Dictating hospital discharge summaries! Aaarrrgh! I don't know a single doctor who enjoys this necessary evil. (For those of you who haven't had the pleasure, a discharge summary is essentially the story of someone's hospital stay.) Not only does it mean 30 minutes of dictating reports, it also means 30 minutes of cranking my neck into an unnatural position to accommodate the terrible ergonomics of the phone receiver.
Check out the protruding vein on my temple - it's pulsating with annoyance.
Well, you may say, why don't you hold the receiver in your hand and save your neck?
Like this, you mean? Great idea, but that leaves just one hand free to flip through a voluminous, poorly organized and ergonomically-obscene paper chart, to reference lab results, progress notes, etc.
It's a frustrating experience, and that leads to rushed, and possible incomplete, discharge summaries.
I always use a hands-free headset in my office - it's comfortable and convenient. Why don't they have one in the hospital medical records dictating suite? As it turns out - nobody asked for one!
A couple of months ago, I spoke to the person in charge of this area and suggested they try setting up a headset. And...
Now check out the protruding vein on my temple - it's pulsating with joy!
I have 2 hands free to flip through the chart. (Electronic charts would be better!) I'm more likely to dictate a thorough discharge summary, because I'm not frustrated by the unwieldy chart, and my neck isn't cramped.
Not only did they supply the headset: (on one phone, as a pilot - excellent plan!)
They also posted an instruction sheet and a feedback form:
What a great demonstration of how to implement a change:Address the client's need/problem.
Start with a small test of change.
Make it easy for them to try the new method.
Ask for feedback.
If you don't ask, you don't get! And it only took me 16 years to ask.
Kudos to Sherry M. for setting this up. Thank you very much!
Sunday, December 14, 2008
What's wrong with this picture? - XIV - Oh, my aching neck!
Tuesday, December 9, 2008
The grass is always greener on the other side...
Check out US President (not yet, but he might as well be) Obama's video blog of his Economic Recovery Plan. He's going to make sure that all US hospitals and doctors' offices are outfitted with EMRs and are connected to each other (3:50 on the video).
EMR and connectivity are part of his core plan. "Cut red tape, prevent medical mistakes and help save billions of dollars each year..." Looks like his administration gets it.
Who would have thought the American health care system would be showing us the way on this?
Sunday, November 30, 2008
Review of Doctor review sites missing an opportunity
Dr. Kent Sepkowitz informs Slate readers that doctor review sites aren't helpful for patients. But can they be helpful for doctors? I think so - check out this old post.
Read More......
Thursday, November 27, 2008
More RateMD fodder
Here's a recent article from the Prairie Post. 1762 Sask docs listed on RateMD. There is no escape!
Read More......
Tuesday, November 18, 2008
Welcome CCHSE attendees!
Thanks for coming to my presentation of BOMB! How a (failed) career in standup comedy made me a better surgeon. I look forward to receiving your feedback. Please click here to take the survey. You'll need the password from your souvenir postcard!
This survey closes on Thursday, November 27.
P.S. Got time on your hands? Check out "What's wrong with this picture?"
Wednesday, November 5, 2008
Come out swinging on private health care!
In this corner, CMA president Robert Ouellet weighs in on how private health care will improve access for Canadians.
In this corner, former NEJM editor Marcia Angell, takes a swipe at American-style privatization.
Judge's decision: Angell
Saturday, November 1, 2008
Macs rule! But let's not be stupid about it...
The medical community seem to be committed Mac users. At our recent Departmental Research Day, several presenters made that clear. But, in a counter-productive way...
The laptop being used for presentations at Research Day was a PC, but several physicians brought their own Mac laptops. Great to see other Mac users promoting the cause, but it turned out to be a distraction. Because they had brought their laptops (rather than just the presentation on a memory stick) there was an annoying delay between presentations while the PC was disconnected from the LCD projector and the Mac was connected.
This was completely unnecessary for some presenters, as they had used PowerPoint on the Mac and could have easily loaded their presentation onto the PC via a memory stick. I do that regularly and the only compatibility issue I have is if I've used pictures from iPhoto without changing their format to a PC-compatible one. I've been burned on that before and so am in the habit of checking such presentations on my office PC.
Other Mac users/presenters were obviously using Keynote, and so couldn't run that program on a PC. I say "obviously using", when perhaps I should say "obtrusively using", i.e. "Hey, I'm using this cool, Mac-only program. Look at these wicked fonts and catchy transitions I can do!" Those bells and whistles are amusing for exactly 2 slides and then they are a distraction from your presentation's message. If that's the only reason you're using Keynote... don't do it. Stick with PowerPoint (on your Mac, of course) and save us the nuisance of switching platforms between presentations.
I admit that I use Keynote for one particular presentation that requires an animation that PowerPoint can't handle. That means I have to take my laptop along whenever I give that presentation. After experiencing the annoyance of several computer changes at Research Day, I'm seriously reconsidering whether that single animation is really worth the grief of lugging a laptop around, rather than just carrying PowerPoint on a memory stick.
Of course, the ultimate solution would be for the AV people to smarten up and start using Mac laptops. As Macs can run either Mac or PC, it makes more sense to be using the more versatile platform.
Thursday, October 23, 2008
HSBC airport ads - Love 'em!
Having schlepped through more than my usual number of airports this month, I've noticed, and enjoyed, HSBC's ads displayed in various walkways.
The ads feature beautifully-photographed images alternately labelled with antonyms, that, well... Check them out for yourself and you'll get the point.
Thursday, September 25, 2008
Wonder words
Long time, no blog. No excuses, just life.
If you're a hospital caregiver, you've seen similar stuff written on charts. Wording notes this way makes it sound like patients are our adversaries. Like we're suspicious of what they say and do. Like the little sneaks can't be trusted. (Oh, he denied shortness of breath, but I think we know better. Refused breakfast, did he? Well, we'll just see about that!)
I've also seen people refer to themselves in progress notes as "The writer" rather than saying "I", as in "The writer observed the patient performing self-care", instead of "I watched Mr. Jones perform self-care." What's the reason for that? Is "the writer" somehow more professional and credible? I also wonder why people write "Patient stated" or "Patient verbalized" rather than "Patient said".
And, if you're a patient, don't ever dare to leave the hospital "Against Medical Advice". If that gets written on your chart, you're branded as an uncooperative jerk.
Which you may be.
