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	I play in a monthly poker game with my buddies every month (I have three young boys, so this is a much-needed escape from talking Thomas the Tank and watching 

 for the umpteenth time…I’m sure you docs can sympathize), and we all talk like we’re pros. Well, we’re not, but if you want a little knowledge to act like you know something about this little game called Texas Hold ‘Em, here’s a quick primer. If you want to know more, just drop me a line at 

, Google “Texas Hold ‘em”, or simply read on!

	Starting with a standard deck of 52 cards, each person (from 2 to 11 players) is dealt two cards, face down, which become their “hole” or “pocket” cards. When everyone has their hole cards, the first round of betting begins, where players can stay in the hand by either betting or raising the minimum amount. A player “folds” their hand when they do not make a bet or “call” or “see” (match a bet or raise) another player, ending their action and forfeiting the pot. Note that in casinos, the dealer never plays; rather, a “dealer button” is passed around the table after each hand. It signifies where the dealing is done from, which is the most advantageous position at the table (“on the button”) because the dealer acts last on every hand. For home game, players act as dealers, with a new dealer every hand.

					One of the more confusing things about poker is the betting, so let’s explain that quickly. To ensure action every hand, forced bets called “blinds” are put into the pot by typically two players before the hand begins. The player to the dealer’s immediate left is the “small blind,” usually half of the normal bet, and the person sitting to the left of the small blind is the “big blind,” usually the amount of the minimal bet. As the deal rotates around the table, each player takes turns posting the small blind and the big blind bets. For players to stay in the hand, they have to bet at least this minimum blind. Blind structures, depending on the type of poker being played, may increase as the game progresses.

	After the first round of betting concludes the dealer “burns” (discards) one card and then turns over three cards in the middle of the table (known as “the flop”). These are community cards, which can be used by anyone to make the best hand possible. Another round of betting occurs after the flop.

	After the second round of betting concludes, the dealer burns another card and then turns over an additional card, adding it to the community flop on the table. This card is called “the turn” or “fourth street,” being the fourth card face up on the table. Another round of betting follows.

	The dealer burns again and then turns over one last card, which is called “the river” or “fifth street,” and adds it to the community cards. The final round of betting then transpires.

	Of the remaining players in the hand, the best five-card hand wins. A player can use any combination of their hole cards and community cards to make a hand, and should the five community cards make the best hand, everyone splits the pot (“the board plays”).

		Royal flush (straight flush to the Ace)

		Straight flush (five consecutive cards of the same suit)

		Four of a kind Full house (three of a kind and a pair)

		Straight (five consecutive cards of any suit, Ace can be high or low)

 — American Airlines; Pocket Rockets; Bullets

 — Big Slick; Anna Kournikova (“Looks good, but never wins”)

 — Flat Tire (“What’s a jack for?”)

Articles

Whether you're looking to walk the walk, talk the talk, or just learn a little bit about Texas Hold 'em poker, this month's Downtime will surely get you started. Shuffle up and deal!

Talking Texas Hold Em

Also known as “Enhanced Definition” or “ED,” it is the video display resolution of your standard DVD. The “p” stands for progressive scan, which means that each video frame is transmitted as a whole in a single sweep, rather than interlaced (“i”), which is two sweeps. A standard television is 480i.

: The video resolution that is considered the standard for HDTV (high-definition television) broadcasts. It is 720 lines in progressive format.

: Another mainstream HDTV format, 1080i outputs 1,080 lines of vertical resolution in an interlaced format. Many people would not see a big difference between a 720p and a 1080i broadcast.

: A high-definition video format with resolution of 1920 x 1080 pixels. The main advantage of 1080p TVs is that they can display all current high-definition formats without “downconverting,” which sacrifices some picture detail. The newest HD DVD and Blu-ray formats are 1080p, and now, a few TVs can accept this signal directly, so be sure to ask when buying.

: The ratio of width to height for an image or screen. A standard television is 4:3, but “widescreen” material like DVDs and HDTV broadcasts are 16:9.

) that splits the video signal into three parts, offering better picture quality than S-video or composite video. Use it when connecting compatible DVD players, satellite receivers, and cable set-top boxes. Most HD-capable televisions can accept component video signals up to 1080i.

 Measures the difference between the brightest whites and the darkest blacks a display can show. The rule? The higher, the better.

 A projection TV technology that uses an array of tiny swiveling mirrors on a chip to create an image. DLPs have incredible color reproduction and excellent contrast ratios (using the latest chips and color wheels) but can suffer from the “rainbow effect” (see below).

 Slowly being phased out by HDMI connectors, DVI is a multi-pin connection intended to carry high-resolution video signals from video source components to HD-capable TVs with a compatible connector.

 Not to be confused with “microdisplays” or rear-projection TVs, flat panels are the super-thin, lightweight units that can be hung on your wall (usually in LCD or plasma format).

 If your TV has this, it can display HDTV formats, but it needs a separate HDTV tuner.

HDMI™ (High-Definition Multimedia Interface):

) carries multi-channel audio and high-resolution video signals in one cable, allowing for a simple connection between source and display. Look for at least two HDMI inputs for your TV.

 Currently used in flat-panel, rear-projection, and front-projection TVs, LCDs use a florescent backlight to send light through their liquid crystal molecules and a polarizing substrate. LCDs provide good color reproduction, perfect sharpness at native resolution, and a bright picture, but they have problems producing deep blacks and can be expensive compared to other technologies.

 Like LCD technology, it is a projection display that combines liquid crystals, glass, and a highly reflective, mirror-like surface patterned with pixels sitting on top of a silicon chip. LCoS systems provide excellent color reproduction and contrast ratios but are very expensive since they are not widely accepted yet.

