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Showing posts from December, 2011

MMSE and Copyrights Part II: Is the MMSE Derivative of Some Other Work?

A couple of days ago we covered Dr. John Newman's NEJM perspectives piece that focused attention on how a company, PAR, is trying to charge clinicians everytime they use the MMSE in clinical practice. To make matters worse, PAR is also trying to take down other tests, like the Sweet 16, that are thought to be derivative of the MMSE . As upsetting as this is, it does beg the question of how the originators of the MMSE, Marshal and Susan Folstein, came up with their test, and whether it is derivative of any other previous cognitive screens. The origin of the MMSE, as claimed by the Folsteins and PAR, is as follows ( taken from the PAR blog ): "We developed the MMSE to solve a clinical problem on a geriatric psychiatric inpatient service. The diagnoses of patients on our unit included depression, dementia, delirium, and occasional late-life schizophrenia. We needed a practical quantitative cognitive exam in order to aide clinicians in determining the severity of cognit

Copyrights and Copylefts in Medicine: The Case of the Wayward MMSE

The Mini-Mental State Exam (MMSE) is the most widely used cognitive screening test. Many have attributed this to the relative simplicity, portability, and brevity of the MMSE, as well as its ability to track the change in cognition over time. However, undoubtedly the biggest reason is that for most of its nearly 40 year life span, it has been free for anyone to use and reproduce, as the creators of the MMSE never enforced their copyright. Our previous GeriPal post on the MMSE's copyright describes how times have changed: “This test used to be freely available online, in books, and on pocket cards that were distributed to medical students and residents throughout the country. This all changed in March of 2001 when MiniMental, LLC (the current owners of the MMSE copyright) granted Psychological Assessment Resources (PAR) the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE. Suddenly, after decades of neglect, PAR began enfor

'Tis the Season: The BMJ Christmas Edition

It's the most wonderful time of the year. No, not because those damn kids jingle belling and everyone telling you "be of good cheer". And not because of those holiday greetings and gay happy meetings when friends come to call. It's the hap-happiest season of all because I just got the BMJ christmas edition in my inbox!  What, you were not so lucky?  Well, I guess someone is on someone else's not so nice list.  Don't worry though, I'll recap the three key lessons I learned after perusing the issue: --------- 1) Never write "Stable Vitals" or "Observations Stable" in a Chart  There are a lot of meaningless rituals that make it into physicians’ notes. One of the most common is using the term “stable” to refer to all aspects of patient care. The most common in the US is the term “stable vitals”. In the UK, “stable observations” takes "stable vitals" place. No matter which you choose, both convey little valuable i


Sometimes the best ideas are so simple that you both marvel at their eloquence and wonder why you never thought of them. In a perspective in the New England Journal of Medicine, Dr. Dan Wolpaw, a General Internist and Educator at Case Western Reserve University presents a simple and eloquent idea that can transform the quality of medical care and medical education. Dr. Wolpaw suggests we add a portable stool to the equipment we carry on patient care rounds. Morning walk rounds are a long standing part of medical culture. Teams of doctors walk the halls going from room to room to see each of their patients and develop care plans. But Wolpaw notes that less and less time is spent truly talking to patients. Team members talk to each other outside the room. Then the team approaches the patient, often standing around the patient who is lying in bed. We don't see the patient eye to eye, but literally look down on them. Wolpaw observes that after rounds, the team does take time to

Discussing Prognosis When Longevity Is the Only Life Limiting Condition

I think we all probably agree that health care providers should give patients with a life limiting illness the option to discuss their prognosis. But what about discussing prognosis with those patients who may not have any particular life limiting illness, but have just lived a long life? Are we as forthcoming about prognosis in this population as we are with a population of patients with advanced cancer? Should we be? In this week's New England Journal of Medicine (NEJM) , Alex Smith ventures outside of the blogosphere to give his perspectives on discussing prognosis with very elderly patients who may not have a dominant terminal condition.  Along with Brie Williams and Bernie Lo, Alex lays out in this perspectives piece the importance of and the barriers to having these types of discussions. I won't recap the article here, except to restate the overarching recommendation that clinicians should “routinely offer to discuss the overall prognosis for elderly patients wi

Potpourri from Clinical Work V

The following observations and questions came up during my recent work as palliative care attending.  Thoughts and responses are welcome: How well do so-called "bridge" programs work?  These are the home-care programs for patients who qualify but whose goals do not align with hospice, or who have serious illness but a prognosis outside of the hospice criteria (e.g. 1 year rather than 6 months).  I have heard rumors that bridge programs may drop patients who do not "cross the bridge" to hospice, or who do not have profitable insurance.  Does anyone know of any studies desribing these programs, and critically evaluating the quality of their services?  This seems to be a potentially important avenue of research. Problems with VA hospice contracts for residential hospice .  A number of area SNF/nursing homes are not accepting the VA hospice contract, or prioritizing it so low as to effectively not accept it.  The fact that the VA will pay for residential hospice

Treating Pain to Reduce Behavioral Disturbances in Dementia

There have been a lot of pharmacologic and non-pharmacologic interventions proposed for the all too common behavioral complications of dementia . Some non-pharmacologic methods have shown to be successful in reducing not only the number of troubling dementia related behaviors, but also in improving caregiver burden ( read about the REACH VA here ). Pharmacologic interventions have not had similar success, although you wouldn’t guess that based on current prescribing habits. Many health care providers still write for mood stabilizers, like valproic acid, despite a high risk of side effects when used in this population and the paucity of evidence showing any effectiveness in improving behaviors. Antipsychotics, on the other hand, have shown some modest efficacy for the treatment of aggression and psychosis over a short 6–12 week course. However, they also have a nasty little habit of causing death in those who take them. What if, instead of trying to treat the symptom of aggre