EP Mobile Update Version 3.6 for Apple Devices

The reviewers at the Apple iTunes App Store have approved the revised version of the EP Mobile app.  For information on why the app needed to be revised, see my earlier posts on the subject.  I removed the drug dose calculators (note though that the Warfarin Clinic module was not removed), but added detailed drug dosing information and a creatinine clearance calculator that can be used while viewing the dosing information.  Other improvements to the app have been made as well.  The changelog is as follows:

Changes from version 3.5
* Removed drug dose calculators as requested by Apple (see developers guide section 22.9)
* Added new drug reference section with creatinine clearance toolbar
* Added creatinine clearance calculator
* Added right ventricular hypertrophy criteria
* Added D'Avila WPW accessory pathway location algorithm

I will release the new version in 2 days (March 22).  If for some reason you can’t live without the drug dose calculators, then don’t update the app.  Turn autoupdate off if it is on to prevent inadvertently updating the app.  Regardless of the lack of drug dose calculators, I encourage most people to update the app, because I think that using the new drug reference information in the app is a better way to determine drug dosages, and because I will continue to add new features to the app, which will not be available to those who do not update.

Note that Android users of EP Mobile still have access to the drug dose calculators, as well as the new features noted above.

I hope that at some point Apple changes its policy and adds physicians to the groups permitted to write apps that calculate drug doses.  After all, it’s what we do.

Countdown to version 3.6 release — Done! Released Mar 22, 2015!

 

Update on EP Mobile and Apple #2

As some of you are aware, the Apple App Store rejected an update to the EP Mobile app based on the presence of drug dose calculators in the app. The App Store guidelines state:

22.9 - Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities

For those who want more background on this issue, see these two previous posts (here and here).

I have decided to go ahead and remove the drug calculators from the app. All the drug calculator code remains in the app and, should Apple ever change their mind(s) on this policy, it will only require changing this single line of code to get them back.

// Sigh!
#define ALLOW_DRUG_CALCULATORS NO

I toyed with putting a backdoor into the app to activate the drug calculators, but I realize if I do something like that it would be my last Apple app. I have modified the app to make up for the loss of the drug calculators, and I think that with these changes you will continue to be satisfied by the app.

Here are the changes.

The creatinine clearance calculator had been embedded in the drug calculators, so it has been promoted to its own discrete module (which is something I should have done anyway a long time ago.

EP Mobile Main Menu Drug calculators gone, creatinine clearance calculator added
EP Mobile Main Menu
drug calculators gone, creatinine clearance calculator added

Instead of the drug calculators, there is a drug reference section. Each of the drugs that formerly had calculators now has detailed dosing information, as well as other useful information, akin to what you find in the Medscape app. (An aside: I think drug dosage information as opposed to drug dose calculators is acceptable to Apple, as it is present in Medscape and other medical apps. Medscape does not meet the Apple criteria mentioned above any more than EP Studios does: it is not “the manufacturer of those medications or [a] recognized institution […] such as hospitals, insurance companies, and universities.”).

Two new modules: Right Ventricular Hypertrophy and Drug Reference
Two new modules: Right Ventricular Hypertrophy and Drug Reference

What makes the drug reference section more useful than the similar information in Medscape is that there is a toolbar at the bottom of the screen that allows you to calculate a creatinine clearance on the fly, and then retains that information while you are trying to figure out the appropriate drug dose. Thus the only calculation done is the creatinine clearance; the physician and not the app decides of the dose. In many ways this is superior than having a drug dose calculator, because more information is presented that may be useful to help decide on the proper dose.  The drug reference section can also be expanded in the future to include information on other EP related drugs that don’t necessary require any calculations to dose, such as amiodarone or ibutilide.

A portion of the drug reference for dofetilide. Note the detailed dosing information and the Creatinine Clearance toolbar at the bottom showing the last calculated CrCl.

 

Finally the D’Avila WPW algorithm has been added, as well as a module on diagnosing right ventricular hypertrophy. I have left in the Warfarin Clinic module too. This module was not called out by Apple on the last review, so we shall leave it alone for now.

I will submit the update to Apple in the next 24 hours. Their review process usually takes about a week. If the approve it, I will not release the update right away, but will give some advance notice on Twitter. If you really can’t live without the drug calculators, then you should turn off auto-update and not update the app. I think though that the drug reference section with the built-in creatinine clearance calculator more than makes up for the loss of the drug calculators, and I encourage you to update the app when it is available.

If you happen to be best buds with Tim Cook, let him know that rule 22.9 is stupid and should be sacked.

How to Build a Better Electronic Health Record Part 27 — Modularity

Editors note: This 27th entry in our web series on EHR design is excerpted from Electronic Health Record Software: Principles and Practices, 3rd Edition, by Paul Lockhart and Janet Twombley-Chu, published by Addison Wesley, June 2089. 3378 pages. ISBN: 103-978-1-4919-0498-5. Reprinted by permission. Amazon listing [1].