: A general term that usually refers to the rear-projection DLP, LCD, and LCoS technologies. These have replaced the old CRT “big-screen” televisions.

: Enabling thin, lightweight TVs that can be hung on the wall, ionized gas (plasma) emits high-frequency UV rays that stimulate the cells’ phosphors, causing them to glow, which creates the TV image. Plasmas are known for their excellent contrast ratios, black levels, color reproduction, life expectancy, and viewing angles.

 A visual artifact that sometimes occurs when viewers look away quickly from their single-chip DLP-based displays. The red, green, and blue on the color wheel are projected sequentially, rather than continuously. 

You're an MD. You dig tech. You dig HDTV and want to get a new tube, but you already deal with enough complex terms in your practice, so you just don't have the time to deal with 3,000 more...

Hardware - HDTV Defined

	Although most may consider portable video players pure entertainment products, several applications do exist for professionals, particularly in healthcare, that enable true productivity in a handheld device. The new ARCHOS 604-WiFi brings real benefit to the workplace, with a 4.3-inch touch screen, 30GB hard drive, and wireless connectivity—all wrapped inside a device that fits neatly in your hand. Introduced in late 2006, the ARCHOS 604-WiFi is the first portable media player with 802.11g wireless connectivity, which lets users browse the Internet with the same device used for media playback. Users can research the Web, send and receive Web-based e-mail, and play media files from the computer onto an external display such as a TV or projector. The 604-WiFi also features a bright, customizable screen with large icons that are easy on the eyes and allow for simple navigation through the features of the product. The touch screen player lets users access media and the Internet quickly and easily either using the stylus, fingertips, or the right side navigation buttons.

X-Rays, Audio Notes, Video Recordings, and a Little Fun

	Because the ARCHOS 604 Wi-Fi houses and can record the full spectrum of media files, healthcare professionals will find several uses for the player in the workplace. Physicians and administrators can both capture and access patient files and records with a few clicks, and view, listen, and record content with ease.

 — The stand-out feature of all ARCHOS devices is video recording and playback. With the DVR Station accessory, the 604-WiFi acts as a portable video recorder. Connected to a TV, it can record any and all programming coming through a cable or satellite signal. This is a great tool for taking the shows you missed or want to show patients or colleagues with you wherever you go.

 — Another coveted feature of the ARCHOS devices is high-quality audio recording and playback. Capture your audio notes for transcription or notes to yourself on your way to and from the office.

 — A fast photo viewer holds files in JPEG, PNG, and BMP formats and features a zoom option and slide show capabilities. Access X-Rays and other image files for quick review or discussion.

 — The 604-WiFi acts as a full back-up and transfer storage device and reads PDF documents. With 30GB of capacity, users can store thousands of documents on its hard drive, connect the device to a secondary computer and transfer documents from one computer to the next.

 — Research the Web in any wireless zone, send and receive Web-based e-mail, and stay connected.

 — An accessory to the 604-WiFi enables users to connect digital cameras, microphones, back-up storage devices, or any USB-enabled device directly to the product for transferring files without the use of a computer.

	The ARCHOS 604-WiFi is the latest in a series of portable media players that work for business and pleasure. It’s priced at $449.99 and comes in a model without the wireless and touch screen options for $349.99.

Provided by Samantha Steinwinder, marketing consultant to ARCHOS and other companies in the digital media and technology industries. E-mail: 

With this new portable media player, physicians and administrators can both capture and access patient files and records with a few clicks, and view, listen, and record content with ease.

ARCHOS 604-WiFi Portable Media Player

Steven Zuckerman, MD, aka “The Amazing Dr. Z,” is a solo-practice neurologist and amateur magician in Baton Rogue, LA. We spoke with The Amazing Dr. Z to learn how he maintains his medical practice and his magic skills, as well as how he incorporates magic into his daily practice.

Can you apply any of your skills as a magician to your medical practice, or vice versa?

 In everyday practice, I always do magic for my patients for fun, and sometimes I do it as a test to see how they’re doing. It’s a great ice breaker and way to make them feel comfortable and to communicate with them on a non-serious/non-professional level.

Would you recommend to other physicians, regardless of specialty, that they get involved with magic? Could it be helpful to their practices?

 Absolutely. In fact, there’s an excellent book on this called 

 that came out about two years ago; some doctors got together with some magicians and came up with a few very simple magic tricks that can be performed using the items in an exam room, like gloves, cotton balls, a stethoscope, or a tongue depressor. Magic is a great thing for physicians to do. The book is geared toward pediatrics, but I designed magic tricks that you can use to do a whole neurological exam. For example, there’s the “paddle trick,” in which you show both sides of a paddle that has a top hat drawn on it and have the patient look at both sides, while you’re watching their eyes move, and all of a sudden, there’s a rabbit coming out of the hat on the paddle. The kids like it, and it keeps their attention, but it enables me to check out their cranial nerves; it’s more fun than watching my finger. Or, I’ll have patients blow on my hand to make a coin disappear, and then they have to reach for the coin with either hand. 

How do you find time to practice both medicine and magic?

 That’s always been a challenge. When I have some time off , I’ll go to a magic convention, or I’ll just sit there and play with cards while I’m talking to patients. They don’t seem to mind too much. 

Other than going to conferences, how do you maintain and improve your magic skills?

 It’s just like anything else; you can get magazines, and you can attend lectures. Once you get to a certain level, you get to know other magicians, and you can talk about what’s current and new. 

What opportunities has practicing magic brought about for you?

