Talk to Your Doctor and Pharmacist

I firmly believe in this. I see too many people avoiding this and causing themselves health problems. Yes, there is a growing epidemic in this country and it is on two fronts. Many people are not talking to their doctors. And, at the same time, doctors are not talking to their patients. These are not what I am referring to, but both are part of the epidemic.

Medical situations arise every day and people think they can handle them without talking to their doctor. A brief article the other day made an excellent point about the need to talk to your doctor. Some people will disagree with what I am going to say, but they are the ones that will end up in the emergency room and the hospital or even the local mortuary. Yes, it is that serious.

When people come down with the common cold or also develop problems with mucus plugging their nose, they head for the nearest store or pharmacy to get a decongestant. If you are healthy and have no known medical problems, chances are that no damage will be done.

But if you have any of the following health conditions, doing this is not advisable. These health conditions are heart problems or high blood pressure, glaucoma, thyroid problems, diabetes, or prostrate problems. With these conditions, it is wise to consult with your doctor. Most over-the-counter products like decongestants are clearly labeled with a warning for high blood pressure but little else. Some do say they will raise blood glucose levels.

Most people will demand privacy and other grounds for avoiding what I am proposing, but after seeing a friend in the hospital recently for just the above situation, I think for the sake of safety, all over-the-counter drugs that require a warning, should only be available through a pharmacy and be kept behind the counter requiring a prescription if they have health problems listed above.

This may be an unnecessary burden on doctors and pharmacists, but in this day with computers, this should be workable. Some patients will go to extreme measures to avoid this happening and shop pharmacies to avoid the need for a prescription. They will do anything to step around the system. The dangers of doing this are there and people still want to ignore them.

This is the reason that I only have two pharmacies and all my doctors know which ones to deal with. If I am looking for an over-the-counter medicine, I talk with the pharmacist after I have read the label. Often the pharmacist suggests another product that does not have the dangers. Occasionally I am told to not take any and go to the doctor. I respect the pharmacist for this and this is one reason for not wanting many pharmacists to deal with for my prescriptions.

I find that these relationships work for my better health care and as a result, the doctors are more confident in what I do. Plus the pharmacist is more willing to answer questions and even supplies me with additional information when it is felt that it will be of value.

Excellent Tips on Patient and Employee Communication

Why would the Center for Healthcare Communication want to confuse the issue on improving patient and employee engagement. When it comes to communication, even the most sincere organizations cannot communicate and try to cloud the issue. What I do not understand is why communication is so utterly impossible and why they need to confuse the issue by using other terms to hide behind.

If they would use the tips they have promoted for engagement and apply them to honest communications, they could improve their organization dramatically.

This is obviously written for doctors and the way they should treat patients. The second part is also for doctors and how they should treat their employees.

#1. “Patients expect doctors to be nice. When they enter a healthcare facility, they expect people to be pleasant and friendly. Does this create good experiences? Yes. Does this create great experiences? Not necessarily. To create great experiences, you must exceed expectations. Here are some ways to exceed expectations.

• Use empathy. Everyone always talks about empathy, but not many people consistently use this powerful tool. Stop the talking, start the doing!
• Use the patient's preferred name. How do you know the desired name? Ask!
• Do something special. For example, if a patient feels anxious, together take a few deep breaths with him or her. Patients do not expect this behavior from a professional, so you have created an exceptional experience.
• Ask the patient his or her goals. Many healthcare professionals are busy telling the patient their suggested medical plan without asking the patient what they actually want.”

#2. “At a recent healthcare meeting, I spoke to an attendee and asked her a question about the hospital where she is employed. She said, "I'm not sure about that topic, I am just one of their nurses." JUST one of their nurses? It is obvious how she feels about her role in the hospital. To avoid the "just" comments, make employees feel a part of the organization rather than apart from the organization. Top tips to help:

• Involve staff in the early stages of any new initiative as opposed to telling them about it after you have made all the decisions.
• Constantly survey employees. Get their feedback on everything.
• Focus on encouraging, not discouraging. If an employee has a suggestion that you don't feel will work, do not brush him or her off. Say to the person, for example, "Thank you for the suggestion. We tried that last year and unfortunately, it was not successful. However, I would like to hear your spin on it."

Yes, positive communications are important and will often put patients at ease and make office staff more attentive. Communications make an office more positive and this will reflect in the staff communications with patients. It is my hope that the term engagement will be relegated to talking about what happens to young couples in contemplation of marriage.

Communication Improves Health Outcomes

Finding this article was a pleasant surprise. Not only that, but the source was even a bigger surprise – Physicians Practice. Most doctors use other terms and seem to love them as a way of confusing true communications. This article seems to be pointing back to the importance of real communications.

