June 14, 2013
Is Your Doctor Listening to You?
Establishing a strong doctor-patient relationship often depends more on you, the patient. This is sometimes difficult during the first few times you meet with the doctor. There are several steps you must accomplish to know that you have the right doctor and can establish a good communication between you. This will also determine the extent of your trust and desire to build a relationship with the doctor.
Probably one of the first steps will be in finding out during the first visits if the doctor uses the “cookbook medicine approach” or the “your story first approach.” It is important to know these as this will determine how you prepare for your visit. Both are polar opposites in their approach and you need to determine which is a better fit for you. I know I prefer the second approach, but I do have one doctor that uses the first approach. There are variations on both approaches and this can be a challenge. I know this because another doctor lets you tell your story first and then goes into the cookbook medicine approach and I had better answer his questions with a yes or no. When he has finished, then I can normally fill in the blanks that he has missed. This may or may not start another round of questions.
His method has resulted in my being more specific when I start and leaving the unrelated material for his questions. As we have perfected this over the years, he has modified his questions to allow for some detail and I give it to him as briefly as I can. One day when I was there for a checkup, or semiannual appointment, nothing was bothering me and I said as much. He stopped, looked at me, and casually asked what to do next. I said cover the lab results and we did, in more detail than he has ever done before. When he finished this, he asked if I had any questions. I told him that he had answered the questions I had as he covered the lab results, and I said we were done. He looked like I had just defeated him in an extended tennis match. I told him to take advantage of the extra time for his next patient and he seemed to recover immediately. He thanked me and told me to set up my next appointment in six months, and handed me the lab request sheet for the next appointment to give the person setting up the next appointment. Then he headed for the next exam room.
The next appointment started out the same and this time he handed me my copy of the lab results saying everything was good and did I have any questions. I said no and he handed me the lab request sheet and said to set up the next appointment in a year. He stopped and then said if I did need to see him before then, paused, and decided to walk out with me to the desk for the next appointment and gave her the instructions and told her to note on my record that if I needed to see him before the next appointment – to schedule an appointment. She put her name and extension number on the appointment slip to use if I needed an appointment earlier than scheduled. It is this type of relationship that I have learned to treasure, but it took some time and learning how the doctor functioned.
I have another doctor that is all together different. He enters the exam room and asks me questions related to the reason for my appointment. Once he is sure I am there for the stated problem, it is all business of my explaining what has happened and when. Sometimes, because of the problem, I have had tests done beforehand and at other times after he is sure I need the tests. While he is waiting the test results, he moves onto another patient and then returns with the completed test results. Most of the time he tells me that here is a prescription for 10 days and communicates with me about calling for another appointment if this does not correct the problem. Because this has been a lifetime problem, he knows I know what to do and is very careful about repeated episodes.
The most interesting of my doctors has been the person I see for diabetes. There it is discussion of my A1c and the meter readings. She could spot trouble areas in a glance and knew what to ask. I am very sorry to see her leave the diabetes clinic. Now I will need to see how the next person handles the appointment. I will need to be on my toes to discern how I will be treated.
I am concerned about the new procedures being handed me by several of my doctors and I sense I am being slowly being pushed out of their practices because of Medicare. It may be because of the 2% cut or for other reasons that are being implemented in the affordable care act. Tests are being cut and I am being directed to the VA for more of my care.
June 13, 2013
Do you know how you receive your lab test results? When I blogged about this last year, I received many emails saying that keeping lab test results just added to the waste of paper. They mostly claimed they could get the test results from their doctor anytime they needed them. Okay, but I have now encountered several more people that asked why I did not cover the length of time they would have to wait for these lab test results once they requested them. Most required waiting two to three weeks and in a few cases, the wait was 30 days. The law is on the side of doctors when they make you wait 30 days.