 The highlight of my magic career was being invited to perform at George Bush’s first inauguration dinner in Washington, DC. They hired 20 of the world’s best magicians and me to perform at the tables before he gave his talk. The guy who arranged for the magicians to perform is a friend of mine. As a doctor and a magician, you’re a little bit unusual, so you have access to the world’s greatest magicians. So, I befriended one, and when it came time for him to do me a favor, he invited me. I did a trick in which you apparently put a pen through a dollar. Part of the story of the trick is that you say, “This is illegal; do you know why?” And the answer is that you’re not allowed to deface American currency. When I said this, the whole group started laughing, and I didn’t know why. As it turns out, I was performing the trick for the Secretary of the Treasury.

The International Brotherhood of Magicians

Quick and Easy Card Tricks and Other Magic

Steven Zuckerman, MD, aka "The Amazing Dr. Z," is a solo-practice neurologist and amateur magician in Baton Rogue, LA. We spoke with Steve to learn how he maintains his medical practice -- and magic!

Split Personalities: The Amazing Dr. Z

We spoke with Joel Frader, MD, MA, Professor of Pediatrics and Professor of Medical Humanities and Bioethics, Northwestern University’s Feinberg School of Medicine, and Division Head, General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL to learn what it is to be a medical ethicist, the latest issues he faces, and how you too can become a medical ethicist.

What does it mean to be a medical ethicist? What are the requirements? 

There aren’t any offi cial requirements in the same way that there are for doctors or lawyers. At some level, it means whatever the individual wants it to mean. Most people who are doing something they call medical ethics do it by virtue of some professional background that involves clinical skills or formal education in philosophy, theology, religious studies, or a similar area; that’s been true for 30-40 years. In the last 15 years or so, there have been a number of programs around the country that award students masters-level degrees in medical ethics, bioethics, or related titles. These people spend one to two years—depending on the program, with some clinical involvement or not&mdash;learning the philosophical, ethical, moral, and intellectual history relevant to the field. People typically end up doing some combination of clinical consultation and policy development, as well as institutional education.

What issues do you deal with on a day-to-day basis? Is this a full- or part-time position?

 It’s very much part-time, although 25% of my time is supported by my medical school to be part of a medical humanities and bioethics teaching program for medical students. I teach various topics in medical ethics in a variety of settings, sometimes in the classroom in the first couple years before the students are immersed in the clinical world. But a large part is for students who are doing clinical rotations in various hospitals, getting them together to discuss cases they have encountered that have posed ethical dilemmas for them. In addition, I do ethics consultation here at our Children’s Memorial Hosptial. I teach residents, nurses, and others about medical ethics. I’ve also participated in writing institutional policies, and I do academic work “scholarshipped” in the field of medical ethics (some is empirical, some is post-ethical analysis).

What ethical issues have arisen from use of new technologies in medicine, such as e-mail contact with patients?

 There have been many issues, although it’s not something I’ve focused on personally. The issues concern privacy—something as simple as knowing whether the person you’re corresponding with electronically is who he or she purports to be. In pediatrics, that’s a big issue, because someone might pretend to be their 14-year-old son or daughter who we’ve promised confidentiality to. And the parent is trying to get around that promise by getting information out of us electronically without our being able to confirm who he or she is. Most of the issues we’ve faced electronically have to do with, in one form or another, privacy confidentiality. On a day-to-day basis, the bigger issues have to do with adequacy of informed consent, end-of-life decision making, limits on medical intervention, and issues around the appropriateness of including patients as subjects in research trials.

In what situations could your expertise be put to best use?

 Issues come up all the time about whether, in our case, parents or young children really understand what it is that the doctors are telling them and proposing for them. Such things as the doctor saying “we think your child should have x, y, z procedures,” and the parent really doesn’t understand what it is that’s being proposed and goes along with it based on simply trusting the doctor, when in fact if the parent understood, he or she may or may not be really interested in going through with what’s being proposed.

How did you get involved in medical ethics, and how would a physician go about becoming a medical ethicist? 

At the time I got interested, 30 years ago, there were no formal programs. So, I took advantage of the Robert Wood Johnson Clinical Scholars program, which is still around and takes people who are fi nishing residency programs and allows them to develop their intellectual interests in issues that are non-biomedical (not laboratory science or clinical trials), but that have more of a public health, health services research, or medical economics interest, for example. I was at the University of Pennsylvania, where I happened to get a degree in sociology and worked with people in sociology in ethics and in law at the time, to develop my interest. These days, one can do a fellowship and/or a masters program at some point in one’s medical career and develop interest in ethics that way. At Northwestern, we recently started a masters program that is primarily designed for medical students to pick up an additional degree with typically an extra year of intellectual work.

What else do you feel our readers should know about medical ethics?

 I think it’s common for medical professionals, perhaps mostly physicians, to think of ethics as something that is sort of on the side, soft, etc., when in fact, if you step back and think about it, the ethical issues have almost everything to do with what’s important about doctor-patient relationships. If you take informed consent as an example seriously, what it means is developing a relationship with patients or their surrogates that allows people to develop a trust that doctors want patients to have in them. It’s not irrelevant at all. It’s at the core of medical practice.

We talk ethics with Joel Frader, MD, MA, Professor of Pediatrics and Professor of Medical Humanities and Bioethics, Northwestern University's Feinberg School of Medicine.

So You Wanna Be a...Medical Ethicist

	Imagine a system capable of streaming video, television shows, music, and podcasts all through the Internet. Picture photos and movie trailers appearing with a double-click of your mouse. Now imagine watching it all unfold in the sanctuary of your living room, on your 52-inch plasma screen.

	Until the advent of the Internet, medical students were pulling research solely out of those abandoned storage facilities we call libraries. Now, computer companies have made the mutual exclusivity of information, entertainment, and communication a thing of the past. Responses to a poll for our 20 Ways to Connect, Manage, and Relax article last month echoed this perception. When asked "what do you do when you're not in the office treating patients?" 65 out of 454 physicians polled mentioned taking photographs, listening to music, watching movies, and playing video games. Because these particular activities are of interest to our readers, we would like to offer a little insight into the world of the all-in-one digital system.

