December 4th, 2007 by Dr. Val Jones in Medblogger Shout Outs, Opinion
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I have witnessed various disappointing doctor-patient interactions over the years. Sometimes the doctor is insensitive, other times he or she doesn’t listen to the patient – and errors can result. Young physicians are more prone to inappropriate patient and family interactions when they are feeling inadequate and insecure. A fellow blogger describes just this kind of problem with a young pediatrics resident:
A meek lady with a white lab coat
walks in and just starts asking medical questions. So
my answer to her first question was “Who are you?” She apologized and
said she was the pediatrics resident and asked a bunch of questions
that didn’t seem to us to have much bearing on the situation at hand.
We asked about why my son was making unusual gasping breaths ever since
he woke up and she said it was because he was crying. We said that he
was making these breaths before he started crying. She then said it was
probably hiccups. My wife, who is a registered nurse, said there was no
way it was hiccups because she felt him pressed against her body and
could tell. The resident then said that it was probably due to the
anesthesia. I could tell she was just giving that answer to say
something but really had no clue what was going on. So I challenged her
on it and said “Have you ever seen this after anesthesia before?” She
paused and said, “Maybe once.”
Although this is not the wost example of an unsatisfying doctor-patient interaction (read the rest of the post to get the full story), it is pretty typical for inexperienced physicians to “make up” explanations for symptoms or problems that they don’t understand. This can be dangerous or even life threatening if certain symptoms are ignored.So how do we protect ourselves against this kind of potential error? Sadly, the current quality assurance programs are rather ineffective. In his recent blog post about ensuring physician quality, Dr. Scalpel published a letter he recently received from his hospital. The letter was prepared as part of the Joint Commission quality assurance program. They actually require doctors to get a letter of recommendation from someone (who doesn’t work with them) to ensure that they’re practicing good medicine… It’s like asking a stranger to grade your work competence.
Dear Dr. Scalpel:
In
accordance with Joint Commission regulations, we are required to
request an evaluation of your clinical performance. The Credentialing
Committee now requires the completion of an evaluation form by a peer in your specialty who is not a member of your group practice.
Attached,
you will find a letter and accompanying evaluation form which you
should forward to a peer of your choice for completion. In order to
proceed with the processing of your reappointment application, it is
necessary that you ensure that the required evaluation form is
forwarded to a peer and returned to us in a timely manner. A return
envelope is provided for this purpose. Please note that the evaluation
form must be returned to us by the person completing the form. If we do
not receive the evaluation form before ________, your clinical
privileges may be interrupted.
Sincerely,
An Unnamed Bureaucrat
So, how do you ensure that you’re getting good medical care? It’s not easy, and you can’t necessarily depend on oversight committees to come up with sensible safeguards. Being an informed patient is part of being an empowered patient – you should do what you can to research your doctor’s and hospital’s credentials and reputation (you can do that right here with Revolution Health’s ratings tool), you should read about your diagnosis or condition on reputable websites like Revolution Health, and you should advocate for yourself or loved one at the hospital when necessary. You have the right to reasonable explanations for care decisions – and if you’re concerned about a symptom, you should ask about it.
Unfortunately, there’s no way to guarantee quality medical care. However, perhaps the most important thing you can do (besides advocate for yourself and become educated about your condition) is to develop a close relationship with a primary care physician. Establishing a medical home with a good primary care physician can go a long way towards helping you to navigate the system. They can be your best advocate in this broken system.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
October 18th, 2007 by Dr. Val Jones in News, Opinion
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You might have seen the recent news about the middle school in Maine – King Middle School, in the Portland school district – that is planning to provide birth control to pre-teens, without requiring explicit parental consent. School officials argue that this will help to prevent pre-teen pregnancies, and estimate that at least 5 out of 135 of their 11- to 13-year-old female students are sexually active already.
While I absolutely sympathize with the desire to avoid pre-teen pregnancies, and I do understand that there is a reality here that some very young children will become sexually active at the tender age of 11, I personally do not support giving pre-pubescent girls hormone-altering tablets. We do not have good studies demonstrating the safety of such therapies in children, and until we do it’s just not medically sound to be offering this treatment. (For example, we don’t know what extra estrogen does to early breast buds, or whether there’s an increased risk for developing breast cancer later on.)
I also think that 11 year olds are not physically and emotionally prepared for sexual intimacy – and the prematurity of this event could be quite harmful for their psyche. We know that 11- and 12-year-old brains are not fully developed to think the way adults do, so there’s really no telling what impact it could have or what long term psychological effects might result.
Apparently sex before the age of 14 is illegal in Maine, so (although there’s no doubt that it may happen prior to that age) it seems that the state’s legal system is not in step with their school system, and that needs to be looked at. It is inconsistent to claim that an activity is illegal for children and then enable it with tax dollars.
