Posts Tagged ‘informed consent’

Medical Second Opinions: An Under-utilized Option for Patients

Monday, May 2nd, 2011

Today’s medical world is vast with various technologies, treatments and options.  So, if a patient is diagnosed with a medical condition, and doctor A recommends treatment A, what keeps the patient from seeking a second opinion? This is an interesting phenomenon.  After performing intake summaries and client interviews for quite a while now, it still amazes me how many people have bad outcomes from surgery simply because they never requested a second opinion. Second opinions are not simply reserved for surgery, though; cancer treatment options, medical therapies for chronic conditions like rheumatoid arthritis or inflammatory bowel disease, chiropractic care of chronic back or neck pain are some other conditions that, in my mind, scream for a second opinion!

Having practiced medicine for 13 years, working with physicians from all specialties, I can honestly say that doctors are not gods. They are human beings, no different than you or me, and human beings are prone to prejudice and errors. Granted, physicians go through a lot of education and training to perform their daily duties, but location of training, timing of training and educational mentors play a huge role in shaping the decision-making process of these humans.

Inherent limitations that can affect physician recommendations

For example, the latest technology for prostatectomy has been the DaVinci procedure, using minimally invasive robotic technology to surgically remove the prostate.  Operation of the robotics involves manipulation of “joysticks”, much like video-gaming. No offense, but if your particular urologist is 60 years of age or older, what are the chances that this particular surgeon is as adept with these skills or technology as a 30-year-old urologist?  Special training is required for use of these robotics, and not all hospitals even have the technology available. Therefore, one’s choices are automatically limited, and a minimally-invasive robotics-assisted procedure may not even be an option! A second opinion by another urologist at a different facility might be able to provide that option. A similar situation would be the use of gamma knife surgery for removal of brain tumors; it is not always an option available based on the facility or the neurosurgeon providing the consultation.

Can recommendations be limited by specialty?

Another example has to do with medical specialty affiliation. If one is trained as a surgeon, he/she focuses on the technical removal or repair of abnormal body parts. If one is trained in radiation-oncology, the focus would be the various radiation technologies available for treatment of disease. If one is a medical oncologist, chemotherapy protocols for the particular neoplastic condition would be the focus.  So who ties all of this together?  First of all, is the tumor even operable? Is the patient a good candidate for surgery? Should one try radiation first to shrink the tumor, then follow it with an operation? Is chemotherapy the way to go, but which regimen of drugs is really appropriate? These are very technical and complex questions. Should one leave the ultimate recommendation up to one specialty physician?

Suggested approach to the problem

For me, it would be a little more comforting to get the same overall recommendation from two independent physicians. What if the opinions differ?  A third opinion? – or, simply focus on the discrepancies with direct questioning of the two physicians and find out the rationale for the recommendation being made. You do not know how many times I have heard, “I trusted my doctor.” I ask you, if your car was making a rattling noise but seemed to be running okay and a mechanic told you a new transmission was necessary at the cost of $1800, would you get a second opinion?

Don’t let fear or reprisal get in your way

One of the main reasons for fear in seeking second opinions is anticipated disapproval and potential retaliation by the first physician or fear of a change in the patient-physician relationship.  I pose to you the following:  if a physician has done his/her research regarding the condition and is confident is his/her recommendation, then he/she should not fear the opinion of a peer. If that opinion differs, it should be reviewed for accuracy and appropriateness because it might just be a viable option not previously considered. If the physician is “offed” by the patient’s search for a second opinion, that physician thinks way too highly of himself/herself; keep in mind that this is about the patient who has a condition that requires treatment, not the physician’s integrity or ego. It is my firm opinion that physicians should be proud of those patients who advocate so strongly for themselves and seek to be educated about their condition.  Education leads to a better understanding of the disease process, better expectation of the “road ahead,” and better patient compliance with medical therapies. Retaliation is prohibited by the medical code of ethics; if there is a retaliatory action, the state’s Medical Board should be notified and prompted to investigate.

Beware of the on-line second opinion approach!!!

Recently, multiple facilities have offered a “second opinion service” via the internet. A patient submits his/her medical condition along with various lab studies and other diagnostic imaging (CT scans, x-rays, MRI scans, etc.) for review over the internet; an opinion is provided based on these facts!  What this really doesn’t take into consideration is the patient!  Patients are people – human beings with emotions, physical limitations, families (or not), previous histories and other underlying health conditions. One of the things I was taught in PA school was to treat the patient and not the numbers!  Not all patients are surgical candidates.  Not all patients can emotionally or physically tolerate some of the chemotherapy protocols. Someone might look good on paper with great blood parameters, vital signs, etc., but in person, one’s assessment changes dramatically.  These virtual second opinions may have their place in certain situations, but I generally have to question the validity of such an assessment.

A “real-life” story

I leave you with a quick summary of a case:  Mr. B was a 40-something, physically fit male professional, who loved to work out and exercise. He developed some mechanical back pain for which he sought treatment. An MRI scan revealed an incidental finding of small spinal cord glioma in the low back. Clinically, there was no evidence to support that this incidental finding was in any way related to Mr. B’s pain. He sought the advice of a neurosurgeon, who immediately wanted to operate. Well, if research had been done, these particular tumors are 99% benign, very slow-growing and can often be monitored for 10 to 20 years before surgery might even be necessary.