	Consider the convenience of a 7-11: quick access to the staples like bread, milk, and eggs, as well as your standard over-the-counter meds and lottery tickets. Multimedia systems work much the same way by providing the same quick access to information as they do video games or movie downloads.

	Taking into account that the average American spends approximately four hours a day watching the boob tube (

), it's clear we like our television programming, and we know how we like it. Add that number to the average 108 minutes we spend searching, the Internet daily, and you have a media audience that spends nearly a quarter of its day partaking in some form of digital entertainment.

 (HP) offers a couple options to assist people in accomplishing this: the HP Pavilion Media Center TV m7780n PC and the HP MediaSmart LCD TV. Representatives from HP wrote to MDNG, stating that the Pavilion Media Center TV delivers high definition movie playback with six times better resolution and three times better audio capability than standard DVD--a perfect addition to any home. The 37-inch MediaSmart TV allows users to access and view their photos, music, videos and a range of Internet services wired or wirelessly through their television--truly a breakthrough in digital convergence, wrote the HP reps. In fact, the HP MediaSmart LCD TV was named a 2006 Electronic House magazine Product of the Year.

	Apple is another corporation that is combining the features of the computer with those of the home entertainment system. The recent launch of 

, scheduled for general release this month, was accompanied by claims it would change] the way you watch digital media. The system connects to your TV via an HDMI port or component video and audio ports. Its wireless capability syncs iTunes customers' library to both Macs and PCs. That goes for digital photos, too. Think of the recreational time that you, the busy physician, will save by having it all in one place.

, the gadget guide, noted similar findings in the still-steady demand for 

, which, in case you've been living in a cave, is a video recorder that automatically finds and digitally records all your favorite shows. By recently teaming with cable provider Comcast, TiVo has made the ease of digital recording even more accessible to its subscribers. Similarly, Microsoft Corporation has stepped up its access to the wonderful world of television with the introduction of the 

. Unlike many multimedia systems, MSN TV 2 is not a PC and does not require any software to buy or install. Rather, a broadband connection and wireless keyboard are all the tools you need to stream TV and all the typical Internet features, including Instant Messenger.

	MSN TV is a set-top box that simply connects to a TV and telephone [or broadband] line, enabling the user to connect to the Internet and read/write e-mail, says Scott Crissman, Senior Marketing Manager, MSN Access for Microsoft Corporation. An advanced functionality of the product is the ability to connect to a home network. This would allow the user to stream photos, music, and videos through the home network to a TV or entertainment system [if the entertainment system is connected to the TV/mediacenter]. Demos are available for free access at 

	Among the core benefits described by Crissman are easy set-up, simplicity of use, and affordability. MSN TV is also a great solution for a second Internet access point in the home. While the kids are on the PC playing games, our users can quickly check e-mail or surf from the comfort of their couch, says Crissman. Paired with Microsoft TracNetTM 100 mobile Internet system (which offers mobile access to all of MSN TV 2's services), you can stay connected, even when you're away from home.

	Moreover, the concept of all-in-one is not limited to the couch potato. Media conglomerates have designed a system with every hobby in mind. Dell Inc., for example, has improved its desktop and laptop systems, namely the XPSTM 710 H2C and XPS M1710, respectively. Both systems utilize high quality processors for the most advanced gaming performance. The result? Turbocharged performance, making it easier than ever to work with digital photos, movies, music, and the Web. Because of the advances in technology today, physicians can enter a huge pool of resources for all of their text and graphical needs.

	Whether searching a database of images, MP3s, or videos, today any individual [clinician, person] with a desktop/laptop PC and broadband connection to the Internet has the power to broadcast the Internet to the world, says Bill Crounse, MD, Healthcare Industry Director for Microsoft Corporation. Additionally, any physician can do telemedicine from his or her laptop PC and take advantage of the latest communication technology, like [Microsoft's] Office Communicator or Windows Messenger that allow you to connect with one or more people via audio/video conference just as easily as you can via e-mail or instant message.

	In today's society, almost everyone owns a computer, but how many people actually use all of the accompanying software programs that come with a new one? Do you want more memory, but don't want to spend the extra money to buy an external hard drive? If so, maybe you should look into getting a computer that you can design from the inside out. Check out Falcon Northwest's 

 two high-tech computers that cater to your needs. MDNG spoke with Kelt Reeves, President of Falcon Northwest, who told us that most of the people who end up purchasing a computer from his company do so after spending time using mainstream computers because they have a clearer focus on the type of entertainment in which they are most interested ... the Gateways and now they're looking for something much more powerful and something that was made specifically for them, said Reeves. So, we're definitely dealing with an experienced computer user.

	The Mach V is one of the longest-running PC series in the industry (in development since 1992), and for the past two years, PC Magazine has voted it as one of the 

. The system's success can be attributed to its constant evolution and customized specifications. Although Falcon focuses on high-end gamers, people who enjoy photography or making videos can also use the Mach V. Said Reeves, Photoshop [for example,] doesn't really use your graphics card much, so all the 3-D capabilities that a high-end gamer might need, a Photoshop person might not. But a Photoshop person is going to need an awful lot more memory, and depending on the size of the pictures they're going to use, they might need a fairly large hard drive as well.

