February 17th, 2008 by Dr. Val Jones in True Stories
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As many of my regular readers know, my dear friend and Revolution Health administrative assistant (Seton) was diagnosed with stage IV colon cancer after giving birth to her first baby. She is doing well on chemotherapy, and working hard to shrink the liver tumors to a size that will allow her to have them cut out, and possibly be cured. On March 9th she’ll be participating in a Race for Colon Cancer walk/run in Central Park, and I’ll be joining her. This weekend I came to New York to practice the 4 mile run with a girlfriend of mine (Karen). Here’s what happened…
As I set out to meet my girlfriend at the southwest corner of Central Park, I became keenly aware that my light windbreaker/t-shirt combo was ill equipped to protect me against the icy wind chill. It was 8:30 in the morning, and as I bowed my head in the face of frigid temperatures, tears streamed down my cheeks while urban grit blew the very moisture out of my eyes. “Whose idea was this?” I asked myself, marveling at the occasional onlooker, bundled head to toe with hats, mittens and face masks. “Oh, yeah – mine. What was I thinking? Why didn’t I look at the weather report?”
About half a mile between my departure point and destination, I began to realize that my ears were in danger of freezing off. “I’ve got to find a hat” I thought… glancing at Citibank headquarters to the right and Meryl Lynch to the left. Where could one find a hat at this time of day, and in this neighborhood? Hmmm… a 24 hour pharmacy perhaps? As I marched towards what appeared to be a distant pharmacy I began thinking of ways to make a hat from cotton strips, Ace bandages, or maybe a shower cap. Severe cold can make a desperate mind exceedingly creative.
As I temporarily thawed myself in the warmth of the pharmacy, I began my search for a head covering. A fleeting moment of triumph gave way to disappointment when a hot pink Santa’s “little princess” elf hat (buried in a discount bin) proved to have the inelastic circumference suitable for a very small child or canine companion. But if there’s one kiddie hat in here, there must be others, I thought. So I combed through the drug store stock with a hopeful eye.
Ah-hah! I discovered a virtual treasure trove of kiddie hats, pinned to the backside of a pillar near the deodorant aisle. Of course, they were each painfully pediatric – with neon colors, gold stars, and little plastic Hello Kitty and Barney type effigies. But, I could see that they were stretchy, and came with some tiny gloves created to be a “one size fits most.” Worried that my girlfriend would have to wait in the cold for me, I hurriedly made my purchase, tore the tags off the hot pink hat and forced it down over the top half of my ears. The gloves covered my four fingers and half my thumb.
I arrived at our meeting place just in time. My girlfriend approached with a quizzical expression, noting the large “Strawberry Shortcake” girl (inside a plastic heart) emblazoned on my hat. I could see that she wondered if my fashion sense had taken a turn for the worse since my move from NYC to Washington, DC two years prior.
I assured her that I had no intention of wearing the hat again, but that desperate times called for desperate measures. She stood in front of me in a full running suit, complete with a layer of long johns, ear muffs, and two layers of Goretex. I felt utterly unprepared in my light cotton shirt and Lycra pants – but at least now that my head was half-covered, I figured that running would keep me from freezing to death outright.
And so we set off on a 4.5 mile jaunt, a hilly distance that neither of us had run in over a year. I had tried to prepare for this day with elliptical training, but wasn’t sure that my cardiovascular reserves would handle this new form of exercise.
Much to our surprise, the icy wind quickly numbed all sensation in our legs, allowing us to jog without much awareness of potential pain or exhaustion. We soon settled into a nice, slow jogging rhythm and took turns catching up on one another’s news. My uphill breathlessness tended to shorten my usually animated description of life-events, reducing me to caveman-like accounts. “Me take new job at hospital. Good.” Though I did much better on the downhill stretches.
In the end my girlfriend and I felt quite triumphant about the fact that we made it the full 4.5 miles without a break. We both knew that another 3 weeks of training should put us in good standing for the Colon Cancer Challenge, though my friend suggested that if I wore the Strawberry Shortcake hat again, she might pretend that she didn’t know me.
Today, of course, all my leg muscles are sore – but it’s nothing compared to what Seton is going through with her chemotherapy. I wish her all the best in her fight against cancer, and hope that my participation in the Colon Cancer Challenge will provide her with some encouragement, if not comic relief.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 1st, 2008 by Dr. Val Jones in True Stories
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For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.
Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:
Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.
Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.
So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.
Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.
How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.
There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?
This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.
I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 27th, 2008 by Dr. Val Jones in Humor, True Stories
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I spent the weekend with 6 nieces and nephews, ranging in
age from 6 weeks to 13 years. One four-year-old niece was particularly
interested in engaging me. I tried to warn her that I was terribly boring and
that I wasn’t good at playing with dolls. But she remained unfazed by my
late-night protestations.
“Auntie Val would you like some ice?” She said, presenting
one melting ice cube to me in her warm hand.
“Hmm… no, not really, thanks.” I mustered a smile hoping
that she wouldn’t feel rejected.
The little girl went on, “Well, my bed is full of soft
blankets so you should put on your jammies and we can go to sleep there. It
will be a lot of fun.”
“Ah… well, that’s very kind of you to offer, but I think I
need my teddy bear to fall asleep. Uncle Steve is my teddy bear.” I pointed at
my husband sitting next to me on the couch.
The little girl replied matter-of-factly, “No he’s not. He’s
your cake.”
“Um… well, that’s an interesting way to look at it.” I
replied awkwardly.
“You know, if you kiss uncle Steve then you’ll be married.”
She went on.
Steve immediately kissed me on the cheek and smiled
triumphantly.
“No, you have to kiss her on the lips, uncle Steve.” The
little girl put her hands on her hips.
“Uh… well… Honey, would you like to marry me again?” I asked
sheepishly.
“Why yes I would…” and Steve gave me a peck on the lips.
Then the girl squealed with glee and ran around the coffee
table one and a half times.
Does this buy me a second honeymoon?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 8th, 2008 by Dr. Val Jones in Health Tips
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Washington DC boasts some of the longest escalators in the world.
I’m not sure who decided to build all these extra long escalators
(maybe an escalator manufacturer had some political friends?) but the
very longest one is at a subway station in Bethesda. One evening my
husband and I happened to be getting off at that subway stop to see a
play and were curious to experience this marvel of human engineering.
As we rounded the corner to the beginning of the escalator, we
encountered a very long line of people. I wondered what they had all
lined up for in a dingy subway station – surely no one was giving out
free country club memberships. As my cogs and wheels turned, I realized
that there was one tiny elevator at the very front of the line. As I
inspected the escalator more closely I realized that the stairs were
not moving. Ugh.
I looked at my husband, I looked at the elevator
line, I remembered my weight loss group, and I hiked up my coat and
began the very long journey to the top of the stairs.
Of course,
when it was time to return home after the play the escalator jubilantly
moved us from the top of the stairs to the depths of the subway
station. Murphy’s Law – it was working for the descending phase of the
climb.
If one of your New Year’s resolutions is to lose weight, please
share your small victories here or join a couple of hundred people trying to do the same. Have you resisted
temptation or gone the extra mile to lose weight and get in shape? I’d
love to hear about it!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in True Stories
5 Comments »
For more than a decade, I successfully avoided a visit to the orthopedist for a chronic elbow problem. Today I reluctantly decided, on the advice of a friend and orthopod, to go to the hospital and find out once and for all what could be causing my elbows to lock during certain exercises.
The process took 4 hours, all told. I registered at the clinic, then proceeded to the radiology suite to wait for some X-rays. There was a long line of legitimate-appearing X-ray candidates before me – some in casts, others in slings, still others limping pitifully. I was just fine and pain free, feeling a bit guilty – as if I might be wasting resources.
I glanced at the films as I put them in a folder to take back upstairs to the clinic – they looked perfectly normal. “Oh, boy.” I thought, “young Caucasian female complaining of elbow locking for 15 years, now with normal X-rays.” I bet the orthopedist is going to roll his eyes at me. I was escorted to an examining room where I sat on a table across from my normal X-rays, clipped on a light box.
A trim and athletic gentleman in his mid 60’s introduced himself to me. He had crystal blue eyes and short white hair… and disproportionately large hands (kind of the way Michelangelo’s David does). I was sure that I was the healthiest person he’d see that day. He glanced at my totally uninteresting elbow X-rays, took a deep breath and raised a skeptical eyebrow as he asked me to describe my difficulty.
“Well, when I’m at the gym, my elbows lock at about 15 degrees from full extension during certain exercises. It’s always during the eccentric phase of muscle contraction, and usually during a lat pulldown or seated row. If I rotate my forearm there’s a snap and the discomfort disappears and I can resume the exercise.”
He was impressed by the specificity of my description, and asked me to demonstrate the problem. I felt a little bit silly, but attempted to keep a straight face. Seeing that we were not going to be able to reproduce the problem without counter weight, the good doctor jumped in to simulate the exercise by pulling on my arm. I pulled back, and we soon realized that he was unable to apply a force strong enough to trigger the problem. In fact, I pulled the poor man off balance and nearly dropped him on the floor.
After a few more maneuvers he concluded that he had no idea whatsoever what the problem might be. He told me that since the X-rays were normal there was probably nothing to worry about, and that I might consider avoiding lifting weights in “clanky gyms filled with smelly, sweaty people.”
He dictated his note in front of me, highlighting my excellent health, unusual strength, and completely benign X-rays. He seemed to relish the whimsy of the fact that he was no physical match for me (a smallish blond woman) and added that I was unlikely to be damaging my elbows at the gym.
His advice, as I had anticipated, was to “stop doing the things that trigger the locking” and to consult him if I developed any neuropathic pain or effusions. He added that I reminded him of his daughter.
Well, it was an amusing interaction – but somewhat unsatisfying. It made me think of all the times that I wasn’t sure what was wrong with my patients, and how disappointed they were when I had to tell them this. Medicine is an inexact science at times – and the best that we can do is rule out the really bad stuff, and shrug when the rest remains unclear.
Have you had a problem but couldn’t find a diagnosis? Do tell…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