Chapter 7
EHR Modularity

7.1 A History Lesson

In the brief overview of software design presented in the first chapter (Section 1.1.5 [2]), you learned that modularity is one of the fundamentals of good software design.  Given this, you might be surprised to learn that modularity was actually avoided in the design of early EHR systems. “But,” you might say, “a monolithic Electronic Healthcare Record system would be unwieldy, unusable, even unbearable to use. Doctors would refuse to use it, or if they did, patient care and physician efficiency would suffer. Certainly in a free market no one would buy such an EHR and the vendors of such a system would soon be out of business. Who in their right mind would design such a system?!”

Who indeed?

A little history lesson. Back in the beginning of the 21th Century, before the Great Revolt (see Section 2.3.14 History of EHR Design, Early 21st Century Failures [2]), monolithic medical software was the established norm. As anyone who has studied this period knows, EHR usability was not a high priority at that time.  Medical software design was actually dictated by politicians, whose lack of programming ability continues to this day. The political system of the time consumed (= wasted) vast amounts of money that required continual donations from large corporate sponsors.  This system of contributions to political campaigns (nowadays we would use the term “bribes”) ensured that a few medical software corporations remained dominant and profitable, while at the same time it eliminated competition from smaller companies.  Quid pro quo gamed the system so that that only a few EHR products could meet the so-called “meaningful use” criteria required by the bureaucrats. The need for data-sharing and interoperability inherent in systems designed for health care was anathema to these few powerful companies (less than 10 companies controlled this market in that era).  In a sense the clients for this software were not the physicians and other health care workers who used it on a daily basis, but the politicians who kept the EHR corporations in a dominant market position. The EHR software business was very lucrative, with applications (including various more or less useless support packages) selling for hundreds of millions of dollars. That’s not a typographical error. Even accounting for inflation, that was a huge amount of money in those days. These companies could sell software code to hospitals and physician practices for hundreds of millions of dollars at a time when far more complex software with tuned user interfaces often was given away for free or at a nominal charge (examples include Linux or the Mac operating systems). Naturally this was an inherently unstable if not absurd situation which was one factor leading up to the Great Revolt, but this is something the curious can look up themselves (a good account is given in [3]).

7.2 Rationale for Modular Design

Enough history! Why should EHR systems be designed to be modular? The answer has to do with the basic fundamentals of software design. To review, here are some of these principles of good software design:

  1. Minimize complexity. Computer systems use layers of abstraction to hide the complexity going on underneath the surface. When we press button on a screen, we don’t want to know what the ones and zeros are doing behind the scenes. All software programming uses abstraction to minimize complexity, but this principal does not stop with the software programmer. The user interface designer also has to adhere to this fundamental design principle and not present to the user anything more than the user needs to deal with.
  2. The Small Tools Principle, aka the Unix philosophy [4]. In brief, linking “small, sharp tools” together in a chain was the underlying design principle of the original Unix operating system, the ancestor of most modern operating systems.  Each software tool can be optimized for its own particular task, and tools can be combined to create larger systems.  This philosophy is modular design in a nutshell.
  3. DRY Principle (Don’t Repeat Yourself)[5] Duplication is evil, resulting in multiple copies of the same data, or coding errors when changes are made in one place and not another — there is a whole litany of disasters that can occur when this principle is ignored. An example of violation of the DRY principle would be having the same ultrasound report repeated in multiple places in the EHR, e.g. in the reports section, and copied and pasted into several doctors’ progress notes.  Inevitably this results in data becoming unsynchronized and increasing storage needs.  Hyperlinks, which refer to a single source of data, are a way to handle multiple references to the same data without violating the DRY principle.
  4. Open Software Principle.[6] In health care as in other data-centric programming endeavors it is important to design an open data standard and open APIs.[7] Application Programming Interfaces (APIs) should be universal and data should be shareable.  These are the bedrock on which EHR applications can be built.  While open standards may not be perfect, they are at least open, and can evolve over time. Witness the Internet Protocol (IP). Designed to transmit data at a time when people used dial-up modems, it was robust enough to handle unanticipated new uses such as streaming video, and could evolve as needed: for example when address space ran out with IPv4, the IPv6 standard was introduced[8].
  5. User Interface Independence.  While the backbone to an EHR (the data format and APIs) should be universal, open, and relatively fixed over time, the overlying UI can be independent and can evolve rapidly.  UI apps can be novel and competition among vendors is healthy. The UI is the top layer of the software stack and it is the sole layer that the user interacts with.  It is the layer most open to creativity (not all users want the same UI).

