The MedFriendly Blog

Guest blog post: Let your diet be Mediterranean

2009-10-24T15:30:00.003-05:00

Do you want to live to be 100 or older? Today’s experts agree that if were born in 2000 or after, you have a good chance of living to be 100. Many of the world’s experts in this field believe that the Mediterranean Diet is the answer.

The Life expectancy chart has risen in the United States, most of Europe, Japan and Canada and if this trend continues, centenarians will be the norm. Researchers in Denmark predict that society will look at old age differently. Instead of the current three phases, which are children, adults and old age, there will be four stages. These stages would be childhood, adulthood and then old age divided into two segments, the third stage being young old, and the fourth stage oldest old.

Japan is the leader in life expectancy. If you were born after 2007, then you are expected to live to be at least 83. In the United States the expected age is 77. The number of people in the United States over age 100 has doubled in the last 15 years.

People debate whether it is healthy to live this long. Studies on people older than 85 are minimal, but evidence seems to be that centenarians are more mentally alert and more independent than ever before. Much of this success is due to early detection of illness and early treatment.

Some of the characteristics that most of these centenarians share are the FOX03A gene, (which we cannot control). Also other important factors include emotional resilience, self sufficiency, intellectually activity. You should have a good sense of humor, involvement with other people, low blood pressure, and a healthy diet. An interesting fact is that 80% of the centenarians in American are women and most of them gave birth after age 40.

Many experts agree that the diet is the most important factor to a long, healthy life, Most of these people recommend the Mediterranean Diet. This diet includes many fruits and vegetables along with pasta and rice. Red meat is not considered as important. Fish should be eaten twice a week. Red wine in moderation is considered healthy and olive oil is consumed daily to cook and flavor foods. This diet includes nuts, usually unsalted, because salt should be limited. The Mediterranean diet is considered an anti-inflammatory, heart-healthy diet. Daily, moderate exercise should be incorporated with this diet.

About the Guest Blog Author

Valery Fortie is the National Awareness Coordinator of Mediterraneanbook.com. As the editor of the Mediterranean book blog, she focus her efforts on providing scientifically driven information to help people eat to lower
high blood pressure and live a longer and better life.

Mediterraneanbook.com is a non commercial website created to preserve the Italian Healthy Eating Traditions. Founded in 2004 in Italy, Mediterraneanbook.com feels very strongly about having informed consumers
on duty in all healthy eating fields.

The Dementia Concussion Link?

2009-06-01T23:05:00.006-05:00

Has the media brainwashed you into believing that suffering a concussion or two is going to cause you to develop Alzheimer's disease? Think again and get the facts at my other website, MTBIFacts.com. Below is a link to a story I just posted on-line tonight.

The Dementia Concussion Link?

Per the corporate medical policy

2009-05-27T21:24:00.001-05:00

If you are considering undergoing an expensive medical procedure such as an MRI or a neuropsychological evaluation, be very careful when the insurance company states that the service will be covered 100% “per the corporate medical policy.” Those five words are they key…per the corporate medical policy. When patients hear this, they tend to think that this means the medical procedure will be paid in full and proceed with the evaluation. What is actually means is that a decision to pay for the service will not be made by the insurance company until after the evaluation takes place. What this often translates into is the insurance company finding every reason in the world not to pay for the service.

As an example, I was once evaluated a child who suffered a brain injury four years prior to the evaluation. There was a question as to whether the brain injury affected his development. The insurance company stated ahead of time that the service would be covered 100% per the corporate medical policy. The evaluation was completed and then the insurance company refused to pay because they said the brain injury occurred too long ago. This is frustrating because this information (the date of the brain injury) was well known in advance and the insurance company could have easily made a determination beforehand. Instead, the patient’s family was told they would need to pay thousands of dollars for the service, which they cannot afford.

Given the above, my advice is as follows. Press the insurance company to provide something in writing saying that the procedure is pre-authorized or not pre-authorized. If the company refuses, you may want to consider switching insurance companies at some point. Make sure the words “per the corporate medical policy” are not included because this only serves as a way for the insurance company to wiggle out of not paying. Secondly, be sure to appeal such cases to the insurance company. If that does not work, contact your state insurance committee. Insurance companies do not like to be bothered by state regulators. If \ this does not work, contact your local congressperson and have that individual call the insurance company on your behalf. You would not believe how effective this can be. Remember, the insurance company needs the help of lawmakers to pursue their agendas and does not want to make any legislative enemies. If the local congressperson does not work, call your state U.S. senator.

Improving your memory

2009-05-22T22:22:00.001-05:00

As a neuropsycholgist, people often ask me if there are techniques they can use to improve their memory. Or course, there are basic things you can do such as write yourself lists, keep a portable memory notebook, use a daily planner, and put your keys in the same place every day.

However, if you want a formal system (particularly one that will help with school), my opinion is that Harry Lorayne takes the cake. When I was in HS, we all had to take a class with a religious teacher who made everyone try to memorize every book of the Bible in order. I knew there was no way I could do that with rote memory skills. So then I saw Harry Lorayne on TV and couldn't believe what I was seeing this guy do (memorizing entire magazines and he could say what page # the information was on!).

So I figured what the heck and purchased his memory power tapes. It was amazing. In the first week of the class, the teacher sarcastically asked if anyone has memorized all the books of the Bible yet. I raised my hands and said, "Not only have I memorized all the books of the Bible, but I'll say them backwards. Or, if you'd like, you can name a book of the Bible and I'll tell you what number it is. Or you can name a number and I'll tell you the book."

Everyone looked at me like I had some kind of super power when I did just that but I didn't. It was also based on an associative memory technique that Harry came up with that involves pairing numbers with phonics. It truly works and to this day I still remember that the 33rd book of the Bible is Ezekiel. You can use it for almost anything. This was just one example. Anyway, for those interested, information is available here, including some old clips of the master in action. I make no money off the sal of this product.

http://www.harrylorayne.com/

World's LARGEST Medical Message Board Created

2009-05-20T23:25:00.000-05:00

MedFriendly is back. Well, the site never actually went away but during the time that I was preparing for board certification, the site was on a definite hiatus, without many updates. After becoming board certified in November 2008, I decided to take a few months off to decide what I was going to focus on. I wanted to continue MedFriendly, but it was clear that the site needed to be overhauled to a database-run system for the advertisements that I have on the site, which would prevent the unattractive appearance of dead links. As a result, I began the process of making this transition, but it will take some time. For now, if you click on a link and it does not work, try changing the extension from .html to .php5 or vice versa.

To commemorate the re-birth of MedFriendly, I have been working for months on creating the world’s largest medical message board which you can now find here:

MedFriendly Message Board

On this message board, you will find a wide array of topics and forums unlike any other on the internet. The message board has the advantage of consolidating an enormous amount of information in one convenient point of access. No longer do you need to skip from website to website to visit different medical forums when they are all in one location. The message board will help build a sense of community and has many fun aspects to it such as the ability to create your own avatar (personal picture to identify you). Topics and forums can be added simply be emailing me through the contact page.

Please take the time to sign up for the MedFriendly Message Board today and tell your friends and family about it as well. The only way a community of members can be built is by signing up. There are few members at the moment because the message board was just launched today. Registration is free, quick, and easy. Be sure to check your junk email box to make sure that the confirmation email was not sent there. As soon as you respond to the confirmation email, you are all set to post.

As to the blog, that will be continuing as well. Not every day, but there will be more frequent posts beginning today on diverse topics that are sure to inform and entertain. Please keep checking back for updates and remember, sign up for that message board. 

The Myths of Mild Traumatic Brain Injury: the 15% number

2008-12-22T01:22:00.005-05:00

One of the most popular myths perpetuated by the media and some in the scientific community is that 15% of patients who have suffered a mild traumatic brain injury (MTBI) do not recover by one year and may even experience permanent symptoms. An important point that I try to teach people is to always obtain the original article that is cited in support of such claims so that the validity of the claim can be examined. In this case, the reference often cited is a 1995 study by neurologist, Michael Alexander. In his paper, he wrote the following: "At one year after injury approximately 15% of MTBI patients have not recovered’’ (p. 1256).

When researchers cite Alexander's study as the only reference for this figure, it casts the impression that he is the person who collected the data to support it. However, if one reads Alexander's paper, it is seen that Alexander based his 15% figure on two earlier studies: McLean and colleagues (1983) and Rutherford and colleagues (1979). To begin with, McLean and colleagues only followed 20 patients for one month not one year. In addition, his study consisted of 11 patients with MTBI, 8 patients with moderate TBI, and one patient with a severe TBI. One can hardly use a study of all severity TBI patients at one month post-injury to argue for the chronic effects of MTBI.

