’s not extensive; I’m sure others have many more and better ones.

GENERAL APPS

#1 Groupwise Mail and Calendar: Loyola uses Groupwise for its mail functions.  This is a little tricky to integrate with the iPhone, so I first started by using the applications (cheap option).  The address book wouldn’t sync, though, and I was annoyed at having to use two calendars, so I sucked it up and paid to have it installed on my phone through our IT department.  We’ll see if it was worth the money, but so far having the calendar in one place is a good thing.  I will probably delete these Apps if the integration works OK.

#2 Drug Apps: I currently have two drug Apps on my phone.  The first one is Epocrates, which I believe most people have used at least once or at some point.  However I read a blog post recently (unfortunately I cannot remember the name of the person who wrote it), and based on that I decided to try out to the Micromedex drug information as well.  I haven’t decided which one I like better.

#3 New England Journal of Medicine This Week: also came from the same blogger (if anyone knows the reference to which I am speaking please let me know).  This was my attempt to try to stay up-to-date on my phone, but I have not really used this application since downloading it.  It allows you to read for free current things from the New England Journal.  That should be a good thing, but I have yet to integrate it into my daily life.

#4 Reach M.D. CME: I am a new attending now, and I have to enter the world of CM E.  I have no idea exactly how I will do this, though I believe that my residency and fellowship attendings used the University weekly conferences on campus as part of their CME.  There are numerous opportunities, though, so I thought I would check this out for the times I’m stuck somewhere and need something to read.  Again, this is a new App for me, and I don’t know if I will use it at all.

#5 iRadiology: My hope was that I would use this to become more familiar with GI radiology.  Alas, I have not done so.  I still think it is worth a shot, which is why I haven’t deleted it.

#6 MedCalc: I use this constantly.  This is a definite necessity for me.

#7 Medscape: This has been helpful at times when my patients present with diseases/problems on which I need to brush up.  It has some interesting information, and I like the differential diagnoses section.  I don’t use it extensively, though, and I rarely use the GI diseases section (have better places to go for that info).

However, as I blog hands-free with Dragon {so cool}, I see that there are many other features on the App that I have never used such as procedures and drug information.  I just found an entire section under procedures called anesthetic techniques.  When you click on it you see an entire section of anatomy throughout the body and a description of the anatomy along with pictures.  I’m not really sure why this is under anesthetic techniques, because I don’t see much discussion about anesthesia, but I think having the anatomy there including natural variance and microscopic anatomy is really cool.

Ahh, I delve deeper and I see all the ophthalmologic procedures under gastrointestinal, so I think Medscape needs to do some serious looking into their current App.  As a gastroenterologist I can’t really tell you the last time I studied glaucoma and penetrating keratoplasty {grin}.

#8 PubMed Lite: There is a full version, but I downloaded the free Lite version just to try it out. It only returns the top 10 articles in your short search.  I will use it when we are in grand rounds or other conferences, and someone asks a question that none of the group knows the answer to or refers to a study that is relevant to the current discussion.  I will try to find it on the spot, so we can discuss it immediately.  Sometimes it works, sometimes it doesn’t.  The frustrating thing is, without a connection through a library system, you usually only seen the abstracts and not full text.

GI Apps (some not really Apps but still useful)

#1 AGA mobile: http://www.gastro.org/mobiletools/introduction

This is new for me.  I saw this on a Tweet from @AmerGastroAssn recently, and I thought it was an excellent idea.  I haven’t used it yet, but I use the AGA guidelines quite often in my practice.  I was really excited to have a quick link to them directly on my home screen.  In addition to the guidelines, you will see a quick view of the AGA home page including policy updates, journal articles, meetings, research findings, core curriculum, etc.