A modular EHR design fulfills all of the above principles. The UI is a separate module from the EHR database backbone, communicating with it using well-defined APIs.  The UI design is based on the role of the user, the situation of the user and the preferences of the user. For example, the appointment clerk wants to interact with a calendar and a list of open appointments. The nurse wants to be notified of doctor’s orders and moment to moment patient status changes. The doctor wants to review old medical records or to write a progress note. The same EHR UI cannot serve all these roles simultaneously. Likewise the work environment plays a role in UI design.  The doctor at his or her desk may want to interface with his or her laptop or workstation using a keyboard. When out making rounds in the hospital he or she might want to use a smart phone to record notes via speech-to-text software. Thus the EHR user interface used will be different depending on these situations, and should be optimized for each of these situations.  EHR systems designed using modules allow this optimization, whereas monolithic, “one size fits all” designs are doomed to failure, as history shows.

In the next few chapters we will delve into the practicalities of modular EHR design.

7.3 Exercises

Exercise 7-1. Using the EHR design toolkit[9], design a UI for entry of vital signs. For writing a doctor’s progress note. Design these for data entry on both a laptop and mobile phone. Try to use the same interface on both devices and then try customizing the interface based on type of device. Which was easier to design? Which was easier to use? Why?

Exercise 7-2. You are back in the early 21th century and have been employed by the Acme software company to design a secret proprietary database format for their EHR. You decide to argue with your manager about the need for a shareable as opposed to secret data format. What arguments would you make? How would your manager likely respond?

Exercise 7-3. Using the toolkit design a billing module. How do you feel the billing request should be generated? Should the amount billed be based on patient complexity or on the specific task performed? Which type of bill is easier to generate? Which would be harder to justify if challenged?  Which more open to abuse? Which type of billing software would you prefer if you were a health care provider and why?

Exercise 7-4. You have been tasked to write a UI system for an EHR. Your clients argue that the ability to cut and paste is crucial, as they operate in an environment that is “paid by the word.” They want for example to copy X-ray reports and paste them into their notes to make them appear more thorough. What arguments can you make against this practice (hint DRY principle)?

Exercise 7-5. Which is better: an annotation in the EHR that the medical review of systems (ROS) was negative or a template that automatically inserts a full 12 point ROS with all systems checked as negative? Give the pros and cons of each system (e.g. Pro: a full template reminds the doctor what points he asked the patient; Con: the full template takes up more space and is not a guarantee that every point checked as negative was actually addressed). How would the billing system referred to in exercise 7-4 bill for these two types of documentation?  Could repeating the same ROS in every different consulting doctor’s note for a patient be considered a violation of the DRY principle?  Justify your response.

—————————————————————–

[Editor again: The post above was inspired not only by the stodgy but somehow comforting style of computer textbooks, such as those published by Addison Wesley, but also by a recent conversation I had with an app designer from Chile whose company designs modular mobile software (the Teamscope app) that interfaces with medical data (clinical research data, but the same principles apply to interfacing with EHR data).  I don’t usually write software reviews (well, one exception comes to mind, my game review of the EPIC EHR), but I think these developers are on the right track.]

Footnotes:

[1] This is a listing in a future version of Amazon, hence it is not available yet.
[2] Only available to purchasers of the full version of this text.
[3] This citation refers to a work that has not been written yet.
[4] See Eric Raymond’s The Art of Unix Programming
[6] This citation also refers to a work of the future that doesn’t exist yet.
[7] Ibid.
[8] http://en.wikipedia.org/wiki/IPv6 Yes Wikipedia is still essential in the future.
[9] The EHR toolkit will be available when the book is published, 74 years from now.

All the President’s Tapes

The Nixon Defense
The Nixon Defense

Richard Nixon’s downfall, a.k.a Watergate — a word whose suffix has become a part of the English language, has always fascinated me. In the summer of 1973, poised between graduation from college and the start of medical school, I spent an inordinate amount of time in front of the television watching the Senate Watergate hearings. In those days before 24 hour cable news and CSPAN it was almost unprecedented for the networks to “interrupt our regular programming” and carry such an event live. I remember John Dean’s relating his March 21, 1973 conversation with Nixon, telling him there was a “cancer on the presidency,” a warning that Nixon ignored, instead reassuring Dean regarding the estimated million dollars of hush money that the Watergate burglars wanted that “we can get that … I know where it can be gotten.” I remember Nixon’s top men, Mitchell, Ehrlichman and Haldeman, stonewalling it, denying the president had any knowledge of the cover-up. At the time it looked like it would boil down to Dean’s word against the president’s, with no evidence against the president other than hearsay. Then, on July 13, 1973 a relatively minor character, Alexander Butterfield, an assistant to the president, was called before the Senate committee in closed session. Apparently one of the lawyers on the committee (a Republican) had become suspicious by the amount of detail available relating to notes about a certain White House conversation, and asked Butterfield directly if there was a recording system in the White House. Butterfield, one of only a very few who knew of the existence of the system (Nixon’s top aides, other than Haldeman, did not know about it) had planned not to reveal the system, but faced with a direct question and the threat of perjury, had to answer honestly. So in public session on July 16th, Butterfield was asked the question by Fred Thompson (yes that Fred Thompson, who was a minority counsel for the committee) before all the TV cameras, and to the astonishment of everyone (including me who saw it live) revealed that every conversation and phone call in the Oval Office and in the president’s Executive Office Building was recorded automatically on tape.

The tapes of course are what destroyed Nixon’s presidency, a self-inflicted wound worthy of the most profound Greek tragedy. It is difficult to fathom the hubris of the man who wanted his every presidential conversation preserved for posterity and then went on to discuss with his aides an ever-evolving and increasingly complex cover-up scheme while his secret taping system was recording every word. Nixon eventually had to give up the tapes after the Supreme Court unanimously forced him to do so, and certain of the tapes, like the June 23rd 1972 “smoking gun” tape, in which Nixon has the FBI limit its investigation of the Watergate burglary for “national security” reasons, led immediately to his resignation. Beyond these several infamous tapes, there are hundreds of hours of tapes relating to Watergate that up until this point had never been transcribed or documented. In John Dean’s book The Nixon Defense: What He Knew and When He Knew It these recorded conversations are described and from the book there emerges a more complete picture of Nixon and what happened that led to his downfall.

The June 17th, 1972 Watergate break-in and bugging of the Democratic National Convention headquarters seem to have occurred due to the over-exuberance of certain of Nixon’s cronies who worked in the Committee to Reelect the President (which actually had the acronym CREEP) including former attorney general John Mitchell, born-again post-conviction Chuck Colson, and possibly Nixon’s top aids John Ehrlichman and H.R. “Bob” Haldeman. They had hired Gordon Liddy, a loose cannon if ever there was one, to find out what the Democrats were up to. Nixon, who it is pretty clear did not know of the Watergate activities beforehand, nevertheless set a tone in his administration that dirty politics was the norm and his associates, only too eager to please him, ended up going beyond the bounds of legality to do so. After the Watergate burglars were arrested, from the very start Nixon tried to limit the political damage to himself. After all, he was running for reelection. He also felt he had to prevent his political allies from going to jail. He had a very difficult time in actually firing Haldeman and Ehrlichman, his two top aides, when it became clear he had to do so. In the Nixon-Frost interviews one can almost feel sorry for Nixon when he talks about this. Yet for the most part the recorded conversations reveal a cold, calculating, ruthless character with whom it is difficult to sympathize.

Nixon based his defense around the March 21, 1973 conversation with John Dean, the “cancer on the presidency” meeting. Reading this in the book (or listening to it; the important conversations are on YouTube), it is clear that Dean, though involved in the cover-up initially, was trying to warn the president (he was after all the president’s counsel) that he risked becoming entangled in the Watergate cover-up. Dean revealed the blackmail demands of the indicted Watergate burglars and clearly seemed surprised that Nixon was willing to raise money to pay them off. Later Nixon and Haldeman would claim that Nixon said on that day that “we could raise a million dollars … but it would be wrong,” but that was a bold-faced lie (here is what he really said). Nixon later blamed the cover-up on Dean and said that he (Nixon) started his own personal investigation into Watergate after the March 21 meeting with Dean.  This “investigation” was yet another cover-up created by Haldeman and Nixon.  It is ironic that in the recorded conversations when this March 21 meeting was discussed, Nixon is constantly worried that John Dean had somehow carried a tape recorder on his person during that meeting and had recorded evidence that would show Nixon was lying. Strangely, Nixon seems to have given little thought to the fact that he himself had made a recording, and that this recording would eventually become public, indeed proving that he had lied. Only occasionally did Nixon give any thought to the automatic recording system. At one point he briefly considered destroying the tapes before their existence was discovered, but Haldeman talked him out of it, because of the potential loss to history. Ah, hubris!

The book may not be as fascinating to those who did not live through the era as it was to me.  It is a long book, and for those interested in Watergate in less detail, Woodward and Bernstein’s All the President’s Men or John Dean’s earlier Blind Ambition are good. Nevertheless all Americans should be familiar with Watergate and how the government narrowly avoided a constitutional crisis.  Compared with the governmental dysfunction today, this was an era when the process of government actually worked.  Though Nixon had his defenders amongst the Republicans, as the evidence piled up against him, both parties united in the impeachment process. The Justice Department, the Supreme Court, and the Congress did what they needed to do. Despite the abuse of power in the executive branch, the other branches of government functioned properly and the balance of power built into the Constitution by the founding fathers saved the day. One wonders though what the outcome would have been if Nixon had not recorded himself, or had destroyed the tapes early on.

The Nixon Defense is probably the definitive Watergate book. Nixon was right about his tapes. They are of great historical interest, but not in the way he intended. They reveal a picture of the downfall of one of the most interesting political characters of the 20th century, a presidential reality show that, like most reality shows, can be banal and riveting at the same time.