This is one reason I encourage asking at the time of your appointment for the lab test results. Yes, it may surprise the doctor when you haven't done this before, but most will do this and if you say that is what you want from now on, they will have a copy ready for you. This will eliminate the paperwork being completed later requesting the lab reports and the up to 30-day wait. I don't expect everyone will do like I do and record the results on a spreadsheet or like a couple of my friends who enter them in a database. The acquaintance from a previous blog is keeping them in a file now and is glad he is as there has been a second time when the doctor overlooked a lab result that could have put him back in a hospital. When he confronted the doctor about this, the doctor played down the importance.
My acquaintance has since transferred doctors and his new doctor agrees with him about the importance of his lab results and covers the lab results with him and makes sure that they do not miss anything. He now talks about what landed him in the hospital the first time. He has type 2 diabetes and had been on metformin for 10 plus years and has had excellent results. It was the Vitamin B12 deficiency that had caused him to pass out and the hospital discovered several other vitamin and mineral deficiencies, some of which required his remaining in the hospital longer to bring the levels back to normal because if administered too rapidly could have had toxic effects.
His wife is very set against any support group and will not let him belong to our group. She does let him communicate with me and read my blogs and some other blogs, so like he says, he is learning. He also does research and continually asks me for more material by subject, but is learning how to find some on his own. He is not afraid to ask questions and has found some of the poor sites with misinformation and this is when his questions increase. He now sends me the URL and I can tell him why the site is good or bad and to ignore it. His new doctor is knowledgeable about vitamins and minerals and is working with him to keep his levels near normal. He says that some foods are now furnishing many of the requirements and he is eating more of these foods and actually liking them.
He is taking a few supplements at the request of his doctor and against the protests of his wife who does not believe in them. On a challenge from him, she had her doctor do the tests for vitamins and minerals and it was discovered she was short of a couple herself. She was not happy to receive the Vitamin D shots and needing to take a couple of other supplements, but is doing so after her doctor discussed what the shortages could cause if she did not take the supplements. Her doctor is working with her to increase the foods containing the shortages and this is helping both of them.
Since Brenda from our group knows her, she has been working with her on the vitamin and minerals and with the help of Brenda's daughter about nutrition. Brenda is also talking to her about letting her husband join our group. So far the answer has been no, but several are saying that she should come as well. We will wait for an answer from Brenda.
The lesson that needs to be learned is that if you are taking metformin, please make sure your doctor is doing the test to determine the levels of Vitamin B12 and while he is at it, also the level of Vitamin D. Read my blog here on Vitamin B12.
June 12, 2013
For those interested in the role of remote patient monitoring (RPM), David Lee Scher, MD is an interesting blogger to follow. He has extensive interest and experience in the field of mobile health. He was a pioneer adopter of RPM as a beta site for Medtronic's Carelink wireless system. This monitored implantable cardiac rhythm devices such as defibrillators and pacemakers.
This has gained attention because of mandated penalties for hospital readmissions for certain diagnoses such as myocardial infarction, congestive heart failure, stroke, and chronic lung disease. RPM is a way of staying in physiologic contact with these patients regardless of their location – at home, during travel, and in care homes. While studies are reflecting radically mixed results, there is promise.
Dr. Scher list five issues he has faced and these are interesting. Please read his blog here and then peruse his blog page here. I will only summarize his writing.
#1. All remote monitoring is the same. There are many definitions for (RPM) from using the telephone for talking to the patients to today's use of implants to cell phones and then to electronic health records.
#2. All remote monitoring is reimbursed. This was a surprise to me. RPM monitoring is reimbursed in the USA and has been for many years. The real surprise is that the rate of reimbursement by the Centers for Medicare and Medicaid Services (CMS) is at a higher level than in-office follow-up.
#3. Patients and physicians will welcome and embrace remote monitoring. Not all physicians are on-board with this and saying that the data is unusable. Many just do not want the expense of having someone to monitor the data being received. Many are utilizing gathering centers and they in turn will notify the individual doctors of alert conditions. With the penalties that are being handed out by CMS, doctors will soon realize they need to use RPM.
