The Digital Doctor

During one clinic session, I look down at my desk and could not see it! It was covered by keyboards, mouse, tablets, smart phones, and all other electronic connection that a doctor needs today. I have my medical notes in my website in a server hosted in USA, my paediatrics notes at UpToDate somewhere else at their company server farm, my half written books and writing projects in Dropbox, my students files in Google Drive, my literature search via Monash virtual library hosted in Australia, my access to Monash online courses in Moodle in Kuala Lumpur, and my patients’ file in a cloud somewhere between Johor Baru and Kuala Lumpur. My Facebook, Linked-in, Google+, Tumbr, Twitter, and Pinterest accounts are in another cloud somewhere around the world. Oh yes, my online gaming Star Trek Online and TitanFall.

Technology has both hindered and helped me. I spent 50% less time talking to my patients and their parents as I used these of their 50% clinic face-to-face time with me to key in their online electronic prescription on the computer on my desk. In the past I was always able to give them my full attention as I sit facing them as I write out my prescription on paper. Now I have to turn away from them 90 degrees to face my computer. It is hard to carry on a conversation when you are facing the screen and trying to type in important information and to double check its accuracy. Believe me, I have tried. I am not that good a multitasker. Patients and their parents are aware of this. After a while there is this awkward silence as I key in their prescriptions.

Another subtle influence I have to consciously resist is that by keying in information and prescription, I am forced to think of my patient as an object. This object is defined by data and numbers. My patients have always been and will be persons to me. I did not sign up to be a doctor so that I can reduce them to data. This aspect of modern medicine is worrisome to me.

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Consulting an Australian Paediatrican

In the first national snapshot of paediatician consultations in Australia published in The Medical Journal of Australia, some interesting facts have emerged.

Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network


Harriet Hiscock, Gehan Roberts, Daryl Efron, Jillian R Sewell, Hannah E Bryson, Anna M H Price, Frank Oberklaid, Michael South and Melissa A Wake

MJA 2011; 194 (8): 392-397

The ten common conditions are listed with the frequency in brackets. The time given for the first consultation is also given  - the first figure shows the normal allocated time and the second the additonal time.


1. Attention deficit hyperactivity disorder (10%) [average consultation time-first visit - 47.6 + 12.2 minutes]
2. Learning difficulty/disability (8%)  [average consultation time-first visit - 55.1 + 15.2 minutes]
3. Eczema (7%)  [average consultation time-first visit - 41.3 + 6.9 minutes]
4. Behaviour (6%)  [average consultation time-first visit -51.3 + 13.2 minutes]
5. Language delay(6%)  [average consultation time-first visit -53.2 + 17.7 minutes]
6. Asthma (6%)  [average consultation time-first visit - 45.2 + 8.5 minutes]
7. Allergy — other food† (6%)  [average consultation time-first visit -36.2 + 7.1 minutes]
8. Dermatological/skin problems‡ (5%)  [average consultation time-first visit -33.6 + 8.2 minutes]
9. Baby check (premature/full-term) (5%)  [average consultation time-first visit -29.8 + 5.9 minutes]
10. Anxiety (5%)  [average consultation time-first visit -50.0 + 11.0 minutes]


I am fascinated by this study. First, what is interesting is that ADHD and behavioural problems forms the large bulk of the Australian paediatricians' workload. Second, is the amount of time allocated to the first consultation.

The situation in Malaysia is very different - both in the type of problems seen for paediatric consultations and the length of time given to patients in the first consultations.

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Children, Inhalers and Spacers

The use of inhalers for treatment of asthma is becoming increasingly popular in children. However there is no standardised technique for maximum efficacy in the use of these inhalers. A recent Australian study of 2-7 years old children (Aerosol Inhalation From Spacers and Valved Holding Chambers Requires Few Tidal Breaths for Children. Pediatrics 2010;126;e1493-e1498) gives the following conclusions


· that normal breathing (tidal breathing) is best – in fact the tidal breaths taken were quite large compared to predicted tidal ventilation, probably influenced by the spacer itself.

· Single strong breathing in (maximal inhalation) was no better than normal breathing.

· There was little difference between the spacers tested (Aerochamber, Funhaler, Volumatic, or modified soft drink bottle)...(not even Coca Cola or Pespsi)

· There was no increase in drug delivery beyond that achieved with 2 tidal breaths for a small volume spacer, and 3 for a large volume spacer.

My recommendation still remains at a single puff from the inhaler into the spacer followed by 6-8 normal breathing (what to do, I am kiasu), followed by another puff and 6-8 breaths using a spacer.


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Top Ten Articles from Medscape Paediatrics

What are some of the top articles paediatricians have been reading this year? Here are ten of them.

Here are the highlights from the Medscape Top 10 for Pediatrics in 2010:

1. Brain Tumour Risk in Relation to Mobile Telephone Use
   Is it safe to take that call? The results of a much-awaited report from the largest international study to date on mobile phone use and brain tumors with particular importance for children who will use these devices for many decades.
2. Immunization Resource Center
   In aggregate, articles about Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) immunization recommendations produce the highest interest among our pediatric members. Although not part of the top 10, this reference center summarizes the recommendations published throughout the year.
3. AAP Issues New Guidelines for Management of Iron Deficiency
   New recommendations for breastfed infants recommend more broad use of iron.
4. Eradicating Head Lice With a Pill
   What works best in persons who do not respond to head lice treatment?
5. Best Children's Hospitals Ranked
   US News & World Report has released its annual list of best children's hospitals.
6. Mupirocin Nasal Ointment Plus Bleach Baths Achieve Long-Term S aureus Decolonization of Skin
   What works best in previously infected children, including those with methicillin-resistant Staphycoccus aureus?
7. Whooping Cough Epidemic Hits California
   Infant deaths have been reported in California, and South Carolina also sees an increase in cases.
8. Universal Predischarge Bilirubin Screening
   Should universal predischarge bilirubin screening of newborns be mandatory?
9. Trashed on the Internet: What Should You Do?
   If patients give bad reviews to physicians on Internet rating sites, does a doctor have any recourse? This article discusses strategies for dealing with the situation and protecting your reputation.
10. Bring Breech Babies Back at 6 Months for Hip Dysplasia Check
    Screening infants for developmental dysplasia at the hip doesn't stop with ultrasound screening at 6 weeks.