	Even though the Mach V is designed for the experienced computer user, photographers, amateur gamers, and other multimedia hobbyists will also fi nd much to like about it and can use the system with the greatest of ease. As with Falcon Northwest, 

 is a company dedicated to delivering leading-edge performance, style, and craftsmanship to discerning PC enthusiasts.

 offers users flexible configurations from an advanced liquid cooling system to a near-silent, air-cooled configuration [andis the only PC to offer such flexibility and upgradeability. According to Voodoo, the OMEN's features include four medium-flow, low-noise fans to make the system as quiet as possible while still optimizing cooling capability, up to four hard drives, and 2GB or 4GB of memory with the choice of dual-core or quad-core central processing units that allow for multitasking. Jeff McCrea, VP of Intel's Sales and Marketing Group, gave praise to Voodoo's efforts by saying, VoodooPC's 

, featuring this latest desktop processor innovation, will wow gamers and media enthusiasts.

 laptops also rely on the Intel Core 2 Extreme QX6700 Duo-Core processor. Built [with] the hard-core gamer in mind, the XPS M1710 lets you watch movies while running a virus scanner, ripping CDs, listening to MP3s and playing games simultaneously. Possibly most notable, however, is its NVIDIA GeForceTM Go 7950 GTX graphics card and PureVideoTM technology. Add to that the XPS LightFXTM 16-color LED lighting feature, and you have an intense gaming atmosphere in a travel-sized bundle.

	Dell also brings its line of XPS models to the desktop world. The XPS 710 relies on an Intel CoreTM 2 Extreme Quad-Core processor twice as enduring as the duo-core to provide high definition media with more customization options than any home PC [Dell] ever built. Its two-stage cooling system combines a liquid radiator with control circuitry for optimal cooling that requires little energy use. Translation? Hours of game play at up to nine degrees cooler than the average desktop platform. Just think of how many extra seasons you can play in Madden 2007 with that kind of staying power.

	For those who prefer a mainstream computer, then perhaps the TouchSmart PC developed by 

  is the answer for you and your family. This touch-screen PC comes with a 19-inch LCD screen, wireless keyboard, and mouse and enables users to perform a variety of tasks, like checking the weather, editing and viewing photos, managing the family's schedule, accessing favorite websites, or watching a recorded TV show. Special features include the HP SmartCenter, used to customize favorite links; HP SmartCalendar, used to maintain scheduling; and HP Photosmart Touch, used to manage digital photographs. At the 2007 Computer Electronics Show, the TouchSmart was named by Yahoo! Tech as its 

	If you're interested in purchasing a laptop with similar features in a lighter model, check out the newest version developed by 

: the TLX. One-and-a-half inches thick and weighing approximately seven pounds, the TLX has a 17-inch screen with a full-sized keyboard. According to the Falcon's website, the new TLX Th in and Light series model defi es the laws of physics. Most people can't believe when they pick the thing up that a screen that big can be in a laptop that thin and that light, said Kelt Reeves.

	Ever wish you could just sit down and relax in front of your television or computer and have access to any form of digital entertainment, right at your fingertips? Perhaps what you're looking for is a system that offers you Internet access and the ability to listen to music, watch videos, and look at photographs, among other activities. Or maybe you'd prefer a system that offers all of these, plus the opportunity to play video games. Media companies have quite literally transformed not only the way we think about information and entertainment, but the way we access it, too.

	Dr. Crounse, emphasizing the benefits of all-in-one digital systems as they pertain to the physician audience, stated, I early on began to appreciate the potential of the Internet to deliver health information and very targeted information to the audiences who need it, it's not just really broadcasting information out, but it's actually a social networking phenomenon that allows two-way communication. [Microsoft's] home entertainment and gaming divisions, Xbox in particular, are doing a lot of interesting work.

	Some of the newer hospitals are revamping their digital entertainment capabilities; building in our Windows Media and 

 systems not only for entertainment, but also for education and communications, ordering meals, filling out surveys and taking part in a host of various services. If your main interest is video games, then check out the 

	Each of these consoles goes beyond playing video games by also letting users play movies, listen to music, and access the Internet with broadband. The Wii is the epitome of the all-in-one system, because not only is it a fantastic video game platform, it also lets users access channels to perform other tasks: the Shop Channel, an online service for downloading video games; the Photo Channel, which enables users to load digital photos from their camera's memory card and then manipulate them a variety of fun and creative ways the News Channel, for accessing breaking news from around the world, and the Forecast Channel, for checking weather reports. Nintendo reps explained to MDNG that the Wii is very unique because of the interactive remote, and the system is twice as small as Xbox 360 or the PS3, so it's easy to tuck away in your entertainment center. It's great for a busy physician, because it's a good way to spend time with the entire family.

	In the January 26 press release announcing the arrival of the 

, Nintendo of America President Reggie Fils-Aime said, "What Wii has done for video gaming we hope it will also accomplish for news. Just by pointing at your TV screen, you become your own interactive editor, instantly accessing the latest headline stories, whether they originate in Kansas City or Kyoto."

 offer similar capabilities, such as wireless remote controls, Internet access, and more. Xbox 360 users will enjoy watching DVDs, listening to music, and viewing photos. The PS3 features a Blu-ray disc player, which enables users to “enjoy next-generation high-definition entertainment, including games and movies,” a 20GB or 60GB removable hard drive, and easy transfer of media files and photos with the PlayStation.