#4. Remote monitoring should be totally automated. No, don't take the human factor out. They are needed to individualize the programmed parameters and alerts because each patient will be potentially different. Data can't manage itself, although some physicians wish this were possible. False positives and negative must be correlated to the clinical condition of the patients. Only this will optimize management. Caregivers must be involved and understand what is happening as well.
#5. Remote monitoring is only for recently discharged patients. It is unfortunate that it has taken regulatory requirements to drive digital technology to be adopted. This has caused much poor technology for healthcare and even poorer patient care. It is the failure of health technology that has not adopted the model of the retail and finance sectors that focus on customer satisfaction and transaction outcomes.
The remainder is my thoughts only and not of Dr. Scher. Because of regulations (laws) mandated by Congress, the opportunistic technology business saw huge profit potential and did not care whether their products served the proper purpose. They could always make changes for more profits and therefore the medical and hospitals of our country were sold a faulty product.
Because of Congressional urging and pressure by CMS, some health information technology companies are attempting to address the issue and correct problems now. Others that feel they are too above this are continuing to look for more ways to milk the regulatory cow. As a patient, I can only hope the milk sours for them and forces them out of business. Both physicians and patients need more productive innovation to make our healthcare system both more efficient and profitable for all concerned.
June 11, 2013
The title of this medical blog is one that I can only say “duh” to. Why the authors decide to insult their readers is another question. They even admit that they have educated not to use certain terms, but they were determined to get them in anyhow. I will let you read the terms they used.
If their statistics are correct why do they not state them instead of using generalities. When authors work for one of the premier medical facilities in the United States, you would think the statistics would be available.
I do agree that most people want to follow their health care provider's advice, but there are reasons why many people do not take their medications as prescribed. I will list the problems as the authors see them (in bold) and then make my comments.
- We do not understand some of the medical terms and terminology used. For some people this can be a real problem either because of interest, level of education, or distractions around us at the time this is being explained. Health care literacy may also be the problem and even literacy itself.
- The patient is not involved in the decision making. This can happen and patients that desire to have a say or involvement simply tune out the doctor at this point (not advisable). This is when the patients need all the diplomacy they can muster to explain to the doctor why they would like to have a part in the decision making process.
- Poor communication on the part of the health care provider. This can be a problem especially for doctors that have difficulty in translating to the patient's level and that can't leave the medical talk alone. I do know one doctor that is aware of his own problem and has a RN assistant that translates for him and does an excellent job of it. Many doctors will not acknowledge this and patients go away wondering what they had just heard.
- Your doctor has an incomplete medical history on you. This unfortunately happens all too often. Many people just figure that this is just old information and the doctor does not need to know this. Wake up people, this may be the missing piece that explains why something is happening or even not happening because of a prior illness. An example is chicken pox. Once you have had chicken pox, as you become older, shingles becomes a real possibility and is several times more painful than chicken pox ever was. The chicken pox virus remains part of you once you have had it and something can reactivate the virus and you now have shingles. Little bits of supposedly unimportant information can solve a lot of medical problems.
- Limited finances or access to health care. This can be a very sensitive issue for some. For others they are not afraid to ask for help. In some rural areas, transportation can be a problem especially with the cost of gas. This is an area that too often the doctor or his staff often could care less about as long as the bill is paid. The efficiency is misplaced when these people are involved. In this case, they take the care out of health care.
- The patient has complex medication regimens. This could also include complex medical problems, but either can be very stressful for the patient and sometimes confusing in keeping all the medications straight.
- The patient may have cultural barriers, memory issues, health beliefs and other issues. These are often overlooked by doctors and their staff, but need to be investigated. The patient also has a responsibility to inform the office about these, but sometimes they forget as well.
This can be a complex issue with a variety of solutions. The authors list the following possible interventions. I don't like this term and would think the term patient investments would be mean a better outcome and the patient would feel more like they were being valued.