The main source of the myth, however, comes from Alexander's summary of the Rutherford article. Rutherford followed 131 MTBI patients for a year and he did indeed find that 19 (14.5%) complained of symptoms at that point. A detailed analysis of Rutherford's patients, however, reveals some interesting details. First, there were actually 145 patients in the study and of these, only 131 followed up. Assuming the missing 14 did not have symptoms one year post-injury, that changes the number to 13.1%. Of the 19 patients who were still reporting symptoms at one year, 8 were involved in lawsuits and 6 (5 of whom were in lawsuits) were suspected of malingering six weeks post injury. Malingering was defined in this study by: bizarre and exaggerated descriptions of symptoms and strange responses during routine examination. Can we really trust the self-report of symptoms in these individuals to be reliable and valid? The answer should be obvious.

In addition to the numbers above, 10 of 19 patients reported one new symptom at one year post-injury that was NOT reported at six weeks post-injury. If the symptoms were brain injury based, they should not appear at one year post injury when not present at six weeks post-injury. More information is that 6 of the 19 patients had only ONE symptom at one year and 7 of 19 patients had two symptoms at one year. This is not enough to classify patients with what is sometimes referred to as "post concussion syndrome" which is traditionally described in the literature as the presence of three or more symptoms at three months post injury. In the end, we are left with 6 subjects who endorsed between 4 and 9 symptoms. And when we take 6 and divide it by 131 we get 4.5%. If we use the entire sample of 145 patients, the number drops to 4%. This is consistent with the estimate (<5%) provided by Iverson in his 2005 review of MTBI. In sum, by simply checking the original sources, one can easily see than the 15% estimate is a truly a myth.

REFERENCES

Alexander, M. P. (1995). Mild traumatic brain injury: Pathophysiology, natural history and clinical management. Neurology, 45, 1253–1260.

Greiffenstein, M.F. (2008). Clinical Myths of Forensic Neuropsychology. The Clinical Neuropsychologist, 10, 1-11.

Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301–317.

McCrea, M. (2007). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

McLean, A., Temkin, N. R., Dikmen, S., & Wyler, A. R. (1983). The behavioral sequelae of head injury. Journal of Clinical Neuropsychology, 5, 361–376.

Rutherford, W. H., Merrett, J. D., & McDonald, J. R. (1979). Symptoms at one year following concussion from minor head injuries. Injury, 10, 225–230.

The U.S. healthcare system has been undermined by not assessing for symptom validity

2008-12-06T01:59:00.008-05:00

These days, many (but not all) health care providers are becoming less and less like scientists and more and more like blind patient advocates. While it is natural for treating providers to advocate for their patients, and in fact, part of their role in many cases, what many appear to have forgotten is that advocacy needs to be based on reliable and valid data. For example, let us say that a patient walks into your office and subjectively reports a plethora of diffuse cognitive and somatic complaints after what appears to have been a relatively mild injury. What is the provider to do? Let us further stipulate that the patient shows up with these same complaints and informs you that he or/she is involved in personal injury litigation or a workers compensation dispute. Should this information be considered in the case formulation and should it potentially alter the plan of care? Or, should these contextual factors all be ignored and shoved aside in the interests of patient advocacy and being nice? Far too often, I see health care providers do the latter and it often causes great harm, despite good intentions by some.

While all ethical health care providers want the best for their patients and do not want to have conflict with them, it is also important to draw boundaries and remember that the patient is not your friend. Trying to become friends with your patient constitutes a multiple relationship that can cloud objectivity, which is so important to the assessment process. Another important factor to remember is that simply because a patient walks through your office doors does not automatically create a situation where you must show 100% allegiance in believing everything the patient says or doing everything they ask of you. While there is nothing wrong with having an allegiance to your patient and being a strong patient advocate, the degree of such advocacy should be modified based on an objective determination of the validity of the patient's clinical presentation.

While many patients present to the clinician's office with an accurate portrayal of their symptoms and problems, there are other patients who exaggerate their presentation for a whole host of reasons. Some exaggerate because they want to convince you that something is wrong, because they want attention for being in the sick role (i.e., factitious disorder), or because they seek some type of external gain such as money in a lawsuit, disability, medications, or avoidance of responsibility. The latter is known as malingering. Patients who exaggerate their clinical presentation may have valid symptoms inter-mixed with exaggerated symptoms. Less common is the patient who has made up a story about a personal injury and is feigning the entire clinical presentation (sometimes referred to as pure malingering).

If the patient's symptoms are purely based on self-report and you have no objective data to support your conclusions, you can potentially fall victim to patient exaggeration. Why is this so important? Improper identification of symptom exaggeration leads to a waste of health care services such as referring patients to needless and endless therapies, tying up access for those patients who legitimately need such services. Furthermore, patients are often granted disability (sometimes for years) or accommodations in school or work that they do not deserve. Many systems that provide disability services or accommodations have quotas on the number of people they will grant such services to. Therefore, granting access of such services to patients who are willfully distorting there clinical presentation is a disservice to those patients presenting in a reliable and valid manner who legitimately need such services.

In my line of work as a board certified clinical neuropsychologist, I frequently encounter situations where symptom validity is not assessed by the health care provider. In many cases, this is because assessment of symptom validity sets the stage for a potential conflict with the patient. In other words, if the provider determines that the symptoms are not valid, this will need to be communicated with the patient in some way, which can upset the patient. The very possibility of conflict with a patient is something that many health care providers do not want to deal with because it can be socially uncomfortable and potentially lay the groundwork for a patient complaint or possible lawsuit. As a result, health care providers tend to give patients the benefit of the doubt and accept self-report at face value. This is a tremendous mistake.

For example, I recently published an article in the journal, Brain Injury, (reference below), showing that 21% of adults who reporting suffering a mild head injury or mild traumatic brain injury failed a very simple test designed to assess the degree of effort they were putting forth on the evaluation. When later asked to rate how difficult this task was, this group of adult patients rated it to be 5.6 out of 10 (with 10 being the most difficult). By contrast, I found that only 5% of children with moderate to severe neurological conditions (e.g., strokes, traumatic brain injuries) failed this same test and that the entire group of children rated the same test as very easy (1.35 out of 10). It is not neurologically possible for a mild traumatic head or brain injury in an adult to cause worse performance on a simple test compared to little children with moderate to severe brain injuries. The only logical conclusion is that the adult group of patients exaggerated their presentation.

Without the use of objective measures such as the one used in my study above, clinicians will find it very difficult to assess for the validity of a patient's presentation -- although they may have suspicions. Objective data helps supplement the confidence one has in those suspicions. Tools are available to assess for validity of cognitive performance as well as the validity of physical, cognitive, and emotional complaints. I will not describe the methods behind these instruments in a public forum, but they are well researched and validated and are very important to utilize.

By not assessing symptom validity, one increases the risk of blind patient advocacy. This can cause one to fall into very bad habits such as not obtaining or reading through the patient's medical records. By not doing so, the clinician misses reviewing important information that may provide an alternate explanation of the patient's presentation or may raise red flags of suspicion. Another bad habit is the willful suppression and omission of information in the clinical note that would show that the patient's problems may be related to factors other than those related to their disability claim. For example, I recall working on a case where a provider omitted that a recent hospitalization concluded that the patient was experiencing pseudo-seizures because this finding highlighted that there was a psychological component to the patient's problems, which conflicted with the claim that all of the problems were neurological. As a result, the tendency is to try to fit a square peg in a round hole and continue to attribute the clinical presentation to a medical cause that does not really exist. Another bad habit is allowing patients to tell you what information goes in their reports, what stays out, and how to write it.

Lastly, it is important to note that the assessment of symptom validity is designed to improve patient care and utilization of the health care system. In many instances, patient exaggeration is related to psychological factors that would be better addressed by referring the patient to psychotherapy rather than tying up medical resources in the community. In this way, patients are better served because the real factors driving their clinical presentation can be addressed, helping them move on to living more productive lives. Of course, not every patient will be happy to learn that there are doubts as to the validity of their performance or symptoms, but I have found that patients are often accepting of such feedback if care is taken to listen to their self-report in a non-judgmental manner during the clinical interview so that a strong rapport is established. This allows the patient to be much more accepting of such feedback because the patient feels that you have listened. Also, the presentation of the feedback is crucial. Rather than calling the patients liars, it is important to emphasize how the information you have gathered can help guide their clinical care. By showing that you listened to the patient, performed a thorough evaluation, and used objective data to make your conclusions, patients tend to be very understanding of such feedback.