Communication is the key that could improve healthcare for doctors and patients around the world. I think it is proper to use this by Dr. Rob Lamberts - “Communication isn’t important to health care, communication is health care.” as it is very appropriate to this discussion.

Research has shown that collaborative communication between clinicians and patients has multiple benefits, including increased patient satisfaction, treatment adherence, and decreased rates of 30-day readmissions. Most clinicians, who average about 250,000 patient encounters over a lifetime, know that communication can help reduce patient safety risks and insurance costs, while increasing their sense of effectiveness and job satisfaction. Yet, an overwhelming majority of physicians has never received professional development on how to manage patient communication.

Doctor-patient collaborative conversations are powerful tools to bring about a change in attitudes while building life skills, knowledge, trust, and confidence. This can ultimately result in meaningful and sustained changes in health behaviors. In a sense, this collaboration allows for clearer expectations, understanding, and knowledge that can enable the doctor to better understand and meet the patients’ needs.

It also can help them empower patients to assume responsibility and take steps, albeit sometimes small ones, to manage their own healthcare. This type of collaborative interaction engenders empathy and trust, all of which increase health outcomes, as well as patient and doctor satisfaction.

Without communication, the doctor patient relationship will not exist and patients will not view time spent at an appointment as time well spent and will feel that the doctors are there only to write prescriptions and pass out pills. Many patients will not understand the need for filling the prescriptions and won't know what the side effects of some medications will be or how to handle them. Lack of communication causes more problems and harms than many doctors realize.

Communication strategies such as Motivation Interviewing (MI), theory of the mind (or mentalizing), and emotional regulation, all constructs shown to increase patient satisfaction, collaboration, and health outcomes, are important elements of any conversation solution that physicians may consider.

I would urge people to read the link the first paragraph as there is more to this than I have covered.

Increasing Doctor–Patient Communications

Continued from yesterday's blog

I admit I don't have much faith in doctors and many patients being able to improve communications under the current circumstances and health care laws. Many patients have lost access to their doctors and have been placed by their insurers with new doctors. This not only make communications more difficult because both are starting over with new beginnings. Others that have retained their doctors are wondering if they have a good thing and why so many others have had to move doctors. A lot of nervousness currently exists and this affects communications.

Nancy Finn thinks technology will help in communications. While she may be seeing some improvements and changes, I have some reservations about what I am seeing in the lack of technology advances and refusal by doctors to accept technology, except what is useful in practice or will earn them money. Some doctors to satisfy the stage 2 “meaningful use” requirements are making use of patient portals on a very limited basis and most are not allowing corrections to records. Believe me, I have tried as I have found some serious errors in my medical record.

Nancy thinks that if patients and providers use tools such as the internet and mobile phones to track medical conditions, everyone can benefit. She also lists tools such as patient portals to engage in e-visits, and email to discuss non-emergency issues between visits.

After doing some research, Nancy may be on to something. This article, published on April 7 in the Star Tribune describes something I was not aware of until I read it. Doctor on Demand started about four months ago and is now in 40 states, with 1000 doctors on staff. A 15-minute video session costs $40. Minnesota Blue Cross and Blue Shield is behind this and telemedicine is being used for home visits and people going to a kiosk which has some instruments available to take vitals. Some even have an autoscope tool with a camera attached to look into ears.

This doc-in-the-box is quite satisfying for many patients. Other doctors are raising the issue of the quality of care, but patient satisfaction is running high. Even advocates for virtual exams say they work best for routine cases, but when it comes to complicated diagnosis and treatment, there is no substitute for an office visit. Even I am going to investigate what may be happening in my state of Iowa and whether this might be available here. I do doubt that Medicare is involved in this, as the only telemedicine they have become involved in to-date is when providers are on both ends.

Nancy Finn also covers wearable devices, phones and the internet to monitor chronic conditions. She lists mobile phones to text instant messaging and to deploy apps to track heart rate, blood pressure, blood glucose, weight, and fitness.

Rather that list the suggestions that Nancy has for patients and doctors, I suggest that you take time to read her blog. One item she did not mention in constructing a personal health record is to make use of Microsoft HealthVault. Read about this here and with any choice you make, please use a secure choice.

I will quote her last paragraph as it expressed my thoughts as well. “When all the parties in the health process understand the need for communication and work at providing the pathways to make it happen there will be less frustration and dissatisfaction, and the safer practice of medicine for all concerned.”