	Sure, you’re probably saying, this is all well and good if all you want to do is play video games and mess around online. But what about more serious, careerdriven activities, like professional photography? We’ve got that covered, too. Apple’s 

, for example, is “the first all-in-one post-production tool for serious photographers.” The program boasts customized, color-managed workfl ows and even provides online tutorials and training certifi cation course(). Whether you want to print a contact sheet or need a lab print, there’s no need to visit your one-hour photo lab. And let’s face it; the quality of a one-hour print—actually produced in three or four hours&mdash;is not of the highest caliber. Users can download a 

	As physicians, you lead a hectic life full of appointments and paperwork, and sometimes you’d like to take some time to enjoy a good movie or some nice music in the peace and quiet of your own home. Our “20 Ways to Connect, Manage, and Relax” poll revealed technologies and strategies used by physicians in dayto-day practice to effi ciently manage patients and deliver the best possible care. Docs mentioned Apple’s Mac systems, laptops, and a slew of Internet websites from which they can print and hand out information to their patients (eg, 

) among those tools used on a daily basis. The best part about these resources? They are just as accessible in the office as they are from your couch.

 is the quietest system on the market today, giving purchasers the option of selecting a video card or a second card for gaming, 2GB of RAM, and a 256MB NVIDIA graphics card. Just like the OMEN, ARIA users can choose up to four hard drives to “copy your entire DVD collection onto the hard drives so when you want to watch a specific movie you just have to scroll through the library and play the movie instead of having to fi nd the DVD, take it out of the box and put it in the computer,” according to Voodoo.

	With a market that’s full of many types of media systems, it’s all a matter of choice. Do you want a video game console that offers DVD capabilities, Internet, music, and videos? Do you want a computer with which you can decide what components to include? Or, do you want a system that offers everything in one sleek package? Lucky for you, there are a multitude of products available for your every hobby, professional endeavor, or sheer entertainment.

Whether you're looking for the best all-in-one television/Internet/gaming PC, or simply a program that provides optimal photographic images, there is a product out there for you. 

Digital Multitasking Systems: All-in-One Media for Your Unique Lifestyle

	You can probably sympathize with the worry and anxiety your colleagues felt following the invention and rapid adoption of the telephone in the late 1800s. For them, this new device sparked concern and debate, raising new questions regarding their duties to their patients. Would the easy access promised by phone service prompt patients to make increased demands on physicians’ time? If so, what obligations did physicians owe to patients calling at all hours of the night? Was it ethical to conduct a medical consultation over the phone? Would answering the phone and briefl y talking with a patient necessarily establish a relationship, making the physicians duty bound to provide continuing care? Would resorting to telephone-based communication depersonalize the historical personal bond between physicians and their patients?

	Today, physicians and patients are wrestling with the changes wrought by new, more powerful technologies and are seeking answers to many of the same kinds of questions regarding the physician— patient relationship that confronted their 19th century forebears. Communication between physicians and patients nowadays is near instantaneous and can be conducted in a bewildering variety of formats: telephone, fax, e-mail, voicemail, video conferencing, and instant messaging. Patients grown accustomed to 24/7 customer service in their other personal and business transactions (especially those conducted online) are increasingly demanding the same level of access to and responsiveness from their healthcare providers. Physicians are struggling to keep up with the demand, but must weigh their desires to be available to their patients against questions regarding reimbursement for time spent, privacy issues, and liability concerns.

	Patients are also demanding more convenience and flexibility from physician practices when it comes to setting up appointments, requesting medication refills, obtaining test results, and other services. In the past, patients had to rely solely on the discretion and timetable of their healthcare providers, but now, thanks to the availability of practice websites featuring applications that enable online appointment scheduling and prescription refill ordering, patients are growing accustomed to on-demand service from healthcare providers.

You Have Mail, But Not From Your Patients

 and share your opinions on physician—patient e-mail communication.

	But perhaps the most profound change to the patient—physician relationship has come about due to patients’ ability to quickly access healthcare information. In the past, patients who desired to read clinical medical information required access to a medical library. Even then, the process of uncovering relevant data was laborious, time consuming, and isolated. The only interactive part of the process involved asking a librarian how to use the microfische. Nowadays the Internet enables rapid access to even the most obscure clinical journals, not to mention dozens of user-friendly sites that distill and interpret that information, leading to the advent of new terms to describe patients and their attitudes and roles vis-à-vis healthcare delivery: “informed,” “active participant,” “empowered.”

	And thus, the patient—physician relationship continues to evolve, with technology playing an ever-greater role in driving the changes. From how patients and providers communicate between office visits to how patients interact with their providers during an exam, from the services patients expect from practices to the ways in which patients search for, internalize, and act on medical information, healthcare information technology is altering the physician–patient relationship in ways great and small.

	We began our discussion by recounting how the introduction of a new communication technology altered the patient—physician relationship. Just as with the telephone more than a century ago, e-mail is a form of communication that was slowly adopted at first but then later became ubiquitous and is changing the ways in which patients and their physicians interact. When it comes to the use of interactive communications technology in practice, physicians have definitely been slow to meet their patients’ demands when it comes to the use of e-mail. It seems like we’ve been talking about physician-patient e-mail for years in the pages of 

. Everybody uses e-mail in just about every other area of their professional and personal lives, but for a variety of reasons (stop us if you’ve heard these: concerns over the privacy and confidentiality of potentially sensitive personal information contained in e-mails; fears that patients would flood doctors’ in-boxes with inappropriate requests, questions, and comments; lack of reimbursement for the time physicians spend answering e-mail queries) this form of communicating with patients has not caught on with physicians. A 

survey conducted last year by the Center for Studying Health System Change

 found that only 24% of physicians surveyed reported using e-mail to communicate with patients in 2004-2005. Contrast that figure with the 80% (80%!!) of patients who told a Harris Interactive Health Care Poll in March 2005 that they would like to communicate with their physicians using e-mail. The relatively small percentage of physicians who have taken the plunge and allowed e-mail communication with patients have reported mostly positive results. The asynchronous nature of e-mail is particularly suited to non-urgent healthcare requests and questions, and patients have been remarkably circumspect in their volume of correspondence. Although physicians’ increased availability via e-mail is no doubt appreciated by patients and the source of no small amount of goodwill, there is another aspect to consider. With increased access comes increased expectations of access and responsiveness, adding to physicians’ burden and altering their relationship, however slightly, with their patients.