#2 University of Michigan inpatient severe ulcerative colitis flare guidelines: (Also not an App) http://www.med.umich.edu/ibd/docs/UM%20Severe%20UC%20Protocol.v2.3.pdfDuring

DDW this year, I was listing to a speaker regarding current best practices for a care of inpatients with severe UC.  As I had a not-so-secret desire to be a GI hospitalist I listened intently.  When the speaker from the University of Michigan mentioned that their inpatient protocol for severe ulcerative colitis was online I linked it to my home screen on my iPhone.  I think it will be a great teaching tool for me to use when I am a consult attending and we have patients admitted with an ulcerative colitis flare.  I believe it is important that we optimize and attempt to standardized patient care (with the caveat that each patient is an individual and might need care that deviates from guidelines).  I applaud the University of Michigan staff for putting this together and making it public.  I just spent 20 minutes trying to figure out who the speaker was (got down the DDW abstract book and searched all Monday/Tues sessions), but I cannot find the right one.  Oh well I tried, and apologies to the speaker.

 

#3 Gene tests from the NIH: (http://www.ncbi.nlm.nih.gov/sites/GeneTests/; or genetests.org) I get nervous when someone with an inherited cancer syndrome comes into the office or into the endoscopy unit for procedures because I am afraid I will order the wrong tests or fail to look for things I should look for, since it is such an uncommon problem.  We had a grand rounds at UNC Chapel Hill not long ago that was given by Dr. Jim Evans (http://genetics.unc.edu/faculty/evans) in the department of genetics.  He mentioned this website, offered by the NIH, which provides an excellent overview of genetic syndromes.  I haven’t needed it yet, (again as inherited colorectal cancer is rare), but I pulled it up today and searched for von Hippel-Lindau.  I was taken to a screen with several options, including lab testing sites, resources, and a succinct summary of the disease, the associated problems, diagnosis and testing, and management (among other helpful items).  I think this will be great resource for those rare situations.

This is a true website, though, so it isn’t as easy to use on the iPhone.

#4 okay now for a real-time App search.  I’m going to open the iPhone and look for the new App from @endogoddess. I should probably follow her on Twitter first {grin}.  So I search for endogoddess, because I have no idea what the name of the App is, and I see EndoGoddess, eProximiti.  For 0.99 cents I can download a diabetes management App.  Oh e-world, if you could see my laughter now!!

I know @endogoddess’s name, Dr. Jennifer Dyer, but I did not realize she was an endocrinologist and not the kind of endogoddess I had in mind (and endoscopy goddess like myself).  I hope she gets fantastic reviews on this, and I hope that it helps a ton of patients.  However I must confess, I’m little disappointed that it is not an endoscopy application.  I was really looking forward to seeing what is going to come up.

I search the App Store now and then for tools to help me be a more efficient and knowledgeable gastroenterologist.  I haven’t done a recent search, and I certainly haven’t looked for patient Apps, but maybe that will be my next challenge.

So random, huh?  I could probably go crazy with weblinks, and believe me I have MANY Apps in mind, I just haven’t found ones that I want.

If I only had a programmer’s brain [whistle Wizard of Oz Tin Man], I’d make them myself, sigh . . .

 


How to Attend a Mega Meeting

May 18th, 2011

A couple of weeks ago, I attended a humongous medical meeting:  DDW 2011.  Digestive Diseases Week is the major yearly international gastroenterology meeting.  Organized by four GI societies ( AGA, AASLD, ASGE, and the SSAT) it brings approximately 15,000 doctors, nurses, PA’s, students, trainees, PsyD, PhD’s, pharmaceutics, devices, software, journals, etc etc etc together for a week in May.

As in the world at large, economics has impacted our scientific love fest.  There are fewer pharma support dollars, people are less inclined to take an entire “week” off work, and so our formerly 5-6 day meeting is now 4 days.

At the same time our session slims down on time, medical knowledge increases exponentially.  Massive amounts of new data are stuffed into these action-packed days.  Processing that amount of information in a short period of time is unwieldly for the average conference attendee.

The DDW session/abstract book is >1000 pages long.  Let’s say that, like me, you are a budding assistant professor who will see many patients with Inflammatory Bowel Disease (IBD).  You show up, eager-faced, ready  to tackle ALL the IBD-related sessions at this year’s DDW.  What will you encounter?

