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.
December 1st, 2007 by Dr. Val Jones in Expert Interviews
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I recently spent some time with Dr. Kevin Means, Chairman of the Department of Physical Medicine and Rehabilitation at the University of Arkansas in Little Rock. I asked Dr. Means about his life, how he chose his specialty, and how he came to Little Rock from New York City. This is his story:
Kevin Means grew up on Long Island and attended college in Binghamton, NY. The summer after his first year of college he began looking for work to help him pay his way through school. Jobs were few and far between, and only “undesireable” work remained for college students. Kevin heard about a position as a physical therapy assistant at a facility for the disabled. They were having a difficult time recruiting and retaining candidates due to the strenuous work requirements – heavy lifting, assisting patients with exercises, and moving imobile (and sometimes obese) individuals around was not feasible for many people. But Kevin was a tall, strong, African American man – undaunted by the challenges.
The first few days filled him with sadness – young men with spinal cord injuries, elderly people recovering from severe strokes, amputees with traumatic brain injuries – all doing what they could in the gymnasium. Kevin surveyed the patients and took to heart the individual tragedies that had brought each of them there. He observed the physical therapists as they encouraged movement in the imobile, taught people how to use shriveled limbs, and helped amputees use new prostheses to walk again. Over time, he began to see that each life was a beautiful story of triumph over adversity, and his initial sadness melted as he witnessed the daily victories of recovery.
Slowly, Kevin began taking on more responsibility at the facility. He would sometimes offer additional therapy sessions to patients and stayed late in the evening to make sure that everyone had a full day of exercise. Although he had no formal training as a physical therapist, he grew to understand and practice their techniques, and was dearly loved by the patients.
One day Kevin was offered an office job that paid substantially more than the PTA position. He accepted it gladly, but in the afternoons found himself thinking about his friends at the rehab facility. He wondered if the patients were being cared for correctly, if they were recovering well, and if the nurses were strong enough to help the therapists transfer the patients safely. These nagging questions burned in his mind as he filed paperwork and made phone calls. He just couldn’t stop worrying about them.
A few days later, Kevin returned to his position as a PTA in the rehab facility. He had learned that working with disabled men and women was more fulfilling to him than an office job. He spent the next 3 years working there part-time, and developed long lasting friendships with the patients and staff.
When it came time to go to medical school, Kevin promised his friends that he would do all he could to sharpen his therapy skills and research new ways to help them become independent in their daily lives. For this reason, he chose PM&R as his specialty and attended residency at the top-ranked Rehabilitation Institute of Chicago (RIC). When I asked Kevin why he didn’t stay on at RIC after his residency, he simply said that they didn’t need him. They had plenty of bright, talented physicians who could help to advance the field. Kevin wanted to go where needs were greater, and where his work might bring new hope to those who had very little.
And so Kevin went to Little Rock, Arkansas in the mid ’80’s – to help to build a PM&R program there. He was single – a fact that his friends in Chicago and New York must have called to his attention. But he forged ahead on faith, assuming that he would meet his wife in good time.
Over the past two decades, Kevin has worked tirelessly to grow and establish the PM&R department at UAMS as a center of excellence in rehabilitation medicine. He met his (now) wife while she was working a second job as a clerk at a department store in Little Rock (she is a teacher), and they have 2 lovely children. Kevin took me on a tour of the UAMS facilities which span 3 modern buildings equiped with 2 large swimming pools, beautiful gardens and multiple gymnasiums.
I watched his face as he looked out onto a team of 30+ therapists assisting disabled adults with their goals in a gym. He smiled at the physical therapists and PTAs and I had to wonder if the scene reminded him of his days in Binghamton, and the friendships that gave him the first glimpse of his calling as a physician.
Kevin never did lose sight of his first love: advocating for the needs of the disabled. His career path has taken him from Binghamton to Little Rock – as he steadfastly fulfills his calling as a nurturing healer, working in places where needs are great, and workers are few.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 27th, 2007 by Dr. Val Jones in Expert Interviews
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I was speaking with Revolution Health expert Dr. Zach Bloomgarden about advances in diabetes care, and I suddenly realized that enhancing compliance with lifestyle measures is more important than researching treatments. In other words, we have the power to cure many cases of type 2 diabetes already – without any new research/treatments. The challenge is sticking with diet and exercise programs. Perhaps the same could be said of many diseases.
I thought I’d share this audio clip of Zach explaining that we already have the tools to radically improve diabetes outcomes and virtually eliminate this disease.
Listen Here
I hope that the new community groups at Revolution Health will help us all work together to get to a healthier place. I’m still struggling along with my diet team. I’m proud of those who have had great success already!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 25th, 2007 by Dr. Val Jones in Expert Interviews
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My former mentor, Dr. Richard Robb, is Director of the Biomedical Imaging Resource Center at the Mayo Clinic, Rochester, Minnesota. I first met Dr. Robb as a Summer Undergraduate Research Fellow (SURF) in the Department of Biophysics at Mayo in 1994. Behind his reserved exterior is a man who is bursting with enthusiasm about the amazing technological advances that are making it possible for us to see cells, tissues, and organs in ways barely conceived of several decades ago. Dr. Robb admits that his passion for improving the quality of anatomical visualization is a response to a challenge once given him by a neurosurgeon colleague: “If I can see it, I can fix it.” Dr. Robb’s life’s work is to enable physicians and surgeons to be more effective healers through direct visualization of anatomy and physiology.