	Patients’ views of their roles in the flow of information regarding diagnosis, treatment, and management is changing to reflect patients’ vastly increased access to reliable medical information via the Internet. No longer content to be passive recipients of healthcare instructions dictated by providers, patients have been recast as healthcare consumers, active and equal participants in the healthcare decision-making process who have been empowered by the knowledge they have acquired through the use of information technology. This has had a profound impact on the exam room dynamic. Nowadays, people are likely to show up in your office, clutching stacks of printouts about diseases, conditions, and medications. They know what they want and they are less shy all the time about asking questions, challenging assumptions, and demanding an increased voice in their care. They’ve seen pharmaceutical ads on television; read healthcare blogs written by patients, physicians, and industry experts; chatted about their condition or complaint with other patients online in forums specifically set up to facilitate interactive healthcare discussions; and e-mailed friends and family to get their opinions and learn about their experiences. The common denominator in all of this is the Internet.

	Never before have patients had such fast and ready access to information of such complexity, varying reliability, and diversity. Although nobody can seriously argue that patients should not enjoy widespread access to healthcare information, Alexander Pope’s dictum that “a little learning can be a dangerous thing” seems especially apt when it comes to online medical information. But the way in which this danger manifests has changed from a few years ago. Before the Internet became so corporatized and settled, before the advent of the current landscape of well-known, user-friendly, and reliable healthcare information websites, patients were more or less on their own, adrift in a rather wild frontier of information and disinformation. Patients, new to the whole online experience, had no benchmarks for quality and reliability when it came to what they read online. They necessarily had to rely on their physicians and other healthcare providers to vet the info they found and brought to the office visit, meaning the traditional patient—physician relationship remained more or less intact, with the physician as still the final dispenser of wisdom. But, as the Internet has matured as a conduit for information exchange, people have become more accustomed to the process of actively seeking out detailed and at times arcane medical information online. Greater demand for better online medical information has fueled the growth of new, more interactive and user-friendly health information websites (and improvements to existing sites), which in turn reinforces peoples’ positive experience with online medical searches.

	This synergistic, symbiotic relationship between patients’ greater demand for a high-quality online experience and the Cambrian explosion of better sites to meet that demand has altered the patient —physician dynamic. Although it is true that there still are a great many unscrupulous websites out there that knowingly peddle false or slanted information, patients by and large are becoming more sophisticated in the selection of their sources of medical news and information. (see "Or Are They?") This has been both supported and driven by an ever-expanding roster of high-quality patient education websites such as WebMD, InteliHealth, Healthology, FamilyDoctor. org, and the like (see "Web 2.0"). As patients’ confidence in their sources of online information has increased, so too has their confidence in presenting this information to their physicians and using it to guide their healthcare decision making, sometimes in conflict with what their doctors are telling them. Anecdotal evidence indicates that the questions of Web-savvy patients are changing from “I found this online, is this true?” to “I found this online, and here’s what I want you to do.” Physicians are spending less time debunking healthcare myths and are spending more time explaining the subtle differences between two treatments or talking about the significance of new study results that their patients found on PubMed. They are increasingly required to guide their patients through an educational and research process that is largely out of the physician’s control and that just was not possible back in the days of handing out pamphlets and brochures. The power of the prescription pad means physicians are still the final arbiters of treatment decisions, but patients nowadays have the information available to allow them to have an ever greater say in what is written on that prescription pad.

survey for Pew’s Online Health Search 2006

 found that only 15% of people “always” check the source and date of the health information they find online. Seventy-five percent of respondents revealed that they check the source and date of online health information “only sometimes,” “hardly ever,” or “never.” That means, according to Pew, 85 million Americans are “gathering health advice online without consistently examining the quality indicators of the information they find.” Why do you think this is? How do you explain the contradictory phenomena of the false legitimacy many people seem to ascribe to information they read online and the equally common view that “you can’t trust everything you read?” How do you handle this basic rule of health literacy with your patients? E-mail us at 

	Patients’ increased access to reliable, easy-to-use, interactive online health information and resources has been mirrored by the explosion in dynamic and portable healthcare information technology now at physicians’ disposal. Physicians have nearly instantaneous access at the point of care to drug and formulary information (

), decision support and evidence-based medicine resources (

). And that’s just through their handheld computers. When you factor in the rapidly expanding roster of comprehensive electronic health record products (more than 50 have been certified by the CCHIT; see the complete list at 

www.cchit.org/certified/2006/CCHIT+Certified+Products+by+Product.htm

) and the burgeoning ranks of more powerful- than-ever laptops and tablet PCs on which to run them, it’s clear that physicians have the means to access more information faster during the patient encounter than ever before.

	But how is this increased access to and concomitant reliance on information technology affecting the physicians’ interactions with their patients? Dr. Michael Wilkes, professor of medicine at the University of California, Davis, is concerned about EHRs’ potential to depersonalize the patient—physician encounter. 

, Dr. Wilkes worries that by introducing a computer to the exam room, physicians are erecting a barrier between themselves and their patients “just as a fence divides two neighbors”—that could undermine effective communication. He acknowledges the theoretical benefi ts of EHRs (reduce medical errors, enhanced quality of care, etc., etc.), but also notes that the practice of medicine, at its heart, “involves one human listening to, talking with, and examining another” human and that anything that could potentially detrimentally affect that relationship should be approached with study and caution. If Dr. Wilkes’ fears prove to be true, then how can practitioners reconcile the definite technical benefits of EHRs with their drawbacks in the exam room? Patients and physicians both are already keenly aware of the lack of time providers have to devote to each patient visit; how will patients react to a physician who spends an inordinate amount of time in the exam room with his or her eyes glued to a computer monitor while he or she furiously clicks through screen after screen entering information? A 

study reported on in the March/April 2006 issue of 

 sought to “determine those factors that influence the manner by which physicians use the EHR with patients and to provide a framework for considering how physicians might best use the EHR to foster therapeutic relationships with their patients.”

