Slow Down Possible in My Blogs

I am not sure what will happen or when. This is so frustrating and wearing on me. I have had a variety of experiences, but no conclusion or definitive word on what is happening or causing me my pain.

On or about the first of August, I started having some pain in the wrist, elbow and shoulder on my right side. After relieving some of the shoulder pain being caused by a rib out of place, the area from the top of the wrist to the elbow became much more inflamed.

On August 8 after not being able to sleep because of my pain, I went to the local emergency room. I estimate that on a scale of 0 to 10, my pain was at least eight if not slightly higher. The doctor on call was sure I had rheumatoid arthritis and did x-rays to locate spurs. After finding none and my comment of not being aware of any arthritis in my family, I got a litany of possible problems – bursitis, tendonitis, and many more “itis” words. I was given a gel prescription, a non-steroidal pain medication with a prescription, and a wrist support to limit my wrist movement, and sent on my way with instructions to see my primary care doctor. The two medications did reduce my pain to about a 6 level, but the misery was still there and would come back before I could take the next pill or apply the gel.

I know I do not have carpel tunnel syndrome as the pain is on the top when my hand is palm down on a flat surface. It starts just before my wrist bone and extends from there to my elbow and the up the outside of my arm to the front and back of my shoulder. I do have to wonder about the bursitis, as I do not have more pain when moving my arm or elbow as bursitis is supposed to affect movement in the joints and is caused by the pad between the bone joints losing its pliancy.

In attempting to get a refill of the pain medication, I needed to see my primary care physician again, go through some more x-rays, and make sure that I had no cracked bones or other injuries that the previous x-rays had missed. The current medication that I am now taking does reduce the pain level to about 2 to 3 and is helpful. I am also taking ibuprofen requested by the specialist that will see me next month to determine what else needs to be done – from nothing to repairing the tendons.

In the meantime, the time I am spending on the computer and doing a lot of typing is becoming a chore and is irritating the muscles in my arm. I will be working on blogs as long as I feel able to continue, but you will have to allow me to miss some days when I am having more pain that I can work with.

Through all this, my blood glucose levels have remained stable which with the pain and inflammation is a total surprise, but is very much appreciated and helps in dealing with the different pain levels and different medications. Will need to pay attention and see what the next few weeks hold.

Are You a Fighter or An E-patient?

First, I take umbrage with the term fighter. Until a few years ago, I would probably have agreed with you or used the word manager. I now prefer the term e-patient. This means empowered patient. It takes the aggressive nature that fighter implies out of the equation. In its place we use empowered. This equates to being a patient with knowledge of the chronic disease or illness, knowledge of the medications utilized, and a desire for more knowledge. It indicates a willingness to be in charge of or take ownership of the disease and work with the medical profession where possible.

I say where possible because there are doctors that are unwilling to work with or even treat patients that are proactive to say nothing about being empowered. When empowered patients interact with excellent doctors that want them as patients, the relationship for both can be very rewarding. Respect for each other is apparent and discussion is the hallmark of this relationship. There is give and take, but neither is trying to out do the other. They each know their place in the relationship and work together. It may not be complete harmony, but the respect is present at all times.

Even though this blog by David Spero is from August 1, 2012, and I may not like his word usage, the ideas he presents need discussion. David highlights a topic I wrote about recently. I know that many patients take medications blindly following their doctor. David says that they do not understand why they are taking the medicine(s) or what the side effects may be. This is true for many patients across all ages. This is a case for what you don't know can kill you in today’s medicine.

This is why we need to become proactive in our diabetes care and then become e-patients. We need to learn all we can about the medication(s) we are taking and even those that we are not taking. We need to know the possible side effects and what the medication(s) do for us. It does not bother me that you may not be able to pronounce the name of the medications. It does matter that you know what each is for and how they may affect your body. It is even more important that you know that you are experiencing a side effect and whether it is a minor side effect that has little consequence to your overall good health, or is a serious side effect that may be life threatening or debilitating. Then you must contact your doctor immediately and discuss the side effects and be knowledgeable about the possibilities of changing medications.

Too many people end up in the hospital because they don't know the possible side effects or ignore what could be a side effect until medical intervention is necessary. With most medications on the market today, it is not wise to assume that your doctor will give you the information necessary or even prescribe the correct medication in every instance. With the growing shortage of physicians, more physicians employed by profit driven hospitals, and many medications entering the market that have more severe side effects, patients of today would be well served to become more proactive in their care. This means using Internet sites like WebMD to check out your medications and learn about the side effects. Or, you may try this website. You may also use your search engine for several terms like “learn about medications” or “learn about rx medications.

