Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

What the heck is a "rehab doc?" Part 1

One medical specialty has managed to avoid (nearly completely) the public eye: Physical Medicine & Rehabilitation (or PM&R). Physicians who choose this specialty are referred to as “physiatrists” or “rehabilitation medicine specialists” or “rehab docs.” But the truth is that very few people understand what they do, and unfortunately the rehab docs haven’t made much of an effort to explain themselves to their peers or the world at large.

A dear friend and mentor once asked me, “why did you choose such an odd ball specialty?” This rather direct question forced me to ponder my career decision, and to determine how it came to pass that PM&R was given the unhappy reputation of “odd ball specialty.” I’ll begin with a little background about the specialty and then explain why I chose to devote my life to it.

The history of PM&R

PM&R really traces its roots back to the American Civil War (1861-1865). This gruesome battle resulted in over 620,000 casualties and over 60,000 limb amputations. The modern specialty of general surgery developed through life saving trial and error on the battlefield. Massachusetts General Hospital, for example, was performing an average of 39 surgeries/year before the civil war, and this increased to 2,427 in the late 1800’s.

But physicians and surgeons were not prepared for the aftermath of war – tens of thousands of maimed and partially limbless now trying to live out their careers in a disabled condition. One confederate soldier, James E. Hanger, lost a leg in the war, and subsequently created America’s first prosthetics company, still in operation today. Unfortunately for the disabled, though, there was no guarantee that appropriate accommodations would be made for them to be fully reintegrated into society.

With the rise of surgery came a major realization: patients did not do well after surgery if they remained in bed. Conventional medical wisdom suggested that bed rest and inactivity were the most effective way to recuperate, but now with thousands of post-operative patients in full view, it became painfully clear that the patients who did the best were the ones that got up and returned to regular physical activity as quickly as possible.

Following this realization, the University of Pennsylvania created (in the late 1800’s) an orthopedic gymnasium for “the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement.”

A young Canadian gymnast trained in Orthopedic Surgery, Dr. Robert Tait McKenzie, was recruited to U. Penn to develop a new field in medicine: “Physical Training.” Dr. McKenzie created a medical specialty called “Physical Therapy” and he was the first self-proclaimed “Physical Therapist.” He wrote a seminal book on the subject called “Reclaiming the Maimed” (1918) and continued to practice orthopedic surgery until his death in 1938.

Other major medical institutions followed U. Penn’s lead, creating “Medicomechanical Departments” at Mass General and the Mayo Clinic. Technicians were trained to assist in helping post-operative patients to become active and reclaim their range of motion – these technicians were known as “physiotherapists” and formed the first physiotherapy training program at the Mayo Clinic in 1918.

World War I (1914-1918) resulted in millions of additional amputations, thus flooding the health system with disabled veterans. In response, the army created two medical divisions: The division of orthopedic surgery and the division of physical reconstruction. By 1919, 45 hospitals had physiotherapy facilities, treating hundreds of thousands of war veterans.

And then there was polio. Suddenly a viral illness created a whole new wave of disabled individuals, further stimulating the need for orthotics (leg braces and such) and rehabilitative programs.

World War II (1940-1945) resulted in yet another influx of disabled veterans. All the while the medical community was developing innovative programs to maximize veterans’ functionality and integration into society and the work place through the burgeoning field of Physical Medicine & Rehabiltiation.

Key players in the development of the specialty:

Dr. Frank Krusen developed the first physical medicine training program at the Mayo Clinic in 1935 and the “Society of Physical Therapy Physicians” (now the American Academy of Physical Medicine & Rehabilitation) in 1938. He coined the term “physiatrist” to describe the physicians who specialized in physical modalities for rehabilitating patients.

Dr. Howard Rusk founded the Institute for Physical Medicine & Rehabilitation in 1950 at NYU.  Excellent research in the field ensued.

Dr. Henry Kessler founded the Kessler Institute for Rehabilitation, in New Jersey, 1949.  More medical research was developed.

Mary E. Switzer successfully lobbied for the enactment of Public Law 565 which mandated that government funds be channeled towards rehabilitation facilities and programs for the disabled.

What’s in a name?

So as you can see, there is some good reason to be confused about the modern specialty of PM&R. It has undergone several name changes, molded by historical circumstance. Today, physiotherapists (they still go by that name in Canada) or physical therapy technicians have become a well known and respected profession: Physical Therapy.

Physicians who specialize in Physical Medicine & Rehabilitation are called rehabilitation medicine specialists or “rehab docs” or “physiatrists.”