Mr. B followed the advice of the surgeon and underwent a resection of this small tumor. The surgery required resection of the S1 nerve root, which affects sensation in the genital region and anus; Mr B was now impotent and had problems with bowel movements in addition to a chronic burning sensation in his genital region. A second opinion might well have saved Mr. B a lot of pain, permanent erectile dysfunction and money required to undergo alternative methods for conception. He’ll never know now.

Have you or someone you know gotten second opinions before making a decision about an important medical procedure? What’s your approach? Have you ever received different opinions about how to treat a condition? How did you resolve this situation? Any tips for others?

Image: Wellsphere.com

Update: After posting Theresa Neumann’s piece this morning, I came across a somewhat related post on KevinMD.com entitled Marcus Welby and the relentless growth of specialization. The author, Jan Henderson, PhD, raises some very interesting thoughts about what I would call the “over-specialization” of medicine. She provides the following quote of Dr. Welby from very first episode of this TV show of years gone by, which – to me – supports one of the concerns raised by Theresa in her blawg:

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

Just some food for thought you might enjoy.

Brian Nash (editor of “Eye Opener”)

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

Monday, April 4th, 2011

Be your own advocate - ask questions!

Thousands of women will have an epidural today to help them through their labor, and many of them will have a running epidural after they have their baby delivered. This is especially true in the time period for those who have had a C-Section.

There’s no doubt that epidurals have been a wonderful tool for doctors to provide patients with relief from the pains of labor and the pain and discomfort following delivery – mainly after a C-Section.

Because they have become so commonplace in hospitals throughout this country – and the world – they seem to have been taken for granted as being “safe” – not just effective. For the most part – they are safe, but they clearly have significant risks associated with them.

Some reports claim that the overall complication rate for epidurals is 23%. These complications range from very minor (e.g. some nausea, vomiting, itching, headaches) to the most major of complications – death of the mother and/or her baby. In between these two extremes lie some very devastating injuries to both a mother and her baby. Just some of those reported are damage to the mother’s spinal cord leading to motor (ability to move legs) and/or sensory (ability to feel sensations) injuries, bowel and bladder dysfunction, foot drop and a host of other potential – thankfully rare – complications.

There is a popular book that many expectant mothers have considered their bible over the years – What to Expect When You’re Expecting, which is now in it’s fourth edition, according to Amazon.com. While no doubt this has been a valuable resource for many moms-to-be, one medical author takes some exception to the section on epidurals:

Epidural anesthesia has become increasingly popular for childbirth. The popular book, What to Expect when You’re Expecting, for example, portrays epidurals as perfectly safe. The risks, however, may be greatly underplayed.

It’s been many decades (four in one instance) since I personally went through the “birthing” process as a parent-in-waiting. I must admit, I have not purchased or read the latest edition of this book so I cannot vouch that this portrayal of epidurals being “perfectly safe” is still the message of this popular book. Obviously it was at the time of the quote by this Canadian medical writer.)

What expectations do YOU have for your special day?

I suspect that many of you are like I was in envisioning what your experience will be like when the day arrives. You have your bags packed, back-up coverage in place if needed, car gassed. The moment arrives and off to the hospital you go. You register, get in your room, the fetal monitor is applied, and you pass the time remembering (or trying to remember) all those things you learned in your birthing classes. Your epidural is placed and all goes smoothly. Finally, the time comes for you to deliver your new bundle of joy. You make it through some angst of birth, see your new addition through tears of joy and relief and get ready for the onslaught of family and friends, who want to see the new arrival to your family. After you and your baby are cleared for discharge, off you go to your home, ready to begin your “new life” of nurturing, educating, parenting – aglow with images of pride, joy and a world of opportunities ahead. Hopefully, that’s exactly how we all hope it works out for you and your family.

To increase your odds that this scenario plays out, I would strongly suggest that you not take for granted the part about your epidural going smoothly. While there are probably many other questions you may think to ask – or should think to ask – here are three suggestions I have for you based on my seeing (as a lawyer) what can happen when the epidural doesn’t go smoothly.

How an epidural is performed

Here is one example available on the internet (YouTube) to show you just how an epidural is done. Unfortunately, it is a bit difficult to understand the speaker (at least for me), but having looked at several videos, I think it gives you a pretty good idea of how this procedure is performed by the anesthesiologist.

httpv://www.youtube.com/watch?v=_WRccCADReY&feature=related

“Have you reviewed my medical history, Doctor? Is there anything else I can tell you?”

Some of the known risks of having epidural anesthesia are connected to your medical history. Sure, you’re assuming that the medical history you gave to your OB during the prenatal visits and to the intake nurse when you arrived at the hospital has found it’s way to your medical record. You’re also assuming that your medical history has been carefully reviewed by the anesthesiologist whose about to put the epidural in your back. Is it there? Has it been carefully reviewed? Ask! There are conditions (e.g. spina bifida, scoliosis, certain heart valve problems, sickle cell anemia, etc.) that can increase your risk of a complication from an epidural.  Are you taking or have you recently taken any type of anti-coagulant such as heparin or coumadin? Make sure your anesthesiologist is aware if this is the case since these drugs can increase the risk of a bleeding complication. You don’t want to have a collection of blood around your spinal cord – believe me!

