20Mar11 California Dreamin’

GH and family are traveling the stunning California coast between SF and LA.

Traveling South from Big Sur along Hwy 1

Among the sights seen: otters in Monterey Bay, the steep shores of Big Sur (in rock slide inducing rain), and elephant seals near San Simeon. Yet to come are the Hearst castle, Morro Bay, and Santa Barbara.

It’s somehow reassuring to know how sparse the population gets between the Bay Area and Southern California, as if humans won’t eventually overpopulate the planet.

A couple of medical items to share:

Another study on prostate cancer. This one, reported on NPR, questions the validity of the “PSA velocity” concept. PSA is a blood test men can have that helps them and their doctors decide if they’re at high enough risk for prostate cancer to consider getting a biopsy. The problem with it as a screening test is that there are way too many false positives (a high PSA value without cancer) and false negatives (a “normal” PSA value but with cancer) that make it a fairly useless (and controversial) screening test.

The “velocity” concept comes into play when the PSA test value is “normal” (i.e. under 4.0), but the absolute value jumps up by more than 75% in one year (say going from 1.0 to 2.0). The study in question determined that the PSA velocity concept lacked validity (in more than 5,000 patients), compared with just checking the absolute value of the PSA itself.

Got that?

I don’t mean to discourage screening (entirely). It’s just that screening tests (like the PSA) are always presented in a way that makes them seem straightforward, when in fact they’re a lot more complicated than that.

Elephant seals near San Simeon

If you like this type of medical skepticism, I strongly recommend Overdiagnosed, the new book by H. Gilbert Welch and his Dartmouth Medical School colleagues, Drs. Lisa Schwartz and Steven Woloshin. They really make you think about the whole process of undergoing medical testing–and hope to make us all much better and more knowledgeable ‘consumers’ of health care. (Perhaps less avid consumers.)

One more noteworthy story from last week:

On the NY Times’ “Well Blog,” Pauline Chen wrote an excellent post titled “What Makes a Hospital Great.”

If you’re an avid reader of GlassHospital, you may find some similarities with what Dr. Chen found and posts that you’ve read here, here, and here.

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13Mar11 Normalization

A lot of what I do as a primary care doctor is reassure patients that they’re normal. This isn’t as easy as it seems.

Many forces cause people to doubt themselves and their health. Since 1997, drug companies have been able to market their medications directly to consumers. Diseases have been created to fit their advertising schemes: Acid reflux. Social anxiety disorder. Pre-menstrual dysphoric disorder. Cholesterol marketed as a disease. Erectile dysfunction.

Ouch. Just gotta walk it off. No testing necessary.

Better living through chemistry? Maybe.

 

The downside is that we’ve created a culture of consumers who expect manufactured remedies for almost anything that worries us. We are losing our self-efficacy.

During my residency, when I figured out that much of what doctors do is reinforce normalcy, I began to doubt myself.

Would this be a valid career?

More importantly, would I be “adding value” to patients and their lives?

Fortunately, the long training process removed most of the doubt. I began to see that helping people understand that there’s no one “normal,” that there’s in fact a wide range of normal, has intrinsic value. And that how that idea is conveyed, how it’s communicated, makes a lot of difference for people.

Moreover, helping people understand that for the most part we’re all within a range of normal, even when we don’t feel normal, is crucial. It’s crucial because if we chase after every abnormal sensation or feeling with medical testing, we not only threaten to break the bank, but we cause harm. By over testing we reinforce the doubts; we medicalize the complaints and give them a life of their own.

Here are some of my favorite examples–none serious, but in the right context of worry, very serious for any of us as a patient:

  1. Muscle Cramps: There really isn’t any good medical model for true muscle cramps. They tend to occur from high tension repetitive stress, like sports. But patients often come in and mention cramps, often that get worse at night. As a precaution, we’ll often check blood potassium and/or magnesium levels. In my experience, they’re always normal. If you can figure an action that’s causing the cramps and change it or stop it, then you’ve solved it. But it’s not easy. For some people, I think cramps are just part of normal life.
  2. Clicking/popping: A patient comes in and says, “My ______ (name it: knee, hip, shoulder, leg, etc) pops. And it worries me.” Does it hurt? No is usually the answer. Popping/clicking/cracking can occur almost anywhere in the body. We’re covered with synovial joints–basically knuckles that can be cracked–even in your chest or back. There’s no evidence that any of it causes anything. True knuckle cracking included.
  3. Gas: I love it when a patient is brave enough to admit they’re concerned about gas. It’s _______ (smelly, frequent, embarrassing). Well, let me tell you. This is normal. You may not want it to be. Your spouse/friend/neighbor may wish you didn’t have it, but it’s normal. Enjoy it. It’s part of life.