With that said, there is no full-proof way to insulate yourself from a patient complaint or conflict. This is most likely to occur with patients who blatantly distort their presentation and have alot to lose by not being able to access the external gains that they seek. However, dealing with these issues is part of the job when evaluating the validity of a patient's presentation, particularly in those with vague medical complaints and controversial medical diagnoses. However, being able to cite objective data to support your conclusions greatly helps in insulating you from a complaint leading anywhere.

In summary, although you may be reducing the chance for any conflict with a patient by not assessing for symptom validity, you can also be making the patient sicker by not doing so. In medicine, this is known as iatrogenic illness -- when the "treatment" makes the patient worse. If you are not assessing for symptom validity, it is important to learn more about the topic and to begin integrating this into your clinical practice.

To learn more about this topic and to schedule Dr. Carone to lecture to your clinical practice, university, or in other settings, contact him at lectures@MedFriendly.com for information on available dates and speaking fees. Dr. Carone is also available for legal consultation (e.g., assessment of case viability, independent opinion of neuropsychological reports) although he does not test patients referred by lawyers or independent medical exam companies at this time.

Reference:

Carone, D., (2008). Children with moderate/severe brain damage/dysfunction outperform adults with mild to no brain damage on the Medical Symptom Validity Test. Brain Injury, 22, 960-971.

Board certification

2008-12-01T23:00:00.003-05:00

Wow. It is hard to believe that I have been away from blogging for almost an entire year. During that time, it has also been amazing to me that people have continued to post on this Blog and have continued to ask me when I will post again. Well, I am officially back in action now and you can count on more thought provoking and interesting posts from yours truly.

What have I been doing all of this time and why did I take so much time off? Well, you can be rest assured that I was not swinging in a hammock as I was being fanned and being fed grapes fresh of the vine. No, far from it. I was pursuing the final stage of board certification in my field -- clinical neuropsychology. In medicine, board certification is commonplace, since over 90% of physicians are board certified. In psychology, however, the reverse is true, with less than 10% of psychologists obtaining board certification status. And of those psychologists, neuropsychology is the subspecialty that tends to pursue board certification, likely because my field is strongly associated with the medical model of training.

So what is board certification and why is it important? Board certification is a mechanism by which one is evaluated by his or her peers to determine if the individual is competent to practice in a specialized area. Isn't that what a license would tell us, you may ask? Not necessarily. In most states, the Psychology Scope of Practice Act is a generic licensing law, meaning that any psychologist can provide specialized services to the public -- if he/she has the proper training to do so. The problem is that states leave it up to the practitioner to decide if he/she is competent to offer specialized services. Unfortunately, some individuals offer services they are not qualified or competent to provide. While one might think that the government would pursue such individuals, this tends to only happens in cases where something egregious has happened to a patient. Far too often, patients are provided substandard care by people who claim to be neuropsychologists but actuallly have very little formal training in the area. This can result in patients being diagnosed with brain damage when there is none, told they have no brain damage where there is some, and referred for all different types of inappropriate treatments, etc.

So how can the public determine who is board certified? For physicians, complete a search on the webpage for the American Board of Medical Specialists. For psychology, search the website for the American Board of Profesional Psychology (ABPP). There you can find numerous board certified psychologists by subspeciality. A few weeks ago, I received a notice that I was conferred board certification status by ABPP in Clinical Neuropsycholy, hence the new initials (ABPP-CN) next to my name. The specific board that works with ABPP to confer board certification status upon clinical neuropsychologists is the American Board of Clinical Neuropsychology. You can search for providers by state and city on these websites. In the interest of full disclosure, two other boards that certify clinical neuropsychologist include the American Board of Professional Neuropsychology and the American Board of Pediatric Neuropsychology.

When I stopped blogging, I essentially decided to take about 10 months off to prepare for an intense three hour oral examination. My mind had been set on achieving this goal ever since I began graduate school, which is why I selected a program (Nova Southeastern University that offered specialized training in clinical neuropsychology that met the training requirements of the American Psychological Association for clinical neuropsychology. This was then followed by a one year internship (neuropsychology specialization) at The University of Oklahoma Health Sciences Center and a two year neuropsychology fellowship at SUNY Buffalo School of Medicine. I then began the Neuropsychology Assessment Program at SUNY Upstate Medical University.

So it has been a long time coming and as you can tell, when you have all of this training, it is very frustrating to see people with next to no training offer themselves up to the public as "neuropsychologists." Making the situation even worse is that there are many well trained people in my field who for whatever reason decide not to pursue board certification. The problem though is that the public has no reliable and practical way to differentiate the person with little training from the one with extensive training if neither are board certified. This is why board certification is so important because it provides the public with a reliable and practical way to determine who meets the training credentials and who has proven themselves to be competent in the area they practice in.

I am happy that I put blogging aside for a year to achieve my goals. And now, I am going to kick back and enjoy life alot more now that I do not need to spend all of my free time studying. There will not be blog entries each day, but I will try to post a few entries a week and provide you with the types of entries you have all enjoyed in the past.

The soda pop blues

2007-12-10T23:00:00.000-05:00

"Just when I thought I had heard it all." That's one of my favorite lines and it never ceases to amaze me how many times I come across something new that I had never heard of before. Now, as a backdrop to this story, I tend to drink more than my fair share of soda, but hey, we all have our vices right? Well, I thought I drank a lot a lot of soda but recently met someone who was consuming two, two-liter bottles of soda a day. So, you may think that would case weight gain, right? Yes, it did. Acid reflux? Yes? But guess what else happened? The acid ate away so much at this person's esophagus that it caused it to rupture! Can you imagine that happening to you?! Good grief.

It's Gotta Be the Shoes

2007-12-08T00:04:00.001-05:00

As the snow falls down from the dark winter sky here in good old Syracuse, New York, it reminds me of a night over 10 years ago when I was playing an intramural basketball game in college. I had purchased a new pair of sneakers that day and wore them to the game. They felt a bit snug but nothing too out of the ordinary. There was a lot of running and stopping as is typical in a fast paced game of this sort. My toes were starting to hurt, but I figured it was just normal soreness from the new shoes and played through the discomfort. But finally, I had to stop. I sat down and took my shoes off and thought I would just re-adjust things to make the sneakers more comfortable. But as I tried to get the shoes back on, I could not do so because of the pain. Confused, I pulled off my socks to get a better look at my toes and I was aghast at what I saw. Both big toenails were literally purple and pushed up from the accumulated blood underneath the nail. Turns out, the blood had actually clotted under both nails due to the tight fitting shoes and constant stopping of my feet, which was jamming my big toes up against the front of the shoe, repeatedly traumatizing them.

It was late and everyone I knew had left as I sat there trying to figure out what to do next. I figured I would just go back to my room and that this would slowly go away. But then I realized this wasn't going to go away any time soon and that I needed medical help. I thought I would be able to fight through the pain and put my feet in the shoes but it was just impossible, no matter how hard I tried. My car was parked deep in the lot on a cold snowy night, and I had no choice. I walked barefoot all the way through the snow to my car. As you can imagine, that was not a fun experience. There was no point wearing the socks over my feet because they were already wet.

I arrived at the local urgent care center and the doctor took a look. He said he was going to take a hot needle and stick it through my toenail to relieve the pressure and let the blood come out. The funny thing was that I normally would associate this with being painful but I was in so much pain from the blood underneath the toenails that the feeling of the needle going through the nail was actually the best feeling in the world at the time and did not hurt a bit due to the relief it provided. The nails fell off a few weeks later and grew back later. So let this be a lesson to people out there to avoid wearing sneakers for the first time during a new game. Walk around in them first to break them in.

We never looked

2007-12-05T06:49:00.000-05:00

It's amazing the kind of things that get written in medical records that never actually happened. For those following this blog for the past week, you know that my son was in the hospital following some complications after a tonsillectomy and adenoidectomy. Either myself or my wife was with him at all times. We know for sure that no one ever checked inside his nose or his ears, yet somehow the discharge summary states the nose and ears were clear. No one did any evaluation of his eye movements yet the records indicate this was formally evaluated. These are not huge deals, but still highlight the point that what the records say happened did not necessarily happen. This is important because some people hold the medical records up to be a flawless document that cannot be wrong. As someone who reads through an unbelievable amount of records every month, I can tell you that almost every case has some type of error. Most patients never know because they never get their hospital records. Some of the errors I have read include two different doctors saying the injury involves different sides of the body, inaccurate time sequences, and my favorite: stating something is non-contributory or "WNL."