“When should I expect to move my legs or bend my knees? How long will I feel numb?”

In most instances, epidural are given to provide analgesia – pain relief (sensory block) during labor and at times for post-delivery (C-Section) pain relief. They are not intended to block your motor function – that is, your ability to move your legs, flex your ankles, wiggle your toes, flex your hips or bend your knees. During a C-Section the drugs being used for delivery are many times different drugs from the ones you are getting via your epidural infusion. You will have a different block so that surgery can be performed safely. You will likely have both a sensory and a motor block! You need to understand the difference.

These anesthesia drugs (the ones given during your surgery) will usually wear-off (varies depending on the drugs and from patient to patient) in a period of 1 to 4 hours. You will typically be in a post anesthesia care unit (PACU) during your recovery phase from anesthesia.

Key: you should not be discharged from the PACU if you are unable to at least bend your knees. There is a scoring system (Bromage) that the nurses and personnel in the PACU will typically use after examining your ability to move your legs, bend your knees, wiggle your toes, flex your hips, etc. to determine if you can safely be discharged from the PACU or if you need to be seen by a specialist in anesthesia to determine if you have a potentially significant complication.

“What exactly should I expect to feel like if I have an epidural running after I deliver my baby?”

I simply cannot stress enough how important it is for you to understand exactly how you should be feeling after you have been discharged from the PACU to your room. Don’t ask your family or friends; they don’t know – unless they are anesthesiologists. There are so many free, uneducated opinions out there that are simply wrong!

One further piece of advice: do not ask the nurse what you should expect to feel like. There is absolutely no doubt that there are many  very experienced and highly capable nurses out there taking care of moms. Unless you intend to ask for and analyze your nurse’s background, training and experience in anesthesia, don’t do it. The drugs used in administering epidural analgesia can vary significantly. The dosing (concentration, volume per hour, etc.) can also vary. Only a specialist in anesthesia can answer your questions correctly!

Know what to look for so that if there is some change in your condition or you start to encounter a feeling or loss of function or sensation, you can tell your nurse or doctor immediately so that you can be examined right away!

I suspect many parents are so caught up in the labor process, or are so exhausted after the delivery or so caught up in the wonderment of having their baby that these issues relating to an epidural may not be very important. If you are in your 20′s, 30′s or 40′s, how important is it to you that may not be able to walk for the rest of your life? It can happen – rarely, thank goodness, but it can happen. I have been involved in cases in which this is exactly what happened! Frankly – I don’t want to see it happen to anyone else. It is incredibly tragic for a mom, a dad and their child – trust me!

One last point before we leave this discussion on post-delivery (post-operative) analgesia. Some hospitals (the number appears to be declining due to concerns about the inadequacy of monitoring) use what is known as Patient Controlled Anesthesia epidural analgesia. Simply put, this is a device (they vary depending on the manufacturer) permits the patient to push a button a infuse a pre-determined dose of drugs (e.g. bupivacaine and fentanyl) into the epidural space for additional pain relief. A patient is actually limited as to how much drug can be used in the course of an hour (determined by what in called a lock-out interval and maximum dosing parameters per hour). While a fixed lower amount of drug flows each hour (known as the basal rate), many patients may require more relief than the basal rate provides.

That being said, if you find yourself pushing the PCA button numerous times during the course of an hour, you should bring this to the attention of your nurse or doctor. Don’t wait for them to hopefully check the machine to see how many times you pushed in the last hour (many forget to do this!). Be pro-active. If you are pushing your PCA button a number of times in the course of an hour, even though you can’t really overdose yourself because of pre-set limits by the anesthesiologist, this may be an indication that something needs to be checked. For instance, the catheter may have become displaced; the drugs may not be distributing equally; you may be having some problem that someone needs to investigate. Don’t keep hitting the PCA pump; hit the call button!

Get information about the risks, benefits and alternative to an epidural!

Having been there (i.e. childbirth) as a father four times, I know – at least from my perspective – how difficult it is to concentrate on issues such as risks, benefits and alternatives involving an epidural. Common sense tell me the ideal time to have this discussion simply cannot be while mom is in labor. If that’s the only chance you have, then fine – take the time and make the effort and have a real discussion with the anesthesiologist. Even if you just cover the 3 items I have suggested above, that will take you a long way.

I have made this suggestion before, but I’ll make it again: make arrangements to meet with someone from the anesthesia department before you get to the hospital to delivery your baby. Don’t be shy or concerned that you don’t want to bother anybody. Bother somebody! There really are an awful lot of wonderful doctors and CRNA’s, who would be willing to meet with you, educate you and answer your questions.  It’s your health,  your body, your future – so protect it!

There clearly are more than “3 questions” you should ask. Many of you have been through this. Many of you have medical training and experience. What questions do YOU think a mom-to-be should ask about their epidural.

 


 

Advanced Directives: The Right to Die with Dignity. Does the Medical Profession Honor Them?