But, you may also have needed to deal with an urgent personal matter, and your doctor didn't see fit to make ward rounds and write your discharge order at a reasonable time. "Uncooperative jerk" cuts both ways. " Discharged self AMA" sounds like we're running prisons rather than hospitals.
Friday, September 12, 2008
Welcome SORN attendees!
Thanks for coming to my presentation of BOMB! How a (failed) career in standup comedy made me a better surgeon. I look forward to receiving your feedback. Please click here to take the survey. You'll need the password from your souvenir postcard!
This survey closes on Saturday, September 20.
P.S. Got time on your hands? Check out "What's wrong with this picture?"
Sunday, August 3, 2008
Tom Peters takes on Health Care
Tom Peters (Re-Imagine) is just a little hot about Health Care. Check out his proposed hospital org chart.
He gets it.
Saturday, July 12, 2008
Sunday, July 6, 2008
Give-away give-away
Here's a news item from CMAJ about US initiatives to free physicians from drug company gifts.
Tuesday, July 1, 2008
Warts and all
Dan Walter put a comment on my last post, and it's left me a bit of a dilemma.
He comments that he's "off topic", and, after I did a little homework/surfing, I think he's right. In fact, his post is essentially spam to promote his website/agenda.
And an angry agenda it is!
Dan has left a link to Adventures in Cardiology which is a bitter-voiced (and perhaps rightly so...) personal account of medical misadventures (yes, that's a euphemism!).
So, what should I do with his comment, which had nothing to do with my post about Powerpoint presentations? My first thought was to just delete the comment and have done with it. Obviously, he wants to draw a wide audience to his website to hear his story. How much of the story is accurate? The tone he takes is aggressively negative ("mangled", "ripped to shreds", "bumbling cardiology staff", "Warfarin is commonly used as rat poison") and, frankly, off-putting.
My immediate, visceral impression was to write him off as a crank. He comes across as an angry man who's more interested in trashing, rather than improving, the system.
But, maybe there's some lessons to be learned here (curse you, cooler, contemplative side of my brain!). If medical staff truly made the mistakes Dan chronicles, then the next steps post-error were most critical in moving on: honesty, communication and transparency. Our provincial licensing body repeated tells us that most complaints lodged against physicians are on the basis of poor communication, whether or not there was any medical misadventure. From Dan's story, it sounds like this was a big part of the problem, compounding the actual medical complications.
Even if the medical team weren't "responsible" for any of the misfortune Dan has described, the system has nonetheless failed him and his family. After all, if we want to consider that we practice "Patient/Client and Family-Centred Care" (PFCC), then it is our patients/clients who get to decide whether or not they are satisfied with the results.
Their satisfaction will be based primarily not on the outcome measures favored by the healthcare system (mortality, infection rates, length of stay), but on their experience in the system. Were they treated with respect and dignity? Were they invited to participate in decision-making to the level they wished? Was all pertinent information shared promptly, freely and in a format that the patient and family could understand and use in collaborative decision-making?
And so, Dan's link remains on my blog. If you do check out his site , try this experiment: Read it first from the point of view of a health professional dealing with this "difficult and demanding" family member. Think about how you would cringe, and look for an escape-route, if you saw Dan coming down the hallway of your hospital ward. What a jerk this guy is! He just doesn't understand the complexity of problems we're dealing with every day.
(As I noted above, this circle-the-wagons approach was my first instinct.)
Then try looking through a "customer-service" lens: I want to provide each client with an excellent experience that will reflect well on me personally, my profession and my institution. How can I change the system (yes, I can!) to serve Dan and his family better?
BTW, it's an open-book quiz - the answers are all here.
Friday, June 27, 2008
A ray of Powerpoint hope
I spent the last week getting hammered by bad Powerpoint.
I was at the annual meeting of the Canadian Urological Association. The speakers were all respected experts in their clinical fields, had excellent command of the scientific evidence supporting their arguments, and rigorously adhered to the Bad Powerpoint code of conduct:Pack your slides with text. Read directly from the slide. Graphs and charts must be illegible. (If possible, download a pdf of the actual medical journal article and paste it onto the slide.) Comment/apologize using the Powerpoint Phrase of Doom.
The list goes on and on.
There was one bright spot, however. One speaker broke the mold. He talked about an esoteric subject (calcified nanoparticles, if you must know), but was completely engaging. He used plenty of photos and illustrations, rather than bullet points. He told a story, rather than recounting facts and figures. He was excited about the topic, and he let his excitement show. (Almost a cardinal sin at a scientific conference!)
While I'll likely never apply his information in my clinical practice, it was the most memorable lecture I attended.
Medical experts/speakers take note: Tell a story. Use pictures. Get excited!
Monday, June 9, 2008
Stop talking over patients!
Today, at the hospital, I saw a porter pushing a patient in a wheelchair. She stopped to talk to an acquaintance as they passed in the hallway. Their conversation was loud and of a personal nature.
As they talked, the man in the wheelchair fidgeted, obviously uncomfortable with being ignored. It made me think of a recent article "Talking over patients: sTOP" in CMAJ's Salon.
sTOP is a different take on the "loose lips" problem in hospitals (and healthcare, in general).
Ken Flegel goes beyond pointing out how rude it is to subject patients to our personal conversations, and tells us it's unethical. "TOP Talk is an unprofessional behaviour not because the topic of conversation is bad, but because the circumstance is an unacceptable time and place for it."
Even if you think that's a little over the top (I don't!), you have to admit that "TOP talk" happens regularly in healthcare settings.
I mentioned the porters in my example, but physicians and nurses are as guilty of this. I don't think Flegel is telling us that we can't have personal conversations at work, but when with our patients, to treat them as special guests.
Like we would want to be treated, if in their shoes.
Or wheelchair.
Thursday, June 5, 2008
Advanced Access updates
You've been keeping up on the latest Advanced Access posts, right?
Wednesday, June 4, 2008
Welcome to Strategy readers!
Plain Brown Wrapper is mentioned in this quarter's Strategy, the CMA's financial management magazine. If the Strategy article led you here, thanks for coming. Have a look around the site. I have the most fun with "What's wrong with this picture".
Also, I'm very excited about our office's ongoing Advanced Access project (latest post here), chronicled at Health Quality Council's website. We're trying to reduce patient wait times in our 9-physician urology group.
Sunday, June 1, 2008
What's wrong with this picture? VII - Reloaded
Remember this post about patient confidentiality on a hospital ward?