This may be a lot of information to digest, but you have the time to do your research and learn. You will need assistance for diet and nutrition unless you have a lot of knowledge or a degree in nutrition. It is best to get professional help. Most physicians do not have the information and most educators do not have enough. I would recommend considering a nutritionist from one of these groups - Alliance for Natural Health, USA, or the American Nutrition Association (ANA). I have only had dealings with nutritionists from the ANA. While they will suggest plans, they will normally work with you and develop a plan based on your needs or what you want to accomplish. They will generally work to make sure your meals are nutritionally balanced or that the meals for that day are balanced. There are other nutrition groups as well that do not operate on mantras, mandates, and dogma.

I challenge you to become an e-patient. This means listening with respect to your doctor, but not being afraid to respectfully disagree or challenge your doctor if needed. Learn about the medications you are taking and the reason you are taking them. Discuss these medications with your doctor and become familiar with his reasons for prescribing each. Then research each to see if you agree with your doctor's decision. Then learn about the other medications that could work for you. Learn about the side effects of those that you are taking and those you could take. Research medications in the same class of each and see if something might actually fit your circumstances and possibly be more effective.

Please consider becoming an e-patient and realize the benefits. Good doctors will appreciate that you are taking ownership of your disease or illness and become more willing to discuss the different treatments. You will be less likely to need to be a fighter as your doctor will be more willing to fight for you instead of with you.

Can We Allow Medical Management Care to Continue?

This is one of the more interesting discussions about managed care. Medical management is managed care and needs to be something everyone is aware of how it will affect him or her. This is a large area of contention between doctors, hospitals, and the medical insurance industry including Medicare. Who is right? After reading and researching this on my own, I think there are valid positions on both sides of managed care. I will say that hospitals have the least favorable position in their goal of larger and larger profits. Physicians may have the strongest positions and the insurance industry has made some very serious and deadly mistakes. In addition, the health insurance industry has too often turned away from serious auditing of fraudulent hospital and physician claims.

The author is well qualified for writing about the topic, but as a patient with a chronic disease, I have some experience with managed care (2004 to Dec 2005). I was constantly battling to remain on insulin, as they wanted me on oral medications. My first wife was also under a managed care plan (1998 to 2002) which prevented some cancer treatments. So the first error in the article is that managed care started to disappear in the early 1990's needs to questioned. At least one commenter to the blog agrees with this. Managed care has continued despite this author’s position. It may have decreased in volume of managed care, but has continued to exist.

I can see both sides; however, until Medicare and the medical insurance industry does their due diligence, most managed care efforts will continue to be less than effective or efficient. Hospitals will continue to recode to obtain fees that should never have been allowed for procedures that never happened and make makes patients appear on paper as being sicker that they actually were. Hospitals will continue to do tests on dying patients that are not warranted, but will probably not be questioned once the patient dies. Physicians will continue to perform tests for defensive medicine purposes to prevent lawsuits.

Some of the comments to the blog are interesting and do point out some areas that are abused by all concerned. It does raise questions about the reliability of managed care; however, other issues that managed care has abused in the past are presented as well. Managed care in the past has been equated with excessive use of euthanasia when proper patient care would have added life and even quality of life. This is a reason to oppose managed care. Under the current healthcare law, it appears that managed care may be even more reckless.

I am in favor of proper managed care, but there will need to be changes to the way it is administered and more thought incorporated into the decision making. In my perspective as a patient, I can see the rise of a new class of patient advocates that will be needed to work for the patient to prevent abuse of managed care. I oppose some of those that are operating now as termed “ambulance chasers”; however, the new class of advocates may need to have some legal training and extensive medical knowledge.

The other requirement that may not be wanted is complete transparency by all concerned – hospitals, physicians, and insurance. If managed care is set up as another entity, then they will need to be transparent as well.

Charity Medical – Problems with State Lines

Even nonprofit medical is stopped at the state line. Even if the doctors in that state will not treat these patients, they will also prevent doctors working for charities from treating these patients, if they are not licensed in that state. How pig headed these doctors have become? They will not treat these patients, and they are damn if they will allow anyone else to treat them.

This is a reason for congressional legislation that would make a doctor given a doctors license to practice medicine in one state, able to practice medicine in any state or US territory. And, no – I am not saying if one state allows a doctor to practice dentistry, that the next state will allow the same doctor to practice oral surgery. This would only happen if the original state allowed both because the doctor qualified for both.

This article in the Tennessean shows what state lines prevent and actions of the medical boards within these states. This is one area, that for the greater good, needs a federal law to allow doctors to cross state lines. With the coming doctor shortage, this will continue to be a problem. Telemedicine is also hamstrung by these same shortsighted medical groups.

I am not a lawyer, but something needs to be done to make it possible for doctors to work across state lines. If nothing more than reciprocity between states and removing the requirement of being physically present to apply to practice and reducing the fee requirement. Maybe a federal register can be maintained of doctors practicing across state lines. This should also apply to nurses, nurse practitioners (NP), and physician assistants (PA).

