January 7th, 2011 by KevinMD in Better Health Network, Opinion
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Doctors today are wary about treating chronic pain. One of the main worries is precipitating fatal opioid overdoses. Indeed, according to the CDC, and reported by American Medical News, “fatal opioid overdoses tripled to nearly 14,000 from 1999 to 2006 … [and] emergency department visits involving opioids more than doubled to nearly 306,000 between 2004 and 2008.”
Requiring chronic pain patients to sign pain contracts is a way to mitigate this risk. But how does that affect the doctor-patient relationship?
Indeed, a contract is an adversarial tool. Essentially, it states that a patient must comply with a strict set of rules in order to receive medications, including where and how often they obtain controlled substances, and may involve random drug testing. Break the contract and the patient is often fired from the practice. Read more »
*This blog post was originally published at KevinMD.com*
January 3rd, 2011 by KevinMD in Better Health Network, Research
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I’ve written in the past that more medicine and tests do not necessarily reflect better care.
There is no test that is 100 percent specific or sensitive. That means tests may be positive, when, in fact, there is no disease (“false positive”), or tests may be negative in the presence of disease (“false negative”).
It’s the latter that often gets the most media attention, often trumpeted as missed diagnoses. But false positives can be just as dangerous. Consider this frightening case report from the Archives of Internal Medicine:
A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain. Read more »
*This blog post was originally published at KevinMD.com*
December 29th, 2010 by KevinMD in Better Health Network, Opinion, True Stories
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Primary care physicians often have to see patients with a litany of issues — often within a span of a 15-minute office visit.
This places the doctor in the middle of a tension: Spend more time with the patient to address all of the concerns, but risk the wrath of patients scheduled afterwards, who are then forced to wait. And in some cases, it’s simply impossible to adequately address every patient question during a given visit.
It’s a situation that internist Danielle Ofri wrote recently about in the New York Times. In her essay, she describes a patient, who she initially classified as the “worried well” type:
… a thin, 50-year-old educated woman with a long litany of nonspecific, unrelated complaints and tight worry lines carved into her face. She unfolded a sheet of paper on that Thursday morning in my office with a brisk snap, and my heart sank as I saw 30 lines of hand-printed concerns.
Ms. W. told me that she had recently started smoking again, after her elderly mother became ill, and she was up to a pack a day now. She had headaches, eye pain, pounding in her ears, shortness of breath and dizziness. Her throat felt dry when she swallowed, and she had needling sensations in her chest and tightness in her gut. She couldn’t fall asleep at night. And she really, really wanted a cigarette, she told me, nervously eying the door.
This is the kind of patient who makes me feel as though I’m drowning.
Dr. Ofri did as many doctors do: She listened appropriately, went over the patient’s history and physical, reviewed prior tests, and concluded that many of her symptoms were due to anxiety. Except, in this case, they weren’t. The patient eventually had a pulmonary embolus, and hospitalized. Read more »
*This blog post was originally published at KevinMD.com*
December 17th, 2010 by KevinMD in Better Health Network, Health Policy, News, Opinion, Research
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Mediation has been cited as a way to lower the cost of litigation and compensate injured patients without going through the ordeal of a trial. In a post from the WSJ Health Blog, the problem is that few doctors are participating.
That’s a problem. A study from a law journal looked at 31 cases that went to mediation and found that,
of those cases, 16 were settled at mediation, 5 settled afterward and 10 weren’t settled. While defense attorneys were less likely to agree to mediation than plaintiff attorneys, lawyers who did participate reported satisfaction with the process, as did “plaintiffs, hospital representatives and insurers,” the study finds.
The authors write that in no cases did physicians participate in the mediation.
Many times, patients resort to suing their physicians simply to find out what happened. In a recent post here, attorney Brian Nash provided perspective from the legal standpoint, and in the comments (now 150+ strong), you can see the dissonance between the malpractice viewpoints of the physician, attorney, and patient. Read more »
*This blog post was originally published at KevinMD.com*
December 2nd, 2010 by KevinMD in Better Health Network, News, Opinion
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Medical students today consider lifestyle an essential criteria when choosing a specialty. It’s become a cliche that most are looking towards the ROAD (radiology, ophthalmology, anesthesiology and dermatology) to happiness.
There’s been some recent media attention at how women are lured to specialties that offer a greater balance between their family lifestyle and professional demands. Claudia Golden, a Harvard economics professor, recently noted that,
high-paying careers that offer more help in balancing work and family are the ones that end up luring the largest numbers of women. Surprisingly, colon and rectal surgery is one of these, because of rapid growth in routine colonoscopies that can be scheduled in advance, giving doctors control over their time. Goldin says 31% of colon and rectal surgeons under 35 years of age were female in 2007, compared with only 3% of those ages 55 to 64, and 12% of those ages 45 to 54, reflecting the fact that younger women are flocking to the field.
Of course, what’s not said is the grueling training that it takes to become a colorectal surgeon — but the numbers cited above do not lie. The new generation of doctors — both men and women — want greater control of their time. That means more shift-work and a predictable call schedule. Read more »
*This blog post was originally published at KevinMD.com*