Update on EP Mobile and Apple

This is an update on my previous post which dealt with Apple’s rejection of an update to the EP Mobile app because it contained drug dose calculators. According to a clause buried in the App Store Review Guidelines (section 22.9, to be precise),

22.9 apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities.

EP Mobile has included such dosage calculators from its very first version, but for some reason the current update (which just added the D’Avila algorithm [PACE 1995;8:1615-1627] for determining accessory pathway location) triggered the discovery that the app was in violation of this rule. I was unaware of this rule, and I don’t think the rule was extant when I submitted the first iOS version of the app in 2012.

I submitted an appeal to Apple stating that as physicians have to calculate drug doses every day there does not seem to be any reason a physician-programmer should not be permitted to write an app to calculate drug doses. A drug company could only produce an app for their specific drug, so they could not duplicate the functionality of having multiple drugs from different companies in one app. I don’t see any incentive for a hospital, insurance company, or university to develop this kind of app, though I suppose it is possible they could. As a physician I developed the app because it was useful in my daily work. It makes figuring out drug doses for certain anti-arrhythmic drugs or anticoagulants much easier. As far as I know that specific functionality is not duplicated in the App Store.

Apixaban Dose Calculator
Apixaban Dose Calculator

Apple stuck to their guns and maintained the app update could not be approved. On Twitter a colleague tweeted this article from iMedicalApps of June 2013 which discusses the problems that Apple has with drug dosage apps. Apple is probably concerned about the FDA’s potential scrutiny of medical apps and possible legal liability for drug dose calculators that could give erroneous information. In any case this article points out that the Medscape app also provides drug dosing information (though only as written information, not as a calculator — I’m not certain, but it appears that the App Store Review Guidelines may have changed from banning dosing information altogether to just banning dose calculators). Medscape is owned by a private company (WebMD) and is neither drug company, hospital, insurance company nor university.

Medscape iPhone app provides drug dose information
Medscape iPhone app provides drug dose information

If the Medscape model for presenting drug dose information is legitimate in Apple’s eyes (as opposed to a violation that just hasn’t been noticed yet), it would be possible to retool my app to provide a creatinine clearance calculator followed by the specific dosing information for each drug. This is not as slick as having the answer just pop up in a dialog box, but on the other hand does show exactly what the dosing criteria are and removes the computer from the decision making process. However if I go that route there is no way to save one of my favorite parts of the app, the warfarin dose calculator. It is an implementation of an algorithm from this paper and provides suggested dosing changes for patients on chronic warfarin based on their INR, INR target, weekly total dose, and tablet size. It suggests how many pills the patient should take each day of the week. Whoever makes generic warfarin is not likely to develop a warfarin dose calculator like this, nor is anyone else.

iOS Simulator Screen Shot Feb 20, 2015, 7.50.40 PMiOS Simulator Screen Shot Feb 20, 2015, 7.50.23 PM

At this point I have requested further information from Apple. Apple has rejected the update to EP Mobile, but they have not requested I withdraw the current version of the program (which still has all the drug calculators in it). Certainly they might do so. In the hopes that their position will change, I have decided to withdraw the update and leave the app as is, unless Apple tells me otherwise. This is not a good long term strategy as I like to update the app frequently to keep it up to date with what is going on in electrophysiology, and I am now blocked from making any updates that don’t remove the drug calculator functionality. If I do release an update that does not contain the drug calculators, I will announce it well ahead of time on Twitter and on this site to give users the option not to update the app. I should also point out that the Android version of the app has not been challenged (Android is very hands off compared with Apple).

I am hoping that Apple will consider this further, based on this section of their App Store Review Guidelines:

This is a living document, and new Apps presenting new questions may result in new rules at any time. Perhaps your App will trigger this.

Who Can Write a Drug Dosage Calculator?

Several years ago I had an idea for a smartphone app that could be used to calculate doses for drugs that are prescribed frequently to patients with heart rhythm problems. These drugs include antiarrhythmics such as dofetilide and sotalol, and the new oral anticoagulants such as dabigatran and rivaroxaban. These drugs are handled by the kidneys, and dosage is dependent on kidney function. The package inserts for these drugs advise the correct drug doses based on the calculated creatinine clearance, a formula that involves the patient’s weight, age, sex and serum creatinine. Once the creatinine clearance is calculated, a lookup table is used to determine the dose. For example, here is the rivaroxaban dosing information:

xarelto

Medical calculator apps are common and invariably include a creatinine clearance calculator. The problem I had was trying to remember all the different creatinine clearance cutoffs for each dose of each drug. This seemed like perfect job for an app. Just fill in the information needed to calculate the creatinine clearance and have the app figure out the creatinine clearance and look up the dose. Thus my app EP Mobile was born. Over the years I have added many more modules to the app, including everything from algorithms localizing accessory pathways to entrainment mapping, but the original concept was to provide the drug dose calculators which remain a key part of the app.

