Saturday, August 28, 2010

Family Medicine: Hope

Hope is sometimes elusive for us.  Many patients over the years have taught me about hope which for me requires continuous learning.  I find hope through prayer, worship, the Bible, music, art, love, etc. If I sense or hear that a patient is becoming hopeless about their condition, suffering, life, etc., I respond to their feelings saying words like, "At times it may feel hopeless", etc.

I have many times suggested that the patient buy a lottery ticket "to remember what hope feels like", if they already sometimes buy lottery tickets.  This usually refreshes their "hope file" (separate from issues of depression that are treated when indicated with appropriate therapy and/ or medication).  One patient won over ten thousand dollars when they bought the ticket, which they proudly announced to my office staff at the next visit, promptly leaving without paying the co-pay.  They might have perceived that I had hope, so I didn't need money.

Hope at the end of life is another important opportunity to help people find meaning.  Many are worried that they won't die well and share concerns about making mistakes or looking foolish to others.  People with cancer are usually more willing to discuss death than persons with severe heart or lung disease.  Often the person with a terminal illness will be more accepting of their situation than relatives.  The relatives have to go on living and the dying person expects peace.  Sometimes one or more relatives is not accepting of the eventual death of the patient and the patient becomes a comforter for the grieving.

I admitted one of my patients with severe lung disease who had a pulmonary specialist and was going to need intubation and ventilation if she was to survive this episode of hypoxemia (low oxygen levels).  She was discussing her options with that doctor and decided to forgo the ICU and asked for a priest for last rites.  She signed the Do Not Resuscitate form and spoke with one of her adult children who tried to talk her into a transfer to the ICU for the intubaton, but she refused.  She met with the priest, asked for one mg of morphine, and died peacefully.  She called the shots and seemed very hopeful to those around her when she was peacefully opting to "go to be with her husband" (who died a few months earlier), as she described her decision.  There are a lot of variations on end of life hope that I will mention from time to time in this blog.

We all seek hope, as we understand it, and don't deserve "false hope".  As a family physician, I try to hold up a "hope mirror" to keep clarifying the patient's sense of hope or hopelessness and to allow them to align with their own brand of hope.  I'm reflecting on a JAMA piece this week that related about false hope sometimes being all you can give.  I would rather seek further clarification about the patient's deeper spiritual values than to withhold the truth from a dying person.  I think there's always a way to connect to a shared truth among caring persons.

Tuesday, August 24, 2010

The Human Centered Health Home: Protecting Patient and Family Doctor Like Neighbors

How do we protect each other in the patient-physician relationship?  What if we try to act like neighbors act?  OK, Good Neighbors, the ones we like.

Let's establish rapport in a respectful way.  Then clarify an agenda for the engagement.  What if we then establish limits for our engagement?  How do we do that?  At the grocery there is a time/ money limit that's understood.  At the doctor's office, most people only pay a small percentage of the initial fee and everything beyond that is free.  There is a huge incentive to want more at those prices.  At the grocery, we would load our cart like it was a holiday if everything after the first $20 dollars was free.  What's to limit the patient from getting excited and wanting more, especially as they realize how knowledgeable their family physician is?

What do good neighbors do?  If my neighbor helps me with fixing my roof, do I ask if he'll fix my car and feed my dog, too?  How do neighbors help each other and set limits in sharing their skills while limiting misuse of each other?  How do they show their love and respect?

How should we protect each others time?  Why are doctors late? Take too much time with some and thereby show disrespect for others?  If our favorite patient in the world is in the waiting room and we know it, do we do better at connecting to the agenda and time constraints of the current patient?  Doctors have tremendous guilt about this issue, and lots of excuses (I'm not exempt from time management problems - sorry, sorry, sorry).  Neighborly patients, how can we share the fix on this?  (Please).

Will technology help us and the neighbors?  Can we refer each other to sites on the Internet that are helpful and maybe cost effective?  Think about this protection issue and let me know your thoughts and feelings about it.

Wednesday, August 18, 2010

August in Family Medicine: Heat, People and Stress

In August, it's hot and humid in Ohio, more this August than last.  That means more office visits to the family doctor for breathing problems for our people with emphysema and asthma.  The ragweed pollen levels in the air increase daily until around August 15th, which I call Ragweed Day (and we're already proudly in the fourth worst allergy area in America-Dayton, Ohio).  Patients often don't notice the breathing becoming more difficult before they notice the chest tightness, which might generate increased concerns about heart problems and further cloud their insight about lung symptoms.  The decreased breath sounds on physical exam may generate a both diagnostic and therapeutic nebulizer treatment with albuterol. The patient notices relief of the chest tightness and the family doctor hears the louder breath sounds and notes the comfort of the patient with breathing.  Many of these patients get an EKG as part of the evaluation to rule out  a cardiac component to the chest tightness.

It's satisfying for me to be able to help people breathe easier and to understand their symptoms, especially when I can reassure them to relieve some worry.  Malfunctioning organs in the chest are often associated with worry, since they can reduce the patients ability to accomplish their daily tasks and raise their concerns about serious disease.

High school sports start in August with conditioning and practices. Heat is a concern there, too.  If the coaches, trainers and athletes are aware of the heat rules for sports and limits of the human body, they are usually safe.  If not, there could be a disaster with a heat stroke, respiratory or renal failure.  Risky business- sports.

Parents seem very interested in school starting.  Students seem interested in being with friends and texting.

Many are losing jobs or running out of savings since losing the job and the value of their investments.  Others are working in the wrong job for their physical circumstances due to employer mandated position change within their company.  We see them for overuse syndromes, sometimes desperate to get physical therapy to buy time to get their old position back or make it to retirement.  A lot of people are very stressed.

The family physician needs to respond to each of these people, families and situations with skill, insight and understanding.  Most of the "pain plus stress" situations take more than the allotted time, since the stress may not have seemed to be a problem until they start to disclose it.  Often, that's a component of their treatment- venting and being with someone who will listen and respond to their feelings.  The human to human validation is an important element of the patient -physician engagement.  People need to know that someone will listen and respond, even though the problem may not be solved (which is hard for physicians, who are prone to want to solve the problem).

August- hot. People- matter.

Sunday, August 15, 2010

Prevention in Family Medicine: Breakfast, Chocolate and Cucumbers

 One of my favorite healthy breakfast foods:
Bob’s Red Mill Organic, Whole Grain, High Fiber, Hot Cereal with Flaxseed, 10g of Fiber per Serving.
This fantastic whole grain cereal is made from a carefully balanced blend of sweet and creamy Northwest oat groats, nutrient rich flaxseed and wheat germ, and high fiber oat bran and wheat bran.  Each delicious serving contains 10 grams of dietary fiber, 1000mg of Omega-3, and a wealth of vitamins and minerals.  Certified 100% Organic by QAI.
Milwaukie, Oregon
It mixes well with oatmeal.  A serving is one-third cup.  I just love reading the label and feeling healthier.  Oat groats?  Healthy Healthy Healthy
New  learning today by reading in Super Sized Kids by Walt Larimore, MD and Sherri Flynt, MPH, RD, LD:  "Chocolate is not a food group-but is okay once in a while."
As someone who trained in Hershey, PA in the M. S. Hershey Medical Center of the Pennsylvania State University, I realize it'll take a while to accept the point Walt is making, but I can do it (forgive me, Mr Hershey).
I'm going to suggest to Hershey Foods a new health food called Chocolate Groats with Flaxseed.  Maybe a compromise product will take care of my chocolate loyalty.  By the way, chocolate dilates the lower esophageal sphincter (probably not Hershey's Chocolate) for you GERD fans (gastroesophageal reflux). 
Cucumbers are also guilty of GERD induction in many.  Chocolate coated cucumbers would probably generate a GERD emergency, but would be another unique compromise food.

Tuesday, August 10, 2010

Radiation: From Three Mile Island to Daily Family Medicine

"A massive uncontrolled release of radioactive material from a Nuclear Reactor at Three Mile Island occurred this morning."

I remember hearing that radio broadcast in March of 1979 in the Milton S. Hershey Medical Center where I was a third year resident in family practice (now family medicine).  I had a pregnant wife and two children who suddenly occupied my thoughts.  They were home in our apartment on the grounds of the Medical Center.  It was Friday morning.  Rounds just ended on Gyn Oncology and all our patients were discharged.  Word from the attending physician was to feel free to do whatever was necessary for ourselves, depending on responsibilities to other services and call schedules.

I had no call for the weekend, and the hospital was being evacuated, so I called my wife immediately with instructions to pack up the kids and all our photos and the lock box with important documents.  The nuclear problem could become deadly.  I got to our apartment and had an intense, strangely empty, familiar feeling.  I heard the popular hit song "Music Box Dancer" playing on our radio as we drove off and frequently for the next few days.  When I hear it now, I get the intense, strangely empty feeling, associated with a fear about harm coming to my wife and sons.  It was a feeling that I had a few times as an Army officer in Viet Nam, where I flew helicopters for the Army Engineers.  Those times were associated with very serious danger or death.  Like the day during Operation Lam Son 719 near Khe Sanh when the US had over 75 helicopters shot down, with significant casualties.  We left Hershey for a Washington, D. C. weekend and the feeling disappeared about 50 miles away.

Years later, when they opened the reactor at Three Mile Island, they found that it had experienced a partial melt-down.  The nuclear engineers involved with the Medical Center in 1979 assured us that there was absolutely no chance that such a thing would ever happen because it wasn't in the nuclear reactor literature.  Basically, it couldn't happen because it had never happened.  That is good "Evidence Based Thinking".  I've been skeptical about an over reliance on "the literature" ever since 1979. 

We Hershey Medical Center residents who were in the AMA Resident Physicians Section wrote a resolution about radiation safety for our AMA RPS Annual Meeting to warn of the dangers of radiation, but our colleagues laughed it off and defeated it.  It wasn't a problem.  We were disappointed that we couldn't communicate better about the unknown radioactive world beyond the limits of the medical literature.

Within four years, the wife of my co-author on the defeated AMA RPS nuclear safety resolution died of an unusual breast cancer (in her 20's) diagnosed shortly after the birth of their son.  Our baby was born with congenital spinal cord tumors, requiring multiple surgeries between ages 4 and 7.

Sometimes these events get one's attention.  Use of radiation in medical  imaging is now expanding dramatically.  I now cringe at patient stories of CT scans done for this or that abdominal or chest pain or neck pain (e.g., a palpable sternocleidomastoid spasm after a described minor trauma).  The serial CT scans to follow an incidental finding of pulmonary nodule, which happens in about  35 % of CT scans of the chest is worrisome.  One study noted that about 11/2% (one and one half percent) of the nodules might become something serious, but usually would show up some other way if left alone.  If a CT scan is done to evaluate a person with flank pain, enough lung base is uncovered to often identify a pulmonary nodule.  Then, they are recommended for "serial CT scans" of the chest every three to six months for three years.

The radiation of  a Computed Tomography scan, aka, CT scan is equivalent to 400 to 600 chest X-Rays.  Different techniques may reduce the radiation, but not a lot, if you ask for hard data (I know sometimes the literature is unreliable, but agreement on the subject is now convincing the FDA to pursue better radiation safety).  You might think that you would be informed about the exact risk of each CT scan if you're the patient, and give "informed consent" in writing (e.g., sign a form), but that usually isn't the case. They don't even have a consent form for CT scans at the two emergency departments that I relate to in a big system of six hospitals.  Don't you think we would be safer if people had an informed choice about the decision to do the CT Scan?  If the doctor ordering the test had to clarify risks and benefits for the patient or patient's parent or guardian, and get a signature, would we have more comfort in our decisions?  Would the decision be sometimes negotiated into a more mutually favorable outcome?

Our use (overuse?) of CT scans is now estimated to cause 27,000 (twenty-seven thousand) cancers per year in another 5 years.  How many of those patients needed the scans?  Physicians would say that most of them did.  How many were informed of the risks versus the benefits?  No one has the data because patients weren't informed in the way we have to inform them of even minor surgeries.  Risks versus benefits. 

If a test had a two percent chance of causing you to get cancer in twenty years would you get it?  What if the problem the doctor has at the top of her probabilities for you (her differential diagnosis) has a ten percent chance of death in two days without the CT scan?  If you had the recurrence of a kidney stone after ten years without one and the first stone passed on the same day with no residual effects, would you want a CT scan to be sure it was really  a kidney stone? Or a urinalysis and a quick history and physical instead of a two percent chance of cancer twenty years later?  These tests are ordered so quickly that the consent form must be insinuated into the process to basically call a timeout in knee-jerk decision making.  Isn't a short explanation of risks and benefits owed to the 27,000 who will get cancer?  When did our physicians opt for these expensive, dangerous shortcuts?  We have to rethink our commitment to "First, do no harm."

Three Mile Island jitters are coming back to me as I hear story after story from my patients about CT after CT after CT scan, none of them with informed consent.  I don't want to hear the "Music Box Dancer" playing in my head every time I'm near a hospital or emergency department.

Saturday, August 7, 2010

Friday Afternoon in Family Medicine: Coal to Diamonds

"Some days are diamonds, some days are stones" is a line from a John Denver song, but it could be a line from a family doctor's blog. It would fit better with many of our family medicine experiences if the second part was, "some days are coal".  Obviously, coal under pressure (a lot for a long time) may become a diamond.  Many of our patient and personal life experiences are like that.  It looks and feels like a chunk of coal, but, with tons of stress over time, it could become a diamond, but it's not obvious during the tons of stress.

Sometimes one of our patients comes through some incredible stress (people, time and/or money stress) and has an amazing transformation.  If they just happen to be in the office Friday afternoon, it might be a week-defining encounter.  Like someone with horrendous back pain who goes through multiple therapies and medications before allowing us to order the MRI that (if all goes well) shows the bulging disc with nerve root encroachment and effacement of (pressure on) the spinal cord.  They continue the opiates, gabapentin, SSRI (like citalopram) trazadone, NSAID, heat, rest and laughter as prescribed.  OOPS!  They aren't able to rest because they have to work, and they might be in the office every ten days or so in a painful fit of dehumanizing pain.

They finally get the surgery, but they get fired from the job because they've been absent too often.  Their "brokeness" precludes continuing their health insurance through COBRA, so they have to use credit cards and money from relatives to pay for office visits and the medications (including the opiates on which they are now dependent).  They don't get the post op physical therapy, so they stay stuck and miserable.  We are pressed to continue prescribing the meds since they have no other doctor.

We start mentioning suboxone as a medication that might help them.  They start suboxone, immediately stopping the opiates.  The pain is controlled.  The brain returns.  The motivation returns.  They get a job, health insurance, resume PT and feel like a human being again, after 18 to 24 months of struggle, pain, suffering and hell.

I walk into the exam room late Friday afternoon and see this person re-humanized and I stare for a few seconds, reflecting on the intense struggles we had during parts of their misery, debating how best to go after the back problem and clarifying my worries about how the opiates were necessary, but risky over-time.  I remembered more or less begging the patient to find a way to get the physical therapy and move ahead.

Now, though, I am tickled at the person I am seeing who has made a come-back.  I feel satisfied about the struggle and the process of care that meanders along with the realities of the human condition and is sloppy but real.  I have the tears of relief now after two years in a sometimes contentious, often imperfect and always caring patient-physician, human-human relationship.

With only one or two patients remaining on the Friday schedule, I was soon able to reflect on the meaning of  this person's quest.  Together, we made a diamond from their coal.