I recently had a case where all the medical records stated that family medical history was non-contributory. This basically means that the family medical history is not important or relevant to the patient's current state. But what often happens is that health care providers do not ask about the family medical history and just say that it is non-contributory when this is not the case. In the case mentioned above, I had forgotten to ask about family medical history. I wasn't comfortable with relying on the medical records saying the family medical history was non-contributory so I called the patient at home and asked her about this. As it turns out, she had first degree relatives with posttraumatic stress disorder, heart attack, hypertension, diabetes mellitus, and cardiac bypass surgery. Yep, that's non-contributory all right. Unbelievable. It kind of reminds me of the phrase "WNL" when neurologists examine the cranial nerves. This abbreviation is supposed to mean "within normal limits." I am starting to think that it sometimes means 'We never looked."

If you want

2007-12-02T22:00:00.000-05:00

These last few days have been crazy which is why there have not been recent blog postings. Although my son was feeling better and came home, he has been in the hospital since Saturday due to dehydration and fever. He basically refuses to drink after having the adenoids and tonsils removed. I am too exhausted to write a long post tonight, but I found one of the events during our stay rather incredible so I thought I would pass it along since it is brief. When my son was first discharged, the surgeon placed him on 7 days of oral antibiotics. We were giving him this to him until he was re-admitted. When he went up to the main floor from the ER, we asked if he was going to get his antibiotic again. The ENT resident said that they normally do not send children home with antibiotics after these procedures so he didn't think he needed it. I don't know if this is true or not, but I then said that the attending had ordered it because he felt he DID need it. So the ENT resident just looked at us and non-chalantly said, 'Well, ok…if you want." To me, that is just a baffling response. If I want?! Isn't it the job of the doctor to determine the need for the medication? In this case, the attending doctor had already ordered it, the resident didn't seem aware of this, and then we mentioned that point it seems "If you want" was a face-saving response. One day later, the pharmacy finally sent up the antibiotic and he took it tonight. Kind of strange that it takes a day to send up one of the most common antibiotics in existence. OK, stay tuned for more tomorrow.

A Tale of Two Residents

2007-11-29T20:48:00.000-05:00

So yesterday, we returned to the hospital for our other child's tonsillectomy and adenoidectomy procedure. We were more worried about this one because he is younger. To read about the positive and negative aspects of our first experiences, please read the Tonsillectomy tales 4-part series. Everything pretty much went well except for a ridiculous situation that occurred shortly after the surgery. My son (who is only two and a half) did not wake up from the anesthesia in a pleasant state. He was crying, screaming, arching his back, and squirming. Of course, the nurse on the floor didn't have the orders for pain meds from the nurse who was with him in the recovery room. This is one of the most annoying and common things that happens upon a transfer to a new floor and can so easily be corrected by implementing an efficient system. How about this idea? Don't transfer a patient to a new floor UNTIL the floor has all the orders for the medications. Sheesh.

Anyway, in the midst of this chaos, a meek lady with a white lab coat walks in and just starts asking medical questions. If anyone has read this blog before, you know that I cannot stand this. Medical professionals need to introduce themselves when they walk in a room. 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 anethesia. 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 aneshesia before?" She paused and said, "Maybe once." That's nice. Then how can that be thrown out so cavalierly as the explanation?! If you don' know, say you don't know, and get someone who may know such as a senior resident or attending physician.

After 15-minutes of needless screaming, the nurse finally comes in with two syringes. One had Tylenol. Another had codeine. Within 5 minutes, my son's face started to swell and get red, as did both of his arms. We told the pediatrics resident about this and she said that it was probably because he was crying. Oh no, I thought, here we go again. So I had to point out that these were new findings since the codeine and that it may be an allergic reaction. She said it may be from the anesthesia. Sighhhh. I again explained that the symptoms just started as soon as he took codeine and that he never took codeine before. I then suggested the possibility of an anti-allergy medication and she said she agreed and would order Benadryl. I sat there amazed that here I am as a non-MD having to lead an MD to figure out what is happening here. So then the nurse walks in and I asked if she had the Benadryl. She said she saw the resident in the hall who just said they are not going to use Benadryl. Ummmmm. Do you think the resident ever informed me of this? Nope. I was of course aggravated at this but then the ENT resident walked in.

What a difference. His first comment to my wife and I was "You two know your child better than anyone and you are the first line of defense." OK, so instantly he is acknowledging we have some insights that need to be listened to since after all, we are his parents. Good. Then he demonstrated he was taking our complaints seriously, examined my son, acknowledged this could be an allergy to codeine, explained the pros and cons of Benadryl at that stage, and assured us this would be appropriately and closely monitored. He also said that he was in charge here and not the pediatrics resident since this was an ENT patient. He also said he would have his senior resident come down to take a look just to be sure. Two different residents, the same exact situation, and both handled in polar opposite ways. What a relief it was to have the ENT resident and I felt very comfortable at that point. We decided not to use the Benadryl in favor of observation. In reality, this story has nothing to do with Benadryl, but has everything to do with communication and coming across professionally. Eventually, the symptoms went away and the breathing problems stopped. Today, my little buddy was having fun scooting around the house on his fire truck. :)

Stupid interviewing techniques

2007-11-27T19:29:00.001-05:00

I had a case recently of a person who went to the hospital with a sudden onset of stroke symptoms. In addition to having expressive language impairment at the time she was also confused and understandably anxious. She was alone and the physicians tried to obtain information from her, which included the estimated time that symptoms began, personal medical history, and family medical history. This is all well and good, provided that it is written in the patient's records that the information was obtained from the patient in an acute confusional state. But it wasn't. The history was reported as if that was the actual true history.

The patient saw what was in the records for the first time when I reviewed them during my own detailed interview. At almost every turn, she said that information in the records was simply not true and emphasized she was interviewed alone in a confused state. This is why when I write reports, I use phrases such as "the patient reported" or "the patient stated." This way, it is clear where the information is coming from. If I have a patient that cannot provide a good history, there are no medical records, and no reliable informants to contact, then I will note that "the patient appears to be a poor historian and therefore the history provided cannot be relied upon as necessarily being accurate." Simple as that. It just amazes me that people cannot use common sense and realize that the information obtained from someone in an acute confusional condition may not be right, and to list in the medical records as if the information is factual is just plain silly.

Drug reps and the bribing of the modern U.S. physician

2007-11-26T00:13:00.000-05:00

Yesterday, I was reading a fascinating inside story
about the life of a psychiatrist who became drug rep, or as some politically correct people would say -- a pharmaceutical salesperson. The psychiatrist wasn't literally selling the medications but he was providing the sales pitch that led to the sale in the end. The article raised many interesting ethical issues and brought to mind that this was a topic I had some strong opinions on yet never voiced on this blog before. So, here we go….

The bottom line to me is that the practice of giving doctors gifts in exchange for a chance to swindle them into selling a certain medication should be illegal. Told you I had a strong opinion on this. For me, it’s a matter of common sense. We are talking about people's health and treatment decisions such as medication selection should be based on the experience of the physician and objective research data. It should not be because I feel like I owe Joe the drug rep for the 10 pepperoni pizzas he just brought by to feed me and my residents.

I am a neuropsychologist and I do not prescribe medications. Despite this, in all of the medical settings I have trained in, I was always encouraged by the drug rep to attend the talk. Now why would that be? Because psychologists are prescribing medications in some states such as New Mexico and they know it is just a matter of time before this happens in more states than not. So why not build the relationships early, they figure. They do not know that I have no intent to prescribe medication one day, but there may also be another reason why they wanted me to attend. Believe it or not, physicians are always asking neuropsychologists what medication they recommend for certain conditions. Knowing this, the drug reps want to get the word out on their medication to as many people as possible. Or maybe they just want me to grab some of the promotional materials and distribute them so as many patients see these as possible and see it as a possible endorsement of the medication.

To those outside the medical community, here is the typical situation: A meticulously dressed young male or female, usually quite attractive, arrives to the hospital with a room set aside to do a talk on a specific medication. The drug rep spends time prepping the room, making sure the food is there and that promotional materials are spread out everywhere. So when you eat the food for the "Wonder-drug" you best believe you will be eating it on a Wonder-drug plate, wiping your face with a Wonder-drug napkin, and drinking from a Wonderdrug cup. You'll be taking notes with your very elegant and shiny looking Wonder-drug pen on some very fancy Wonder-drug paper. You may be slightly distracted by the Wonder-drug clock you received, or maybe you'll be busy reading the pamphlet of glossy Wonder-drug propaganda sheets you were handed about the medication. You'll hear some of the presentation, but you'll probably be distracted by going up for seconds in the lunch line since the selection of food and the quality of it is ten times better then anything the best chef can hope to serve up in the hospital cafeteria.