Friday, December 3rd, 2010

Anyone who has presented to a hospital with some type of ailment in the last 10 years or so has been asked about advanced directives, a living will and/ or medical power of attorney. What are these things?  What do they do?  Better yet, you may ask: what are they intended to do?

Advanced directives are legal documents prepared while an individual is of sound mind that indicates his or her wishes with regard to medical decisions to be made in the event that the same individual becomes incoherent, comatose, or unable to make decisions for themselves.

These directives are intended to instruct the care-providers with regard to various medical interventions should their condition warrant intervention. These can be as “simple” as resuscitation orders (being “coded,” “shocked,” being intubated and/or placed on a mechanical ventilator), or they can be more complex such as gastric feeding tubes if one cannot eat by mouth, dialysis should one’s kidneys fail (even temporarily), intravenous fluids or intravenous nutrition, blood transfusions, surgical procedures if the condition is deemed terminal, pacemaker/defibrillator placement, and many other form of possible medical intervention.  A living will is a form of advanced directive that is less precise, but it is a legal document indicating a patient’s wishes with regard to end-of-life or terminal-condition medical care without assigning a medical power of attorney. A medical power of attorney legally identifies an individual, who is intimately trusted by the patient to make appropriate decisions with regard to medical care in accordance with the patient’s wishes should the patient become incapable of making those decisions. The American Academy of Family Physicians offers good information with regard to these topics.

How well does the medical community deal with these issues?

This is all well and good from the patient’s perspective, but where do the physicians and other medical care providers fall in line with such legal documents and end-of-life ethical decision-making?  According to an electronic survey of 10,000 physicians in 2009 by Medscape on medical ethics, a physician’s personal bias and personal beliefs played a role in their approach to end-of-life care. A second article from Medscape dealt specifically with end-of-life issues.

When queried as to physicians recommending or administering life-sustaining therapy, when one judged it as futile (otherwise terminal condition), 23.6% of the respondants (~5,300) said “yes”; 37% said “no”; 39.4% stated that their decision was situational. The second end-of-life ethical dilemma involved whether the physician would withdraw life-sustaining care in accordance with family wishes even if the physician thought it was premature; the results showed that 54.5% would NOT withdraw care while 16.3% would withdraw care, leaving 29.2% deciding upon the actual situation. Let’s not overlook that astounding number – only 16.3% said they would follow the patient/family’s wish to withdraw care!

Various rationales were cited as to why these physician-respondents held such opinions. Some questioned the motives of the patient’s family members, while others noted fear of litigation for providing medical interventions.  The very definition of “futile” took on both curative and palliative connotations. The legitimacy of advanced directives were also questioned since these can become viewed as stagnant, especially if created 5 or 10 years earlier while the patient was in a different mindset. Keep in mind, people do change their mind, as do their perspectives with age, experience and wisdom. Likewise, advanced directives need to be changed, modified or simply updated periodically to reflect such changes.

The Terri Schiavo lesson (if there was one)

The Terri Schiavo story brought the whole end-of-life ethical decision-making into the limelight in 2005. This very sad story was in the headlines every day as legal maneuvering played out on national television. People were divided on “who was right,” and they will always be divided. These decisions are personal. They are difficult to share and discuss with family members, let alone physicians, who are admitting patients for the first time. In Maryland, physician assistants have been required to acquire continuing education hours in end-of-life care on a yearly basis for the last 10 years! This is a critical step in understanding the terminal stages of disease as well as the psychologic impact it can have on patients and their families.  Being comfortable with the discussion of death and dying, and doing so with dignity, is a key component in the management of end-of-life decision-making.

A Personal Experience

On a personal note, as a practicing physician’s assistant, I have been involved in end-of-life decisions with several family members as well as patients presenting to the ER in my 13-year Emergency Medicine career. The family members I have encountered have run the gamut from cancer-related deaths to brain hemorrhages to congestive heart failure leading to kidney failure.

One memorable, personal, family incident that sticks involved a relative, who had been living with a stroke, chronic lymphocytic leukemia followed by the development of large cell lymphoma. The two different courses of chemotherapy for the lymphoma resulted in damage to his heart, causing episodes of ventricular tachycardia (a life-threatening heart rhythm); however, the lymphoma had returned, and he couldn’t eat due to illness.  His options with regard to the cancer were extremely limited with an extremely poor prognosis, but the cardiologist wanted to insert a defibrillator in case the ventricular tachycardia re-occurred; the defibrillator would deliver an internal shock to the heart to return it to a normal rhythm and prevent death. Well, what is worse in this case – dying from a painless, silent heart dysrhythmia or suffering from malnutrition and systemic pain from the cancer that was everywhere in his body?  This situation required forcing both the oncologist and cardiologist to meet with my relative and with the our family to discuss each option and the prognosis. My relative decided he wanted to go home as soon as possible without the defibrillator; he died within a few days, silently and by all observations – peacefully. That was his choice, and it was honored after convincing his caregivers to abide by his decision.

