February 19th, 2010 by Nicholas Genes, M.D., Ph.D. in Better Health Network, Opinion
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There’s an adage I often think about: “A physician’s job requires the expression of confidence. The researcher’s role is to express doubt.”
This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed — in the lab, a year’s worth of experiments is summarized with “seems” and “suggests,” and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.
As a student on clerkships, I couldn’t quite wrap my head around the residents’ ambitious plans for patients: Read more »
*This blog post was originally published at Blogborygmi*
February 12th, 2010 by Shadowfax in Better Health Network, True Stories
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Sometimes in this job you just get lucky. You have an elusive and/or dangerous diagnosis just dropped in your lap. Something devastating that you would never have been able to tease out otherwise just gets handed to you by the patient. There’s a catch, though: you have to be smart enough to know when to listen to the patient, when not to blow off their crazy talk as just crazy.
So it was recently when I saw a guy with back pain. From the chart, it didn’t sound like anything complex: a middle-aged to older guy, maybe 60 or so, with a history of chronic back pain and multiple surgeries for the same. He was on Oxycontin 80 mg three times daily (a very high dose, and a red flag for an ER doc naturally suspicious of drug-seeking behavior). I went to see him, and it was clear in seconds that this dude was JPN: Just Plain Nuts. Read more »
*This blog post was originally published at Movin' Meat*
February 3rd, 2010 by DrRob in Better Health Network, Health Policy, Opinion
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I was talking to a fellow physician about a mutual patient. I had information that would help him in their care and he was taking the unusual step of asking me for my information. I was impressed.
“Could you fax me those documents?” he asked. ”Here’s my fax number.”
I scrambled to get a pen to write down his number. Then I had a thought: “I could email you those documents much easier. Do you have an email address?”
Silence.
After a long pause, he hesitantly responded, “I would rather you just fax it.” He said no more. Read more »
*This blog post was originally published at Musings of a Distractible Mind*
August 10th, 2009 by DrRob in Better Health Network, Opinion
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Let me kick the hornets’ nest again. I still have misgivings about sending information like this to my patients:
How does one not trained in what to overlook interpret the above? To me, this lab result is entirely expected for this patient – given the other medical history that is there. My concern is that this will either cause unneeded worry, or it would prompt a phone call to ask about labs that I would be quick to accept. Yes, there are times when this may help the doctor who overlooked abnormal tests in error, but the majority of abnormal lab values are not significant. The vast majority are insignificant. I’d put the rate at nearly 10:1.
When we e-mail patients their lab results, we have two options: to send the actual report, or send an abbreviated form of it. Here is what I sent this patient (for these actual labs):
I had a woman complain to me when I didn’t send her this “sanitized” version of her thyroid labs. She didn’t understand the lab report and just wanted my explanation. Which would you rather have? Do patients really need to know their MCHC, RDW, RBC count, and absolute eosinophil count? Do they want to? I don’t care about those numbers 99.9% of the time I look at them.
Here’s another example:
“Doctor! I am really worried about my Bun Level and Carbon dioxide levels. I read that these can all mean I am dehydrated! They also can mean I am going into kidney failure. I don’t want to go on dialysis! And what about the monocytes and MPV levels? One website I saw said this could mean leukemia.”
Sound outlandish? Sound like something that won’t happen much? Wrong. We spend a very large amount of time explaining these basically normal (MPV?? Absolute Monocytes??). All lab tests need to be put in the perspective of the patient’s age, disease state, race, and medications they are taking. They also need to be seen as a single point on the graph and so must be looked at in comparison with previous lab tests. How would I interpret this? Normal.
Do you, my readers, REALLY want to see the absolute monocyte counts and MPV?
Here’s another:
Look at all the extra information put at the bottom of the lab report. What does it mean?
Most of this is fluff meant to keep the lawyers happy. The average patient will not quite know where to look here and will either just be confused by it or become anxious and want to question this as being abnormal. ”I thought you said my diabetes control was good, but the diabetes test was high according to this!” or “A hemoglobin of 6.5 is dangerous, isn’t it?” I have had both of these comments from patients.
Here’s a typical echocardiogram report:
What percent of patients want all of this? I don’t! I really could care less about everything above the “Impression” section from the cardiologist. I was not even aware that pressure had a halftime. None of these findings are significant.
The cardiologist has to include all of these in his note for herself because of documentation requirements and because the fine details mean something to her. But they mean nothing to me, and I would prefer just getting the “Impression” sent to me. Why should patients be different from me?
Wouldn’t you rather get from me something that says: “Your echocardiogram looked good”?
I really think that giving full access to all information opens a hornet’s nest of its own. We will spend a lot of time educating our patients to the nature of medical information and medical terminology. Again, I am fine with having folks who feel they need this information; but I am a little skeptical that they really do need it.
I don’t need most of this stuff, and would be much happier if I got only what I asked for.
*This blog post was originally published at Musings of a Distractible Mind*