Physicians do not have a lot of time to read research independently, but they need to make the time. If they don't and they rely on their information from biased sources who have essentially bribed them, how are the patients supposed to benefit? If anyone thinks bribe is too strong a word, consider that there used to be (and maybe there still are) programs in which physicians can earn points for how many of a certain medication prescribed. Earn more points and you get a bigger gift, such as a trip to the Bahamas. How is that not corrupting? Is any physician doing this with bad intentions? I doubt it. But do many physicians have their eyes closed as to how they are being manipulated, however so subtly? Probably not, or if they do, the thoughts are likely minimized. Also, not all physicians attend these lunches and some are able to see through the fog. But too many are not and it those physicians that concern me. As a patient, how am I to know? The only answer is to make it illegal for drug reps to provide gift-based lunches when trying to sell a medication. Can't make it illegal. Then have the American Medical Association implement this into the ethical code. Oh, sorry, can't do that because they are making millions off providing the drug companies ways to identify physicians and their prescribing habits. Click the story in the first paragraph to read more.

Lastly, I am not opposed to drug reps speaking to physicians, but it needs to be done without any type of gifts. Just come by, let people bring their own lunches again (gasp!), do the talk, take some questions, and end any sense of impropriety.

Heart warming story

2007-11-24T21:41:00.000-05:00

Sometimes, patients give you insights into things in life with just a few simple words. I figured I would share this story around the holidays. It's a short story but sometimes short stories provide powerful messages. So here goes. I was interviewing a female patient once and her family was trying to give me some insights into her kind demeanor and personality, which I was already able to detect from the interview. When she stepped out of the room, one of her family members mentioned how her son was born with a developmental disability. No one knew exactly what the diagnosis was but the child had been going through evaluations from numerous specialists. One of the family members asked her "What if it is autism?" Now, I am not sure what type of answer they were expecting but I don't think they anticipated the one she provided. She reportedly paused, turned her head towards the person who asked the question, and answered "Love him."

Who is the "crazy" one here?

2007-11-20T23:11:00.000-05:00

I recently saw a case of a man who suffered a severe traumatic brain injury and spinal cord injury. He was rushed to a local hospital and placed on life support. The doctor told his wife that he had less than a 1% chance of living and suggested removal from life support. Amazingly, this suggestion came less than 12 hours after the injury. Anyway, the patient's wife held physicians in great regard and had the mindset that "the doctor must be right." She again asked if he was sure the chances of living were less than 1% and he reportedly said yes once again. At this point, the patient's wife elected to remove him from life support. But something happened -- he kept breathing. And a few hours later, something else happened -- he opened his eyes, gingerly removed the cold compress from his forehead, folded it again, and placed it back on his head. He then lapsed into unconsciousness again. Amazed, his wife ran into the hall and asked for another doctor's opinion. The second doctor reportedly stated that if the patient is still breathing by himself the next morning that they will transfer him to a level one trauma center.

The next morning came and the patient was still breathing. His wife decided to have him transferred immediately. It is at this point that the most distressing event occurred to the patient's wife. She stated he overheard one of the nurse's say that the wife was "crazy" for trying to keep him alive and transfer the patient. Well, seems to me that the wife was correct because now the patient has regained many of his cognitive faculties (although not at the level he was before the injury), can hold a perfectly normal conversation with people, and although still partly paralyzed, can enjoy watching and interacting with his children. This was an important story which highlighted that doctors are sometimes too quick to elect to pull patients off life support and that some patients can pull through and fight the odds. We owe these patients the chance to make that fight (at least give them more than 12 hours!). To not do so, well, that is what would be "crazy."

What To Do When You Cannot Afford Medications

2007-11-19T18:42:00.000-05:00

Unfortunately, many Americans find themselves in situations where they cannot afford medications. There are many reasons for this such as: a) no insurance coverage, b) termination of coverage through workers compensation or no-fault insurance, c) excessively high co-pays combined with a limited ability to pay due to poverty. As a result, many patients assume that there is no way to get the medication they need when this is not necessarily the case. What follows is a list of resources that you, a loved one, or friend can use to obtain the medications you need when limited finances are an obstacle.

1. CONTACT THE PHARMACEUTICAL COMPANY THAT MAKES YOUR MEDICATION

Did you know that many pharmaceutical companies have special programs for those who cannot afford it? Generally, a three-month medication supply is provided. After this time period, a new request is needed just as a new prescription is needed when refills are exhausted. Medications are shipped directly to the patient or physician in about two weeks, but some programs request up to a six-week lead time. The following resources can help you find medication assistance programs:

Partnership for Prescription Assistance: The Partnership for Prescription Assistance brings together America’s pharmaceutical companies, doctors, other health care providers, patient advocacy organizations, and community groups to help qualifying patients who lack prescription coverage get the medications they need through the public or private program that is right for them. Many will get them free or nearly free. Its mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible. Through this site, the Partnership for Prescription Assistance offers a single point of access to more than 475 public and private patient assistance programs, including more than 180 programs offered by pharmaceutical companies. Patients can determine which programs they may be eligible for by answering questions and using the online application wizard. To access the Partnership for Prescription Assistance by phone, you can call toll-free at 1-888-4PPA-NOW (1-888-477-2669).

Needy Meds.com: A non-profit organization with the mission of helping people who cannot afford to pay for their medications. Click this link to find patient assistant programs through their website.

2. CHECK IF YOUR STATE HAS A PHARMACEUTICAL ASSISTANCE PROGRAM

Many states have pharmaceutical assistance programs for qualifying residents. Qualifications vary, and some programs are only for senior citizens. The American Association of Retired Persons Foundation (AARP) maintains a state by state list of these programs with contact information. If your state is not listed, try contacting your county health department (check your telephone book) to see if there are other programs in your particular state or county.

3. CONSIDER GENERIC INSTEAD OF BRAND NAME MEDICATIONS

After a certain period of time, pharmaceutical companies must allow other companies to produce their medication. Generic medications must have the same active ingredients as the name brand, but the inactive ingredients could be different. Inactive ingredients may include colors, preservatives, or other fillers. A pharmaceutical company that wishes to sell their generic medication must prove to the Food and Drug Administration (FDA) that it is equivalent (known as "bioequivalent") to the brand name medication. To be bioequivalent, the active ingredients in a generic medication must be absorbed at a similar rate and in a similar amount as the brand name medication. The generic does not have to act exactly the same as the brand name medication, but it does have to fall within certain guidelines set by the FDA. These guidelines may vary from medication to medication.

To be sure that the generic medication you are offered has been established as bioequivalent to the brand name, always check with your pharmacist. Your pharmacist has access to information about generic medications from the FDA's Orange Book. The Orange Book contains listings of medications and their bioequivalency status. The electronic version of the Orange Book is searchable by active ingredient and brand name.

If your doctor has written a prescription for a medication using the brand name for that medication, the pharmacist must fill it with that specific medication. The pharmacist can call your doctor and talk about substituting a generic form of the medication. Alternatively, you can talk with your doctor about generic vs. prescription medications when the prescription is written.

Generic versions are not available for all brand name medications, but it is worth asking your doctor about this since it can save you significant money. For more information on generic medication, see the website of the Office of Generic Medications from the FDA.

4. ASK FOR FREE SAMPLES

If there is no generic version of your medication available, ask if your health care provider has samples of the medication. Many doctors are given free samples of commonly used medications by drug company representatives. This is not a long-term solution, but a few samples might be able to hold you over until a real solution is found.

5. LOOK INTO PILL SPLITTING

You may be able to save money by purchasing your medication in a double dose and splitting the pills. Again, you will need to discuss this possibility with your health care provider. This approach cannot be used with all medications.

6. ASK FOR LONGER PRESCRIPTION INTERVALS

Instead of getting a prescription filled that will only last 30 days, you can request one that will last for 60 to 90 days if you anticipate future financial hardship or termination of insurance benefits. Your health care provider's willingness to do this will depend on the type of medication. For example, this request will be more likely to be granted for an anti-depressant medication than a narcotic pain reliever, due to the addicting qualities.

7. CONSIDER APPLYING FOR MEDICAID

Medicaid is a health insurance program funded at the federal (national) and state level for individuals and families with low incomes and resources. The application process, eligibility requirements, and coverage policies vary from state to state. In some states, people who qualify for Supplemental Security Income (SSI) automatically qualify for Medicaid. It is best to contact the Medicaid agency in your state for an application and any questions you may have, particularly about whether or not Medicaid covers prescriptions in your state. Your local Department of Social Service (check your telephone book) may be able to help you with the process. In New York state, the website for Medicaid is found here. In Syracuse (Onondaga County), the contact information for Department of Social Services is Onondaga County Civic Center, 421 Montgomery Street , Syracuse, New York 13202-2923 (phone: 315-435-2928).