Doctor–Patient, Communication Needs More Focus

This blog by Nancy Finn is a topic favorite and can really get me wound up. Communication is a term that many dismiss as unimportant in today's medicine. Physicians like the term patient engagement, and other buzzwords to describe one-sided communication and then claim patients do not communicate.

While this is true for many patients who are passive in nature because they expect the doctor to ask the right questions and give all the right medications. Too often these patients are over medicated and given too many unnecessary tests. Communication is a two-way method of making the most of situation and getting quickly to a proper diagnosis. But the failing of today's health care is the lack of effective communication, not only by the doctor, but by many patients as well.

Some of the reasons include:

1. Many drama kings and queens,
2. Many cannot concisely explain what is bothering (or ails) them,
3. Many patients do not have the terms to use (health literacy),
4. There is too little time with the doctor, and
5. Many doctors cut the patient short from giving details.

This is sad that in this day and age, with many tools available to doctors and patients for better communications, the art of communication falls by the way-side and is not used. While it is estimated that 80 percent of serious medical errors involve miscommunication between caregivers. This happens in hospitals and between doctors when a patient is referred to another doctor. This is even more complicated now that electronic health records have entered the picture.

It is simplistic if every doctor is an hospital employee and the patient record is open to every doctor in this case. But let an outside clinic become involved and the error rate is back at the 80% level as one electronic health record (EHR) is isolated from another EHR and they are not allowed to communicate. Currently, most patients have no authority to transfer information from one source to another. Most records are HIPAA protected and a doctor or the patient is not allowed to override this isolation even if both agreed. Therefore, the doctor or someone he designates needs to print out the information to be transferred and this is the source of most errors.

Hand-offs is one area where communication has to improve. This is especially true for the elderly being discharged from a hospital to their home or to a nursing facility. The office visit is another. Poor communication is blamed for patient frustration, non-compliance with treatment and medications, and general lack of trust in the physician.  It is said by some that many doctors are interested in their patients and desire to make the right medical decision about medical care.

Doctors do have many distractions, such as continuing education, licensing tests to take, and government and insurer paperwork to complete. The number of required tests and conditions the primary-care doctors need to screen for, has increased dramatically. Then add to this the treatment regimens for chronic diseases like diabetes, heart and lung disease, cancer, and other problems that have become more complicated. These all make the 15 minutes for an office visit more difficult. Little time is available for communication and this puts more pressure on the doctors and unfortunately can cause more diagnostic errors.

Continued in tomorrow's blog

What Communication Does and Does Not Do

This is a classic case of poor communication and then excellent communication. This is based on a true experience of a relative, but names are withheld at his request.

The doctor did not explain the possible side effects or instruct the patient to call if he experienced any of them. Statins that are prescribed are often just handed to the patient with no explanation. Many doctors are very sure of their abilities and figure that the patient should just follow orders.

Then when the patient starts experiencing muscle pain, he is surprised and either stops taking the statin or heads for the computer and looks up the side effects and stops taking the statin. Some profanity is said about the doctor and the patient says nothing to the doctor.

The lack of communication continues at the next appointment and the doctor asks why his bad cholesterol (LDL) is still elevated. The patient says he does not know. Therefore, the doctor prescribes a stronger dose of that statin. This time the patient decides to talk with his pharmacist. The pharmacist asks if there has been any muscle problems and the patient says yes.

The pharmacist asks if he used any other pharmacies and the patient said no. The pharmacist asks if the patient is still taking a certain medication and the patient answers yes. The pharmacist says she will call the doctor's office as he should not be taking but 10 mg of the statin to avoid problems with that medication. When she hangs up with the doctor, she says the doctor had gone ballistic and would not give the lower dose. She said he was to stop the other medication, but she could not recommend that.

Patient asks what he is to do. Pharmacist asks if he would see another doctor. Patient asks if this doctor knows how to communicate with patients. That he does the pharmacist says and dials the phone. When she hangs up, she says the doctor will see him in 30 minutes on the second floor in this building. The pharmacist then says to wait a few minutes and she will print off a list of the medications that he is taking and side effects of each and conflicts with other medications.

The pharmacist then has a copy for the doctor and discusses them with the patient. The patient is now enthused about seeing the new doctor and happy with the pharmacist.

When the patient completes the paperwork and meets the new doctor, the patient is surprised at the amount of time the doctor spends reviewing his records. The doctor then discusses the medical history with the patient and covers the medications the patient is currently taking. He then calls the pharmacist and asks her two questions and writes three prescriptions for the patient, and then discusses each with the patient.