I suppose that education about the use of condoms and access to them (without aggressive promotion of them) may be acceptable at this age. After all, condoms can prevent STDs and don’t have medical effects on the body as a whole. But my plea is that parents take the lead here – and educate your children about the risks of STDs, pregnancy, and the emotional damage that premature sex can have on a young person. Advocate for abstinence as a first choice, explain that condoms are non-negotiable, and try to help them turn their focus away from sex and towards more age-appropriate endeavors.
A new Dove advertising campaign asks parents to talk to their kids before the beauty industry does, and I think the same goes for sex and the media. Today’s parent must launch a preemptive strike against the over-sexualization of children, or risk having their 11 year olds taking estrogen patches from a school nurse without their consent.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
October 7th, 2007 by Dr. Val Jones in Book Reviews
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I’ve been reading Mindy Roberts’ hilarious book: Mommy Confidential: Adventures From The Wonderbelly of Motherhood. I particularly enjoy the moments she captures about her son, Will. I thought I’d share some excerpts with you to give you a good chuckle:
***
Today at Jake’s 6th birthday party, Will rushed up to me saying, “Mommy! There’s a dead squirrel over there! Hurry mommy, before he goes to heaven!”
***
Will is obsessed with size differentials among animals and the relative strengths and weaknesses of each as they relate to other predators. He wants to know exactly how big everything is so that he can determine how many predators it takes to bring down each type of prey. Among the factors are: height, weight, speed, habitat, how far it can jump, whether it can rear up, whether it can swim, and how sharp the teeth are. Usually he wants to know if, say, 20 wolves can take on 10 tigers, but this morning’s question took the cake. “Daddy, can 10 monkeys take down a zebra?”
You can find Mindy’s book at her website.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 7th, 2007 by Dr. Val Jones in Expert Interviews
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Two new studies reported increasing suicide rates in teenagers. The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.
What could be causing these tragic increases? I interviewed Revolution Health psychologist, Dr. Mark Smaller and child psychiatrist, Dr. Andrew Gerber, to get their take on this disturbing trend.
1. In previous research,
increased suicidality was associated with SSRI use in teens. Now this study
suggests that lower SSRI use is associated with increased suicidality. How do
you explain this?
Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens. However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant. The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage. What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living. A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented. This is not being done in enough instances. With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.
Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.
First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.
Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.
Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.
The
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
do.
With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).
2. Is there a role for
SSRIs in teens?
Dr. Smaller: I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.
Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.
3. What would you counsel
parents about these drugs?
Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help. The mental health professional and the parent must have a working alliance to insure that the treatment is successful.
Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
families.
4. What do you make of
the suicide rate increase in girls? What could be behind
this?
Dr. Smaller: This is alarming. The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty. The teen years can be fraught with family issues that exacerbate moods and create symptoms. Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls. Social roles, peer pressure and issues, academic demands and family strife all contribute. The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.
Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 22nd, 2007 by Dr. Val Jones in True Stories
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Dr. Sid Schwab recently wrote a wonderful blog post about what doctors feel when they treat patients who remind them of their own kids. For example, he describes how it makes the physician want to run home and hug his/her kids out of gratitude that they’re ok. His post reminded me of an experience I had in the pediatric Emergency Department where I came face to face with memories of my own childhood trauma.
I was bitten in the face by a neighbor’s dog when I was about 4 years old. It was unprovoked and completely unexpected. The dog had no history of viciousness and I had no history of tormenting the creature. I was standing in the hallway, eye to eye with the dog (we were the same height) and I reached out to gently pet him when he attacked me. My parents freaked out, blood was pouring out of my face, and apparently it initially looked as if he’d gotten my left eyes since it was covered in blood. I was rushed to the local hospital where a family physician cleaned me up and put stitches in my cheek, eyebrow, and corner of my eye. It was hard to sit still for the numbing medicine and I was crying softly through it all. I don’t remember the details of the event, but I do still have the scars on my face – scars, I am told, that would be less noticeable if a plastic surgeon had closed the wounds.
Flash forward 30 years and I’m working a night shift in the pediatric ED. A father carries in his young daughter, crying and bloody. She had been mauled by a dog – and had sustained injuries to her face only. I escort the little girl to an examining room and begin flushing her wounds with saline to get a sense of how extensive they are. Dad goes to fill out paperwork while mom holds the girl’s hand.
It was eerie – her injuries were very similar to my own. I figured she’d need a total of 15 stitches or so, all on the left side of her face. There was no missing flesh so I knew that the cosmetic result would be good. I explained to her mom that we would be able to stitch her up nicely – and that she’d likely have minimal scarring. The mom asked for a plastic surgeon – and I agreed to call one for her right away.
That night I had a new appreciation for what my parents must have felt when I was bitten. I could see these strangers’ concern – how they hoped that their little girl wouldn’t be permanently disfigured, how they wanted the most experienced doctor to do the suturing, how they held her hand as she cried. It was really tough – but we were all grateful that the injuries weren’t more severe… and I was glad that I didn’t have to do the suturing. I showed the girl my scars and she seemed comforted by how they had turned out. This experience reminded me how personal experience can add a special dimension to caring for others, and that sometimes having been a patient can make you a better doctor.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
