August 16th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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In an effort to provide round-the-clock emergency care for their patients, physicians often share an on call schedule. The physician on call makes him or herself available for emergency consultation for 24 hours or more at a time. Unfortunately, patients seem to misunderstand the role of the on call physician – believing that being on call is a form of extended office hours for their convenience. Here’s one doctor’s account of the non-emergency services he provides on-call, and the attitudes that drive him crazy:
One of my biggest challenges is
understanding why patients consider an emergency as anything that they
don’t want to wait until Monday, or even daylight. They want lab
reports. They want advice on whether to get a flu shot. They want to
know what that green cough medicine was their doctor recommended 3
years ago. They want their medicines— that they only seem to know by
color—refilled. And, of course, they are not satisfied with a few pills
to get them through the weekend. They’re not going to pay a “full”
copay for less than a “full” prescription.
A related challenge is that, when I call a phone
number after being paged, the person answering the phone is almost
never the person who paged me. Sometimes it is a teen who answers the
phone with a “Yeah” or a “What?” That there is an important call
expected and that there is an emergency going on in the house is beyond
them. Eventually, I persuade them to find the sick person, and from the
amount of time they are gone, the house must be a mansion.
Sometimes a man answers the phone, and says, “Here,
I’ll let you talk to my wife.” Funny, he’s the one with the problem,
but he somehow cannot talk. I imagine him sitting in the background
like a king who cannot be expected to do his own talking, while his
servant/wife explains his symptoms. Sometimes, if the person having the
emergency is a teen, I have to talk to the mother, because the teen
won’t come to the phone (an interesting twist). The teen won’t tell Mom
exactly what the problem is either, so I have to ask the mother my
questions, then she yells them down the hall, listens for the answer,
then relays the answer to me. Example: “My daughter Susie has a cough.”
“Does she have a fever?” “SUSIE, DO YOU HAVE A FEVER?” “NO.” “No,” “Is
she bringing up any sputum?” “SUSIE, ARE YOU BRINGING UP ANY SPUTUM?”
“YES.” “Yes.” Well, I don’t need to go on, but it can, interminably.
Sometimes the person having the problem is not
available at the number when I call. “Hello, this is Dr. Constan.”
“Hello, this is Mrs. Smith, I’m calling about my mother, Mrs. Jones,
and she wants to know what to do about her abdominal pain.” “Could you
please put her on the line so that I can talk to her?”
“She’s not here, she went shopping.”
“Oh.”
Sometimes the person doesn’t answer, at all. I’ve
called back promptly, yet “there’s no one home.” What gives? They call
back later to fill me in on what happened at the ER, like I need to
know. They had called me then decided it wasn’t necessary to talk to
me, they wanted to go to the ER anyway. Then, why did you call?
Sometimes when I call back, I get a busy signal. How does that happen?
You page a doctor then tie up the line so I can’t call back! I imagine
that you figure you should first seek advice from the doctor then seek
advice from all your friends and relatives, whomever you can get on the
line. Later you say to yourself, “I wonder why that darned doctor never
called me back.”
…
The advent of Caller ID has produced its own set of
challenges. The person pages me, leaves their number, but when I call
them, they won’t answer the phone because they don’t recognize the
number displayed by the Caller ID. I imagine them standing by the
phone, staring at the number, and reasoning: “Now, I’m having a serious
emergency here, but I don’t want to take the chance of answering this
call and having to talk to a telemarketer. What do I do? Best not take
the chance.” Later: “I wonder why that darned doctor never called me
back.”
If I talk to an answering machine, I usually offer
that the patient can call me back later if they still need help. One
lady called me back and told me that she was home when I called, heard
me leaving the message on her machine, but couldn’t come to the phone
because she was doing her vacuuming. How has outrageous fortune
relegated my services below those of a vacuum cleaner?
Although all the above challenges tend to wear on me
toward the end of the weekend, I try to be professional and caring
about each call (just ask my family). It’s my job to stay the course
with no laurel wreath expected on Monday morning. It was a surprise and
joy to me recently when, at a party, I was introduced to a nice young
couple. “You’re Dr. Constan! We called you 2 years ago about our sick
child. You were so helpful. We’ve always appreciated what you did for
us.” The challenge of weekend call should have more such awards.