Well, they fixed the problem!
And so simply and elegantly, too. They just turned the req over before clipping it up. Sure, anyone can still take a look at the req, but they have to make an active effort to do so.
Well done!
I also learned something from this experience. When I had originally noticed this problem, I brought it to the attention of the ward clerk. The response was essentially: "That's the way we do it here, and I don't see a problem with it." That's often the response I get when I point out some of the situations that I gripe about in What's wrong with this picture?
Maybe it's because I don't present the problem in a compelling way. Or maybe there just isn't a strong culture of patient-centredness out there yet. Or maybe I'm telling the wrong people.
Choice number three seemed to be the problem this time. The nurse manager actually found the problem through this blog and then fixed it. She wished that I had brought the problem directly to her attention. She was right.
So, in future, if I'm serious about getting something fixed (rather than just generating material to post here), I'll talk to the person who has the authority to make the changes.
Thursday, May 29, 2008
Complications
As I started reading Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science, my first reaction was Nooooo! Don't give away the secrets!
When relating his first attempts at an invasive procedure (central venous catheter insertion), Gawande is so frank about his uncertainty and shortcomings, that it made me squirm to recall my own similar experiences.
All physicians gain experience through practice - on real, live patients. This practice, during residency, is supervised by senior attending physicians. However, as Gawande points out, the degree and proximity of supervision varies according to circumstance.
How do we balance being honest about our level of expertise against wanting to spare patients unnecessary anxiety? How can residents learn a new procedure if they don't perform it on a patient?
Gawande explores these questions with astonishing openness. Plus, he's a great storyteller. His story of the failed tracheostomy (lost airway, anyone?) made me cringe.
Non-physicians read this book at your own peril. You may dispel the myth of the infallible surgeon.
Thursday, May 15, 2008
RateMDs lawsuit
An Edmonton urologist has slapped RateMDs with a $12M lawsuit. Apparently he was upset about the "bad publicity" from his RateMDs page.
Talk about counterproductive. Now he's got that "bad publicity" all over the papers.
Sunday, May 4, 2008
I blog, therefore I am
"Friends tell me that I will take naturally to blogging because I am in possession of many poorly considered opinions about issues I understand only marginally."
A wry take on blogging, at The Atlantic.
Read More......
Crash and Learn II
Some more ideas from Crash and Learn by Jim Smith Jr.
Chapter 2 - Room Setup Mistakes
My first inclination was to skip this chapter. After all, in most cases, I don't have much say in how a room is set up.
Or maybe it doesn't matter to me how the room is setup, as long as everyone is facing the front and can see me.
Or maybe I'm not aware of the recent breakthroughs (there must be some!) in room-setup theory that optimize audience experience.
It's a brief chapter, but Smith has a couple of suggestions that would be a departure from the traditional medical lecture setting:Have a brief, content-related activity waiting for the participants when they enter the room
Play music (!)
My three top mistakes are:
1. Not having an activity to engage my audience as soon as they enter the room
2. Not playing music (!)
3. Letting the room get too hot
My action steps to correct these mistakes are:
1. Create a "Welcome" slideshow. Maybe something like the clips that play in movie theatres before the previews start - trivia questions, short cartoons, etc.
2. Play music (Need those portable speakers!)
3. Check out the thermostat before starting. Asking someone in the room to be in charge of opening a door or window if it does become too hot.
I'm committed to correcting these mistakes because:
1. Having the audience focused on an activity will make it easier to get their attention when I want to start speaking.
2. Music might be a way to get the audience's energy up if the presentation is late in the day.
3. Audiences can't concentrate if they are physically uncomfortable. They will be thinking about their discomfort rather than the message of my talk.
Monday, April 28, 2008
JAMA body slam
Some of my posts on the pharmaceutical industry have been strongly-worded. Or at least I thought so until I read this Globe and Mail piece. It's an absolute smackdown by no less than the editor of JAMA.
Think medical journals, and the studies they publish, can't be influenced by drug companies? Ha! Think again.
Thursday, April 24, 2008
The old one-two
The underdog pharmaceutical industry finally has a wingman in their role of David vs. the Goliath of government regulators! (What's the emoticon for dripping sarcasm?)
This CMAJ article discusses Canwest Global Communication's upcoming challenge to the government's ban on direct-to-consumer drug advertising. Dr. John Abramson, of Harvard Medical School, begs to differ.
But, according to Canwest, the ban is a breach of the Charter of Rights and Freedoms.
Pay no attention to the big bags of cash behind the curtain.
Tuesday, April 22, 2008
Healthcare efficiency
Interesting post on "Healthcare Efficiency" (April 17) about preventing hospital acquired infections in the US. Love the last paragraph about healthcare workers resistance to the ideas behind Quality Improvement and change (? Change) in general.
Sunday, April 20, 2008
Crash and Learn I
I'm still fussed about the presentation I gave at SAHO earlier this week. I've been making notes on what to improve for next time, and I have a strong feeling that I could be doing a lot more with my presentations.
I think I can apply some of the ideas about transparency from today's earlier post to improving my presentations. That is, I'm going to make a commitment to improve, and record my efforts here.
Yesterday, I picked up Crash and Learn - 600+ Road-tested tips to keep audiences fired up and engaged! by Jim Smith Jr. He's described as "a sought-after motivational speaker". It's just over 100 pages and I liked the practical, bullet-point tips and "war story" format.
As is the case for most physicians, I haven't received formal training on how to speak in public, give presentations, or teach a class. Yet, I'm called on regularly to do all these things. I just follow the "traditional" approaches to lectures and Grand Round presentations, i.e. stand at the front (behind a podium) and talk. Non-stop. For the full hour, if not longer.
We've set the bar so low in most "medical" presentations, that it's a rare treat to see a speaker who brings something (anything!) fresh and exciting to their presentation.
Let's see what Sought-After Motivational Speaker Jim Smith Jr. has to offer.
Chapter 1 - Facilitation Mistakes
In this chapter, "Jim's Gems" seem more applicable to facilitators leading interactive sessions than to the lecture format taken in most medical settings. Nice tips on how to involve your audience, get people back from breaks on time, and deal with distractions.
Hmm... Maybe "lectures" should be made more interactive in order to engage audiences. Why don't we do that routinely? Perhaps because we don't have the training, experience and confidence to do it. Plus, if I involve the audience, I might lose control of the session.
Smith emphasizes the need to open the session in a strong, memorable way. Use a story, powerful quote, "get-up-out-of-your-seat" activity, or a surprising, powerful statistic. He has similar suggestions for a strong closing.
I was surprised to read that he avoids closing with questions and answers, suggesting "The wrong question can sour the atmosphere, leaving a bitter closing taste. Moreover, you might run out of time without thoroughly answering the question." So, I guess you need to have a prepared closing that gives a reliable, strong, positive finish to your presentation, and plan to deliver the closing after the questions and answers.
Take-away quote: "View your participants as the most important people in the room. Put your ego in check."
Now, I hate the self-help books that have "reader participation", i.e. write down your action plan at the end of each chapter. But, as I'm committing to doing this publicly, here we go:
My top three mistakes are:
1. Not opening sessions in a strong, memorable way
2. Going off on tangents when answering questions
3. Too much telling, not enough asking during the session
My action steps to correct these mistakes are:
1. Open with a related story
2. Ask for the question to be repeated or restated, or paraphrase the question back to the questioner, so I can focus my answer
3. Structure presentations with points where audience can make suggestions. Or solicit questions during the presentation
I'm committed to correcting these mistakes because:
I want my audience to be engaged in the presentation, keep their energy up, and answer questions to their satisfaction.
I've got a presentation to give tomorrow, so I'll try to come up with a relevant story that I can open and close with.
Blogging to a better you
This Globe and Mail article struck a chord with me. While I haven't been blogging about the intimate topics (personal financial disasters, obesity/weight loss) discussed, I have had some of the same thoughts expressed by the bloggers interviewed.
The article's theme is: Making your personal goals public will boost your resolve.
A small example in Plain Brown Wrapper was my New Year's resolution to wear my name tag at work. I'm sure no one at the hospital reads PBW, but the possibility that someone might catch me without my tag and comment "Didn't I read your blog..." was a motivator. I've been pretty consistent in wearing it.
My Advanced Access blog has put our project into the public eye. We get about 700 hits every 2 weeks. Just knowing that so many people are following our progress keeps me focussed and excited about the project.
I agreed with many quotes in the G&M article, like "... she receives some of the best feedback from readers when she posts entries that make her feel vulnerable." and "... blogging is not for the faint of heart."
But, I take issue with "Openly failing, however, is a blog risk... many bloggers opt for anonymity." Certainly, some problems like addiction may be so stigmatized that open discussion would jeopardize one's personal and professional life. But I've found that people are generally understanding of your shortcomings, particularly when they're revealed in the context of an improvement goal. Anonymity makes your commitment much shallower.
Thursday, April 17, 2008
Oh, the irony!
I've been quite liberal in my derision of poor Powerpoint presentations. But Mr. Smarty-Pants stepped in it big-time this week.
I appreciate an excellent presentation. At meetings or rounds, I really enjoy a speaker who has taken the time to put his/her audience first. Who makes sure the audiovisual material is appealing and appropriate. Who checks that all the necessary equipment is available and functional.
I like to give a good presentation. And I cringe when something goes wrong. Like earlier this week.
I was invited to present our Advanced Access project to the annual meeting of the Saskatchewan Association of Health Organizations in Regina. I was excited to be asked and put a lot of work into the presentation.
I used lots of graphics and photos, and kept text to a minimum. (Only one bullet point slide out of 42!) I stuck to 3 main points. I included some video clips to illustrate my points.
And that's where the wheels came off the wagon.
There was no speaker system to amplify the sound from my laptop. It wasn't a big room, but people at the back couldn't hear the clips. What better way to have your audience's attention wander?
To make it worse, one of the themes of my presentation was "It's all about your audience". I was trying to apply the metaphor of a performer and his audience to the concept of patient and family-centred care in our Advanced Access project. I went on and on about how important it is to think about what engages and entertains your audience (or what's important for your patient). Then, I play the video clips and half the audience can't hear them.
Just to balance my karma, another theme was "Do it", meaning, don't be afraid to try new things and fail at them, because it's always a chance to learn from mistakes. This was the first time I'd included a lot of video clips, so it was a nice demonstration of how to screw up when you try something new. Irony was having a field day.
My first inclination was to blame the conference organizers. I'd given them plenty of notice that I needed to plug into an audio system, but nothing was provided. But, I have to take responsibility myself. I've often seen speakers stymied when they couldn't get a computer or projector going, and thought "That's pathetic that you are so reliant on your slides to speak about this topic. You should be prepared for tech glitches." It was my turn to be stymied.
For next time, I'll have to see about getting a small, portable speaker that I can connect to my laptop. Oh, geez, I just had an esprit de l'escalier moment: I should have taken off my lapel mike and laid it on the laptop's speaker!
Anyway, thanks to everyone who was kind enough to come to my presentation. Sorry for the glitch. Try me again and I'll have it fixed.
Tuesday, April 15, 2008
What's wrong with this picture? - XIII
This is the Brandt Centre in Regina. It's an arena/events centre.
And avalanche area!
Unbelievable! They built it with a sloping, ridged roof that dumps chunks of ice and snow onto bystanders.
Kids... Don't slam the car door!
What's wrong with this picture? - XII
Chef?!
Oh, yeah... The new Buffalo Chicken Bite with Ranch dressing!
C'est magnifique!
Monday, April 7, 2008
Front page news! Engineering techniques improve health care.
This wasn't on the front page of the Globe and Mail, but it should have been! Check out the examples of "using math and technology to re-engineer how the system works".
Sunday, March 30, 2008
What's wrong with this picture? - XI (De-Sign)
This is a sharps container in the OR.
I definitely agree that we don't want to misplace pointy stuff with body fluids on them. But is this the best way to ensure safe disposal?
Here's a mobile computer monitor in the ER. It has 2 huge screens mounted at head height...
... and a tiny support stand that makes it necessary to...
... tape this handwritten note to the screen.
Who designs this stuff? Do they get any feedback from endusers? Would they be upset to see that the product they created has to be kludged with warning signs?
If you'll forgive me a little corny wordplay, doesn't the word "design" imply "de-sign", i.e. function is obvious and intuitive without ad hoc instructions? Even better, shouldn't the product somehow force us to use it safely and appropriately?
Recommended reading about design: Small Things Considered - Why there is no perfect design, by Henry Petroski.