-See Next Post for the rest of the story –
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The "non-compliant" patient

It used to strike me as odd that physicians used somewhat hostile language to describe patient behavior – “the patient is non-compliant,” “the patient refused [this-or-that drug or procedure],” “the patient denies [insert symptom here].”

After many years of using these words, I forgot just how inflammatory they are. They became part of my language, and I used them every day to describe people. I’m not really sure how this phraseology became common parlance, but it is a tad adversarial when you think of it. It sets up a kind of us versus them environment. And really, medicine is all about us in partnership with them.

I was reminded of this fact as a friend of mine described a recent “non-compliance” episode. She had been complaining of shortness of breath, and had some sort of suspicious finding on her chest CT. The pulmonary specialist (called a ‘respirologist’ in Canada) recommended a bronchoscopy. Here’s what she says,

I wish I had the chance to explain to my respirologist why I was non-compliant about the bronchoscopy. I got the impression that she thought I was being “difficult” for no good reason, and that I was wasting her time. But the truth is, all my life I’ve had this vague sense that anything big going down my throat was particularly scary to me. I knew I had trouble gagging down pills, but it never occurred to me to mention that. I also chew my food to death in order to swallow it comfortably, but I never thought about that very consciously, either. It wasn’t until months later when I had to undergo surgery for my gallbladder that my anesthesiologist (who had to intubate me) discovered that I had an internal throat deformity.

So my point is that it might be valuable for the respirologist to know that when a patient is very scared of something (especially when she is usually never scared of tests, needles, etc), it could be an important clue. I know now that bronchoscopies are not without risk. A bronchoscopy technician might not have handled the situation nearly as well as that highly-trained, very experienced anaesthesiologist did.

What I learned is this: patients don’t know how to explain things that they haven’t thought much about before, especially when they know that their doc is understandably pressured to get through her scheduled appointments on time. All they know is that they’re scared and that they want to run away. They’re not primarily out to exasperate their docs with their noncompliant attitude. Still, it isn’t easy being a doc. I’m sure noncompliant patients are indeed very irritating. But it isn’t easy being a patient, either. Being looked down upon is irritating too. Not only that, but the patient has a lot more to lose if a mistake is made. But what can you do? Everybody is under a lot of pressure when it comes to medical issues. We all just have to try to be understanding and do our best to work together for a good outcome. It’s in the best interest of both parties, so it shouldn’t have to be a battle!

Have you been a “non-compliant” patient for a good reason? Do share.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Your mom will always be your mom, part 1

Alright, I confess – my mother is probably the number one fan of this blog. Ever since I told her I’d be writing one, she has been reading it faithfully. I asked her not to post comments (only because it’s a tad embarrassing to have your parents interacting with you in front of an audience, and frankly, I haven’t noticed a single other blogger doing this!) but alas, she couldn’t resist on that last one. And that’s ok, because I know you readers don’t mind.

My mom does have rare occasions of impulse control failure. One of the more memorable ones was during “Parents Day” at my medical school. The Alumni Association had planned a reception for the parents of the incoming class of 2000 at Columbia U. College of Physicians & Surgeons. There was a full agenda, and my mom quickly noticed that the surgeon who’d saved my life was slotted to speak. The auditorium was full of hundreds of proud parents and their kids, all excited about embarking on a noble career in medicine.

Well, just as my former surgeon was introduced and was walking to the podium my mother jumped up and ran in front of him and asked if she could please have the mike. The MC was visibly nervous (not as much as I was), but after quickly sizing my mom up, she decided that it would be ok to let her have the podium briefly.

In one of the most moving speeches in recent memory, my mother proceeded to explain the story of how Dr. Schullinger had promised not to give up on me (a baby with little chance of survival) and how he had kept his promise to this day. She described the miraculous abdominal surgery (where he had to remove most of my colon), and how he had faithfully responded to every Christmas card she sent him, reporting on my progress for 26 consecutive years. She thanked him for what he did, and pledged that her daughter would devote her life to “doing likewise.”

Well, that brought down the house. Everyone cheered for Dr. Schullinger, who turned beet red (he’s a very shy and humble person) and stumbled through the beginning of his speech. It was a great moment in medicine.

Of course, I was teased mercilessly for the rest of the year – my classmates called me Valerie “semi-colon” Jones, and they would ask if my mother was going to help me with my homework… But kids will be kids.

What I learned from my mom that day is that this old Hebrew proverb is important to follow:

“Never withhold good from those to whom it is due, when it is in the power of thy hand to do it.”