The MedFriendly Common Sense Diet

2007-11-18T18:59:00.000-05:00

Every where you look these days, someone has their new master plan for the BEST diet in the world. And once you believe you have found the best diet, it sometimes starts to take on religious overtones. You do your daily dieting ritual and spread the word to others about how your diet is the best and how the others diets are wrong. As an example, just think back to the war of words between the Atkins dieters and the non-Atkins dieters. Each side swore they were correct and each side had evidence to support their claim.

Has anyone ever stopped to think that if there really was one and only one diet that worked, wouldn't everyone be using it by now? What diets do is they provide people with a sense of structure to help them more carefully monitor (e.g., calorie counting) their gluttonous impulses or put them on a specific schedule so they no longer need to worry about making improper food choices. The diet also provides the person with a belief system (e.g., carbs are evil) that fuels the motivation to continue the dieting program.

The truth is that there actually is one and only one diet that works, but the truth is that no one can sell it since it requires you to take control of your decisions rather than having the dieting program make all the decisions for you. Since no one has given this diet a name, I am going to name it here today. It is called the MedFriendly Common Sense Diet. The basic common sense equation behind it is as follows: If you burn more calories than you consume you will lose weight. Simple as that. This means (and here is the hard part everyone), you have to exercise. That's right, you actually have to move and get your body going to burn calories.

When it comes to dietary selections, just use plain old common sense. Check the fat content of everything you buy and generally try to avoid servings that contain more than 3 grams of saturated fat and 600 mg of sodium. Remember that food items in the store contain multiple serving, so if you eat that microwaved meal with 3 grams of saturated fat per serving and there are 3 servings, well, you just ate 9 grams of saturated fat my friend.

Pace yourself to eat three meals of day and keep at least two of them relatively light. Get some fruits and veggies in you each day. If you hate veggies, try the new V8 fusion drink which tastes like a fruit drink but actually has a full serving of veggies in it. Work in a few salads throughout the week if you can, have some fresh fruit, eat some fiber, avoid large amounts of red meat, and drink plenty of water. Just monitor yourself informally. I am convinced that the reason diets fail is because ultimately people feel like they are a prisoner to the constraints of the diet, give it up engorge on all the food they were denied during the diet, gain all the weight back, and then later chose some other diet and the cycle repeats again.

With the MedFriendly Common Sense Diet, you don't have to feel like a prisoner. You are allowed to make your own judgment calls during the week. If you see some pizza or cake that you want and think you've eaten your fair share of healthy food that week and have exercised like you should have, then go for it. You need to use will-power and self-determination to do this. If anyone has questions or comments just let me know and I'll post responses here in subsequent entries. This is the approach I follow and have never had a problem. No more rituals, no more imprisonment, and no more food that tastes like cardboard. Take your life back, use common sense, and enjoy the food that life has to offer.

*Note: This posting does not constitute medical advice. As usual, you should check with your physician before making major lifestyle changes.

Hell week

2007-11-17T15:29:00.000-05:00

This has been the week from hell. You've had them before. The type of week where EVERYTHING goes wrong. It was a nice intermixture of family and work-related stressors all of which were more extreme than normal. One was on Monday, another in the middle of the week, and yet another on Thursday and Friday. Hence the delay in blog entries. Each of the events that happened to me are now successfully resolved with the only lingering side effect being residual exhaustion since I did not have the chance to sleep, having had to bring my dog to a pre-planned vet appointment at 8:40. When you are in the midst of the week from hell, there are a few things you can do to help yourself navigate through it as best as possible.

The main thing to do is to moderate your reaction to the stressor. This gives you a way to take control over an event that may have initially been beyond your control. For example, it would be beyond your control that someone sent you and email with distressing content but you can control how to react to it. Monday's event was related to a stressful family member email I received at midnight. I reacted to the email and chose to take a route to end further discussion on the matter. This prevented my week from being even more hellish because it ended the conversation and eliminated the need for a constant back and forth flow of emails. Nevertheless, I went to bed later than I should have and paid the price the next day in terms of how I physically felt.

In the middle of the week, I had an overly complex case at work that took the entire day and was mentally draining. Since I was exhausted from earlier in the week, this just made things worse. And then, I had a work-related crisis towards the end of my day on Thursday which required me to kick into high gear and push my body past its limits (past 2am) to address it. Unlike Monday's event, this was a serious matter and one in which I had to invest the proper time into to make sure it was addressed properly.

Throughout the week, I purposely stayed calm and relaxed, well aware that if I became overly emotional that I will not be able to control these situations and deal with them as effectively as I needed to. Finally, it is all over and I am thankfully off one Monday. Tonight, I am going to turn into Rip van Winkle and get the sleep I need. Back to the regular blogging tomorrow. I would be interested in hearing on how some of my reader's deal with their hell weeks or some examples of your hell weeks.

The Chief Complaint

2007-11-13T19:32:00.000-05:00

In the introduction to yesterday's blog entry on the popular Kevin MD blog it was noted that physicians are trained to write the chief complaint in quotations so it is phrased in the patient's own words. Coincidentally, this was exactly the topic I planned on blogging about today. Over the years, I have read thousands of medical reports from physicians from all sorts of specialties. For those who list a chief complaint section in the report, many use the quotation system noted by Dr. Kevin. Unfortunately, there have been many times where I have read these quotes and just shook my head because of what was written. Here are some examples of what I have seen, starting with my favorite.

Chief complaint: "Uh."

Chief complaint: "I don't know."

Chief compliant: "Hi, I'm John."

These three separate examples tell me absolutely NOTHING! Well, ok, it tells me tat when the physician walked in the room and said "So, Mr. Jones, what seems to be the problem today?" that the person responded "Uh." But so what?. The body of the report would obviously contain reasons about why the patient came in but that is beside the point. The chief complaint section is designed as a way to convey what is most distressing to the patient. If you are not going to put something in that section that conveys this, it is best to just leave the section blank. When I interview patients, I ask them "What are the three main symptoms that bother you the most at this time in your life. It could be a physical symptom such as a headache, an emotional symptom such as depression, or a cognitive symptom such as a memory problem." I ask them to rank these symptoms in terms of which causes the most distress, the second most distress, and the third most distress. Once you have obtained that information, you are conveying real information and helping you and your readers better understand the patient. Now that's something worth putting in quotes.

The Inappropriate Use of Quotes in Healthcare

2007-11-12T19:28:00.001-05:00

On my Christmas wish list this year, I have just added another item…that health care professionals reduce their use of putting what patient's say in quotations without any explanation as to what the content of the quotes mean. This practice can be very misleading. For example, I recently reviewed records of patient who was collided into during a sports game. The records state that after she was hit, she did a "back flip." Now, what do you think of when you hear the word "back flip?" I think of someone who literally flipped over backwards, which would be quite a traumatic event and indicate that the person was hit with a significant amount of force. These are important things for me to know when I am trying the determine the nature of the injury. So when interviewing the patient and discussing this event she again used the term "back flip." So I asked her "Did you literally flip over backwards?" She said no, that was just her term for landing on her back. Big difference! But you would never know that if you just relied on the note that said "back flip" without an explanation.

Another recent case I reviewed said that after a head injury that the patient "saw Tweety birds flying above her head." Sounds funny and like something out of a cartoon but I was left wondering, was the patient just joking or was she hallucinating? Again, an important distinction and one with diagnostic implications, but it was not clarified in the note.

While the above example may not seem a crucial matter, there are times when putting terms in quotes can lead to misdiagnosis. A common area where this occurs in the area of mild traumatic brain injury (i.e., concussion). To meet the criteria set forth by the American Congress of Rehabilitation Medicine for concussion diagnosis, one needs to have evidence of an alteration in mental status such as loss of consciousness, disorientation, memory loss surrounding the event, etc. A focal neurological symptom would also count but we won't go over that here. So I was reviewing the records of a person who suffered a head injury while the patient was in front of me. Turns out, he had been diagnosed with a mild traumatic brain injury because he told the provider that he was "dazed" after the accident. The provider took this as an indication of altered mental status. However, when I spoke with the patient he denied any loss of consciousness, any disorientation, or any memory loss surrounding the event. So I turned to him and said "Well, what did you mean when you said you were dazed?" He said he meant that he was surprised about what happened but had no alteration in his thinking abilities. In actuality, he never suffered a mild traumatic brain injury but was told that he had. That's a problem folks.

Lastly, there are times when use of quotes is appropriate. Examples include when the patient cannot clarify what he/she means beyond saying whatever was said in quotes. In this case, I would put what was said in quotes but also mention that it is unclear exactly what was meant. There are other times when patients say something truly bizarre that you can only capture in a quote but in that case it will be clear to the reader why you are using quotes. The key point to ask yourself when using quotes is "Am I leaving things unclear for whoever who may read this in the future?" If the answer is yes, ditch the quotes.