Saturday, March 29, 2008
Free lunch with whine
Predictably, after the CMAJ's editorial about pharma influence over physician behavior, industry has fired back. In a letter to the Globe and Mail yesterday, Rx&D CEO Russell Williams sputters:Canada's Research-Based Pharmaceutical Companies (Rx&D), an industry association that represents major drug firms, has had a code of conduct for many years that specifically bans offering gifts or other incentives to gain influence with health-care professionals.
Anyone who has evidence of a violation may lodge a formal complaint, the results of which are posted publicly on our website.
Well, Mr. Williams, no one accused your crew of being blatant about it. You may not be offering free vacations or rounds of golf (anymore), but there are still plenty of less extravagant freebies to be had. It reminds me of the old joke attributed to Winston Churchill. As I mentioned in my last post, the local reps are more than happy to buy us supper (and line up to do so.) Of course, this is in the context of supporting "legitimate" educational endeavours, such as Grand Rounds.
There are also the lavish lunches the reps buy for our office staff. But those couldn't possibly be considered an influence on physicians, could they? Let's not be naive. A cozy relationship with my staff earns drug reps access to physicians' schedules and coveted appointment times.
A particularly devious technique is using office staff as go-betweens. Last month, one of my staff (knowing full well that I rarely see reps) stepped into my office and held out a business card asking, "Can you see him? He just bought us lunch." Wow, maybe next time, they'll start sending doe-eyed orphans with chronic diseases to plead their case. Or a fluffy kitty with a big satin ribbon around its neck. (FYI: I declined the offer to be educated.)
Mr. Williams, don't get so upset about about the CMAJ editorial. It was directed at physicians, not at your industry. Despite your letter to the contrary, we already know that your members' interactions with physicians are designed to influence behaviour and market your product. That's a given.
What's in question is how physicians should respond. What is our responsibility to our patients and society in general?
If your industry truly believes its stated objective -To educate health professionals and consumers in the optimal use of medications
- then put your money where your pious protests are. Tally up everything you currently spend on marketing/promotion/education and give that amount to the proposed Institute of Continuing Health Education. No strings attached.
Thursday, March 27, 2008
Free lunch
This week's CMAJ editorial is a kick-in-the-pants for most practicing physicians. We get roasted for accepting perks from drug companies. And, mea culpa, this week, I had supper at Grand Rounds courtesy of one of our pharmaceutical reps.
The Globe and Mail commentary on how cozy some of us are with pharma reps quotes Prof. Arthur Schafer, "They (physicians) deny that they're influenced - all of them do deny that they're influenced."
Well, duh! Of course we deny we're influenced! If we admitted that we're influenced and yet continued to accept freebies, the cognitive dissonance would fry our brains. It's like those people who talk on cellphones while driving (you know who you are). Despite evidence to the contrary, those drivers have to deny that they are driving while concentration-impaired, otherwise they'd have to change their behavior.
(Quirks and Quarks podcast about cognitive dissonance here.)
(Star Trek fans only: Check out this classic, campy demonstration of the detrimental effects of cognitive dissonance.)
I rarely see drug reps in my office, but I admire their skill in getting the job done. They are universally intelligent, courteous and personable - essential behaviour to develop personal relationships with docs. That personal relationship is the key to exerting influence without burdening the poor doc with inconvenient thoughts of unethical behaviour. As the CMAJ piece points out, pharmas' business is to make money, not educate doctors.
Who am I to talk? This week, I sold my soul for some Greek ribs and a Caesar salad.
Let he who is without sin throw the first dinner roll.
Monday, March 24, 2008
Has it been 10 years? It seems like only yesterday...
After I ranted about pharmaceutical companies direct-to-patient marketing on Friday, I was interested to read the Saturday Globe and Mail's piece on the 10th anniversary of Viagra. It's worth the read.
I was struck by sociologist Dr. Barbara Marshall's view on the marketing of Viagra:
"Men had to be retrained to understand occasional erectile failure as a disease, a disorder that needs to be treated rather than something that happens once in a while in the normal course of events."
The article mentions many of the celebrities who have "endorsed" Viagra (and cousins, Levitra and Cialis). At the 2002 Canadian Urological Association meeting, I remember the excitement in the conference hall when Viagra pitchman/hockey legend, Guy Lafleur, was introduced as a speaker. This was during the scientific session and Mr. Lafleur's speech had not been included in the morning's program. He gave a nondescript, rah-rah, glory days spiel that had nothing to do with urology.
Nonetheless, many of the good old boys were thrilled to see a sports hero in the flesh, and several dashed out of the conference centre, purchased hockey jerseys in a nearby sports memorabilia store, and hurried back to have them autographed. Some of the stick-in-the-mud, wet blanket types (yeah, me) were disgusted that the conference organizers had let this blatant pandering take place. Was Pfizer in some way $pon$oring that CUA meeting, you ask? Don't be so cynical!
(BTW and FYI, during his tenure as Viagra spokesjock, Mr. Lafleur insisted he did not have to use the product. Now you may be cynical.)
Read More......
Sunday, March 23, 2008
Jay Parkinson redux
Remember Jay Parkinson? In his comments on that PBW post, he hinted at a new venture that would "seriously turn some heads". He's been a busy boy...
In his own blog, Jay outlines the features of hello health. This service is to be provided through Myca - a Quebec city-based company that intends to provide its services in the US. I can't wait to see Myca's EMR interface.
After reading Jay's ambitious goals for hello health, I can answer my own "cherry-picker or visionary" question.
Go, Jay!
Friday, March 21, 2008
Cynic's corner
Maybe I'm too cynical.
I just watched a TV commercial about fibromyalgia. I don't watch a lot of TV, so maybe this commercial has been running for a while, but it's the first time I've seen it. It had high production values, so it didn't look like a public service announcement.
So my immediate (and very cynical) thought was: Some pharmaceutical company has a new drug targeted to people with a diagnosis of fibromyalgia.
The ad gave a website address for more information: www.myfibrorelief.com. I'm going to surf over there right now and see whether my cynicism is misplaced. Be right back...
... I'm back.
Bingo! Pfizer it is.
Pfizer's website has an interesting feature offering a free "My Fibro Relief Kit". Except that it's not free. Sure, you don't have to pay for it, but you do have to submit personal information and are asked to complete a questionnaire. After that, you'll receive information about the condition, tips on how to get relief, etc.
If Pfizer is so concerned about the well-being of fibromyalgia sufferers, why not just post this helpful information on the website without making them jump through hoops? Could they have a hidden, less-altruistic agenda?
I remember a similar phenomenon when Viagra was released. (Coincidentally, also a Pfizer product, but I'm confident I could tar all the pharmas with the same brush).
The company had never previously expressed an interest in men's sexual health. Yet, all of a sudden, it was running ads exhorting men to "talk to their doctor" about erectile dysfunction. Men were encouraged to take a questionnaire about their sexual function. That questionnaire set the bar pretty low, i.e. there would be very few men who wouldn't be candidates for Pfizer's drug.
Of course, I'm not naive about pharma's intent in direct-to-patient marketing. They're in the business of selling their product for a profit. I'm just suspicious when they insist that their primary goal is patient welfare. Isn't the primary goal of any corporation the same - shareholder value? I just hope the pharmas achieve that goal without stepping on patients' welfare.
I guess I am a little cynical.
Sunday, March 2, 2008
Help wanted? (What's wrong with this picture? - XI)
The Canadian Medical Association is running a Help Wanted campaign to convince politicians and the public that Canada needs more doctors.
Here's the eye-catching ad that ran in the Globe and Mail yesterday:
Earlier in the week, I received a CMA mail-out containing a postcard. There was an exhortation to mail the postcard to the Prime Minister to draw his attention to Canada's physician shortage.
I didn't mail it.
Some times I ignore similar calls for political action purely out of apathy. This time, it's a stand on principle. I reject the premise that having more doctors will solve problems of access and quality in Canadian healthcare.
It may be part of the answer, but this campaign (see "alarming facts") ignores some broader issues.
"Do it yourself?" over the picture of a man suturing his own wound is a dramatic demonstration that some medical care should be provided by trained professionals (pace Rambo). But, is there an opportunity to educate patients to manage aspects of their care that currently "require" a physician? Why not DIY?
Most diabetics manage their own insulin to control their blood sugar. We trust patients to self-administer their prescription meds. What other "medical" duties can we educate our patients to perform? Can other personnel free up physicians to do the tasks that truly require their expertise?
The "More doctors. More care." slogan suggests that we're doing a great job already; we just need to more of it. There's remarkably little nuance to this argument.
What if we're not operating at maximum efficacy? If we crank up the number of practitioners, we'll multiply waste and poor quality.
Please note that I ask about operating at maximum efficacy , not efficiency. Many physicians are already putting in long hours and would find it difficult to work harder/more efficiently. But what are the outcomes of those long hours? Are we making a positive impact on chronic disease? How often do we really need to review the stable hypertensive's blood pressure? Or, in my practice, the man with an undetectable PSA after he's had surgery for prostate cancer?
Are we even asking ourselves these questions, or are we completely occupied with the struggle to keep our heads above the ceaseless demand for medical services?
Over the last year in my office, we've reevaluated many of our practices/traditions/habits as part of our Advanced Access practice. Many of our procedures don't add value for our patients, and (by definition) are wasteful to the system. We're trying to change, but it's challenging, given the demands of a busy surgical practice. And (let's not ignore the 800 lb. gorilla in the room) the absence of fee-for-service remuneration for quality improvement efforts.
How much waste could be trimmed if the CMA put some of its "Help wanted" budget into quality improvement training, mentoring and support for physicians? How much physician time would this free up for additional patient care?
Dr. Day, show me some creativity beyond the sledgehammer approach of expanding the physician workforce.
Then, maybe I'll sign your postcard.
Wednesday, February 27, 2008
Start spreading the news - Advanced Access is working!
I'm catching up on work after a week off, so here's the lazy man's post - a link to last week's Advanced Access progress report.
Thursday, February 14, 2008
Would you like whine with that?
I pity the poor medical students who do clinical rotations with me. They have to listen to me complaining non-stop.
They're always polite and attentive about my griping. I hope they don't think their rotation assessment could be affected by the quality of their sympathetic nodding.
When a student is in the office with me, my main topic to moan about is inadequate information in the referral letters I receive. I've blogged about this before. Anyway, a senior medical student just spent a few days with me in the office, and yesterday, I was in mid-kvetch when I thought "I gotta stop whining about this and actually do something about it."
We've had success with sending out a checklist to referring doctors regarding a specific condition (microscopic hematuria). We ask for certain information and test results to be sent along to us, before we see the patient. You can see the letter on our office website.
I'm thinking of a different approach for information on a person's past medical history, medications and allergies. I'll try sending out a questionnaire directly to the patient. After all, it's the same questions they'll answer when they come to see me anyway.
This isn't earth-shattering, I know. It's already done in many offices, whether ahead of time, or as something to be completed when the patient arrives at the office. I'm sure there will be lots of forms and templates I can steal (I mean, collaborate non-consensually). I'm thinking I'll send out 10 trial forms with the patient's appointment letter and ask them to either mail the form back or fax it to me. I'll keep track of who had the forms sent to them and how many are returned.
I'll let you know how it goes.
Friday, February 8, 2008
Advanced Access updates
I missed linking to the last few "Adventures in Advanced Access" posts. Here they are:
Not So Happy Holidays
Darwin's Cystoscope
Blog's Breakfast
Alberta Bound
What's wrong with this picture? - X (Med school, Old school)
This lab coat, belonging to a senior medical student, was hanging in the lounge last week. The pockets were stuffed to bursting. In addition to 6 (!!!) reference books (Surgery on call, Internal Medicine on call, etc.), there was a set of critical care flashcards. Geez, buddy, are you part pack mule?
How about trading your collapsed vertebrae in for a PDA? Get some electronic references installed and whip it out when you see your next patient with Dengue fever.
Better yet, convince the College of Medicine to provide access to a standard set of digital reference books (reviewed and approved by faculty) to all medical students. You could use them through any internet connection (ideally wireless via PDA) and they would be updated more regularly than print references.
Monday, February 4, 2008
No-show no-no
I received this transcript from a CBC Radio Saskatchewan program:CBC-RADIO, SASK. FEBRUARY 4, 2008. 6:30 HRS.
There could be warning signs at the doctor's office that say you have to pay a charge for missed appointments
PAT HUME [ANNOUNCER]
Don't be surprised if you see warning signs posted on the wall at your next appointment with a medical specialist. Those signs advise patients that if they miss or cancel appointments they could be billed. For skipped appointments the average is between $30 and $50 dollars. For missed procedures the cost is much higher.