For a complete version of this article, please visit www.PMDLive.comThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 14th, 2007 by Dr. Val Jones in Expert Interviews
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In a recent study conducted by the Agency for Healthcare Research and Quality (AHRQ), it was argued that better primary care could prevent 4 million hospitalizations per year. This staggering potential savings – on the order of tens of billions of dollars – seems like a good place to start in reducing some of the burden on the healthcare system (and reducing unnecessary pain and suffering). I interviewed Dr. Joe Scherger, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine (UCSD) and member of the Institute of Medicine, to get his take on the importance of prevention in reducing health costs.
Dr. Val: What do the AHRQ
statistics tell us about the role of primary care in reducing healthcare
costs?
Volumes!
Primary care works with the
patient early in the course of illness, maybe even before it has developed, such
as with prehypertension and prediabetes. Primary care focused on prevention
with patients keeps people healthier and out of the
hospital.
Dr. Val: What can individual
Americans do to reduce their likelihood of having to be admitted to the
hospital?
Prevention begins with the individual,
not the physician. 60% of disease is related to lifestyle. Bad habits such as
smoking, overeating, not being physically fit, and stress underlie most common
chronic diseases. If Americans choose to be healthy and work at it, we would
save tremendously in medical expenses.
Dr. Val: Are there other studies
to suggest that having a medical home (with a PCP) can improve
health?
The medical home concept is new and lacks
studies, but the work of Barbara Starfield and others have confirmed the
importance of primary care and having a continuity relationship with a primary
care physician. The more primary is available, the healthier the population.
The opposite is true with specialty care.
Dr. Val: Why did the
“gatekeeper” movement (promoted by HMOs) fail, and what is the current role of
the family physician in the healthcare system?
The
“gatekeeper” role failed because it restricted patient choice. Patients need to
be in control of the health care, which is what patient-centered care is all
about. HMOs put the health insurance plan in charge, something which was hated
by patients and their physicians.
Dr. Val: In your work with the
IOM (specifically in Closing the Quality Chasm) did the role of primary care and
preventive medicine come up? If so, what did the IOM think that PCPs would
contribute to quality improvement in healthcare? Did they discuss (perhaps
tangentially) the cost issue (how to reduce costs by increasing preventive
measures?)
Just before the IOM Quality Reports
came out, the IOM did a major report on the importance of primary care. The
importance of primary care and prevention are central to improved quality. In
the “Chasm Report”, the focus was more on the patients taking greater charge of
their health care, and the realization that primary care is a team effort, and
not just a role for physicians. The reduction in costs comes from making health
care more accessible (not dependent on visits) through health information
technology and the internet. Preventing disease, and treating it early when it
comes, are the keys to quality and cost reduction. Revolution Health is a
vehicle for this, consistent with the vision of the “Chasm Report.”
Dr. Val: How can patients be sure that they’re getting the best primary care?
First take charge of your
own primary care. The traditional patient-physician relationship was, “Yes
doctor”, “Whatever you say doctor”. Your care would be limited by the knowledge
and recall (on the spot) of your doctor.
Much better is a “shared care” relationship with your primary care
physician and team. After all, the care is about you. Be informed. Make your
own decisions realizing that the physician and care team are advisors, coaches
in your care. You may agree with them, or disagree and do it your way. By
having your own personal health record and being connected to resources like
Revolution Health, you are empowered to get the care you want and need.
Finally, choose your primary care wisely. Not just anybody will do. Your
primary care physician is as important a choice as your close friends. You need
to like and trust this person. Have a great primary care physician who knows
you and cares about you and your health care is in real good shape. But, no
matter how good she or he is, you still must take responsibility for your care.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 17th, 2007 by Dr. Val Jones in Uncategorized
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Just because a drug is new, doesn’t mean it’s more
effective. A recent
article published in the Annals of Internal Medicine demonstrated that older
diabetes medications may be equally effective as some of the newer, more
expensive drugs.
Now this comes as no surprise to physicians, who know very
well that some of our “old standby” meds work just as well as their newer, more
expensive versions.