So if someone has done something good for you, or you notice an act of kindness – why not shout it from the hill tops? May goodness rise above the low level grumbling that we live in day to day.

Let’s revel in the sunny parts of life.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Patient advocacy: a baby’s life is saved

Ok, so now that I’ve given you a really good example of the dangers of VIPs bullying doctors, I will present the flip side of the coin: a good kind of patient aggressiveness.

A 10 month old baby was vomiting and febrile, and her new mom brought her in to the hospital for an evaluation. She was told that it was gastroenteritis (my favorite diagnosis of late) and that the baby would get over it soon enough. The young mother insisted that she knew her baby, and that the infant had never been this fussy and that there really did seem to be something more serious at play. Again, she received eye rolls from everyone from technicians to nursing staff to physicians. “New mothers are so histrionic,” everyone thought.

But as the evening wore on, the baby became fussier and fussier, and began scratching herself all over. The nurses came in and tied her chubby arms and legs down so that she wouldn’t tear her skin. The mom wrung her hands all night. The doctor went home, yawning and sure that the baby would be fine in the morning.

Several episodes of violent, projectile vomiting ensued, and the mother pleaded for someone to take another look. No one would listen, as the doctor had written in the chart that the baby had gastroenteritis, so that was what it was.

In the middle of the night, after the physician had gone home, the mom insisted that the nurses page him to come back to the hospital. The nurses initially refused, but the mother told them that she would personally make their night miserable if they didn’t comply. The annoyed physician came back to the hospital against his better judgment, and found the mother and baby looking far worse than when he’d left. In fact, the baby’s vitals were becoming unstable and her abdomen was quite distended.

The physician ordered an abdominal x-ray series. It showed an advanced intussusception and the belly was distended with gangrene. He knew that she was likely to die. He asked the mother if she wanted him to call the general surgeon (who had no experience with operating on babies) or if she’d like to take a chance and get the infant to an academic center in New York City that had a team of pediatric surgeons on call. Time was of the essence, but surgical expertise varied greatly between the two options. The mom could tell that the physician was terrified, and her instincts told her that she should get the most experienced doctor to operate on her baby.

A few hours later, the baby was rushed into the O.R. at Columbia Presbyterian Hospital. The pediatric surgeon on the case told the mother that it was unlikely that the child would live, but that he promised not to give up on the baby. At that point, the baby was septic and seizing.

In a truly miraculous turn of events, the surgeon was able to resect the dead bowel and save the baby’s life. If the baby had arrived even a few minutes later, she probably wouldn’t have made it.

So in this case, I applaud the mother for being persistent and forcing the medical staff to take a closer look at this “gastroenteritis.” In our imperfect medical system, patients and families must sometimes advocate for themselves in order to get the attention they require. This story, in particular, means a lot to me, because I still bear the abdominal scar from the surgery.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Do VIPs get better medical care?

People often believe that the medical treatment that VIPs get is far superior to the care received by “common folk.” While it’s true that a VIP might get a nicer hospital room, the care received might actually be inferior.

Why? Because all of the anxiety and pressure to perform all possible tests to rule out all possible problems results in higher risk to the patient. Most tests are associated with some degree of risk – catheter infections, phlebitis, dye alleries, anesthetic reactions, and so on. Though these risks may be small, they are additive.

Beyond the risk of unnecessary tests, is the risk of unnecessary medications. When a VIP complains of an issue, he may get additional medicine. Medicine has side effects, and side effects can have serious consequences. Consider the deadly side effects of pain medicine that a dear patient of mine once had.

Then there’s the pressure that physicians feel to do what the patient requests, rather than exercising their clinical judgment.

In one particular case, a young executive came to the ER complaining of abdominal pain. The physicians ran all kinds of tests and concluded that he had a common stomach virus. The man was convinced that he had appendicitis and called in a favor from his “connection” who knew the CEO of the hospital. The hospital CEO questioned the physicians taking care of the man – whether they could say with 100% certainty that this wasn’t appendicitis. They said that it was highly unlikely, but that the only way to be 100% certain would be to remove the appendix and examine it under a microscope. The CEO asked them to take the patient to the OR. Of course, the executive did not have appendicitis. He did, however, undergo an unnecessary surgery, which his insurance company paid for in full, contributing to potential increased premiums for the others in his company’s group. Did this VIP get better care? I think not.

In my next post I’ll discuss how one VIP bullied his way into the hospital without even being truly sick, causing all kinds of problems that dragged on for months!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles