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Wednesday, April 29, 2009

Beginner's Luck & the Darlin' Spector of Universal Health Care: Obama's First Hundred Days

Today was Barack Obama's 100th day as president, giving us wags an irresistible chance to bloviate.

Are you healthier than you were on January 19? Probably not. Will you be healthier in the future, based on the last 100 days? Probably so, though not for the reasons you think.

Pres. Obama chose a guy from Scranton, Pennsylvania as his vice president. Joe Biden had been commuting home from Washington DC on the train, sharing seats with passengers he came to know well – like Sen. Arlen Spector of Pennsylvania. Biden influenced Spector's decision to change his party affiliation, giving the Democrats a nearly filibuster-proof majority in the US Senate. And it significantly strengthens the chance of passage of legislation favored by Pres. Obama like the coming universal health care bill.

Today the Senate voted by 53-43 to accept the president's budget, which includes funding for universal insurance. Sen. Spector, along with all the other Republicans, voted No. Presumably the newly Democratic Sen. Spector will vote Yes in the future, adding a critically important vote to the slim majority for the very controversial universal health insurance bill, forthcoming by October.

The conservative Democrats who voted against the budget because of what they saw as its excessive funding will likely insist on cost controls in the future universal health insurance bill, according to today's NY Times. Electronic medical records are being touted for this purpose for their role in limiting costs. For example, an EMR might reveal to a doctor that an expensive test like an X-ray or CT scan has already been performed, saving costs and time in the hospital. Or the legibility of the EMR's typed doctors' orders and progress notes might prevent costly errors. Or the automatic reminders generated by the EMR might lead to the earlier detection and cheaper treatment of cancer. Of course, in addition to these financial benefits of the EMR are their savings of lives and suffering: fewer days in the hospital, invasive tests that need not be performed, less chemotherapy, etc.

Obama was lucky to have Sen. Spector become a Democrat. Arguably, he created his own luck by choosing the guy from Scranton as a vice president. Either way, the result is a higher chance of passage of universal health insurance, and of substantial financial support for the widespread use of electronic medical records.

The result, ultimately, in your life: you're more likely to get an automatic reminder from your doctor about your next appointment. When you call your doctor's medical practice at night and get a covering doctor on call, that doctor is more likely to have electronic access to your medical record, and to give you better advice. When you're in the hospital, the computer will be more likely to intercept would-be overdoses and wrong drugs.

And, if you’re one of the 50 million Americans who don't have health insurance now, you'll be more likely to get coverage, and health care, based on Obama's decisions, and luck, during the last 100 days.

These likely future improvements of broader health insurance and broadened use of EMRs add to those in Obama's first month.

All in all, not a bad start in improving public health.

Tuesday, April 28, 2009

The very thought is dreadful: Hastening the Surgical Recovery Process

Kat Sanders' story:
The very thought of surgery is dreadful, and I don't think people in their right senses would volunteer to go under the surgeon's knife. I do know that there are hundreds of thousands of people who willingly undergo cosmetic surgery, but I really don't see the fun in this process. Of course, they reap the benefits of their patience, and well, persistence.

But it's a whole new ball game when you must be cut open in order to recover from an illness or if you've suffered an injury. Sometimes, you're not prepared and the surgery has to be done in an emergency. Whatever the reason you're on an operating table, your first thought is survival (even a minor surgery could go wrong if luck is not on your side), and once you pass that hurdle, you're going to be wondering how long it's going to take you to get back to normal. Those were the exact same thoughts going through my mind when I had to have a knee surgery to get my ACL (anterior cruciate ligament) reconstructed. I was anxious to know how soon I could go back to playing racquetball (which was how I sustained the injury in the first place).

If you want to get back to normal as soon as possible after a surgery, here's what you need to do:

· Don't hurry the process: This may seem contradictory to the subject of this post, but let me explain. My doctor was really good, not just in the operating room, but also in his bedside manner. He assured me that I would be back on court in three months. But it actually took me six to really get back to form. He was only trying to get me to be positive when he gave me the ballpark figure of three months. The truth is that I needed to give my body more time to adjust to my new ligament, and the longer I waited, the stronger I became. If you hurry the process, you're only risking injuring yourself again.

· Listen to your doctor: No matter what you think is best for you, it's better to listen to your doctor. If you're asked to follow a physiotherapy routine, do it. Don't overdo anything though, in an effort to get better sooner. Your body is not a machine that you can push beyond limits. You need to respect it and allow yourself enough time to rest and recuperate before it becomes as good as new.

· Stay positive: When I had my ACL reconstruction, one mistake I made was to browse the Internet and read about the surgery. I say mistake because I was mostly bombarded with negative news and reactions. But thanks to the support of my friends and family, I was able to stay positive, and now, eight months on, here I am, fit and back on the courts again. When you start thinking that you can do something, your mind conditions your body to believe that it is possible. And this is why a positive attitude works wonders when you’re recovering from a surgery.

Thanks to Kat Sanders for writing this post. Kat regularly blogs on the topic of online surgical tech school at her blog iScrub. She welcomes your comments and questions at her email address: katsanders25@gmail.com

Read a story about another athlete’s recovery from knee surgery.

Thursday, April 23, 2009

Run the talk: The Boston Marathon

More than 26,000 runners ran the 113th Boston Marathon on Monday. Among them were numerous athletes who were raising money for cancer research, via Dana Farber Cancer Institute's Jimmy Fund, and many others wearing the yellow LiveStrong jerseys of Lance Armstrong's foundation. Some had hand-written on their shirts "for Mom," or other loved ones, presumably cancer victims.

The Jimmy Fund aimed at a fund-raising goal of $4.85 million through the runners' efforts. The runners benefit from the exercise, too, and all of us benefit from their inspiration, and their perspiration.

It was a stirring sight, as always, to see the runners of very different levels of ability.

Bravo! Encore!

Advice: You can walk the talk about fighting disease, and sometimes you get to run the talk.

Read a story about another athlete’s fund-raising to fight disease.

Sunday, April 19, 2009

Making the programs especially desirable: Surgical errors in babies' treatment at a Boston teaching hospital

A Harvard teaching hospital in Boston just announced that it has suspended its program of heart surgery for children, just after making serious "technical errors" in surgery affecting two babies. One baby suffered neurological damage, and was transferred to Children's Hospital. The other is still at the same hospital, weeks after the March surgery, and is recovering. The physician hospital spokesman said that "patient privacy concerns" prevented him from describing the surgical errors in more detail.

State health officials recommend that hospitals perform at least about 25 adult heart operations a month, but they do not set a standard for pediatric heart surgery. The hospital where these errors occurred performed an average of only four or five of these operations a month. By contrast, surgical teams at Boston Children's Hospital perform about 90 of these operations each month.

Practice makes near-perfect for surgical teams, as it does for everyone else.

Dr. Peter Manning, director of cardiothoracic surgery at Cincinnati Children's Hospital Medical Center, said that cardiac surgery can be lucrative and prestigious for hospitals, making the programs especially desirable for hospitals.

Advice to parents considering surgery for their children: Get your child to a hospital with a surgeon and surgical team who perform that specific operation frequently.

Read a story about appropriately assertive parents’ preferences in a teaching hospital. Thanks to Liz Kowalczyk for the source story in the Boston Globe on April 17.

Thursday, April 16, 2009

The bleeding was mysterious: Re-admission to the hospital

Here's the story of Jocelyn Angel Mommy of Melbourne, Florida, found on Nikki's Project Angel Mommy on MySpace:

I married a man who already had two children (then ages 11 and 9) from his first marriage. It was my only marriage and I had no children and I really wanted to have my own but I had to wait till he was ready which took more than 6 years. We did conceive quickly though and I found out I was pregnant on my 36th birthday in April 2004. My pregnancy was rough on me -- I was extremely nauseated and vomiting a lot for the first couple of months. But I was starting to feel better and get excited around halfway through and I allowed myself to believe I would really be bringing a baby home.

On Aug. 10, 2004, at 22 weeks, I started bleeding at home. I was admitted to Labor & Delivery and the bleeding was mysterious but they found my blood pressure to be extremely high. Although I was released the next day with meds (bleeding had stopped), the BP didn't come down so I was readmitted a few days later. I was in the hospital for another 10 days but nothing they did kept my BP down so I was transferred to a larger hospital in Orlando on Aug. 24th. There I got very sick very quickly and was diagnosed with severe pre-eclampsia and HELLP syndrome...my life was in immediate danger and my only chance was to deliver the baby immediately.

[HELLP syndrome, a variant of pre-eclampsia, stands for: Hemolytic anemia, Elevated Liver enzymes and Low Platelet count, according to Wikipedia.]

Jocelyn was one of the people whose "bounce-back" re-admission to the hospital can indicate that the quality of care during her first hospital admission had been sub-par. This is a disturbingly common occurrence. In a recent study in the New England Journal of Medicine of April 2, Dr. Stephen Jencks and his collaborators found that one-fifth (20%) of Medicare inpatients were re-admitted within a month of their discharge. The results: great suffering, like Jocelyn's, and great costs, many of them unnecessary.

Apparently, many of the re-admitted people in the study had not seen their primary care doctor between the two inpatient stays. Dr. Jencks found that half of the patients with medical (i.e., non-surgical) discharges had not had a doctor's office visit between the two hospitalizations.

Advice to people who are leaving the hospital: Make sure you see your primary care provider right away, and make sure he or she knows you've just left the hospital.

Thanks to Jocelyn and Nikki.

Monday, April 13, 2009

Leviticus and clinical guidelines

I just had another birthday, and, with my daughter's Bat Mitzvah coming up, my own Bar Mitzvah, 39 years ago, came to mind. (A Bar Mitzvah is a religious ceremony when a Jewish 13-year-old formally takes on the obligations of adulthood, in front of friends and family.)

My Torah (Old Testament) portion was in Chapter 13 of Leviticus, where God gives instructions to the priests – the closest thing then to doctors – on how to diagnose various skin conditions. Various types of skin blemishes and conditions are described and differentiated, to allow differential diagnoses, with different treatments prescribed for each.

In three key ways, this method is superior to that often used by today's doctors. First, the guidelines in Leviticus are clearly authoritative. The source has credibility among the priestly medical practitioners of that time and place, e.g., with reference to the proper sterilization of cloths. God clearly specified that under certain circumstances the double washing of certain cloths can make them clean enough for re-use (verse 58). Hospitals might find their policies on sterilization and the prevention of infections are somewhat less clear, and are less authoritative, than this, as the embarrassing news about the recent spate of hospital acquired infections makes clear.

Second, the guidelines in Leviticus were widely known. They had been published in numerous languages, and the Bible is the most widely owned book, so everyone could refer to them if needed. By contrast, often today's doctors aren’t aware of consensus guidelines, and don't heed them.

Third, the guidelines in Leviticus have been translated into a language that consumers can readily understand. Note that they originally appeared in a language – Aramaic - readable only by a few. This may be the biggest advantage that Leviticus holds over modern clinical guidelines, which are generally known only to doctors. Only now, with the Internet, is diagnostic information readily widely available to laymen.

The clinical guidelines in Leviticus are authoritative, widely known and available, and clearly understandable by laymen – excellent goals for more modern clinical guidelines in our more skeptical era.

Read a story about modern diagnosis in the Internet era.

Sunday, April 12, 2009

Thousands of miles away, but right there: Pharmacy computer alerts

Something is better than nothing. On a recent trip my cold turned into an infection. The local walk-in clinic prescribed an antibiotic.

My drug insurance company – thousands of miles away, but right there on my pharmacist's computer – refused to pay for it because the prescribed antibiotic interacted with another drug I am taking.

Death, a stroke, or at minimum, a very bad headache would have ensued.

The pharmacist called the doctor, and something suitable was submitted. So there are some beginnings on shared electronic health data, and I am very glad.