The patient asks a few questions and the doctor explains that he will have a blood draw before leaving and another appointment in four weeks with a blood draw before that appointment. This will tell them the status under the current medications and what changes occur in the four weeks for possible needed perscription changes. The patient is told if any of the side effects that they have discussed are noticed, the patient is to call the office immediately, and hands him a card with the phone number and his name on it.

The doctor hands him a two sheets for the blood work and asks if he has more questions. The patient says maybe by the next appointment as he was going on the internet to do some reading. The doctor asks if the patient has an email address and then asks for it saying he would send him an email with an internet listing of reliable sources and at his next appointment, they would set the patient up with a patient portal to his records and secure email to ask questions of the staff.

After the blood draw, the patient goes to the pharmacy. The pharmacist fills the prescriptions and also covers the side effects. She asks if the doctor had covered these and instructed him to call if any developed. The patient says yes, and thanks the pharmacist.

The second example is what should happen, but seldom does. The first doctor wonders why his patients are not taking their medications, but figures he is better off without non-compliant patients. The second doctor knows what happens and makes sure he covers side effects and explains them to the patient. The second doctor also instructs the patient what to do if he experiences any side effects.

The second doctor also asks about dietary supplements and looks for problems and this is the doctor we all need, but often cannot locate. Therefore, we have work at training our doctor and talking very carefully with our pharmacist.

Pilot Program on Food-Insulin Gap Helpful

This is great news and I hope hospitals are paying attention. Two articles on the same topic – here and here. Again communication is the key and this is often lacking across hospital departments as they think (more like don't) the other department is on top of things. It is surprising what a little cooperation does for the health of patients with diabetes. If you, as the patient, have been allowed to manage your own diabetes, then this study will not benefit you.

This also brings up an idea for another study while thinking about studies. I would like to see a study where the patients that are capable, emphasis on capable, are allowed to manage their own diabetes while in the hospital. Some hospital kitchens are capable of providing a list of the foods on the tray and the carb count of each food item. This would allow those on oral medications to medicate accordingly and those patients on insulin would be able to inject appropriately. This study could be done in hospitals that have an endocrinology department with specialists in diabetes employed by the hospital or attached to the hospital. I dare say that the patients would be more satisfied and not under the stress normally felt when the blood glucose is allowed to run above 180 mg/dl to 220 mg/dl that most hospitals allow.

Back to the study. Dr. Dace Trence, who was not involved in the study, carefully pointed out, “Hospitals may be motivated to do so because they could face penalties from Medicare if they do not. Hyperglycemia in the hospital is now a [national hospital inpatient quality measure], so you can imagine how important it is to try not only to prevent hypoglycemia, but also hyperglycemia."

Considering Dr. Trence's statement adds value to this study and may make hospitals consider this necessary. Shwetha Mallikarjuna, MD, an endocrinology fellow at Southern Illinois University (SIU), Springfield, presented the study at the American Association of Clinical Endocrinologists 2013 Scientific & Clinical Congress in Phoenix.

Often it is the simple interventions are the best medicine, like telling floor nurses that meals are on the way so they can coordinate insulin dosing for hospitalized diabetics.  The study demonstrated that patients received prandial insulin on time with significantly greater frequency when food service and nurses coordinated care (50.4% versus 35.5%). When patients are forced to let hospitals dictate when insulin is injected, the idea of injecting after a meal is a common practice and when a nurse can count carbs and know how many units to inject; this will help prevent a hypoglycemic episode. This is good for the patient and the hospital.

Mallikarjuna did note that their study was limited by a low sample size and low power. She said the study was also limited by poor patient matching. She said that a larger follow-up study is ongoing.

I see a few positives from this study and the potential for good being part of the penalty system being put in place by the Centers for Medicare and Medicaid Services. How much this will benefit patients still is to be determined.

Is Your Doctor Listening to You – Part 2

Part 2 of 2 Parts

In this part I will cover a blog from Dr. Rob Lamberts. I have followed his blog regularly for several years and enjoy his writing style. I also like his outlook on doctor-patient relationships. Occasionally he will cross into doctor-speak, but he generally says what needs to be said in patient terms for everyone to understand. He has a knack for bringing out the best in communications from the patient and from following him on Facebook I can understand why his patients want him as their doctor.

Doctor Lamberts tries to follow this list as a doctor when seeing patients: (Bold are his headings and comments are mine). Read his blog for his analysis.

