Why is Facebook Worth $75 billion?

Last month a story stated that Facebook was valued at $75 billion on the so-called “second market.” This figure was repeated in a Slate post today. Even if Facebook’s true value is one tenth of that, it’s a lot of money.

Will someone please explain to me why it is worth so much? OK, I understand that Facebook has over 500 million active users who spend over 700 billion (yes, billion) minutes per month on the site. That is certainly a huge number of potential advertising targets.

But do you know anyone, anyone at all, who has ever clicked on Facebook ad on purpose? I don’t, nor do any of my Facebook friends. The ads are mostly quite cheesy. See screen capture below.

[Slightly off point but I can’t think of even one thing to do in Westchester County or North Jersey combined.]

I realize I am but a mere doctor and doctors are notoriously bad businessmen and investors. It’s likely I just don’t get it. But, in fact, I just don’t get it.

Scrub Suits in Public: Yes or No?

Medical personnel shouldn’t wear scrub suits in public because of the risk of spreading infection. That is the opinion of a retired anesthesiologist named David A. Martin, whose comments were featured in a recent post by William Heisel, a noted health care reporter.

Dr. Martin was particularly concerned about scrub-clad staff patronizing restaurants. He backed up his feelings by asking two such individuals to leave a restaurant, which, surprisingly, they did. His actions were based on the theory that scrub suits are contaminated with hospital-acquired bacteria which could be transmitted to the general public.

While there are numerous reports that scrubs and lab coats worn by medical staff are in fact colonized by pathogens, there are no published papers linking bacteria on scrub suits, lab coats, neckties or cell phones to documented transmission of disease. [See bibliography below.]

So how should we medical people react to Dr. Martin’s position?

In an era where nearly every day a new report emerges that medical errors are killing more patients than the bubonic plague, we need to be aware of our highly visible profile. In the words of the noted philosopher, Andre Agassi, “Image is everything.” Although I doubt very much that anyone is harmed by a nurse or doctor wearing a scrub suit in a restaurant, it just does not look good. Scrubs should also not be worn on a bus or on a trip to the mall.

I would hope that the guys who work in sewage treatment feel the same way about their attire.

Bibliography
Scrub suits & lab coats
Scrub suits & lab coats
Scrub suits & lab coats
Scrub suits & lab coats
Scrub suits & lab coats
Cell phones
Ties

Still more “Why our education system is in trouble”

I have shown you a few previous examples of rather bizarre questions from a fifth grade mathematics book here, here and here. Here’s another. In case you can’t make it out, it says “Explain why you have to rename 4 1/4 if you subtract 3/4 from it."


Ok, the authors of the book apparently have decided that the only way a fifth grader could solve this question would be to “rename” 4 ¼ as 3 5/4 and subtract ¾. Several fifth graders confronted with this rather easy problem simply did the calculation in their heads without “renaming” the larger number.

However, in today’s math world, you absolutely must “show your work.” Thus, a child with even a modest flair for math is told that solving such a question “in your head” is not permitted. So instead of rewarding a kid who “gets it” without the need to “rename” anything, he must go to the trouble of showing his work for every similar problem.

This results in the child a) questioning the sanity of the system and the teacher and 2) seeing math as drudgery rather than enjoying it. And people wonder why China is surpassing the U.S. in science.

PS: Isn’t the instruction to “rename” the number oddly worded? Why not use the word “convert”?

A Radiologist’s Idea of a Definitive Report

Here is an excerpt from the text of a CT scan report I received today:

The appendix is dilated and mildly thick walled with mild surrounding induration [sic]. There is gas within the lumen, but there is also an appendicolith at the base of the appendix with a smaller appendicolith in the mid appendix. The findings are concerning for appendicitis. No other inflammatory changes are seen. There is no adenopathy or free fluid.

IMPRESSION:

The appendix is dilated and mildly thick walled with suggestion of mild surrounding inflammatory change, although there is air within the lumen. There is an appendicolith at the base of the cecum. The findings are suspicious for mild acute appendicitis. Clinical and laboratory correlation are recommended.

I think it's somewhat mild. Don't you?

As the old joke goes, what is the radiologist’s favorite plant? The “hedge.”

EMR Follies, Part 2

The other day I posted a story about one of the pitfalls of the Electronic Medical Record (EMR). Here are a few more.

1. In some versions of the EMR it is very easy to copy and paste. This leads to the creation of duplicate progress notes such as the following passages which were buried in a pair of nearly identical 500+ word notes:

03/09/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”
03/10/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”

2. The ability to copy and paste coupled with the ease of dictation results in voluminous notes. As you may know, coding (directly linked to reimbursement) for visits is based on the extent of the care given. “If it’s not documented, it didn’t happen,” goes the saying. But now we have the inverse. It is so easy to document that notes are easily puffed up to “document” extensive encounters with every patient.