  • 61 sessions, presentations, or lunches on IBD
  • 91% with overlapping time slots
  • 591 posters/abstracts (reading @ 2 min/abstract = 19.7 hours)
  • (748 by my co-fellow’s  count = 25 hours)
  • numerous  “un-official” off-site CME events, usually pharma-sponsored

(BTW, it took me about 2 hours to figure this out.  It took an additional 3 hours to plan my time.  No Joke.)

Unless you know something I don’t, you can’t be in multiple places at once.   How will you deal with this?  Even further, what if you are simply a general practitioner who wants to stay current with the GI times?   All this “overchoice” may lead you to cry “forget it!” and head up to the Mag Mile for some shopping.

Therefore, having an attack strategy to manage one’s time is absolutely imperative to surviving a Mega Meeting.

I didn’t do so hot this year.  Despite having a strategy for myself, I failed to employ it in a timely manner.  I give my self a C+.  This is because I missed out on seeing my fellow friends who were presenting, and I didn’t even get close to the poster sessions.  I fell short because I seriously underestimated how long it would take me to prepare.

So, next year I’ll do better by sticking to my strategy and planning this BEFORE I board the plane.

To help all you Mega-Meeting attendees out there, here’s my strategy, developed over ~ 6 years of Mega Meeting attendance.  I’m a trainee, so this is specifically for early career professionals and students.

BEFORE YOU GO

Get some cards with your contact information.  You’ll meet people or see old friends, and this is a quick way to pass along your info.  Pack your registration information and your abstract book if you have it.

WHAT TO PACK

This is really personal.  I’m a travelling carpet bag, so I take more than I need.  I wear flats, slacks, and a long-sleeved shirt with a sweater because I freeze during these things.  I bought a very special leather rolling briefcase to take my stuff.  I always bring my computer so I can take notes.  Obviously, I carry more than the average attendee.  If you take notes in your abstract book, you’ll be toting a huge book around, but you could get away with a shoulder bag.  I wanted room for pens, camera, phone/charger, computer, notebook, snacks, toiletries, umbrella, and a water bottle.  I.E., I was in it to win it.  I did pretty well with this.  I LOVE my new professional conference bag–ladies this is a McKlein Glen Ellyn rolling briefcase in red leather.  Gentlemen can certainly enjoy it too, but the majority of your gender appeared to be in the “black leather” shoulder bag category.

McKlein Glen Ellyn Wheeled Briefcase

Step 1: PRESENTATIONS/SESSIONS

Read all presentation titles for all the sessions for all four days, and bookmark the individual presentations and/or sessions you want to attending.  Skim this and do not linger.  IGNORE conflicting times.

This took me the 2 hours on the plane.  Luckily I could do it because there was wifi on the plane.

Next examine the  overlapping sessions and make a choice.  Topics are commonly repeated, and you might catch a similar session on another day.   Prioritize in the following way:

1) Career building

2) Knowledge building

3) Friend/colleague building

Step 2: NETWORKING DAY

Make a list of all the people you need to meet while you are there.  Go to the index and look them up.  Bookmark their posters and sessions.  Add them to your session list and re-examine your overlapping time slots.

MAKING PROFESSIONAL CONTACTS AT SCIENTIFIC SESSIONS IS CRUCIAL TO CAREER ADVANCEMENT.  If you are building a career, you MUST NETWORK.  Say hello to old mentors and friends.  Build in time to meet people in your field, introduce yourself, and promote your interests.  You have no idea where this may lead, but this is the time to build those future collaborative networks.

Step 3: NETWORKING NIGHT

Add your non-scientific meetings/cocktail times/meet-ups/study section meetings to your calendar.  Usually these do not overlap with the scientific sessions.  Often at night & off-site, these will require transportation.  If you don’t have any cocktail meetings planned, you should track some down for your career’s sake.