It’s not Marcus Welby who will be taking care of you

Our current medical system is so over-burdened with patients at every level of care that the days of the old-fashioned family doctor who still admits his or her own patients and “rounds” on them every day (in addition to fulfilling their office obligations) are long-gone. Some patients are admitted to “hospitalists” (whom they have never met before) while others get admitted to whomever might be on-call in any variety of specialties (whom they also have never met before). Specialty medicine is just that……they focus on their particular specialty (as in the case of my relative). So, having a heart-to-heart discussion with your trusted family physician regarding your beliefs about end-of-life issues many (if not most) times never translates to the acute medical condition that lands you in the hospital. Even nursing home patients with DNR (do not resuscitate) forms can be ignored if they are not properly completed or the patient is not wearing the matching bracelet!

It seems that not only do patients need to be educated about the benefits of an advanced directives, living will and power of attorney, but physicians also need to be educated regarding compassionate, end-of-life and terminal care involving the whole being, such that they can communicate with family members, accept advanced directives and offer solutions to the dilemmas often faced by confused and emotionally drained family members faced with such situations.

Just as there should be dignity with life, there should be dignity with death.  It is the responsibility of both patients and providers to ensure this aspect of the human condition at whatever stage of a patient’s illness.

Have YOU ever been faced with such a situation?

Have you ever been faced with a situation where you were asked to make care decisions without an advanced directive? Have you ever found yourself in a situation where there was an advanced directive but the physician would not abide by it? Do you believe that it is a patient’s right to determine how they want to die and what medical interventions should be withheld under certain circumstances? How did YOU deal with such a situation?

Photo from enrichmentjournal.ag.org

Why don't patients ask questions of their doctor?

Monday, May 31st, 2010

My wife came back from a doctor’s appointment the other day, and immediately, I noticed that she looked puzzled and somewhat confused. So, I asked her about her appointment.  She went over her discussion with the doctor as I kept probing with questions about their conversation.  I found myself asking the following question more than any other: “Well, did you ask him about…?” Before too long, doing what I do for a living, I could not help but wonder why patients aren’t more inquisitive. Is there something about the patient-doctor relationship that makes patients not want to ask questions of their physicians?

Surely, the primary responsibility for gathering information about the patient’s medical conditions is and should be with the physicians. After all, their knowledge of medicine is vastly superior to that of the average patient. Still, when a patient has questions, there is often no good reason not to ask them. Consider a physician who orders hormone replacement for a female patient with a history of blood clots or hypercoagulability of which the physician is unaware. Consider another patient who develops a series of complications after a surgical procedure but who decides to tough-it- out and not ask any questions during follow-up appointments with the physician. In both of these examples, the patient risks developing potentially life-threatening conditions, and, if the patient knows or suspects that possibility for whatever reason, it is probably not a good idea to assume that the doctor will be the one to ask the right questions. So, why are patients sometimes reluctant to ask more questions about their medical care or condition?  I don’t presume to know the answer, but I suspect, in part, it has to do with the patient’s expectations.

For example, when I am pain, I don’t really want to have an extensive Q & A session with my doctor. I just want treatment!  It is simply mentally relaxing to just let go and have someone else take care of me. In addition, my knowledge of medicine is superficial at best. I don’t feel comfortable asking questions if I don’t know what I am talking about. My ego would rather have me in pain than allow me to question a doctor at the risk of looking like a fool.

On a subconscious level, I am probably also dealing with preconceived notions about doctors.  As long as I can remember, I have been told that doctors are intelligent and in control. After all, who else is capable of getting into medical school and then have the stamina to survive some seven to ten years of medical training? All of this makes me think that my doctor can only make the right decisions about my medical care. And then there is the medical office or the hospital. The smells, the patients (most with problems far worse than I have), the complicated machines that look like they belong in a sci-fi movie don’t exactly add-up to a familiar, comfortable environment.  I am in pain, uncomfortable, and somewhat intimidated – not exactly an environment conducive of critical thinking.

Well, if this is how other people feel, I think that might explain why patients are sometimes not as inquisitive as they should be.  What do you think?  If you are a patient or a physician, your feedback is much appreciated. Of course, everyone is welcome to comment.

Contributing author: Jon Stefanuca

Editor’s Note: This piece was written by Jon Stefanuca. My own wife has an advanced degree in pathology, did surgical pathology and autopsies. She DOES ask questions! Do you really need a medically-related degree, however, to ask the basic questions so that you have a clue what you’ve just agreed to by way of medical care? I think not. Moral of the story: be your own patient advocate! If you need help, then have a family member or a close friend accompany you if you have any doubt.

Best Hospital Rankings – A reply to Dr. K – what's best for YOU?

Thursday, May 13th, 2010

As readers of our blog know, Dr. Kevin’s blog serves as the source for a number of our posts. Recently, Dr. Kevin posted somewhat of a spin-off -Top hospital rankings doesn’t mean the best medical care | KevinMD.com – of a post he had done earlier about “Top Doctors” does not equal (necessarily) “Best Doctors.” Then today, as I was going through my News Feed on Facebook, lo and behold, here it is again.  I agreed wholeheartedly with him then and  now, and I find myself saying “Amen” to his post.  Problem is – what is the answer, Dr. K?

Check out his blog. He identifies the issue, but does he really suggest the answer? My humble opinion: afraid not!