Over 30 states have the law now that a doctor needs to physically see a patient before a prescription can be written. Read my blog here about this. This may need to be modified to allow for an examination by a nurse, NP (nurse practitioner), or PA (physician assistant) and then a prescription issued by the doctor after a video conference with the nurse, NP, or PA. This might also include a pharmacist. For telemedicine to work, medical groups will need to work together and not cripple ideas that could save lives. As many situations currently exist, doctors are doing harm to patients by preventing them being seen by nurses and others capable of using telemedicine and getting prescriptions to people in need.

If state medical boards and the different medical organizations continue to block and cripple new medical initiatives, the medical community will have no one but themselves to blame when the backlash from the patient community happens. In some rural communities, people are already displeased that doctors cannot use telemedicine to assist them and in others, they are losing their doctors because hospitals either have bought out a medical practice and closed it, or have hired the doctors away to larger cities and bigger hospitals. This means longer travel times for the people in these areas to see a doctor. Some people do not have the resources or ability to travel these distances.

Think Outside the Box for Patient Care Models

Where does this all stop? The more I read and research, the more I have to wonder when the medical community is going to change? Will it be necessary to legislate at the federal level? Or will the states step up and learn to cooperate? With the information that I am finding, it is doubtful that the individual states will learn to cooperate because of heavy lobbying by the different medical groups in their state. Each group seems to think that they have the propriety right to control medicine in their state.

Reciprocity is a word used to describe cooperation among states and is the hallmark for private individuals, certain industries or occupations, and some professions. To the medical community, the word reciprocity is a word to be avoided and downgraded at all levels. Private citizens can obtain a drivers license in their state of residence and are allowed to drive in any state and even in most countries around the world. Truck drivers and bus drivers for hire can obtain a commercial drivers license in their state of residence and drive in any state and many countries.

Yet the medical profession limits the license to practice medicine to one state only and to be able to practice in another state, the doctor must apply for a license and be accepted by that state to practice medicine in that state. They must be physically present to apply and meet the requirements. Plus the fees for each state must be paid to continue practice.

With the coming shortage of physicians in the USA in the years ahead, laws will need to be changed so that a doctor licensed in one state may practice in another state without the legal hoops to jump through. To accomplish this, it will probably be necessary to have federal legislation that will negate state laws and allow this to happen. A federal register may be necessary to maintain records of doctors practicing across state lines. Under current laws in many states, medical associations have crippled many of the practices that are needed to replace the shrinking numbers of physicians.

At present, we have estimates and really guesstimates of the physician shortage coming. We know that the numbers of people entering the medical profession is decreasing and that many doctors will be retiring in the next ten years. Using the figures from the American Medical Association, it is estimated that by the year 2020, there will be a physician shortage of 91,500. This will mean not seeing your doctor as often and appointments that will be delayed with longer waits between visits. Missing an appointment will be penalized with even longer times between appointments.

This is the reason to start thinking outside the box now. Telemedicine will need doctors that can practice across state lines and an expansion in nurse practitioners, physician assistants, and nurses to assist doctors in telemedicine to examine patients in rural communities and allow physicians to prescribe medications that the NPs, PAs, and nurses are seeing. Even some nurses may be used to examine some patients. Then using some pharmacists to see patients and possibly use telemedicine to report to doctors and obtain prescriptions. It may also be necessary for some NPs, PAs, and Pharmacists to have prescription authority for prescription renewals and some medications. Federal laws will probably need passing to make this happen, as again current laws in many states supported by different medical organizations have or will cripple this going forward.

With concierge medicine expanding rapidly because of cuts in Medicare and insurance companies’ reimbursements for procedures, the doctor shortage may become even more critical. In my own experience of working as a volunteer peer mentor for type 2 diabetes patients of two doctors in a concierge practice shows that for many chronic diseases and illnesses this may be meaningful use of resources in a shared medical appointment setting. Other doctors are also using peer mentors and even a few doctors are using knowledgeable patients in peer-to-peer settings.

Even retail clinics and community clinics are gaining in acceptance, especially among patients. This blog brings up a type of clinic that does exist, but I do have to wonder if it will remain in existence in the workplace of large employers, as is the case in California. She does make an excellent case for this work place clinic in her second blog.

We all are optimistic even with the coming shortage of physicians. However, many physicians’ organizations are still lobbying heavily to prevent further expansion of telemedicine, practice across state lines, even limiting concierge practices, and in general working hard to create a medical monopoly for physicians and discouraging any type of thinking outside the box. With most physicians now working for hospitals, they have gained a powerful ally in discouraging many of the medical experiments.