Have you ever had a discomfort/odd sensation for which you sought help from your doctor and were made to feel reassured without a lot of diagnostic fuss?

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1 Comment Posted by in health & wellness, humor, patient experience, primary care
6Mar11 Whoops!

I write this blog to try to bring transparency to medical practice. In trying to explain and demystify medicine, I’ve found that I use my ‘patient hat’ to explore topics that you want to know about. Even when I wear my ‘doctor hat,’ there are many things that remain inexplicable to me.

As one example, I’ve often wondered: Who had the shocking boldness to try stimulants on people with attention deficit disorder?

Here’s how I imagine that conversation must have gone:

Mmm Mmm Good!

Psychologist: We keep getting these hyperactive kids referred to us for therapy. I wish there was some pill we could give them to calm down.

Researcher: Have you tried sedatives?

Psych: Yes, but the parents complain that their kids just sleep all the time and aren’t doing better in school.

Researcher: Wait! I know! Let’s give them Ritalin and see what happens!

Psych: [Groans.] Oh sure, great idea! Take some amped up kids and give them uppers. Yeah, that’ll work.

I remember learning about this in medical school. It still doesn’t make any sense to me. But it works. Was it clever neuroscience or just dumb luck?

Similarly, there are often examples of medical errors where the natural reaction is, “How on earth could that happen?”

The most outrageous of these are the stories of wrong site surgery. Imagine going in to have part of your leg amputated (not so easy, I imagine) then waking up to find out the wrong leg had been removed. That would be pretty upsetting. This is the reason that medical authorities have come up with the idea of “never events:” things that should never be tolerated in the world of medicine.

Well, add one more to the list.

Last month a hospital in the U.S. admitted that a kidney was transplanted into the wrong patient. Oops!

As egregious as this seems, it’s not so difficult to imagine. All kidneys look pretty much the same. And even though they are typed (i.e. blood typed) and have identification, it can be easy to confuse things like “the type O kidney goes into the blood type B patient (type O is acceptable to anyone)” or “we need to save that type O kidney for this type O patient.”

Huh? I’m confused already, and we’re only talking about one kidney. Imagine having several operating rooms going at one time (multiple donors and recipients), and you can imagine it’s not that hard to get confused. One transplant surgeon told me that at big centers that do multiple transplants on the same days, the error that happened is not all that far-fetched.

Two good things happened here:

  1. The recipient of the wrong kidney didn’t wind up getting sick or rejecting the kidney, since in fact it was a type O (universally accepted) kidney.
  2. The hospital admitted its error and apologized for the mistake. Oh wait. At least I hope they did. They did in fact temporarily shut down their program to investigate the error and hopefully find ways to prevent something like it from happening again. [As of this post, they are up and running again.]

Which gets me to the bottom line of this week’s post: March 6-12th is national Patient Safety Awareness Week, so declared by the not-for-profit National Patient Safety Foundation. If you’re interested further, there are some worthwhile blog posts and podcasts offered up on the interesting “Engaging the Patient” blog, hosted by the for-profit, but high-purposed, Chicago-based Emmi Solutions. [Imagine: a business created around the idea of improving patient experience.....]

I’d be interested in your thoughts on the quality and content of their blog. Anyone knowing the origin of psychostimulants for ADD is also encouraged to comment.

-GlassHospital

 

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2 Comments Posted by in medical errors, medical innovation, patient experience, patient safety, transplant
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27Feb11 23 & You

Imagine there was foolproof test that could tell you if you had any illness at all.

[Picture Dr. Crusher from Star Trek-TNG and her little handheld that she could wave over you to make a diagnosis. Yeah. That'd be useful.]

May the time not be too distant...

Perhaps you’ve heard how lousy some of the tests we currently use in medicine are for detecting disease: There are false positives and negatives (e.g. mammograms and PSA tests), they are often inconvenient (e.g. colonoscopies and PAP smears), and often we don’t really know the best thing to do with a given result (e.g. should all patients with osteoporosis be on a drug like fosamax?).