Let’s explore some ‘tips and tricks’ for you to get close to the right answer. I say ‘close’ because there really is not a perfect answer. If you get great care and all goes well, then that was the best hospital for you and your problem. These after-the-fact answers are always 100% accurate when seen through the best medical instrument available – the retrospectroscope. If you are interested in some tips and tricks for picking an institution for future, non-emergent care, read on.  Let’s see if we can provide you some guidelines for your selection process.

Having been involved with issues relating to the care rendered at numerous hospitals in Washington, D.C., Baltimore and far beyond for many years, I have my own personal opinions where I would go to be treated and where I most assuredly would not go.  In fact, I have often joked that I need to get a medical alert bracelet reading – ‘in event you find me unresponsive do NOT take me to Hospital X (fill-in the blank).”

Lawyers doing medical malpractice have a pretty darn good sense of which hospitals give the best care.  Does the general public? As Dr. Kevin points out, reputation and marketing of that reputation is not the end-all-be-all of defining which hospital (also insert ‘doctor’) gives the “best medical care.”

There’s a certain hospital here in Baltimore that is constantly listed as the “Best.” While that institution does have some of the ‘best’ doctors and allied health specialists, it is also well known to provide substandard care at an alarming rate. The local maxim goes – “If I wind-up having a rare disease, that’s the place I want to go for treatment; however, if it’s garden variety, no way – no how!” Why? Just too busy, too arrogant, not patient- friendly, too willing to turn patient care over to resident-staff-only surveillance and so on. Maybe they are just bored by the ordinary health issue – not complex enough. Who knows?

But here’s the catch – just as ‘top hospital’ rankings doesn’t mean (necessarily) best medical care, nor does overblown reputation mean that there aren’t some, if not many, outstanding physicians at these same institutions. Titles, marketing banners and magazine covers simply do not answer the search for the best institution for your care.

Let’s face it, in an emergency situation you are going to the nearest available institution at least until you are stabilized medically. Whether you elect to stay there for ongoing care may well be a different issue. The more common situation you will probably face is when you are going to undergo elective procedures or care.

Since you are reading this blog, you undoubtedly have a computer. Have you done your homework? Going online to learn more about your medical condition is a good place to start. No, I’m not suggesting you check-out what ranking your doctor or his/her hospital has; that information is precisely at the heart of the problem.

Let’s take one example of putting research into the decision-making process. An obese patient determines that he/she would benefit by bariatric (weight loss) surgery. Putting aside those who see this as a quick-fix alternative to Jenny Craig or Weight Watchers, John Doe (J.D.) – our hypothetical patient – might consider researching the various forms of bariatric surgery. Does J.D. know if he should have gastric bypass surgery or gastric banding? If gastric bypass, does his doctor specialize in open procedures or laparoscopic surgery? Does he know the different approaches a doctor can take? What are the risks of malabsorption or the post-operative complications associated with that form of surgery? Had J.D. just typed in “bariatric surgery” in whatever search engine he likes, he would see there is a world of information out there about the types of bariatric surgery, the risks associated with such surgery and so on. Did that handout he received from his doctor really fully educate him on the alternatives to what was recommended to him?

Okay – let’s focus on J.D.’s surgeon. Does he/she have a ‘preference’ for doing open versus laparoscopic procedures? When is the last time, if ever, he/she did one laparoscopically? Consider: did J.D. think that might be the reason why he/she is recommending J.D. undergo an open Roux-en-Y? Is this really in J.D.’s best interest?

Let’s put you in J.D.’s shoes. Would you ask your prospective surgeon what his/her complication rate is? How about  mortality rate? If you think surgeons don’t know their morbidity/mortality rates, think again. What is the most frequent complication your surgeon  encounters following the surgery or treatment you are considering? Are you, for some reason, at greater risk than other patients for encountering this risk?

Hopefully by now you get the drift. This is your body – protect it! Last time I checked, we’re only here one time around. If your doctor makes you feel ‘uncomfortable’ because of his/her reaction to your questions or  the time it takes for  you to understand what you are agreeing to undergo surgically or medically, that might just be a telltale sign to move on.

Best Doctor/Best Hospital? Hopefully, by doing your homework and having a meaningful discussion with your doctor and understanding better the hospital where this will all be taking place, you will determine exactly who is the “best doctor’ and which is ‘the best hospital‘  for YOU! At least this approach will give you a better chance of a good outcome and experience than making your choice based on a title, magazine cover or a banner hanging on the hospital’s facade.

By the way, the same can be said of lawyers. Are we listed as the ‘best’ and ‘super’? We sure are, but you should ask us (or any lawyer you have occasion to meet) the same type of tough questions. Be pro-active. You’ll be better-off for it.

Have you ever wondered how people get in clinical trials? Well, you should check this out.

Monday, April 26th, 2010

Are you aware of clinical trials that may be in your neighborhood? I just happened to come across this link to clinical trials.  Perhaps you are a lot more savvy than I (which would not surprise me one bit), but you can get ongoing information on these clinical trials by going to a website called Clinical Connection.

For example, there’s one in Baltimore for overweight folks being conducted at Harbor Hospital involving a new investigational medication.