Dr. Joe Pfeifer is President of the Saskatchewan Medical Association and a surgeon in Saskatoon. He says in his practice approximately one out of every ten patients misses or cancels appointments each day. Pfeifer says people also skip MRIs, CAT Scan and colonoscopies, procedures with huge waiting lists.
DR. JOE PFEIFER [President - Sask Medical Association]
Patients who do not show for appointments or procedures just create more of a burden on the system. It's a little disappointing that sometimes people have an attitude that is not the most responsible when it comes to health care because it is needy and there is such a shortage of resources and physicians. It's just sad to see them used badly.
PAT HUME [ANNOUNCER]
Under the Saskatchewan Medical Association's guide to uninsured services patients can be billed up to 50% of the cost of the missed appointment or procedure. Pfeifer says his office has seen fewer no-shows since a warning has appeared at the bottom of appointment cards.
Since we started our Advanced Access project last year, I've paid more attention to missed appointments or "no-shows". We've been tracking them regularly. In our practice, there's a 10-15% no-show rate. No-shows are different than cancelled appointments in that we at least get some warning about cancellations. Not so no-shows. They're completely wasted capacity. We don't know about them until after the appointment time has passed.
That's very frustrating for busy physicians who are trying to deal with long wait times. However, I'm disturbed by the tone of the CBC interview. It makes it sound like an adversarial process. Us vs. them. Only bad people miss appointments.
And they should pay a price!
What we have here is a treatment prescribed before a diagnosis is made.
Before laying blame, physicians need to look at the reasons for no-shows. Perhaps the letter announcing the appointment went astray. When that has happened at my office, the patient (or the referring physician) will call after a few weeks to ask when their appointment will be made. My staff will tell them that their appointment date has already passed, and we'll make a new appointment. Sometimes, under those circumstances, the patient will apologize for not attending the first appointment, even though it was our error in not notifying him!
Perhaps the problem is lack of transportation (Saskatchewan is a big place!), a sick child, or another unpredictable event. (Hard as it is to imagine, a doctor's appointment isn't always the most important event in a person's day!)
I'm interested in how no-show's relate to the length of wait between referral date and consultation date. When we started to work on reducing wait times in our office, patients were waiting up to 4 months for appointments. I have trouble remembering appointments 2 weeks from now (ask my wife), let alone 4 months!
Certainly, if you have a medical problem that's painful or debilitating, you'll remember that appointment with the doctor. But some "problems" (such as abnormal lab tests like high PSA levels, or traces of blood in the urine) don't cause symptoms. Pretty easy to forget when you're trying to get a crop off the field.
I wonder what charging for no-shows accomplishes. Perhaps it does reduce no-show rates, but what does it do for physicians' relationships with their patients? Given the relative lack of specialists in Saskatchewan, will some patients feel pressure to pay the fee, even if they had a valid reason for missing the appointment. And, if exceptions are allowed, who's going to judge their validity? I know I already have enough work to do without adding administrative work. I doubt that my office staff would be happy in this role, either.
Although it's certainly inadvertent, the message I get from the CBC piece is that the system is built to suit providers, not patients. Rather than blaming patients for missing appointments, let's try this: Ask what we could do differently to serve them better.
Could we:Let patients choose their own appointment time?
Phone patients with a reminder 48 hours in advance?
Reduce our wait times?
By the way, doc, if you work on reducing your no-show rate, you'll also increase your revenues. (In a more satisfying way than by nickel-and-diming your patients with punitive fees.)
Physician, heal thyself.
Thursday, January 24, 2008
False positive
My daughter wanted to know about false-positive tests this week. She's a fan of the TV medical drama, House, so I caught a bit of it while I was doing the dishes (you'll have to take my word for it).
An oncologist had to break some disturbing news to a patient. Of course, there was a twist.
The man had been diagnosed with terminal lung cancer, but it turned out that the test was incorrect, i.e false-positive. He didn't have cancer at all. The oncologist expected that the man would be thrilled to hear the news. He wasn't.
The oncologist couldn't understand why the man was upset. Surely he should be overjoyed at having his life sentence lifted!
The problem was that the man had already acted on the false report. He had told his friends the bad news. He had sold his house and spent the money on a trip to Europe. While he was happy that he didn't have cancer, he was not pleased with the profound effect this false alarm had on his life.
A similar situation comes up very commonly in urology practice. Men are often tested for prostate cancer using prostate-specific antigen (PSA). Well, at least they think they're being tested for prostate cancer. The PSA blood test doesn't actually give a yes-or-no answer to this question. It just tells us how suspicious we should be and whether further testing is warranted. The higher the PSA level, the greater the likelihood that prostate cancer is present.
But there's a twist here, too.
Benign prostate enlargement - very common in men over age 50 - also causes the PSA level to rise. In fact, when the PSA is mildly elevated (for example, between 4 and 10), it's more likely that the elevation is due to benign disease rather than cancer, in a 2:1 ratio. That's a lot of false-positives.
The abnormal PSA level leads to further testing, usually a prostate biopsy. This involves inserting a probe into the rectum and using a needle to take samples of the prostate. It's uncomfortable and carries some risk of complications. Also, men with abnormal PSA levels suffer anxiety about the possible cancer diagnosis.
When there is no cancer present (i.e. the PSA level was up because of benign prostate enlargement), the man goes through a needless biopsy and worry. Yet, when I call men about their negative biopsy results, they universally say "Whew, that's good news."
I sometimes wonder why they don't react like the patient on House: "You mean I went through all that worry and that biopsy done for nothing? I never had a problem in the first place. If I hadn't had that PSA test done, I could have been spared all of this. That test was a false alarm!"
When a false-positive test comes back, it means we've taken a healthy person (well, at least, they don't have that particular disease) and put them through stress and further testing that is of no value to them. Many people rationalize this with the old "Better safe than sorry" argument.
Of course, it's up to each man to decide whether he wants to take the chance of having a false-positive result. That means he should be informed of the risks and benefits of PSA screening before being tested. My experience is that most men haven't been informed before testing. Many of them aren't even aware the test was done (usually as part of "routine blood work") until they're called with the abnormal result.
"Better safe than sorry" only holds true if the patient has had the chance to consider how much "sorry" they're willing to accept to be "safe".
Tuesday, January 22, 2008
Outside the RateMDs box
A member of my spy network reported overhearing some first-year medical students talking about their clinical shadowing.
Medical students are required to spend time with clinicians in order to get a broad exposure to the various medical disciplines. These students were planning to surf RateMDs to check out potential mentors for shadowing!