I caught up with Dr. Robb (at the Society for Women’s Health Research briefing on imaging and women’s health) and asked him a few questions about the future of medical imaging. Here are some excerpts from our interview:
Dr. Val: What is micro CT and what information does it give doctors?
Dr. Robb: Micro CT is a specialized kind of scanner that works on the same principles as regular CT scanners but it can capture images at much higher resolution. Structures as small as 5-10 microns in size can be seen. Although this is an emerging technology used primarily for research purposes, it has tremendous potential and implications for the future. With such resolution, we’ll be able to do “virtual biopsies” of suspicious tissue that we find with a regular CT and then zoom in with the Micro CT to get a close look at microscopic detail without having to do a biopsy to study them.
Dr. Val: What is SISCOM and who benefits from it?
Dr. Robb: SISCOM is an acronym for “Subtraction Interictal Spect COregistered to Mri.” It is used to pinpoint small parts of the brain that cause epileptic seizures, so that surgeons can effectively remove the diseased tissue. SISCOM uses radioactive tags that are absorbed by the parts of the brain that are over-active during a seizure, and they glow like a lightbulb on SPECT brain scans that are subtracted and registered onto MRI scans. The radiologist can pinpoint the exact focus of the abnormal epileptic discharges and then show the surgeons exactly where they need to resect the tissue. This technique allows surgeons to cure many patients who suffer from seizures that don’t respond to medications.
Dr. Val: What is the most exciting new imaging technology under development and how will it impact health?
Dr. Robb: The most exciting future technologies will allow us to visualize tissue functions at a chemical level. In the next 10 years we’ll see major advancements in image resolution and micro imaging techniques, and eventually we’ll be able to see individual molecules. This technology could actually eliminate the need for surgical biopsies, replacing them with “virtual or digital biopsies”, including close up images of cells and chemical reactions, such as diffusion, all in the context of surrounding macro-sized structures. The effect of the chemical actions and reactions will be expressed visually at the organ function level.
Also, in the next 10-20 years the development and clinical use of “nanobots”, or tiny robotic elements, that can be ingested or injected into the body will become manifest. These may be used with special biomarkers – substances that preferentially label tissue types and pathology within the body. These traveling nanobots can, for example, either go to the biomarkers or expore intelligently certain anatomic domains, taking pictures inside GI tracts, pulmonary airways, or even blood vessels. They will then analyze these images for detection and characterization of abnormalities (like a polyp) followed by administering treatment to the abnormality (e.g., remove it by ablation or radiation or chemicals). The nanobot will remain in the body until it has removed or repaired the targeted pathology or trauma, then it will exit through natural means or “self-destruct” in a safe way. Nanobots could reduce the need for more invasive surgeries, and dramatically improve clinical outcomes with very low risk and morbidity.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 13th, 2007 by Dr. Val Jones in Health Tips, News
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Diabetes is a tricky disease. Sugar build up in the blood stream can damage tiny blood vessels that supply nerve endings, resulting in skin numbness. The feet are at the highest risk for nerve damage (neuropathy) and folks with diabetes often cannot sense pain in their feet.
How many of us have gotten blisters from ill fitting shoes? Painful, right? Well imagine if you didn’t feel the pain of the blistering and kept on walking, oblivious to the injury. Eventually you’d have a pretty bad sore there. This is what happens to people with diabetes who don’t choose their shoes carefully. In addition, sores don’t heal well because of the decreased blood supply to the area (from the damaged blood vessels). And to top it off, the high sugar levels in the sores provides additional sustenance to any bacteria that might be lurking on the skin. It’s pretty easy for diabetics to develop infected wounds, which can grow larger and even require amputations of dead tissue.
A recent research study suggests that the secret to avoiding this downward spiral is in choosing shoes that fit well – though they estimate that as few as one third of people with diabetes actually wear optimal fitting shoes. This may be because there is a strange temptation for people with diabetes to choose extra small shoes due to their neuropathy. When normal sensation is lost in the feet, tight fitting shoes actually feel better because they can be sensed more readily by the brain. So even though spacious shoes that don’t cramp the toes or cause blistering are the best footwear, they don’t always feel as comfortable. However, patients with diabetes who are properly fitted for orthopedic shoes with the help of a physiatrist or podiatrist, may substantially reduce their risk of ulcers.
So the bottom line for people with diabetes: choose your footwear carefully, and get professional help to make sure that your shoes fit well. Proper shoes could help to decrease your risk for foot and leg ulcers and potential amputations.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