Examples:

  • AGA Diversity Reception
  • AGA Women’s luncheon
  • University Alumni receptions
  • Other professional society receptions
  • AGA PAC Policy Roundtable
  • Study Section business meetings

Step 4: MAINTAIN PERSONAL CONNECTIONS

Look up your trainee friends who may be giving sessions/posters.  Hey, you fly out to this once a year.  Have fun, talk about the kids, etc.   Often other trainees have posters, and they are stuck hanging out by them in the middle of the day.  Give them a lovely surprise and go visit them so they don’t pace the two steps in front of the poster for 2 hours.

Step 5: POSTERS

This one is tough.  This is where I bombed it this year.  I usually do key-word searches on the abstracts using the abstract disc.  I tag the posters I need to check out.  I didn’t do this, and I missed a lot of posters.

This year was particularly tough because I will be a new faculty this year, responsible for  two new fields-IBD & Nutrition.  Do you have any idea how much stuff is out there on IBD (see above)?  It’s impossible to cover!  So, a second strategy is to tag the main poster categories and stroll down the aisles, stopping at interesting titles.

Step 6: TRANSPORT

This is mostly for people who can’t afford the DDW hotels.  Use your traveling skills and remember that the time saved by using non-conference transportation (the lines are KILLER at the shuttle) may be worth the $2 train/bus ride.  Also think about time wasted on the busses:  if you are invited to networking meetings that overlap, and it would take you 30 min on the bus, suck it up and pay the $10-$15 bucks for a cab.

Step 7: FOOD

I get my coffee and breakfast before I get down to the meeting.  I go to the 7-11 before I board the train and I get my coffee and several non-junky snacks to carry in my ‘mobile office’.   The markup at the conference can be stiff, and the time to wade through the lines can decrease your poster-browsing time.

Step 8: WHAT YOU MISS

This may not be important enough to you each year, but if you REALLY feel you missed some great stuff, then you can usually buy the videos of the sessions.  It’s pricey, so weigh how much you really need it.  I decided that I needed it to prepare for my upcoming boards and to learn all the nutrition information I missed.  I paid $600 onsite (the attendance discount) for a disc of all the educational sessions. OOUUUCCCHHH but I hope worth it.

Everyone approaches these meeting differently, so plan it based on what you need to get out of it.  If you need a broad overview of medical management, you may skip all the poster/session searching and attend the post-graduate courses.  If you are later in your career, this will be “old hat”,  and you probably spend more time social networking and moderating sessions as opposed to attending them.

One last note on the rising use of social networking at Mega Meetings: this year I “tweeted” during the entire session.  It was a lot of fun, and I “met” several new people.  It kept me awake and forced me to process the information quickly and correctly (no one wants to tweet something incorrectly).   If you use twitter (or even if you don’t) you can follow the hashtag of your meeting (ours was #ddw11) to see the tweets from various attendees.  You’ll also see vendor announcements and spammers, but the humanity of all the Mega Minds attending the Mega Meeting may surprise you.

Finally, if you got through all my OCD’ish Type A Super Gunner suggestions,  you might question whether anyone enjoys this stuff.   Having fun is what life’s about–if you don’t enjoy your profession, then you shouldn’t be in it.  I had a great time at DDW.  At the end of the day, relax, have a drink, and ponder for a bit the amazing work that your colleagues are doing.

GI Movie Quotes

December 9th, 2010

I am going to save this one for a presentation:

‘Burn after Reading’

Clooney: is that goat cheese?
Malkovich: Yes, chevre, that is a goat cheese
Clooney: because I have ‘lactose reflux’ and I can’t uh
Malkovich: ‘lactose intolerance’ or you have ‘acid reflux’, they are different you know
Clooney: yes I know that
Malkovich: so you misspoke
Clooney: well thank you for correcting me

    About Me

    Professional Gastroenterology Fellow

    Amateur Martha Stewart/Bob Villa/Julia Child/Collette Peters

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