Brilliant. (Really.)
Most of the comments on RateMDs pertain to the physician's affability and communication skills. When patients are unhappy with a physician, it almost always means that communication has been poor.
As such, if physicians are rated highly on RateMDs, they're likely to be pleasant to spend time with under other circumstances, i.e. clinical shadowing.
Plus, they'll be good role-models. That counts for something, too.
Hey, you kids! How about a mash-up that combines the list of College of Medicine-approved clinicians with their RateMDs profiles? It'd save you time and probably make for some entertaining reading. Let me know when you've whipped it up.
Saturday, January 19, 2008
Holidays on-line
Google does it again! We just moved our office holiday calendar on-line and it is great!
Until this week, all the docs in our practice requested and recorded holidays on a paper calendar. That meant that we had to be at the office to check the calendar and write in our requests.
Now, the paper calendar has been tranferred to Google Calender. Each doc has his/her own holiday calendar, which Google merges onto a master calendar.
My wife and I just decided on a trip we'd like to take. Rather than waiting until I'm back at the office on Monday to book the days off work, I just checked the calendar on-line and submitted my requests by email.
We can also clearly see how many people are away during any given week, in order to avoid leaving the practice short-handed. At year end, tallying up the number of holidays taken will be easier, as each physician's calendar can be reviewed individually.
Easier holiday planning brought to you by Google.
Thursday, January 17, 2008
Enough with the miracles already!
Physicians, please take this oath:
"When a patient makes a recovery that seemingly defies the odds, I will celebrate the event, but will refrain from invoking supernatural explanations."
Translation: Stop calling stuff "miracles"!
Our local paper recently carried the story of a woman who recovered from an overwhelming critical illness. She reported that the doctors involved called it "a miracle" that she survived.
When physicians resort to the "miracle cure" hypothesis, what they're really saying is:
Your outcome has been much better than I predicted. I don't see a flaw in my reasoning, acumen or experience. Ergo, it's beyond rational explanation. A miracle!
Why not try "I'm very pleased that you have recovered. My prediction was incorrect. I'll certainly learn from this experience."
Let's be honest about our cognitive shortcomings.
Saturday, January 12, 2008
Re: WWWTP VIII - links fixed
Sorry if you had trouble following the links to the CMAJ letters in "What's wrong with this picture? - VIII". I've repaired the link so it connects to the Dec. 4, 2007 letters to editor.
What's wrong with this picture? - X
Today's WWWTP is a new post, Darwin's Cystoscope, at Adventures in Advanced Access.
Thursday, January 10, 2008
Information please, doctor
I just finished my morning office and I have to get this off my chest:
I saw 2 elderly men, whose referring physician's letter essentially said:"This man has multiple medical problems..."
... with no list of the problems! So, I had to find out about all the problems myself.
Also this week, I heard from a patient's family member who wondered why the patient was repeatedly asked the same questions by each physician/nurse who saw him:"Is there no method of charting that follows patients to reduce this issue and frustration for both staff and patients?"
Bingo! Electronic health records will certainly help with this, but in the meantime, would all the referring physicians out there please help out and send your patient's past medical history details?!
We've developed a checklist for patients being referred for microhematuria. Maybe we need a checklist for all patients that says "Please include the reason for referral, patient's past medical history, list of medications and allergies". Is it really necessary to give that reminder? If I were a referring physician and received such a checklist, I think I'd be insulted. "Well, duh, of course I send along that information. I don't need to be reminded."
OK, I feel better now. On with the day.
Wednesday, January 9, 2008
Whoa to checklists?
Atul Gawande's at it again. Check out this NY Times op-ed about how bureaucracy shut down a successful program that reduced central line sepsis.
Excellent clinical care is no longer possible without doctors and nurses routinely using checklists and other organizational strategies and studying their results.
- Gawande
Read More......
Tuesday, January 8, 2008
Thursday, January 3, 2008
New Year's Resolution
Old joke:
You're working class if your name is on your shirt.
You're middle class if your name is on your desk.
You're upper class if your name is on the building.
So what does this picture mean?
This the CEO of the Saskatchewan's largest employer - Saskatoon Health Region. And she's wearing a name tag.
It's not just for this photo-op, either. I've seen her around several times over the last month and she was wearing the name tag each time. What's up?
When I spent some time at Calgary Foothills Hospital last spring, I noticed that all the staff wore name tags. Including physicians. I found that unusual because most physicians in SHR don't wear name tags in the hospital.
Granted, most residents do wear their name tags, but it's unusual to see staff physicians wearing them. A notable exception would be the ones who wear lab coats at work. In those cases, they leave the name tag clipped to their pocket and don't have to worry about moving it between different items of clothing. (It also means they don't change/launder their lab coats very often, but that's a whole different subject...)
I think physicians don't see a need to wear a name tag. Most of us are well known to the staff in the hospitals that we frequent. A name tag would be a nuisance to cart around, especially if you're changing in and out of scrubs several times a day.
However, there may be some good reasons to wear one:
Collegiality - if other staff are required to wear name tags in hospitals, do physicians deserve an exemption because we're somehow... exempt? (Trying to avoid using "superior" here.)
Courtesy - new staff, or staff on wards I don't visit often, may forget/not know my name. Same for patients and their families, if we've only met recently and/or briefly.
Security/Patient privacy - This is the big one. I can probably walk onto any hospital ward (where I'm not well known) in the city, flip open any patient's chart and start reading. A layperson could probably get away with the same thing if they were neatly dressed (or in scrubs!) and had an air of confidence. I think it would be rare to be challenged.
So why does our CEO wear a name tag? She's not involved in clinical care. She's one of the most recognized people in the health region.
Could she be modelling appropriate behavior? That would be very sneaky.
Anyway, here's my New Year resolution: I'm going to start wearing my name tag at the hospital. If you see me at the hospital without this -
- call me on it.
And mention that you saw it on Plain Brown Wrapper!
Read More......
Tuesday, January 1, 2008
New Division of Urology website/blog
The new year sees the launch of a new Saskatoon Division of Urology blog. But you can't see it.
Sorry to be a tease about this, but it's intended for internal communication among our urologists.
I see it as a repository for meeting records, schedules of grand rounds and journal club, call schedules, etc.
As with all new things, the challenge is in selling it. I'll load up the blog with stuff like links to the health region's digital image/X-ray archive, our call schedule, and clinical guidelines. We'll see if the urologists think it's worthwhile.
