Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

The "non-compliant" patient

It used to strike me as odd that physicians used somewhat hostile language to describe patient behavior – “the patient is non-compliant,” “the patient refused [this-or-that drug or procedure],” “the patient denies [insert symptom here].”

After many years of using these words, I forgot just how inflammatory they are. They became part of my language, and I used them every day to describe people. I’m not really sure how this phraseology became common parlance, but it is a tad adversarial when you think of it. It sets up a kind of us versus them environment. And really, medicine is all about us in partnership with them.

I was reminded of this fact as a friend of mine described a recent “non-compliance” episode. She had been complaining of shortness of breath, and had some sort of suspicious finding on her chest CT. The pulmonary specialist (called a ‘respirologist’ in Canada) recommended a bronchoscopy. Here’s what she says,

I wish I had the chance to explain to my respirologist why I was non-compliant about the bronchoscopy. I got the impression that she thought I was being “difficult” for no good reason, and that I was wasting her time. But the truth is, all my life I’ve had this vague sense that anything big going down my throat was particularly scary to me. I knew I had trouble gagging down pills, but it never occurred to me to mention that. I also chew my food to death in order to swallow it comfortably, but I never thought about that very consciously, either. It wasn’t until months later when I had to undergo surgery for my gallbladder that my anesthesiologist (who had to intubate me) discovered that I had an internal throat deformity.

So my point is that it might be valuable for the respirologist to know that when a patient is very scared of something (especially when she is usually never scared of tests, needles, etc), it could be an important clue. I know now that bronchoscopies are not without risk. A bronchoscopy technician might not have handled the situation nearly as well as that highly-trained, very experienced anaesthesiologist did.

What I learned is this: patients don’t know how to explain things that they haven’t thought much about before, especially when they know that their doc is understandably pressured to get through her scheduled appointments on time. All they know is that they’re scared and that they want to run away. They’re not primarily out to exasperate their docs with their noncompliant attitude. Still, it isn’t easy being a doc. I’m sure noncompliant patients are indeed very irritating. But it isn’t easy being a patient, either. Being looked down upon is irritating too. Not only that, but the patient has a lot more to lose if a mistake is made. But what can you do? Everybody is under a lot of pressure when it comes to medical issues. We all just have to try to be understanding and do our best to work together for a good outcome. It’s in the best interest of both parties, so it shouldn’t have to be a battle!

Have you been a “non-compliant” patient for a good reason? Do share.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Rare skin disorder may be triggered by wart virus?

For those who are faint of heart, please do not click on this link (via KevinMD). This poor man living in Eastern Europe developed a rare disorder (called Lewandowsky-Lutz dysplasia) where he had growths appear on his hands and feet starting at age 14. Many years later the growths are quite disfiguring and difficult to remove.

Some speculate that this may be similar to a warty disorder in rabbits. Either way, it is a little disturbing to me that this condition could be triggered by a virus. Viruses, of course, can be quite contagious…

Any dermatologists out there want to weigh in?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Speed & quality: are they inversely proportional in medicine?

In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).

The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought?  PROBABLY NOT. Will some important detail slip past them?  SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART.  I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.

All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.

Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Medicine’s "secret" code

To you Internet savvy folks out there, LOL means “laugh out loud” but to us doctors, “LOL” usually means “little old lady.” We have shorthand for everything, and our notes can look like stock tickers to the uninitiated.
For example, “NAD” means “no acute distress” (which, when translated into consumer speech, basically means that the person looks well). We shorten common words with an “x” after the first letter. So “diagnosis” becomes Dx, “treatment” becomes Tx, and “past medical history” becomes “PMHx.” Of course, there are some exceptions – “significant for” becomes s/f and “chief complaint” (or the reason why the patient believes he or she is there to see you) becomes CC. The events leading up to the chief complaint are called the “history of present illness” or HPI.
We also abbreviate the most common diseases, so that hypertension becomes HTN, diabetes mellitus is DM, heart attack is MI, and coronary artery disease is CAD. We like to use “status post” to indicate “after” something happened. And many symptoms have shorthand: DOE means “dyspnea on exertion” which is basically that you get short of breath when you walk. Or chest pain, CP. We sometimes use “?” when the patient is a poor historian (this usually indicates psychosis, dementia or severe language barrier). The pain scale is always listed as a fraction of 10. We can summarize a person’s mental status with how alert and oriented (meaning they know their name, where they are, and what the date is – they get 1 point for each of 3) they are. Vital signs (VS), such as temperature, heart rate, blood pressure, and respiratory rate, are considered “stable” or VSS if the values are all normal. Now let’s see if you can decode these short medical notes on 2 theoretical patients in the ER:
Patient#1
CC: ?DOE
HPI: s/p long walk
PMHx no DM, CAD, HTN
PE: LOL in NAD, A&Ox2,VSS, 0/10
Dx: r/o MI
Patient #2
CC: CPx1 hr, 10/10
HPI: s/p walk
PMHx s/f DM, CAD, HTN
PE: LOL in AD
Dx: r/o MI
Now, both of these patients have the same diagnosis listed, but I can tell you that the first patient is going to wait around for many hours before she’s treated, but the second case is going to marshal the cavalry immediately.
Can you picture in your mind’s eye what patient #1 is like? A little old lady who appears physically well but is complaining of shortness of breath (we think – we’re not really sure what her main problem is as indicated by the question mark) and is a little bit disoriented. She has no major medical problems.
Now the second lady has severe chest pain that has been going on for an hour. She has all kinds of risk factors for a heart attack and appears unwell. This is worrisome, indeed.
So that’s your crash course in medical short hand. Do you think you can crack the code on your next chart review?
My next post will discuss one consumer’s fear of medical shorthand… So stay tuned!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Your mom will always be your mom, part 2

I’m afraid you’re going to need a box of tissues for this next post. My good friend Carolyn (she is the Cancer Center Manager at Revolution Health – and has a great blog) sent me a link to a story she wrote about a school program developed to raise awareness of the dangers of drunk driving. It’s called: “Fatal Choices – Shattered Dreams.”

Basically, the entire school goes through a detailed reenactment of a fatal car crash where several classmates are killed. Part of the program requires that all the kids (and their parents) imagine the goodbye letters they’d write if they knew they would be killed in a drunk driving crash. Carolyn and her daughter wrote these letters to one another, as they imagined this horrific scenario:

Dear Mom & Dad. I really don’t know what you are supposed to say in a good bye letter. I couldn’t even imagine waking up one morning and not coming back to see you later that same day. Today, that unimaginable thing became a reality. Dad – if I could go back to this morning knowing what the day would bring I wish more than anything that I just would have said I love you instead of griping about stupid things. I truly do love you and hope and wish that after my death, you can move on, heal and live an amazing life full of happiness. Mom – my only regret with you is that I did not even get to see or speak to you this morning. I would give a lot just to be able to see you this morning. You are the one person that I would not mind being completely like when I grow up, if I would have grown up. You are more than just my mom, you are the one I can talk to and count on. I love you so much! Both of you mean the world to me and I would give anything just to be able to say good bye. I love you with all my heart and I hope that after my death, everything will be OK. I wish you both the best life you could possibly have and please live it the way you would with me there – with happiness, excitement and adventure. Thank you for everything you have given me. You are the absolute best parents I could have asked for. I love you forever, wherever. Erica

Here’s what Erica’s mom, Carolyn, wrote:

We thought we had a lifetime to talk to you, call you on the telephone or e-mail you, but this will be the final time we will write:

Dear Erica, This is not the proper order of things – parents bury parents and grandparents. We are not supposed to bury our children, but yet, here we are saying good-bye for the last time. We hope you left this world knowing that we loved you more than life itself. If either of us could trade places with you, we would do so without hesitation. Our lives will never be the same. They say time heals all wounds, but not this one. We have holes in our hearts since you are gone, and we will be this way until the end of our days. We will never see you graduate from high school. We can imagine the smile on your face as you are with your friends when you leave high school for the last time as a graduate. We will miss seeing you swim in college, something we know you were looking forward to. We’ll never see you graduate from college – beginning what for most is the start of a lifetime of rich and fulfilling experiences. We will not see the love you show for others as you proceed with your career as a neo-natal nurse. How many babies will never know your soft and caring touch? We will never see you walk down the aisle with the love of your life. We will never hold your children. But the most tragic thing of all Erica, we will never hold you again – something we cannot bear, but must now deal with. Puffy, Puppy and Kissy are with you in your final resting place. We hope that whatever journey you take from here on – that they bring you comfort throughout eternity. Remember us as two people who loved you so much that even in death, we want you to be comfortable and at peace. Good-bye for the last time, Erica. This is not the proper order of things, but we will love you forever.

This sort of program and reflection may truly save lives… Do what you can to support this initiative.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »