Family Medicine Activist: Radiation Safety- Who Cares?

 
In 2010, 80 million CT scans were done in the United States.  In 15-20 years, those scans will have generated 30,000-60,000 cancers in the recipients of the 2010 CT radiation by conservative estimates.  I have concerns about the amount of imaging done in our country.  The business models of the CT owners and users may be driving the use of CT more than the clinical decision making processes of the physicians ordering the scans.  Will it slow down?  No way.  Here's a good article published this year by the American Cancer Society in CA A Cancer Journal for Clinicians:

Cancer Risks Associated With External Radiation from Diagnostic Imaging Procedures

Should you be informed of the benefits and potential harms of a CT scan if someone recommends one for you?  Do you know even one person who went to an ER, got a CT scan (or two, or even three) and was informed of the potential benefits and harms of the test?  I am a physician--I don't.  I now ask patients daily (OK 3 or 4 days a week) if they received what's called Informed Consent forms to read and sign before they got a CT scan.  NO ONE gave informed consent for the CT scans.  NOT ONE PERSON remembered giving  INFORMED CONSENT for their ER CT scan.  NOT ONE.

If a test could lead to an increased risk of cancer, does a patient have a right to know that in deciding whether to go ahead with the path recommended by the physician they just met in the ER?  Or even their personal physician?  Should patients be informed?  Should patients care about radiation safety?

What do you think?

Family Medicine Activist: Using Creative Tension

Remember my post about Tension Mounts? Patient, Doctor and Prescription Tension Mounts
Tension isn't only negative.  It can be positive, even creative.  I enjoy creative tension.  As the poet Grace Curtis discussed the use of tension in her writing, Tension in Poetry, there is "tension—that creates a more pleasing and more important experience for the reader."  So, too, the Family Physician may employ the use of creative tension to help the patient to create a more meaningful experience in their interaction.  The relationship -based nature of Family Medicine develops a broad context in which the patient-physician engagement occurs.  This breadth, which includes extensive value sharing, enables the dyad of patient and physician to explore more variables that impact decisions during their current engagement (clinical encounter or office visit).  


Either party may seek a tension point to lock in an element of the decision(s) to be made as a result of this encounter. 
 "I can't really afford to smoke, I don't know why I continue." Patient
"Confusing, isn't it?" Doctor "Yes, I'm like trapped in smoke- and broke" Patient
"What would you rather do with the money?" Doctor
"I haven't thought about it that way." P
"Well, how much money is it?" D
"One pack a day at $5 a pack" P
"OK, so what would you do with $150 dollars each month?" D
"I would fix my car... and buy my mother a birthday present." P
"What about the trip with your son that you mentioned a few months ago?" D
"How did you remember that?"P  "I could remember how you looked and beamed when you talked about taking your son back to see your grandmother before she passes on." D
"That is important to me and will be a lasting memory for my son.  Can we work out a plan to quit smoking so I can do that for my son?" P


You may feel a bit of tension as the dyad of patient-physician above stays engaged around the issue of patient values, goals and dreams (aka, nicotine dependency and smoking cessation -for coders).  They discuss people, money, time, family, commitment, etc, in the clinical context of smoking cessation.  Both patient and doctor continue the creative tension as they move toward successful goal accomplishment.  The earlier value sharing in previous visits by the patient enabled the physician to mention the trip and the son which kept up the creative tension.


How might you use creative tension in your life?

Family Medicine Activist: My Colonoscopy- When is Yours?

"Are you awake now?" I heard out of the corner of one ear which motivated me to open my eyes.  "Yes.  I'm cured," I responded in relief and hope and light-hearted expectation.  My rational brain had also turned on reminding me that I was waking up in the recovery area after my colonoscopy.  (Yes, I "got it behind me", but no, I didn't put it on TV like Katie Couric).

I looked up at a red-headed nurse type person, Paula, who had a reassuring presence while calmly asking me, "Have you expelled all your gas?"  (In other circles, this wouldn't have been much of a conversation starter, but it was welcomed and timely in the gastrointestinal recovery area).  "No, I'm too polite to do that," I quipped.  She quickly replied, "This is not the place to be polite."  So I allowed my innards to express their relief at her boundless tolerance.

Paula further clarified that I was OK and brought me the bag with my clothing and gave further instructions about leaving.  Another person arrived with my Discharge Instructions and the report of the procedure, including photos of my colon which will not be included with this post.  The warnings about the IV sedation were many, including "DO NOT drive, work around a stove, use power equipment or machinery, consume alcoholic beverages or make any major or legal decisions for the rest of today."  Does blogging constitute a major decision?

I was impressed at the entire practice of Dayton Gastro Endoscopy-Beavercreek, from their parking lot through the double electric doors to the sign that instructed me to wait here for the next receptionist to Kerrie who signed me in, scanned my Insurance card and photo ID, and directed my wife and I to the endoscopy waiting room.

Next was Michelle, an RN who entered clinical information and asked for clarifying information to satisfy the electronic record on her computer.  After getting my vital signs, she directed my wife back to the waiting area and led me into the pre and post procedure prep and recovery area, opened the door to a unisex restroom, handed me a plastic bag (with draw string) and instructed me to remove all clothing except shoes and socks and put on the gown (I assumed that the open area was to be in the back.  Conveniently, there was a commode for any last minute colon clearing needs.