“Some possible interventions include:
- Patient-education classes
- Providing interpreters for foreign speaking individuals
- Simplified medication programs
- Empowering people to self-manage chronic diseases
- Written instructions or pictures specific to a person's literacy level
- Provider consideration of economic constraints
- Appropriate follow-up care”
Now whether these are only for the health care provider or the patient can assist in some of them is dependent on the area. Interpreters is something that patients could do for themselves. Patients do need to consider learning and taking a more active role in their care. Often they have never been taught the skills even to make this possible and they innocently think everything needs to be done for them.
This makes it more difficult to assist them and give them the skills they need. They do need to be taught to ask questions, but they don't know where to begin. This is when you need to ask them if they have someone that could help and then you work with them together.
For other people, they may just need to be encouraged and shown how to ask questions and learn about their medical condition and the program they need to follow. Consider telling them to invite a family member or friend to their appointments, to assist with understanding instructions.
There are many aids that may be used and the staff of most offices should have a list to give to patients and where they may be acquired.
Another area that is often overlooked is the pharmacist. Most, but not all, will take the extra time with a patient to explain the different medications and the importance of each. They can also reinforce what the physician has said and even make a list of when each should be taken. I have queried my pharmacist when I have seen studies advising switching from AM to PM and the reverse. In one case the pharmacist said I was reading the study correctly and if it was not for another medication I am taking, she would recommend my switching. Under the circumstances and the medication, she could not let it happen and advised me accordingly. She did say to let her know if I was taken off that medication and she would revisit the issue.
June 10, 2013
The weekend after our meeting with the doctor, a group from another town about 20 miles distant, asked Tim and I to speak to them on insulin. Because of the doctor involved, we decided not to accept. We had a suspicion of what may have been behind this and as such, I was thankful I already had another commitment. Tim said he agreed with me and agreed we should not become involved in this since this doctor had the reputation of not wanting his patients on oral medications to test.
Tim sent the regrets explaining that I had a commitment and he would not do this by himself. Tim called me the next day saying something that was a total surprise. This doctor was asking for our help on insulin and testing for all patients with diabetes. He was realizing that he was in the wrong and felt that since our group was having so much success and had in fact converted several of his patients to testing, that he needed to learn about us and to get his patients started in testing. Tim added that he felt we should accept the challenge. I stated that I was committed to my meeting and that he should talk to the local doctor and maybe he could attend with him. I said that maybe Allen should go as well.
The following day, Tim called again to say the local doctor had called this doctor and said that he could come if allowed along with Allen and Tim. Tim said the doctor was happy with this and that yes, he wanted this very much. I said this was great. I then explained my commitment of a late afternoon medical appointment and a speaking engagement in the same town to a diabetes group that had been scheduled a month ago. Tim said this sounds good as three of us were involved in spreading the word. I suggested to Tim that Allen should raise the issue of vitamin and mineral testing on their way there so that if necessary, they could sound out the doctor before the meeting about raising this in the meeting as well. Tim said they would be traveling in the same car and he felt this was worth exploring. I said good, and that we should have a meeting the day following to cover both meetings and learn from each other. Tim agreed and asked about including the doctor and I thought why not and told Tim to explore this.
So the day following our meetings, we met after hours at the doctor's office and had a good discussion. This doctor had forgot there were three groups in our town and the size of the groups. The third group was now at six members and hoping to add more members. The group the local doctor led was now at 10 members and he felt that would be more in the coming months. The group that I had spoken to was 18 members attending and they were hoping to grow. The two doctors leading this group were confident the number would grow. Tim stated that the group they had met with was 9 members and that they were shocked that there were so many groups. The doctor commented that this doctor realized that his diabetes patients were being spread out in different groups and knew he was being called out about not testing. He just did not have the knowledge he should about diabetes. At first, he was angry at what was happening. Then he realized that it was him causing his own problem and he needed to learn.
The doctor from our town said this was good for several reasons. He continued that we were being asked to speak for the next several months and now that this doctor was aware of my blog, he wanted me to speak about that. Allen said he had been asked by several of the people there if I was for real and a few had read some of my blogs, but wanted to know if I meant what I was saying. Allen was happy to say that he was the one I had written about in the testing for B12 and Vitamin D and yes, I was interested in people and helping to educate people about diabetes.