1. Listen – He finds a lot of keys by listening.
2. Direct the dialog – Here he means not just asking the right questions, but keeping the patient on track. He will not accept a patient's self-diagnosis, but he wants to hear the patient's story and see if he comes to the same conclusion.
3. Believe the patient – He does not want to be considered ignoring a patient. He realizes patients can be self-conscious about what they are saying. He wants the patient to tell him what the problem is and will help by asking questions.
4. Examine – Dr. Lamberts uses the examination to get more pieces of the puzzle and develop a more complete picture of the problem.
5. Get more data – Family members can often provide other data and it is important to listen to them when an incomplete picture is present. Dr. Lamberts feels that this sometimes prevents additional visits for the same problem. Sometimes more visits are necessary to get more facts or until he asks the right question.
6. Make a list – This is not just the list that the patient may have which can often provide keys, but Dr. Lamberts makes lists also. He wants to know what are the things he can rule out, and what other possibilities are still in play. This is used to aid in determining which test may or not be needed.
7. Address the fear – Many times this is what brought the patient to the doctor. This fear needs to determined and confirmed as this will help the patient understand what is happening and know that their concerns are being addressed. It is also important to know when the patient does not have fear and may only need an excuse for work or school.
8. Order the right tests – More tests if often not better and can confuse the issue. Dr. Lamberts is correct here and only orders the test to rule out important bad diagnoses or strengthen the case for others. I like his thoughts of tests are not meant to change what I know, but to change what I do.
9. Look for patterns – It is often the pattern that makes the diagnosis, not the symptom. Getting a good, factual narrative from the patient, often eliminates many of the symptoms and creates the pattern.
10. When all else fails, do nothing – This is difficult for most doctors. The key here is ruling out serious problems. Communication is the next key so the patient understands to call back or get another appointment if the symptoms or a pattern develops. When the patient understands the plan and knows they will have follow-up, patients will cooperate with doctors that communicate.

Dr. Lamberts concludes his blog by giving advice to patients and is worth quoting.

“Let me end with a bit of advice for patients:

1. Tell your story first. If you have theories, tell them only after you’ve told the story, otherwise you may cause the doc to jump to conclusions.
2. Don’t be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.
3. Say why you came to be seen. What is the worst symptom and what do you fear the most?
4. Don’t insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.
5. Get a plan. Understand what the plan of action is, and when you should call or come back in.
6. Don’t ever assume. If you don’t get results, never ever ever ever assume “no news is good news.” Never. You got that? Never.
7. Try not to be an interesting patient. It’s bad when you are a puzzle to your doctor. Words like, “man, that’s interesting,” or, “I’ve never seen anything like this before,” are usually bad signs. It’s even worse when you are presented in front of a group of doctors or are published in a journal. Don’t seek fame in this way. Stay boring.

P.S. That last one is tongue-in-cheek.” Emphasis in bold is mine.

Don't get me wrong, both doctors have good things to say, but I personally feel that Dr. Lamberts is a doctor I would enjoy seeing more than I would Dr. Wen. This is contrary to what I would normally think or do. Both blogs are worth the time reading on a regular basis.

I will mention another blog of mine using lessons doctors have learned by listening to patients.

Communication, Communication

Communication is the latest buzzword in medical circles today. Only they are calling it something else now. The medical professionals want us to think of it as “patient engagement.” How obtuse do they think we patients are? Communication by any other name is communication and I do not think they are doing us as patients any favors by trying to divert our attention away from this.

Dr. Rob Lamberts must be pointing this out to his colleagues in his blog of March 11, 2013 after attending the HIMSS conference. He admits he is snarky about this and from his blog you should have no doubts. I think a statement he makes needs repeating, “Communication isn’t important to health care, communication is health care.” Too many doctors forget this! That is why they have come up with the term “patient engagement” to muddy the waters.

We as patients need to have and use more communication with our doctors and not just when we are in the exam room. There, too many doctors talk at us and not with us, go on autopilot as if we aren't there, and too often come up with the incorrect cause of why we are there. I am upset because now doctors will use this term as a way to convince others that they have meaningful use of their medical health records (MHR) or electronic health records (EHR) when in reality, it is only the records they are interested in.

By using and adding data to your health record, they can become more efficient at billing us or our insurance carrier for more money. This in turn will garner them large sums of monies from the government for implementing the electronic health record system. Few patients currently have access to their complete medical records and this may become even more difficult in the future as more of our records are hidden from us behind a cloud of ambiguity and as programmers figure out how to make this more difficult with systems that are more proprietary not available to patients. Yet, every day we read that more of our electronic health records have been compromised and information stolen by electronic thieves.

I would like to quote Dr. Lamberts blog, but that would not accomplish anything. He says it much more eloquently than I can. I would rather you took the time to read his blog and hopefully arrive at the same conclusion. If you do not, then don't be afraid to tell me so.