-Hal Winsborough, Madison, Wisconsin

The pharmacy's computer alert, and the pharmacist's reaction, prevented injury to Hal. However, these computer systems are only as good as the human pharmacist who heeds, or ignores, the alert. Here's another story, about a pharmacy computer alert that a pharmacist chose to ignore and override.

Thanks to Hal Winsborough for his letter to the editor, published in the New York Times of April 11.

Saturday, April 11, 2009

Take your stupid X-rays!: A patient's choice of treatment

Dr. George Reskakis' story:
It was the first time I had met Cynthia. She was dressed impeccably in a blue suit with an understated brooch on the collar – a woman who clearly took care of herself. So I was surprised when she complained of bad breath.

She just wanted a teeth cleaning. As part of the standard conversation with new patients, I explained the need for a proper evaluation, including X-rays.

She was unequivocal: "X-rays! No way!"

In 28 years in general practice, I have seen the full range of reactions to the dentist’s chair. Personal experience plays a part. So do the stories of friends and family, and "I'd rather have a root canal" jokes. The Internet can give people enough knowledge to be dangerous. A trip to the dentist gives people the motivation to be insistent, even demanding, regarding care that might not be appropriate.

If I do what they want I risk missing something or making poor treatment decisions. If I do what is right, I risk losing a patient who needs help.

I explained that for a dentist seeing a new patient, a thorough exam and a set of good X-rays are the foundation of good care, and that the current guidelines from the American Dental Association suggest that healthy adults without evidence of tooth decay or additional risk factors should have films taken every couple of years.

She had last had dental X-rays three years earlier. We talked for 15 minutes more about X-rays – the modern, digital system, the minimal amount of radiation she would receive, and its quick and painless nature.

I did not want to lose her as a patient, but I could not give in. I told her I couldn't ignore the possibility of underlying disease. I needed X-rays if I was going to treat her.

"Fine," she said finally. "Take your stupid X-rays."

It wasn't until after we completed her treatment (root canals, gum surgery, two posts and two crowns) that Cynthia confided the reason she had fought so hard against X-rays. Her mother had died from cancer that was caused by radiation treatment as a child.

We talked again about radiation, and the difference between diagnostic radiation doses and therapeutic radiation doses. In the early 1950s, I told her, the doses were hundreds of thousands of times what is used today; there was not enough evidence yet of radiation’s harmfulness.

Cynthia came around to the idea that X-rays are a safe and useful medical tool.

Advice to people thinking of having diagnostic tests: Find a doctor who will listen to your concerns and take the time to discuss them with you.

Read a story about a dentist's patient-mindedness.

Thanks to Dr. George Reskakis for his article in the NY Times of November 18, 2008.

Tuesday, April 7, 2009

Between sandwich bites: Testicular surgery against a father’s wishes

This is a father's complaint to the Nevada State Board of Medical Examiners:

To whom it may concern, from one who it has concerned greatly:

It is said that the greatest skill of a doctor is their bedside manners. I could agree with this in theory, the theory being predicated on the hope, my hope that the doctor is operating on all cylinders, is integrated, aligned, smart and most importantly honest. A doctor can have a wonderful personality and a wonderful bedside manner and yet, be completely deceptive, dishonest and completely unconcerned with our welfare when compared to standard practices and of course legal liability. It appears in our mostly litigious society doctors are scared of lawsuit and therefore will be most versed in how to avoid lawsuit secondary to their professional skill.

Such is the case with Dr. J.

I met her on what may have been considered a routine pre-surgical consult. The surgery we discussed was an exploratory surgery for my son's ascended right testicle. I asked lots of questions. In my world, this surgery was going to be a simple procedure because I felt a lump on my son's upper right pubic bone, which gave me assurance that his testicle was there and merely required some medical assistance to return it to where it belonged in his scrotum.

It seemed it would be a simple procedure on the doctor’s part as well because she was far more concerned with eating her lunch in either a recently vacated office or an office she has recently moved into. I followed her into this room to continue my line of questioning. I asked her about her rather flippant line where she said his testicle would be removed if it was less than the size of her pinky fingernail, while ceremoniously indicating such with her extended digits.

I asked her- "What if it is exactly the size of your fingernail?"

"I would still remove it," she replied between bites of her sandwich.

"Really? I don't like that idea. If it is the size of your fingernail, then I expect it stays in. In fact, I'd prefer if his testicle is not the size to move, then it is left alone," I said firmly. She nodded in agreement with her mouth full.

Little did I know at this point I should have pursued a more explicit confirmation of my request, as in I should have gotten this confirmation in detailed affirmation, notarized and with a medical examiner witness.

Because as it turned out later, the doctor removed my son's right ascended testicle without actually measuring it at all. To further add insult to injury to my son and to my duty to protect as Father, she claimed that it was a pre-cancerous situation and that the testicle would be tested for cancer cells. This of course was just a ruse and was never carried out. Of course a young struggling testicle will show no signs of cancer. The main problem I learned from my multiple attempts to find a pediatric urological expert witness is that Doctor J. toed the line of medical malpractice liability. If anything atrophic (by her view) is left in the body, then that is a more litigious situation then actually following the patient's parent's request. In fact, the doctor now sanctimoniously hides behind even more medical legalese by claiming that she did what was "clearly in the best interest of the patient."

How does she know what is in the best interest of the patient?

Oh, because she refers to "a multitude of medical research findings" which only gives her a bigger trench to sit with her other than conscious behavior.

I clearly told her what is in the best interest of my son and she affirmed my request. If she was somehow medically bound to complete my son's procedure with a forced removal of his testicle, then she should have told me clearly at our meeting. Because if she told me at our pre-surgical operation meeting that she is required by medical directives to avoid any future lawsuit and to remove my son's testicle I clearly would have opted out of such a railroaded situation and continued my exploration of alternative therapy.

This is the crux of my crucifixion. And this is also where I hope and pray the doctor is nailed for negligence.

There are errors of omission and then there are errors of commission.

And then there are errors of both. Errors of commission are answering a question incorrectly, which she did. Failing to answer a question or to answer a question in full is an error of omission. She did both while gleefully eating her packed lunch. Such contempt.

I choose at this time to abbreviate my letter and my complaint. I'm sure there are things I could have done differently and things I could have said differently, yet clearly someone in the room of pre-surgical consultation was licensed as the professional, yet clearly my curious questioning was indignantly refused. If I asked nothing, I could accept my results. If I refused nothing, I could accept my results. If I clearly asked and directed the doctor and she told me clearly what she was legally required to do, then I would have accepted an entirely different outcome.

The doctor should listen closer to patients, especially parents.

So in fact, bedside manners are very important. Maybe all of this would have been very different had the doctor demonstrated polite, concerned, engaged listening. And I know it would have been a significantly better outcome if the doctor revealed direct honesty of what is medically required in her surgical procedure. She even could have done this between sandwich bites, or preferably after lunch.

Advice to parents: Specify your preferences for your child’s surgery in writing beforehand and have the surgeon sign it.

Read another story about the lack of informed consent for testicular cancer.

Thanks to Bryan Brey for sharing his story.

Sunday, April 5, 2009

A Sea of Broken Hearts: Fatal errors in a young athlete’s medical treatment

Dr. John James tells the heart-breaking story of his son's medical treatment:

I lost my 19-year old son several years ago in Texas due to multiple medical errors. He had collapsed while running, self-recovered, but was taken by ambulance to a hospital in his college town. There cardiologists evaluated him for 5 days and could not find any cause of his collapse. They delegated his followup to a physician in training in family medicine, she gave him a clean bill of health, and two weeks later he collapsed and died while running.

There were several catastrophic medical errors. First his cardiologists failed to apply a national, widely published guideline for potassium replacement in a person with cardiac arrhythmias, they failed to make an obvious diagnosis of acquired long QT syndrome, and they failed to warn him properly that running would be hazardous to his life. They wrote in the medical record that they warned him against running just after they gave him a second dose of Versed, a drug widely used as a sedative and known to cause amnesia. His discharge summary gave the only written instruction: do not drive for 24 hours.