In fact, if you go to this link, you will see that there are over 15 clinical trials for all types of conditions in the Baltimore area alone. If you are willing to travel 50 miles or less, there are even more in which you can enroll.

Do you have moderate or severe pain from osteoarthritis of the hip or knee?  Well Annapolis just might the place for you to visit and try out a new drug.  You have to be  over 18 years of age and according to the website, “study participants may be compensated for time and travel. All study-related care is provided at no cost and health insurance is not required to participate.”  I don’t know what “may be compensated” means – but if you are interested, check it out.

On the national level, the home page of Clinical Connection says there are 105,555 clinical trials underway – and there’s probably at least one in your neighborhood.

Do you suffer from chronic low back pain of greater than 3 months duration? That’s right – there’s a trial for you taking place at 7 locations, including California, Arizona, Florida, Washington and Nevada.

You name the condition – there just may be some free study out there waiting for you to volunteer.

These programs undoubtedly have very extensive packets of information about the study guidelines and the risks and benefits of the drug or therapy under study.  These trials are called clinical trials since the manufacturer has presumablyjumped over the hurdles of early non-clinical research in order to take the next step – how does our product work with real people?

Make sure you understand what you are signing up for before doing so.  Who knows, it may turn out that you get some real benefit from participating – hopefully you will not be a statistic in terms of adverse outcome. Just take time to understand what you are getting yourself into and what rights you are waiving.  If you’re good to go, we wish you well!

"Top doctors may not always be the best physicians" via @KevinMD – A Commentary and Some Tips

Monday, April 26th, 2010

OK – so I’m a bit late with this one – since it was posted on April 21st – but sometimes even an ‘old’ post is worth a comment or two.

Dr. Charles writes in his post Top doctors may not always be the best physicians

Some of these doctors are excellent, but many are simply “notable.” They may be well-connected, in leadership positions, or presidents of this or that society. Many are excellent self-promoters, branding themselves through the name brand institutions they work for and the billboards that increasingly advertise their faces. Many are simply well-known or popular among their peers.

Well, he’s spot on with that one.  Of topical interest perhaps in the legal arena is that unless the opposing lawyer isasleep, objections in a courtroom to the question – “Doctor, have you ever been listed in (fill-in the name of the local magazine that rates physicians) as a ‘Top Doctor’?” are universally sustained by the judge.  Maybe judges understand better than the public that ‘Top Doctor’ status may not really be relevant to a physicians ‘expertise’ in a given subject area.

Before going any further, let it be said, however, that many times “Top Doctor(s)” are just that – they are some of the best  in their given specialty or subspecialty.  But how does the public know which ones are the entrepreneurial self-promoters and which ones are the real deal?  I might suggest that if you read Dr. Charles’ piece that you not stop until you read the ‘Comments.’  Here’s just a sample:

This from a gentleman named Kevin Falchuk, who provides the disclaimer – “I think you make excellent points, and this is coming from me, the President of a company called Best Doctors. We’re responsible for creating some of these lists.”

With that said, Mr. Falchuk notes:

[T]he issue in medical care isn’t your doctor’s reputation. Instead, it’s the extent to which he or she is able to spend time with you, think about your problems, and render good advice.

Let me add a few other suggestions:  While you are spending time with your doctor, if you are dealing with a life-threatening or potentially life-altering condition and not just the common cold, you may want to find out what his/her experience is in dealing with your condition.  In the right situation ask – is a referral to a specialist advisable? Perhaps a second opinion? If a course of treatment is recommended, are their alternatives?  What are the risks and benefits to each approach?  Does the recommended treatment have any known and likely side-effects?  Is there anything in your medical history that puts you at greater risk for known complications?

While it is never a good idea for a lay person to diagnose himself/herself, if you are recommended a course of treatment or a surgical procedure, perhaps you might consider educating yourself on what’s out there as far as information about the risks, benefits and alternatives of a procedure or treatment plan.  If you do and you have questions, contact your physician and ask about your concerns. However, sage advice on this approach might be – “If you trust Google more than your doctor then maybe it’s time to switch doctors.” Jadelr and Cristina Cordova, Chasing Windmills, 08-21-06

I suspect that somewhere during the course of the informed consent discussion with your physician, you or a family member will get a pretty good sense of whether the physician with whom you are speaking is the person for you and truly is one of the Best Doctors for your condition and treatment.

There’s a lot of talk about the medical profession learning how to improve on patient satisfaction. Why should you care if others think your doctor is tops or the best in some magazine?  While this may be a way to initially chose from the dozens of specialists in any given area, it should not be the end of the search.  Choice of physicians – as with any group – yes, even lawyers – is there for you.  Once you are in that physician’s office, only you can decide if he/she is the best doctor for you and you alone.  Also – keep in mind that not all the best doctors (or lawyers, or candlestick makers) are listed in such publications.  Whether your doctor is or is not is perhaps of no moment.  I have always believed in a system that is based on common sense – be an educated patient, ask questions, listen to the answers and follow your brain and your heart. While it does not guarantee a great outcome, you will have at least done what you can do to make sure that – your doctor is the best doctor for you!