Though it hasn’t reached the proverbial tipping point, we have already entered a whole new era. Cue the cliche music.

For what seems an ever-decreasing cost (it was thousands, then hundreds, recently $499, now $199) you can literally spit into a test tube and get your own genetic information from several different commercial companies. There are many novel aspects to this trade:

  1. The direct-to-consumer nature of these businesses bypasses the ‘medical establishment’ (i.e. your doctor or ‘medical home’) entirely.
  2. The amount of information you get is truly astounding. Overwhelming, in fact.
  3. The information is ‘actionable intelligence’ that allows you to make health decisions to prevent disease before it manifests.
  4. By undergoing such an analysis, the possibility of developing more tailored treatment exists (i.e. medication that specifically targets your disease).
  5. You can learn the truth. The painful truth. About yourself. About your lineage (are those your real parents?).

Before taking the plunge, read up on genetic testing and decide if it’s right for you. Though the promise of prevention and good health exists, you’re far more likely to come away with more questions than you do answers. The tests show tendencies (or ‘potential susceptibilities’); they are not of a binary yes/no, ‘disease or not’ nature. This can be frustrating. And once you learn about your genetics, there’s no turning back. Knowledge is power, but it also brings responsibility.

As I alluded to above, sometimes the information revealed can shake up perceptions of the self. And since there’s no doctor or genetic counselor between you and this information, it can difficult to interpret. And I took a course in this stuff.

There are a lot of questions out there that make genetic testing still something of a Wild West in medicine. Among them:

1. Should commercial direct-to-consumer genetic tests be subject to regulation by the FDA?

2. Walgreen’s was planning to sell a $20 retail kit that consumers could buy and send in. The kits never reached the shelves. What happened?

3. How safe and private is your genetic information? Can it be used against you, to deny you health coverage or life insurance? What are your rights with regard to knowledge about your own genome?

Fortunately, there is a federal law known as GINA: The Genetic Information Nondiscrimination Act (2008), which makes it illegal to discriminate in hiring or providing health insurance to an American because of his or her genetics.

Any readers out there that have used one of these services? Would you be willing to share your feelings about the experience?

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2 Comments Posted by in genetics, patient experience, preventive health, technology
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20Feb11 e-Doctors

When I use the term “Telemedicine,” what does it mean to you?

In current parlance, it usually refers to radiologists looking at digital images of x-rays and other scans from locations remote from the site of acquisition. [Think "outsourcing" where the radiologist could even be as far away as India.]

Chatting with your doctor via computer link-up. He sure looks ready for action!

But according to a recent conference I attended, Telemedicine could mean so much more: It can range from synchronous video chat between a patient and a doctor, to conferencing between doctors, to allied health professionals (nutritionists, physical therapists) giving live (or canned) presentations to groups of patients–who are geographically far apart.

The technology is already here. The biggest obstacles to widespread adoption of Telemedicine is, you guessed it, payment. Or what health care people call reimbursement.

Our current system rewards in-person visits in a fee-for-service model. Each episode of care is monetized. The more episodes, the more charges. Health care reform will supposedly bring about bundled payments, whereby health care teams (not just us doctors) will provide care for patients assigned to us for monthly charges paid to us by insurance companies, as part of an arrangement known by the widgety name “Accountable Care.” In an accountable care model, doctors would be paid for seeing patients in person or not–so suddenly email, video chat, and data transfer sound a whole lot more convenient for both parties in terms of time and convenience.

How can a doctor examine a patient remotely, you say?

No one thinks Telemedicine will replace the face-to-face encounter; instead, it will augment it. For certain items, a doctor can get readings from a machine-e.g. blood pressures, weights, or glucose levels. Digital photos and video chat work well for skin issues.

In mental health, where resources are often in short supply, Telemedicine has taken on an increasing role in doctor-patient virtual visits.

Soon, your smartphone will have a front-loaded camera, which will allow real-time video chat. No more having to use a desktop or laptop to Skype; even basic calling packages will have this functionality built in.

Technology and innovation will drive medicine toward a more patient-centered convenience; there will be more remote diagnostics and consulting, and less face to face time. Patients will respond by taking more charge of their own records, and decide with whom and to what extent to share them from cloud-based, encrypted storage systems.

The day cannot be too far off. After all, we already have a plethora of e-Patients.

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8 Comments Posted by in computers, health care finance, health care reform, patient experience, technology
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