	The authors reported that the presence of an EHR (and its associated viewing screen) in the exam room definitely influenced the interaction between physician and patient. The physical presentation of the EHR itself had an effect: “Large, fixed monitors located in the corner of the examination room caused consternation among both physicians and patients, whereas flat-screen monitors on mobile arms were universally praised.” Although the “ability to rearrange the position of the monitor changed the dynamic of encounters” by offering physicians “the opportunity to engage patients in their own medical record,” the authors note that “this flexibility was infrequently used because of a predominance of biomedically focused practice styles and a relative lack of physician interest in fostering patients’ involvement” (see The Devil Is in the Details).

					Consumer demand for more powerful online healthcare tools is being met by what has been termed “Web 2.0,” 

as describing “a second generation of the Internet that is focused on the ability for people to collaborate and share information online.” In addition to Steve Case’s much-talked-about 

, other websites that incorporate the principles and concepts of Web 2.0 (sometimes referred to as Health 2.0 in the context of online healthcare information) include 

. All rely on interactive networking, information sharing, and open communication between patients and professionals. Check out these sites when you get a chance. Your patients definitely are.

	Another behavior-modifying effect associated with EHRs noted by the authors was that the immediacy of electronic access to information aff orded by the EHRs meant that “a concomitant pressure existed for physicians to enter chart notes in the examination room,” leaving the studied physicians feeling “conflicted between recording medical information in the EHR and giving one-on-one attention to their patients.” And another determining factor in how comfortable physicians and patients were with the presence of an EHR in the exam room? The physician’s typing skills. “The simple ability to type,” noted the authors, was “crucial to using the EHR effectively with patients.” One participant went so far as to opine that a practitioner won’t be able to effectively use an EHR if he or she can only hunt-and-peck or has to constantly look at the keyboard as he or she types.

	The study’s authors report still other “subtle effects on the flow of the encounter.” Namely, they noticed the tendency that, once physicians entered the exam room, they “most commonly walked straight to the monitor after only a brief greeting. They then opened the EHR and oriented themselves to the patients’ previously documented information while their patients either silently sat idle or concurrently related their reasons for the visit.” Some physicians avoided this by first interacting with patients and listening to their concerns before engaging with the EHR, but the disruptive effect of the EHRs were clear. It was almost as if the focus of the encounter switched from the traditional subject (the patient) to the means by which the subject’s information was recorded. Patients with minor medical problems seemed most satisfied with the use of EHRs during their visits, since the EHRs’ preloaded data entry templates enabled attending physicians to “point-and-click to complete the history, physical findings, assessment, and plan.” This benefit did not extend to all manner of visits and patient complaints, however. The authors note that these templates “did not attend to the patients’ narratives or emotional issues, nor did they help manage the complexities of patients with multiple or chronic complaints.” In other words, patients with diseases and conditions that conformed to the technical dictates and limitations of the EHRs had the most positive experiences, since their physicians’ behaviors were altered the least by implementing the EHR workflow. The relationship was necessarily altered by the technology intended to facilitate and improve that relationship.

 was particularly instructive. It illustrates that whether information technology aids or hinders the patient—physician relationship depends on the dynamic of that relationship. The authors report that physicians displayed “three distinct types of practice styles related to EHR use. Informationally focused physicians commonly positioned themselves at their computer monitors and used computer-guided questioning to focus on problem-oriented details. Physicians with an interpersonal style were led by patient narratives; they either sat or stood away from the computer or faced their patients using the mobility of the computer. Physicians with a managerial style alternated their attention in defined intervals between patients and the computer…

Whether physicians perceived the EHR as important in developing the meaning of the encounter influenced how they used it. Those who saw the EHR as a means for collaboration were more likely to share the screen with their patients than those who used it more narrowly as a medical record.”

Are We Making Mountains Out of Molehills?

	So, what are physicians to make of all this talk of changing relationships and dynamics? In the case of EHRs, it’s still too early to tell, but studies such as the one reported in 

 indicate that the matter deserves a great deal of study and consideration in order to avoid negating EHRs’ benefi cial aspects by allowing their introduction to compromise interactions with patients. When it comes to patients’ use of the Internet and their assertiveness in presenting information and expectations that physicians will incorporate it into treatment, 

 is (and has always been) of the opinion that more is better. Far from representing some sort of threat, patients’ newfound confidence is something to be encouraged as it can lead to a deeper, more dynamic relationship with their physicians. We suspect most of our readers will agree. Besides, you’re still number one in your patients’ eyes. A 

 indicates physicians are still considered by 62% of patients to be the most trusted and highly valued source of medical information. When asked where they preferred going for specific health information, more than half reported that they wanted to see their physicians first. Of course, when questioned about where they actually went for information, 49% reported going online first, with only 11% seeing their doctor first, but don’t worry; that’s just a reflection of the Internet’s proximity and convenience. We think.

One Final, Rather Sour Question: Will Information Technology Inadvertently Promote Regressive Patient Selection? 

	Perhaps one of the most insidious ways in which increased adoption of information technology may alter or even compromise the patient—physician relationship in the not-so-distant future is through the externalities some fear will accompany the transition to P4P, a concept that is heavily reliant on health IT. Namely, will P4P financial incentives tied to achieving acceptable treatment outcomes (as determined by adhering to pre-determined guidelines and meetings target outcomes) induce practitioners to (consciously or subconsciously) select only healthier patients and/or those most likely to be able to meet treatment goals? How might this alter patients’ opinions of their physicians? E-mail 

New technologies and new expectations are combining to change the ways patients view their relationships with healthcare providers. Traditional roles are being skewed, and we examine further.