Computer May Be Better Than Your Doctor in Providing Information for Obtaining Your Informed Consent

Tuesday, April 13th, 2010

When most people think about medical malpractice, they think about a doctor making a mistake during surgery, or failing to order a necessary test, or making the wrong diagnosis. In other words, a mistake in the actual rendering of medical care. However, a doctor can also be negligent in his or her communications with a patient even before the doctor undertakes the treatment at issue.

Under the law, a doctor is required to explain to the patient the risks, benefits and alternatives of treatment so that the patient can make an informed decision about whether to proceed with treatment. This is called “informed consent” and is a critical step in the process of getting competent medical care.  

While some doctors and hospitals have generic consent forms that you sign before surgery, the actual informed consent process is typically handled by the doctor, usually in the doctor’s office. At this time, the doctor is required to explain the treatment, what it entails, the risks involved (i.e., death, infection, etc.), and whether there are any less  invasive alternatives or other available options for care. If the doctor fails to thoroughly explain these issues, then he or she can be held liable if the patient did not understand the full ramifications of the procedure and suffered injury as a result.

One of the difficulties of informed consent is that it is usually done verbally, and we all know the difficulty of trying to remember all the details when someone is explaining something to us, whether it’s directions to a local store, or how to program a new cell phone. It can be especially difficult in the context of a doctor’s office when the patient is already under stress and is being bombarded with complicated medical terminology. It is not surprising that many patients have little or no recall of the actual risks of treatment that doctors routinely say they explain to their patients.

One method that is currently being explored to improve this process is the use of computer programs to help educate patients. In a new study, researchers at the University of Melbourne and Austin Hospital in Australia tested a computer program in forty patients scheduled to undergo surgery to remove the prostate gland.

The computer program included slides with animations detailing the procedure, its potential complications and the post-surgery recovery. Each slide contained questions for the patient to answer, and he could move on to the next slide only after he gave the correct responses.

Patients were randomly assigned to one of two groups. One group received standard informed consent verbally from their doctor. The second group got to use the computer. The study found that the patients in the computer group scored much higher on test questions about the procedure – 78% correct answers versus 57% in the standard group. Why the difference?

Having patients answer questions helps turn the process into an “education and knowledge tool,” according to Dr. Nathan Lawrentschuk, one of the researchers on the study, which appears in the urology journal BJU International.  It may also allow doctors and nurses to “hone in on areas not understood, rather than assuming our patients understand what we say,” Lawrentschuk told Reuters Health in an email.

We look forward to further advances in this technology so that patients can make informed decisions about their medical treatment. Let us know if you have ever given ‘informed consent’ after being advised of the risks and alternatives by a computer.  We would appreciate you sharing with us how, if at all, that process improved your understanding of the surgery you were about to undergo.

Physicians to test new emergency treatment for traumatic brain injuries

Monday, March 1st, 2010

Traumatic Brain Injuries (TBIs) occur, sadly, much more frequently than you may think.  The effects are often permanent, life-threatening and/or significant in nature.  TBIs can negatively affect many vital parts of one’s daily living, as well as the people around them.  A recent article discusses a new emergency treatment that may help combat those effects.  This treatment is spear-headed by the Emergency Department of Stanford Hospital and Clinics, as well as the Santa Clara Valley Medical Center, and is more fully detailed below:  

The Stanford team and physicians at 16 other U.S. sites want to test the efficacy of a new drug treatment. In a phase-3 clinical trial that has been approved by the U.S. Food and Drug Administration, patients with traumatic brain injuries would receive progesterone, a hormone normally found in our bodies, to determine if it helps lessen brain swelling and damage.

Animal studies and two small clinical studies have indicated that progesterone may be beneficial in treating TBI patients. Quinn, who is an associate professor of emergency medicine at the Stanford University School of Medicine, also noted that progesterone “has been around a long time, and it’s a substance we know a lot about” because it has been used for birth control and for hormone therapy.

In the trial, TBI patients who are brought to Stanford, Santa Clara Valley Medical Center and the other participating medical centers would be separated randomly into two groups. One group would get an IV mixture that has progesterone, and the other group would get an IV drip without progesterone. Everyone enrolled in the study would receive standard medical care for a brain injury — maintaining blood pressure and providing oxygen — and all patients would be contacted by telephone every month for five months, to check on their progress before returning at six months for final neurological testing.

The proposed trial is unusual because the IV treatment would have to begin within four hours of the onset of an injury — at a time when most TBI patients aren’t alert enough to give consent, and their families can’t get to the emergency department fast enough to give consent. “The people we see in the ED often come in unconscious, and we know from experience that finding family members to give consent for treatment in the emergency setting can be difficult,” Quinn said.

The consent controversy is one that will most likely not go away anytime soon.  The article states that there are federal laws in place, that allow such procedures to occur, without the patient’s informed consent.  With this in mind, Stanford has posted a link for interested individuals to take a survey, in regard to their feelings regarding such a procedure.

We leave you with some somber statistics:

Every 15 seconds, someone in the United States suffers a major traumatic brain injury. Every five minutes, someone is forever disabled as a result of a TBI. Some 52,000 deaths per year are caused by these injuries. TBIs are the leading cause of death in people aged 1 to 44.

Let’s hope these numbers decrease as time goes on, with advances in safe medical technology and innovation.