For example:
For mild to moderate acne treatment, good old Clearasil may be all you need.
A study
published in the Lancet found that over-the-counter topical treatments (benzoyl
peroxide based) worked just as well as more expensive new oral antibiotics
(including minocycline).
For mild to moderately elevated cholesterol, there doesn’t appear to be much
advantage to taking a newer statin than on older one. The cost difference may be as much as ten
times more, for small gains (if any).
For example, mevacor (lovastatin) is as inexpensive as 0.24 cents/pill
while lipitor (atorvastatin) can run up to $2.54/pill.
Dr.
Charlie Smith, former president of the American Board of Family Practice,
recommends these very cost effective medications to his patients as needed:
Hydrochlorothiazide for hypertension (from 8 cents to 20 cents/pill)
Bactrim (trimethoprim/sulfamethoxisole) for urinary tract infections (15
cents/pill).
Ibuprofen for pain relief/arthritis (about 7 cents/pill).
So consumer beware – those medications that you see in all the TV ads may not actually provide substantial benefits over older, less expensive drugs. Be sure
to ask your doctor if a less expensive medication might be appropriate for you… or
better yet, healthy lifestyle changes can sometimes make the difference between needing
a medication and not needing it at all.
*Drug prices may vary.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 20th, 2007 by Dr. Val Jones in Opinion
3 Comments »
Little did I know that there is a raging debate about whether or not it’s a good idea to circumcise male babies. I was reading #1 Dinosaur’s blog and almost fell off my chair at the passionate series of comments. Apparently, 90% of American males were circumcised in the 1960s, but that rate has dropped to about 57% today.
Pro Circumcision: circumcision decreases the rate of transmission of HIV and HPV and is hygienically desirable. It does not appear to adversely affect sexual function, is a fairly minor and non-traumatic procedure, and is a reasonable health intervention.
Against Circumcision: condoms are more effective at reducing HIV and HPV transmission than circumcision. It is ethically wrong to circumcise an infant because he cannot give his consent and the procedure is painful. Some people believe that there is an important sensory nerve in the frenulum that is often severed during circumcision.
The American Academy of Pediatrics takes the position that: Existing scientific evidence demonstrates potential medical benefits of
newborn male circumcision; however, these data are not sufficient to
recommend routine neonatal circumcision.
The American College of Obstetricians & Gynecologists takes no position: Newborn circumcision is an elective procedure to be performed at the
request of the parents on baby boys who are physiologically and
clinical stable.
I had always assumed that circumcision was a personal choice that people didn’t feel that strongly about one way or the other. I guess I was wrong!
Why do you think this topic is so passionately debated?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 14th, 2007 by Dr. Val Jones in Health Tips
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Every once in a while a friend or family member is in a bind and asks me if I can prescribe them some medication. When people have a case of painful otitis externa (external ear infection), some tinea corporis (ringworm), or just need an allergy medicine refill, for example, and can’t get an appointment to see their doctor for weeks, I generally feel badly and offer to prescribe them something to tide them over. I know it’s not right to prescribe medications to folks who aren’t technically your patients, but it just seems worse to watch them suffer with a time-sensitive illness that has a simple cure.
Today I had to look up all the various and sundry treatments for ringworm. According to my Pharmacopoeia (and eMedicine.com) pretty much any antifungal cream on the market is a possible treatment for it… so how is a doc to choose the best therapy? Is it trial and error? Is it pick the cheapest medicine on the list and cross your fingers?
There are times when many different medicines are appropriate treatment options, and the best choice requires a bit of guess work mixed with past experience. Since I can’t find any literature suggesting that one topical treatment is more effective than another, I just chose a common, inexpensive cream. Sometimes medical decision making has its gray areas… Wouldn’t it be nice if everything had one clear answer?
Oh, and if you do have ringworm, keep in mind that 1) you can catch it from your dog – and yeah, Fido could catch it from you 2) you are contagious to others 3) it’s easy to treat with pretty much any anti-fungal cream or lotion (apply twice a day for 2 weeks or so) 4) if you can’t get to see your doctor, using over the counter Monistat may do the trick in a pinch. If your skin is not responding to the cream – better get checked out to make sure it really is a fungal infection and not something else.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