Guest Blog Entry: The Conflicted Patient

2007-11-11T23:20:00.000-05:00

This week's guest blog entry is the longest that has ever been posted here, but I urege that not to dissuade you because as you will see from reading the first few sentences, the author draws you right in. The author in this case is known on the medical blogosphere as "SeaSpray." She is a prolific blogger and you can visit her blog site here.
SeaSpray worked in a local hospital for 20 years in Patient Access (primarily emergency registration) but also Out Patients and Admitting. In addition to working at the hospital, she also worked at the Hospital VNA as a Lifeline Rep in which the primary focus was working out in the field visiting clients for the purpose of installation, educating client and family about the program along with follow-up tech support with lots of TLC mixed in.With that beind said, here's SeaSpray...

Part I - Background for the latter part.

After working for 20 years in Emergency registration with the hospital staff & patients, I know exactly what happens on the crazy nights in the ED when the rigs roll in seemingly non stop, sometimes accompanied by the paramedics (which is never good), the patients lie in stretchers in the hall because there are no other beds left, and the walk ins keep coming in like the outdoor signage is advertising free samples. Most of these patients believe that their emergency is “the” emergency and they are rarely alone which adds to the ever crowding ED. The phones are ringing, the patients get impatient, and everyone on both sides wants everything done yesterday. Among the emergent patients are some truly critical patients who will have priority with the staff. In compliance with the universal law of the ED -things get backed up! And amidst all of that there will invariably be grumpy patients who aren’t emergent that want to know why they can’t get a bed and why can’t the doctor “just look” at them so they can go! They are oblivious to the fact and perhaps wouldn’t care that a patient just died in room 3 and that staff is valiantly performing CPR on a cardiac pt in room 4, nor do they seem concerned that they can hear a multi-trauma pt screaming in pain down the hall. I understand the frustration coupled with desperation of both the staff and family when things are going south. I have seen how in the midst of this chaos they still find the time to console a grieving spouse or encourage a young mother. And on these shifts they don’t have time to eat and can barely stop to use the restroom.

Whether at my desk, a patient’s bedside or somewhere in between, I was at a good vantage point to observe both staff and patients. I know the ED staff’s goal is to treat and move the patient out the doors or onto the floors ASAP. Yes, sometimes a patient does get lost in the mix and staff isn’t always perfect but most of the time they give 100% and then some. I know how the staff thinks…the conversations between doctors, nurses and any other hospital employee that joins in. I know.

I also know how the patients and families think and react. I tried to diffuse the potentially negative situations by explaining that the staff was concerned about them but that they were tied up with another emergency and would be with them as soon as they could. I have heard all the complaints and witnessed the tirades and walk outs. Sometimes they did have legitimate concerns and complaints but most of the time not at all. While never showing my true feelings to the patients, I often thought that I would NEVER act like “they” were acting. (Judgments come easily when you’re not walking in the same shoes.)

Part II – View From the Stretcher

Then I became a patient. I don’t mean the kind of patient getting routine tests and exams but the kind of patient who is dependent on the assistance and skills of the medical professionals because they are so ill or in so much pain and maybe even a little scared, whether it is for one night or a chronic illness requiring “frequent flier” visits.

It is a given that the patient’s perspective regarding treatment may differ from that of the staff. I have had ample opportunity over the last few years to look through a patient’s eyes…my eyes, but from the unique perspective that I had always been the one on the other side of the desk interacting with the patients. Now…I was the patient looking up from the stretcher. I suppose I could be labeled as the conflicted patient. Regardless of my reason for being in the ED or an inpatient, it was always difficult for me to be “just” the patient. I continually saw things from the “staff” perspective, even at my most dire moments. The only exceptions were being in need of intervention for the most excruciating physical moments and even then I felt guilty for “bothering” them. While writhing in pain with my first kidney stone and vomiting, I remember thanking the OR staff for helping me before they put me out because I know how hard they all work and I wanted to let them know I was grateful for their help. As a patient, I also try to give encouragement when something isn’t going right (like not getting the IV in) or whatever else might apply and they are always appreciative.

Aside from a few exceptions here and there, I have had mostly terrific experiences at the local hospital I have chosen for my health care. That being said, the last two visits were less than stellar. The first negative experience involved post-op nurses who did not listen to me when I knew I was right about needing a foley catheter. I politely asked twice but they told me to calm down, stating it was normal to feel that way. One nurse said to me. “You DON’T want a catheter!” This was my fifth ureteral stent placement and I could feel the difference from the previous times. AND I didn’t need too “calm down” as I was never agitated. But instead of being assertive, I suffered in quiet desperation with tears silently streaming down my face. Their view of me was obscured by the curtain but fortunately my doctor came back in, asked me what was going on and took care of me.

A more recent experience involved going to the ED this past August. I was feeling great after the urological procedure and my friend, her daughter and I were going out to a late lunch but about 10 minutes after leaving the urology office, I started feeling weird and I thought maybe my blood sugar was low because I hadn’t eaten since the night before and now it was going on 4 in the afternoon. Even after orange juice I was rapidly feeling worse, actually feeling like I might die (not exaggerating) but I didn’t tell them how bad, just that I needed to go to the ER. I was so weak that I had to have her daughter call the urology office from my cell and then I left a message telling them which hospital I was going to just in case it had something to do with the procedure. I got sick in their car just before getting there. Suffice it to know I was quite ill and needed assistance to get into the ED. I know how triage works and so very much understood the 2 hr wait in the waiting room. An ED nurse came out to apologize and I said, “Don’t worry…I’m o.k. and I know exactly what you are going through because I worked in ED registration for 20 years.” (Lie #1 but I could see how busy they were) Two hours later I was still too weak to walk and so a nurse pushed me in a wheel chair to my room.

They put me in one of the trauma rooms at the far end. It was cold with two air conditioning vents blowing directly down near me. There were 2 huge bright light panels shining down on me that never shut off and there was no call button and no pillow although there was a sheet. I wasn’t feeling pain at this point because of the Percocet I had taken earlier for the urology procedure. I did request a pillow. When the nurse returned she hooked me up to an IV pump but forgot the pillow. I could hear the rigs rolling in one after the other on the other side of the door that was in the room and so I didn’t want to bother her. I was also NPO (not allowed to eat food or drink by mouth). However because she hooked the pump into my right arm, I set the pump off every time I moved my arm. The pump alarm went off for long periods because obviously they were tied up in the ED. I was embarrassed that I did it AGAIN. (After a while I shut the alarm off my self anytime I activated it.) However, prior to that, when the nurse came to shut the alarm off I told her I needed to take my antibiotic because of the urology procedure and also medication for HTN but she said “No, your NPO.” My husband found someone and I eventually got a pillow. I had pain in my right upper quadrant and right flank…I would say a 5 out of 10. They never did bring the pain meds.

The ED doc came in to tell me I would be going for an ultra sound and then he apologized for my having to wait so long. I smiled and said, “That’s ok…your busy saving lives…I understand.” (Lie #2 but I didn’t want to bother him). To which he said “Thank you, but you are important too.” I thanked him. It was nice to hear him say that. It wasn’t ok and I was miserable. I also asked him for meds and he said he would have the nurse get them but then she never did. If it was a regular room it would’ve been o.k. but this was awful. After 6 hrs in that room with only a sheet I was freezing. I would have asked my husband but I didn’t want to wake him because he needed to go to work in the morning. By the time the ultra sound tech came to get me at approximately O1:00 she could see my teeth were chattering, she felt my arm and got me a warm blanket. BTW that warm gel never felt so good.

On the way back to my room there was a cheerful patient standing at her doorway that recognized me from when she first came in and said, “You’re STILL here?” I smiled and said “I’m still here.” *Mental note made, this pt who didn’t appear as sick as me who came in 2 hrs after I was waiting in the waiting room is in a good room, with low lights, a television (not that I would’ve watched-I needed to sleep if possible), a call bell and better controlled temperature. I hadn’t eaten since 10 pm
the night before and so now 27 ½ hours later I was feeling hungry, feeling pain and now feeling scared because I didn’t understand what was going on. And I was feeling forgotten and neglected by the ED staff and then feeling guilty for feeling that way because truthfully, the rigs were still coming in and I knew they must have been having a hellacious night. Still it was what it was and I felt what I felt.

The ED doc came in about 02:00 to tell me that I had pancreatitis that appeared to be caused from the gallbladder, maybe a little stone blocking. He recommended admission and stated that I would need a procedure and possibly surgery. My internal stressometer was off the scale but I didn’t let on to him. I was additionally stressed because I believed the serious urology concerns were behind me and now I was being told I would need another procedure and possibly surgery for something else. I told my husband to go home because he had to get up in a couple of hours. I couldn’t sleep because of the bright lights and I was feeling awful physically. I gave up and just sat up on the stretcher with legs dangling over the side because my back was beginning to bother me lying on the stretcher. But I had wrapped the blanket and sheet around me because I was getting cold all over again.