The doctor had discussed vitamin and mineral testing with this doctor before hand and had given Allen permission to bring up the topic. He knew there were tests, but had not taken them seriously, so he would also need to learn more about them. The doctor with us said he will be working with this doctor over the next few months until he can get to some continuing education courses and felt that this was a step in the right direction. We all agreed and Tim said he was surprised that this doctor was actually transferring a few patients to our town that needed insulin. The local doctor confirmed this and said there was too much for him to learn for the patients he had and had asked if this would be possible.
This was why the doctor wanted us back for more talks to his group since we knew insulin and this might help make the transition for these patients easier. I commented that none of us were patients of his. Our local doctor admitted to having only a couple type 2 patients on insulin, but he would look to us for assistance. I suggested that since the three of us all were at the same diabetes clinic, maybe he could talk to them as well. I pulled out the card I had and photocopied it for him. He looked at it and said thank you, as he was not aware of the clinic being so close. He knew of the one in another larger city south of us, but not this one. He then said that he recognized the doctor's name, but did not realize where he was practicing.
He said he had the permission to refer the patients to our group for education if we were willing. After a short discussion about location, he said he would rather use video and have them learn this mode so they could email us when they had questions and use video if needed at any time. We agreed that would work for us and I explained I was already doing this for several doctors in other states. The doctor wanted to learn more and asked if I would email the contact information so that he could check how this was working. When I said yes, he handed me a card of his with an email address on it. He explained that was the office email address and for this purpose only. Then he added his home email address and said this was the one Tim had. I said I also do some peer-to-peer work for the doctor on the card and he said good. That would give him a good reason to call him and asked other questions.
Then he surprised all three of us and thanked us for our being up front in our recent conversation. He had approached us with other motives and when we had been up front with him, he realized that we were more interested in education than taking patients from doctors. He as very appreciative in being asked to go to the other doctor and felt this was a real help in getting this doctor on the right path. He said this proved to him that we wanted to help more that hurt those doctors that were not as knowledgeable about diabetes. He said that talking about the diversity of topics that Allen and Tim had covered during the meeting even showed that doctor you were more interested in education than pushing patients away from him.
Allen then asked if he knew the doctor he named. He said yes and was there a problem. Allen said this was the doctor he had left because he would not test him for vitamin and mineral shortages. That if it had not been for Tim and I taking him to see their doctor and the tests proving he needed shots and vitamin and mineral supplements, he might not be alive today. The doctor said he would get this corrected if possible, but it may not be easy. He asked us if this is what we do when a doctor does not step up when asked. Allen said yes, and he had not planned to leave this doctor, but when the test were done and he was asked to surrender his license because he was severely deficient in Vitamin B12 and D, he knew that it was severe. He had not liked having his license taken, but after considering the alternative of having to surrender it to the state, and then having so much on record, he said that that made him feel better. He stated that when his levels were normal they had given his license back and that made him feel even better about it. Allen said that our aggressive nature after the doctor refused to do the tests probably saved his life and for that, he was grateful.
The doctor looked at us and said that you normally give the doctor the opportunity to make the mistake first. I said that the doctor they were now working with had a reputation and it was the pharmacist that sent them to another doctor. He said either way, we are not trying to divert patients away without cause, and we all said yes. He then said we could consult any time with him and if we had a doctor that refused to step up, to bring the patient to him and he would see that they were taken care of and what needed to be done. If we were correct in our thinking like we seemed to be, then he would attempt to get the situation corrected. He said even if this meant loosing a friend and colleague which he then told Allen that the doctor was that he had left. He said that yes, he was aware of his position on vitamins and minerals, but for him to let someone on metformin become that deficient was inexcusable and he agreed with our actions.
We concluded and went our way home. Yes, several emails followed, but we wanted to think more about what had transpired.