Or maybe not. I routinely update the app, and submitted an update a week ago to Apple (not related to the drug dose calculators). For the first time ever I received a rejection from Apple. They quoted this from their App Store Submission Guidelines:

22.9 Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities

Attached were screenshots of the offending calculators:

A drug dose calculator
A drug dose calculator

I am a physician. Part of my job is to calculate medicinal dosages, as the legalese above terms it. This is not the job of hospitals, insurance companies, or universities. Ultimately I as a physician am legally responsible for calculating correct dosages. Yet somehow physicians are left off the list of those qualified to submit apps that calculate drug dosages. The development of an app that simply does what the drug package insert instructs the physician to do in order to calculate a drug dosage, but in an easier manner, should not be restricted to drug companies, hospitals, insurance companies (insurance companies?) or universities. The few of us physicians who are also app developers are certainly in as good a position as any of these other parties to develop apps like this. The algorithms to calculate these doses are extremely simple.  As my app is open-source, the source code is freely available for anyone to inspect to make sure the calculations are coded properly.

I appealed this decision to Apple and I hope they reconsider. I doubt they will. I see the handiwork of Apple’s legal department here. Don’t trust physicians to figure out what tools are useful on their own. Far better to let them go back to carrying around a bunch of drug company propaganda plastic rulers and let them do those creatinine clearance calculations by hand, using long division. Just like back in the good old days.

Memories of Van Cliburn

Van Cliburn
Van Cliburn

In the long struggle between the United States and the Soviet Union, from the end of World War II until the end of the Soviet era in 1991, there were intense moments of high drama, like the Berlin Blockade and the Cuban Missile Crisis, intermixed with moments when the icy hostility melted a bit. With both countries armed to the teeth with nuclear weapons of a power sufficient to destroy out planet many times over and a firm policy on both sides with the ironically apt acronym MAD (Mutually Assured Destruction), the stakes that world leaders were playing with could not have been higher. The path that eventually led to the defusing of this dangerous situation was not direct. Certainly the final act was played out by Ronald Reagan (undoubtedly his greatest role) and Mikhail Gorbachev, but long before that a young Texan, a classical pianist, was one of the first to breach the barriers between the two countries. In 1958 he won the Tchaikovsky Piano Competition in Moscow, the first American to do so. He played two great Russian concertos in the last round of the competition: the Tchaikovsky 1st and the Rachmaninoff 3rd. He won the hearts of the Russian people as well as the judges of the competition. Nevertheless they cleared their decision with Premier Nikita Krushchev. Krushchev reportedly asked them: “Is he the best?” When answered affimatively he stated: “Then he should win.” After the competition he returned home to a ticker-tape parade in New York City, and a full concert schedule. His records (LPs) were all hits, and I personally bought a lot of them. In later years he received some criticism from music reviewers for a conservative repetoire and rote performances, but at his peak he was a tremendous musician. His recordings of the Prokofiev 3rd Concerto and the Rachmaninoff 2nd Sonata are cases in point.

Van Cliburn and Krushchev
Van Cliburn and Krushchev

I first saw him perform live in a concert that I believe took place in 1966 in Philadelphia. He performed 3 piano concertos in one concert with Eugene Ormandy and the Philadelphia Orchestra. The 3 concertos were the Mozart number 25 in C major, the Beethoven 4th, and the Rachmaninoff 2nd. I well remember his appeararnce on stage, sitting very tall and straight-backed on the piano chair, swaying side to side with the music. Playing 3 concertos in one concert was and is quite a feat. It was rebroadcast on the Philadelphia classical music channel (WFLN) a few weeks later and I made a tape recording of the whole concert from my little transistor radio. Over the years I lost all my old tapes. I wish I still had that one. I have never heard of another recording of that historic concert.

Cliburn appeared frequently at the Robin Hood Dell concerts. These were summer concerts performed outdoors in Philadelphia. On these occasions he wore white formal attire. My friends and I attended these concerts and at the end of each concert, went up to stand in the front row to watch Cliburn give a series of encores. We went often enough to know that when he played Chopin’s Polonaise in A flat it would be the last encore of the evening. He was always generous with his encores and gracious to his audiences.

Van Cliburn died on February 27, 2013 at age 78. He played for presidents, world leaders, and for all the rest of us. He was a sorely needed bit of warmth in the midst of the Cold War. By any measure he was a great American and I count myself fortunate that I was able to see him perform in person on several occasions.

Somewhere in the Middle of the Atlantic Ocean

Just a brief post today (internet service is poor and expensiveIMG_0008). Right now I am 3 days out from New York City, nearly halfway to Southamptom, England, on the majestic Queen Mary 2. This is the view out my cabin balcony. The ocean is shrouded with fog. We are moving along at 23 knots, slower than the liners of old that made the crossing in 5 days — a concession to fuel economy and an attempt to keep the ship as stable as possible in the rough waters. Surprisingly, the outside air temperature has been warm in the high 60s. It is windy, but comfortable out on deck with just a light jacket on despite the date being January 6th.

The 7 day crossing allows adequate time to stop and contemplate the wonder of this world of ours, tucked away in a spiral arm of one of billions of galaxies. There is so much water here on our planet! It is hard to appreciate unless you spend days on a ship crossing an ocean. Of course not many people have time to spend a week on ship, especially hard-working Americans. By the time you arrive at your destination, your week of vacation is over, and you’d have to fly back. Indeed most of the travelers on the ship are British, of retirement age, or both. Ship travel is actually a bargain, considering what you get. It is like eating in a fine restaurant 3 times a day, staying in a fancy hotel for a week, and traveling to Europe all for just a little more than a plane ride. Yes you can do it for less than a thousand dollars a person. But time is money and one thing people don’t have much of these days is free time for themselves.  So instead we have to suffer being crammed into ever-shrinking space in airplanes.

The ocean is ever-changing and yet always seems to remain the same. Now that we are beyond the continental shelf, it is miles deep. There is a vast unknown world out there. It is an awesome and fearful sight. It reminds me of how weak and small we are compared with the power of nature. One can’t help but admire and wonder at the pluck and certainly foolhardiness of those who first crossed it in their fragile wooden boats.

Early this morning we crossed close to the site where the Titanic went down, over a hundred years ago, perpetual reminder of how we are never as smart or clever as we think we are.

Tips for an Extended Stay In Europe

IMG_20140615_103318243_HDRMy wife and I are heading back to Europe again for an extended stay.  A year ago we did the same thing, moving to Paris right after we both retired from our medical careers.  We are planning another 6 month stay.  Prior to this second visit, I was able to think about the things that we did right and the things we did wrong on the first visit. Here’s some of the lessons learned:

  • Staying more than 3 months in France. This requires a visa (in the UK you can stay for 6 months without a visa). Or, you need to be or be married to a European Union citizen.  If you are married to an EU citizen, as I am, you can apply for a Carte de Séjour, which is what I did last time. Be warned: it is much easier to get a visa!  If you go the Carte de Séjour route, you must bring your birth certificates, marriage license, financial records, must open a bank account in France and show you have a steady income, must get all your documents in English translated into French by a state-approved translator, and must be prepared to struggle with the French bureaucracy. Only the persistent persevere. I was able to complete the process, but I don’t recommend it unless your are planning permanent residency in France and have no other option.  Fortunately it will be easier for me this time.  Due to a recent change in British law, I was able to obtain UK citizenship via my mother’s being a UK citizen when I was born (prior to the recent change in the law, you could only claim citizenship through your father, believe it or not!). So I don’t need a visa and can stay in Europe as long as I want through my new UK citizenship.
  • Packing. Last time my wife and I took two moderately sized suitcases each and our carry-on bags with us. This time we are down to one suitcase each. We ruthlessly cut down on what we are bringing. In France nearly everyone dresses in black or gray clothes, so no point in bringing any other colored items. Except for our dictionaries and this essential book we are not bringing any physical books. They are just too bulky and heavy. As much as I love real books, this is one situation where eBooks are essential.  Last time I brought stuff I didn’t wear or use at all. Not this time.
  • Electronics. In order to continue writing posts and developing apps in Europe, I need my electronic gear! When I first came over last year, I was worried that I couldn’t get by with just my laptop with its 15″ screen, as opposed to my big screen system at home. As I have already discussed this is not a big deal anymore and I am totally comfortable doing all my computer work on my Mac Book Pro. Since I do Android and Apple app development, I need at least one device of each for app testing. I have my Android phone (Motorola Droid Maxx) and an Apple iPad Mini 2. I called Verizon about unlocking the phone and apparently all their 4G phones are unlocked by default (an interesting tidbit I hadn’t known). When I get to France I will take out the sim card (it is removed by pulling out the volume control) and get a French sim card. Cell phone data and phone minutes are very cheap and easy to buy as needed in France. Never use your US phone service in Europe, even something like Verizon’s International Plan. It is crucial to turn off your service when you leave the country, or you might be stuck with huge data fees. With all the data syncing that phones do in the background, you can easily run up hundreds of dollars of fees in a few minutes. Fortunately, at least with Verizon and AT&T, it is possible to put your contract on hold while you are abroad. You pay a minimal fee ($5-10 per month), are able to restore service when you return to the States, and as already mentioned, get to use the same phone in Europe with a European sim card. Note that the phone needs to have GSM capabilities which most modern phones have, and may need to be unlocked by the cellular provider — call them to do this. The only disadvantage to suspending or pausing your service is that the contract period is extended by however many months you suspend service, and your eligibility for a phone upgrade may also be delayed.
  • Pausing other services. Services like cable, satellite, internet, phone, trash pickup and so forth should also be paused. This is easy to do online or by calling each company. Again the monthly cost is low while these services are paused, and it is easy to resume service once you return. Mail delivery is a special case. For a brief trip you can have the Post Office hold your mail, but for a trip lasting months this is not possible. We use a mail forwarding service (US Global Mail) that can sort and scan the mail we get, with the option to open and scan or forward what we want to us. It is important to try to go paperless with all your utilities and services, so that you minimize the physical mail you receive, as it costs money to forward mail to France.
  • Health insurance. It is necessary to carry Health Insurance abroad. We use GeoBlue. It is relatively inexpensive but requires you maintain a Health plan in the US as well. We are working on getting health insurance in Europe which would be cheaper, but you can only qualify for this if you are European citizens.
  • Internet. I should mention that the internet service in France is very good, especially compared to the disgracefully slow service I get living just outside of Denver. Free internet at cafés and restaurants is somewhat less available than in the US. Usually you have to ask for a sign-on code to use this. There are some public hotspots in parks, though this is not as widely available as I would like.  TV and internet phones come with residential internet service, and the internet phones are handy for calling back home for free.

So these are some of the tricks we’ve learned from our last extended stay in France. I’ll be happy to answer any questions either here or on Twitter (@manndmd).

Is Medical Board Certification Testing Outdated?

vintage-elevator-operatorTimes change, and, as with Darwinian natural selection, those who adjust survive and those who don’t perish. Henry Ford’s assembly line greatly ramped up the production of automobiles but put many people out of work. The elevator operators of my childhood are long gone. Those who have embraced new technology have usually thrived; those who have fought it or failed to understand it have suffered. Witness the success of Amazon versus the demise of Borders.

Medicine is a conservative business. Who else still uses beepers and fax machines? Doctors have been slow to adapt to new technology, such as Electronic Health Record systems. Nevertheless, despite challenges, I don’t see doctors going the way of elevator operators, at least for the foreseeable future. But there is a medical industry that does need to go the way of the dinosaurs: the medical testing industry.

To briefly recap, doctors used to take a board certification exam after residency that provided lifelong certification.  In the case of internal medicine doctors the examination agency is the American Board of Internal Medicine (ABIM) which is one of the specialty boards that make up the American Board of Medical Specialties. Arguing that the rapid changes in medicine warranted periodic recertification, but probably also noting that once per lifetime certification is not as lucrative as repeated certification, the ABIM subsequently imposed a requirement that certification testing had to be renewed every 10 years. Still not satisfied, the ABIM came up with Maintenance of Certification (MOC), consisting of a lot of busy-work for the already busy physician that includes a mandate to carry out non-IRB approved research on physicians’ patients.

Judging by social media, MOC has really hit a nerve among physicians. I and many others (e.g. see Dr. Wes’s website, containing many good articles on MOC and exposés of the ABIM) have written about MOC, and the whole board recertification fiasco has finally reached the mainstream media in a recent New York Times article.  Despite the aversion to MOC, many physicians don’t seem to be as upset by the every 10 year retesting. Yet the whole concept of sitting down to take a test as a means to assure that a doctor knows what he is doing is as outmoded as using a dial-up modem to assess the internet.

When I was in academics, my colleagues played a game that consisted of arguing a point by quoting some obscure statistic from some obscure study. Something like: “Well, in the MADEUP-VII trial, subgroup analysis of incidence of restenosis based on horoscope sign showed that Scorpios had a 32% risk reduction compared with Virgos, with p less than 10 to the minus 20th.” I was never too good at that game, which is one reason I went into private practice, only to learn that private practice docs played the same game. I’ve considered doing a study comparing these off-the-cuff literature quotes with the actual published data. I don’t think the correlation coefficient and p values would be very good.

There’s really no need to play that game anymore. Just as with the invention of writing poets no longer needed to memorize the poems of Homer, and with the invention of the printing press monks no longer needed to copy books by hands, with modern technology I don’t have to memorize detailed results of medical studies for later regurgitation at Grand Rounds. Today I carry around in my pocket a computer with always-on internet access — a computer much more powerful than the computers that were used to send men to the moon. I have apps that can check drug doses and watch out for drug interactions. I can look up anything in a few seconds. With this capability it is not only unnecessary, but would be reckless for me to rely purely on my memory, especially when dealing with the potentially catastrophic results of making a mistake.

I’m not saying that doctors don’t need to know any facts or memorize anything. I’m not saying that doctors shouldn’t attend lectures, go to medical meetings, or carry out Continuing Medical Education. But the fact is that, as with any craft, the best teacher is the work itself.  Being asked to regurgitate memorized facts on a test is not a test of anything other than the ability to memorize facts. It is not a reflection of how doctors do their jobs today, and is not a indicator of competence in the field of medicine.

The medical testing industry needs to go the way of the elevator operator.