The nurse came in around 03:45 and this is when it happened. First though, remember my 20 years experience with understanding the dynamics of a busy ED? Remember my sensitivity to the plight of the busy ED staff trying to juggle everything and my reassuring the patients? Drum roll please……I crumbled like a little girl and with tears welling up in my eyes… I asked the nurse, “Why did you put me in THIS room? Why does the woman who came in after me and doesn’t seem as sick have a nice room? (There could have been 10 women like that) Did I do something wrong?” I can- not -believe that “I” uttered THOSE words to an ED nurse and was ashamed the second the words left my mouth. She said, “Oh n-o-o-o. We’re just busy.” She checked my BP which had now spiked up high (it wasn’t when I first came in) and had me lie back. She left but came back with the blood pressure medication I had requested earlier. She apologized for not bringing the pain meds but said I would get them when I got to my room. Without any mention from me, she apologized about the lights stating that they are unable to turn them off in that room and she apologized that it was a cold room. From that point on she was attentive toward me, being extra nice until I was transferred upstairs at 04:30.

BTW- it is a good thing they didn’t give me the pain medication because the floor nurse told me she was about to give me the Morphine. I stopped her from giving it to me because I get violently ill form that drug. She said it was in the admit orders and was hesitant to believe me. (sigh) This time I stood my ground. I explained that I told both the triage and ED nurses that they should never give me Morphine or Dilauded. She came back later, apologized and said I was right. At least I was assertive with this.

Part III – Final Thoughts

Please know that I am aware (and was at the time) that I was not having a life threatening emergency or even a 10 out of 10 pain experience and things could have been so much worse. I admit that I was also feeling angry. I was feeling banished and forgotten. Yet I knew that in the ED you get whatever bed is available although sometimes they will put certain patients in specific locations for a purpose. I also knew that as great as ED staff is…they do forget people. I have done that with patients on my end of things when it’s super busy…it happens. Did that happen to me? Maybe, but I also didn’t speak up for myself. I lied or omitted information almost every time I had an opportunity to be proactive about my care because I was trying to be supportive of them. Perhaps if I hadn’t done this, the doctor and nurses would have re-evaluated my location. And I would surely verbalize my concerns if an acute medical problem exacerbated because in the end there is no other choice. The shocker for me was that I became this whiney, self pitying patient –ugh!

Also please know that I am not writing this post to complain but rather to share my observations. I am perplexed with my inconsistency in being proactive with my health care when I am in a hospital setting, although I am totally open with my private physicians. One would think that because of my experience in the medical environment that I would naturally assert my concerns until I feel heard. Yes, I do ask for help, but there have been other times in the past where I have held back because I continually identify with the work environment and don’t want to bother anyone, hinder the process or make waves when I disagree. Regarding my crumbling like a little girl if I hadn’t been so worn down from hunger, exhaustion, pain and stress and I had stopped projecting myself on the other side of the stretcher, identifying with the staff -but instead was honest with “my” concerns; I don’t believe I ever would have said what I said. I had a weak moment and I just crumbled. I was in the ED for 11 hours. (I recently read on another ED blog where patients are in the ED for 24-48 hours!)

And if I, a person who has been in the business for 20 years could feel so distressed, how much more so would an individual who doesn’t have any understanding of what goes on in a hospital? Do other health professionals feel conflicted when they are patients? Do doctors and nurses feel compelled to tell the staff how to do their job? Or do they retreat as I sometimes do? I did read about a physician who as a patient in the hospital withheld his personal opinion because he didn’t want to be competing with his colleague who was treating him, but that somehow worked against him although I don’t recall why.

When is nice too nice? Who is it really serving? What is the gain? What is the loss? Honesty and open communication is key and is what best serves the common goal to facilitate healing. I have always thought of myself as being compassionate with patients, but my journey as a chronically ill patient these last couple of years has all the more enriched my perspectives regarding patient experiences and I know that when I return to work, I will have even more to give back…because I have really been in their shoes and I have walked the walk.

Just Leave Me Alone

2007-11-10T19:18:00.000-05:00

One day, I had a patient who had been through the most unbelievable history of botched medical care and botched surgeries, basically leaving him without an intestine, with possible dementia, and with a possible seizure disorder, among many other things. His neurologist had stopped practicing and he was transferred to someone new who had some different opinions about some of his problems. For example, the new doctor thought he may not actually be having seizures and that some of his problems may be due to dysfunction of the autonomic nervous system. As a result, the doctor was considering changing his medication. The patient, however, had been through so much medical duress and years of finding a medication regimen that he was happy with that he was very upset about the prospect of ANY changes. The patient was also upset he was referred to me for a neuropsychological evaluation because he did not see the need for it. He also did not see why he needed to stop driving even though he had been driving through red lights and exhibiting poor judgment on the road. He did not see the need to have someone take away his access to guns even though he had suicidal thoughts at times. In his words "If you take away my guns, I'll just use some other method one day if I ever feel like killing myself."

It was clear that this man had poor insight but it was also clear that he was just plain fed up with everything. In describing his plight, I will never forget how he looked at me and said in the clearest and most deliberate manner, "I…just…want…to…be…left…alone." He did not want to be tested, did not want his medications changed, and just wanted to stay home and accept his fate. Although I did not think he was making all of the right choices (which I made this clear to his wife), I felt a profound feeling of sadness for this man's situation and could see myself thinking the exact same thing if I were in his situation: "Just leave me the alone." The interview took so long because of his complex medical history that he was scheduled to come back another day for testing. He never retuned.

When is a doctor a doctor?

2007-11-08T19:30:00.000-05:00

Earlier this week, I wrote two blog entries that created quite a stir in the medical community which you can read at here and here. One of things you will notice is that one or two people wrote comments that poked fun of the word "doctor." This was done by referring to me with the word in quotes and by with another comments saying: "Great, a PhD posing as a doctor."

I know some are going to take this post as being defensive, but that actually is not the intent. The intent is to expose the logical fallacy behind this ridiculous argument. Trust me, I have full confidence in the fact that I am a doctor and I believe that people who use the term in a disparaging way towards others are really saying more about their low-self esteem than anything else because they appear to me to feel threatened by others use of the term.

So let's start with some facts, shall we? First, what is a doctor? The origins of the word come from the Latin word "docere," which means "to teach." According to Merriam-Webster's Online dictionary, here are the relevant definitions of doctor to this discussion, which you can see here if you want:

1: A person who has earned one of the highest academic degrees (as a PhD) conferred by a university

2. A person skilled or specializing in healing arts; especially : one (as a physician, dentist, or veterinarian) who holds an advanced degree and is licensed to practice

Now, isn't it interesting that the dictionary actually lists "PhD" as an example of a doctor? This really destroys the argument that if you have a PhD and call yourself a doctor that you are somehow "posing." Let's look at the second definition. I am a neuropsychologist and psychology is a field that does help people heal. It lists physicians, dentists, and veterinarians as examples; more on this later) but does not say these are the only people who can use the term. It also refers to having an advanced degree and a license to practice, both of which I possess.

So where does the problem lie? The problem lies in the fact that some physicians who have their bowties and penny loafers on a little too tight want to monopolize their use of this term to inflate their feelings of self-worth. I am sure you can find a definition of doctor somewhere that says "physician" as one of the lists but is not the only one by a long shot.

Now, here is where we turn the situation away from PhDs just to let you know how silly this situation gets. I cannot tell you how many times I have heard physicians (people with an MD) refer to other types of MDs as "fake doctors." The two most commonly cited groups I hear this about is psychiatrists and physiatrists. Psychiatry is put down because they see "mental health patients" and do not perform surgery. Physiatrists (who are rehabilitation medicine doctors) are often put down because some of the elitist physicians consider it too easy. Just so I am clear, I think that is absolute nonsense. I work closely with both psychiatrists and physiatrists and have great respect for them and they deserve to be called doctor if they earned the degree. I have heard physicians say many times that dentists and veterinarians are not real doctors. Gee, both prescribe medication and can do surgical procedures so I don't get that one. I guess teeth and dogs aren't difficult enough for the "good 'ol boys" perched in their ivory towers.

And lest anyone think this problem is isolated to doctors, it is not. I have also heard many bedside nurses say that nurses not providing bedside care (e.g., those who work in the OR) are not real nurses because they are not doing the "real nursing work." When will it end? When each person is capable of being comfortable in their own skin and do not need to demean others to feel better about themselves. To quote the eminent scholar, Rodney King, "Can't we all just get along?"