I slowly opened the door to leave the restroom clad in my hospital gown ineptly trying to keep the back side closed from view of any non-HIPAA compliant gazes of other patients.  A friendly nurse directed me to the gurney type bed where I received instructions from Kathie as well as an IV in the back of my right hand.  Jerry, the CRNA (nurse anesthetist) introduced himself and asked the questions that let him know that I'm at low risk for disaster under anesthesia.  I emphasized the C5-6 (neck) arthritis with radiculopathy that may be flared up if I'm in the wrong position too long.  We seemed to connect in a reassuring way, consistent with my other interactions on this great day for colons.  Kathie and I conversed about her family and my practice.

Then Dr. Jonathan Saxe showed up.  I've known him for 12-15 years and we've worked together on some challenging patient situations in the Kettering Medical Center when I used to admit and care for my own patients there (now I'm using the hospitalist service- South Dayton Internists).  I obviously have confidence in Dr. Saxe skills and judgement.  (I would have been comfortable having the procedure done in several Greene County and Dayton area locations, by the way, but I'm only having one procedure and had to decide.)  We greeted each other and I could tell I was both patient and medical colleague throughout our engagement.

Yet another nurse greeted me as I entered the procedure hallway and the room where my colonoscopy happened within five minutes.  They positioned me and Jerry said words to the effect that "I'll see you ...(somewhere that I've forgotten) and I closed my eyes and said "Good night".  I felt a warm tingle all over my trunk, arms and face.  Then I heard Paula in recovery.

I'm blessed to have a healthy colon.  Many aren't.  Colonoscopy is an extremely useful way to clarify the status of your colon when the need for invasive prevention of colon cancer or diagnosis of colon problems arises.  Join me and Katie Couric, if colonoscopy could help you, and schedule yours through your Family Physician after clarification of your need and your health.  By the way, many general surgeons also do colonoscopies, too, especially in Greene County, OH where I live.

Family Medicine Activist: Let's Cry Together

"Dear God, sometimes I feel uncomfortable when someone cries in front of me.  I know you've provided tears for times when words aren't adequate to express the depths of pain and suffering.  Jesus wept.  Teach me to embrace the tears of those who are hurting and at times even to weep with them.  Amen."       from Don't Sing Songs to a Heavy Heart by Kenneth C. Haugk, PhD p.65

Meandering through life exploring various aspects of the human condition, one easily finds joy and grief.  Tears may denote both states of being.  When do we learn how to cry?  When do we learn adult crying?  When do we learn to avoid crying?  When do we learn to suppress the tears of others?

Physicians may be as comfortable or uncomfortable with tears as the general population early in their career but should develop strategies over time to enable them to find a balance between caring and working.  We have a certain "physicianly" presence/power that evolves with our training and experience that may add to or detract from our compassion.  How might one explain this power/compassion contradiction.  How might a physician understand, learn and even manifest compassion for/with a crying patient?  

I found some clarification in The Healer's Power by Howard Brody, MD, PhD (1992, Yale University Press).  While the White Coat Ceremony in medical school serves to help students to understand the obligations and potential separateness of our profession, the virtue of compassion (as demonstrated by countless Family Physicians) "is integrally linked to the ethical use of power in the physician-patient relationship. Surely, being with the sufferer and helping him find his own story to attach meaning to his experience is a prime example of shared power. Few things that the physician can do have the capacity to empower the patient to a similar degree.... To be compassionate in response to the suffering of the patient is therefore one of the most powerful things a physician can do: but this is possible only to the extent that the physician is willing to adopt a position of relative powerlessness, to acknowledge that the patient's suffering has incredible power over him and that he cannot remain unchanged in the face of it. This is a major irony of the physician-patient relationship, in which a sense both of one's own healing power and of one's necessary humility forms a synthesis of the apparent contradiction of power and powerlessness." 

Those words of Dr. Brody imply that comfort with tears might be at the confluence of  the physician's "healing power" and their humility.  Some physicians may not feel ready for this type of struggle in their professional development, quickly offering tissues to the crying patient in an effort to stop them.  Other physicians may tear up in acknowledgement of the power of the patient's suffering.  We need to more readily share our humanity with our patient.  Let's cry together.

Family Medicine Activist: I Love Cholesterol!

Are you bored hearing about cholesterol, yet?  Are you tiring of the religious fervor about Lipitor and other statin drugs that are prescribed to lower cholesterol?  Are you shocked that lab results representing "normal" or "controlled" cholesterol are moving targets (we keep lowering the "normal" range)?  Would it surprise you to know that your personal physician gets a bonus if enough patients with diabetes take statin drugs?  Is there an end in sight to the obsession with cholesterol by the medical profession?

Cholesterol has been given a bad rap.  It's a vitally important chemical in your body, especially in every cell wall and your brain.  I Love Cholesterol!

Eating cholesterol does not give you heart disease.  Eating fat does not make you fat.  Now you know.

Starch is the evil empire in the food world that makes you fat and gives you a better chance at a heart attack.  We eat a lot of it.  Strangely, it doesn't have much flavor of its own, so we slather it with butter and sour cream (baked potato) or peanut butter and jelly (white or whole wheat bread or worse yet, a bagel) to kill ourselves with it.

Now you know.