I have written a book called "A Sea of Broken Hearts" that chronicles my son's botched care, the cardiologists' clumsy tampering with evidence in the medical record, and why we need a national patient bill of rights.

Dr. James' Advice: What should I have done differently? First, I had an intuition that his college-town hospital and especially the cardiologist assigned to his case were in over their head. I sensed this when his cardiologist was not interested in me getting my son's previous electrocardiogram that the Air Force had done a few months before. I should have followed my intuition.

I was not aware of how easily one can be manipulated by fear. In my son's case we were told the woeful story of Pete Maravich who collapsed and died suddenly. At the time, we did not know what informed consent really ought to be, and so we were frightened into allowing invasive testing. In my book I give good (but not absolutely conclusive) evidence that the invasive testing set my son up for death. This was combined with Alex's untreated, severe potassium depletion.

 I should never have been so trusting. I should have asked to see the details of the results of every test that was done. This way I might have found out that the hospital had screwed up his cardiac MRI. I should also have demanded to see his medical records at least twice a day. I really did not know much cardiology at the time, but I might have seen the major change in his electrocardiogram that showed that three risk factors for sudden death had disappeared...temporarily. There is no evidence in the record that his cardiologists ever looked at this second electrocardiogram.

As Julia Hallisey DDS wrote in her book "The Empowered Patient": never trust your heart to a single cardiologist; get a second opinion. I would add: make certain it is an independent second opinion rendered without knowledge of the first opinion.

Read about the organization Dr. James has launched, Patient Safety America.

Thanks to Dr. James, a patient safety hero, for forming a nonprofit organization to help others, and writing his son's painful story.

Thursday, April 2, 2009

Tired but wryly triumphant: Culturally competent care for a Somali patient

On an afternoon in late September, Dr. Douglas Pryce and Dr. Osman Harare, the interpreter and patient advocate, emerged from an examining room looking tired but wryly triumphant. They had just finished negotiating, politely but persistently, with a patient who – just as politely but persistently – had refused to allow any blood tests because it was the holy month of Ramadan and he feared that having blood drawn might be a sin.

Finally, they telephoned an imam, who declared that there was no sin. The blood was drawn.

Dr. Pryce says that one of the great joys of working in a hospital like Hennepin County Medical Center in Minneapolis is finding ways to bridge such cultural divides – and knowing that his patients are better off because of it.

Advice to people of another culture: Find a medical provider and interpreter who respect your cultural beliefs and medical preferences.

Read another story about culturally competent care.

Thanks to Denise Grady for the source article in the New York Times of March 29.

Wednesday, April 1, 2009

An April Fool's Daydream: The physical exam

A few days ago I got a warm, funny postcard from my doctor, reminding me of my upcoming appointment, asking me to email him my medication list, and inviting me to email him with any questions I'd like to discuss. In the card, he congratulates me on the progress I've made on my fitness plan, which he has monitored by email since my last physical exam. (He'd asked whether I preferred a letter, postcard, or email for the reminder, and since I'm not concerned about confidentiality, I preferred the postcard.)

A day or so before the visit, I email him my medication list, which my pharmacy had emailed me.

When I arrive, as I've been told, I first fill out a form asking what I'd like to talk about during the visit. The assistant hands me some patient education materials about the condition I've mentioned, and I read it during the short wait to see my doctor.

In the exam room, the nurse takes my weight, blood pressure, and pulse, and shows me on a graph how they compare with my past readings.

The doctor runs through my written questions. He refers to the problem list in my electronic medical record, and the note that the ENT specialist had emailed into it, which recommended surgery for a benign nasal polyp. My primary care doctor discusses the trade-offs of different options, and supports my decision not to have surgery for now. He advises me on how to use an inhaler that can shrink the polyp, forestalling or delaying the need for surgery. He realizes from the pharmacy's medication list and refill history that I've been using the inhaler every other day instead of daily, and we discuss that. By the end of the visit, we have discussed my fitness plan and my risk factors. At the end of the visit, he hands me some printed information about my condition and his suggestions, and the recommended date for the next appointment.

Advice: Dream big dreams, and work hard to make them come true.

Read another physical exam story.