3. Because they are so long, they are difficult to read and the black-on-white appearance of the words on so many screens causes the reader to skim over most of the note and go straight to the plan or recommendations.

4. For privacy reasons, most of these programs shut down if one does not touch the keyboard or mouse within a minute or two. This means if one gets a phone call or other distraction, one often has to log in again. Again for privacy reasons, passwords must be changed frequently. I am unaware of massive attempts by hackers to access medical records. Most of the time they really aren’t that interesting.

5. Nurses’ notes have become very easy to write thanks to pop-up windows. In addition, regulatory agencies have mandated “documentation” of multiple nursing interventions and screens (likelihood of falling, skin condition, pain assessment, nutrition, etc, etc). Not only is the nursing record unreadable due to its size, the zeal to document has taken the nurse away from the bedside. They are so busy documenting that they have no time for patient care.

6. This is analogous to the lament from patients that their doctor no longer talks to them but rather sits facing the computer monitor so he can document his comprehensive visit.

7. Reviewing a record for assessment of quality of care is almost impossible as it is no longer possible to “leaf through” a medical record. And if the record is printed, one gets a two-foot high pile of paper with every iota of information about the patient’s admission. And it’s all black text on white paper so important items cannot be distinguished from garbage.

Yes, I know I have omitted references to the good features of the EMR, (instant access—while sometimes cumbersome—to old records, legibility, etc). But it is my blog after all.

EMR Follies

Soon I will write a more definitive blog on the shortcomings (and there are many) of the electronic medical record (EMR). I am working at my clinical job this weekend. I couldn’t resist sharing this with you. At my hospital, the dictation system is great. Dictations of the history and physical (H&P) examination usually appear in the EMR within an hour or so of their dictation. When the physician logs in, he sees a list of documents to be verified with his electronic signature.

I was asked to consult on a patient on the internal medicine service today. Below is a screen capture of the list of her medications in the dictated H&P. The H&P had been verified by the doctor who dictated it. If you can overlook the fact that the patient was on 22 different meds (not a record for patient on the medicine service, by the way), check out #13 on the list.


Yes, it is the wonder drug _ _ _ _ _. So what happened? For whatever reason, the doctor obviously did not read his lengthy H&P. (Remember, it was a medical patient.) He signed off on it without a glance. Should I ignore this and go ahead with surgery on the patient? What if the drug was Coumadin, an anticoagulant, which is often given in a dose of 5 mg?

What's that you say? Ask the patient? Well, like many patients, she has no idea what medications she is taking. The list was brought in by a relative and is nowhere to be found. Ask the doctor who did the H&P? No, sorry. It's a hospitalist service and she was admitted two days ago. The doctor is off this weekend. Via a blood test, I was able to determine that it was not Coumadin.

Stay tuned for more examples of EMR follies.

Resident Participation in Surgery: Analysis and Opinion

A recent column about resident involvement in the operating room by surgeon Pauline Chen in the NY Times has drawn a fair number of comments as has a similar post by blogger KevinMD. Both refer to a paper published on-line in the Journal of the American College of Surgeons. The abstract of the paper suggests that the presence of residents in the operating room is associated with somewhat higher rates of short-term morbidity and complications but lower mortality rates.

As is the case for many medical topics on the Internet, everyone would benefit from reading the entire paper and not just the abstract. There are some issues. For example, the paper says that resident involvement leads to more complications. It is not clear to me how the presence or absence of a resident in the operating room has any impact on the development of postoperative complications such as urinary tract infection, venous thromboembolism, renal insufficiency, cardiac events or neurologic events.

Furthermore, the supposed mortality benefit of having residents was seen mostly in the most complex cases. Obviously, a number of confounding variables (attending surgeon experience, nursing experience, hospital and surgeon volume, ICU care, to name a few) may affect the outcome of a complex case. Also, the authors did not describe the level of resident participation. Were the residents merely holding retractors and assisting or did they perform significant portions of the procedure? This information was not available due to the retrospective nature of the study.

Most importantly, the body of the paper (not the abstract) concludes as follows: “Ultimately, there appear to be no major, clinically significant differences in surgical outcomes based on resident involvement and patients and other stakeholders can be reassured that resident involvement in surgical care is safe”

I agree with many of those who commented regarding the following points:

Asking the attending surgeon to exclude residents leads to differences in postoperative routines and may result in poor outcomes. The attending surgeon is not in the hospital 24/7. If you get sick at night, it is better to have residents who are familiar with your case see you.

The only way for residents to learn how to be surgeons is to perform surgery. It is not fair to take advantage of the positive attributes of a teaching hospital and ask that residents not be involved.

If you don’t want residents in the OR and/or taking care of you, choose a non-teaching hospital. In teaching hospitals, residents are part of the package.

Disclosure: I was a surgical residency program director for 24 years.