What Do Doctors Read?

New Year’s resolutions, gotta lose weight, exercise more.  It does get a bit annoying to read all of our good intentions and then we fall off the wagon one more time!  As I look ahead to 2015, I begin my term (one year) as president of Tulsa County Medical Society (TCMS).  No resolutions I can’t keep, just hard work and lots of meetings.  The best way for me to share my thoughts and vision for 2015 is to let you in on my first newsletter of the year.  (unabridged)


It’s Monday morning and I haven’t rested well from the weekend. With a full schedule at the office, I don’t have time for interruptions. I check my e-mail first thing in the morning and today I wish I hadn’t. I have four prior authorization phone calls to complete today, and two of them have already been denied. “What?” I asked as the insurance representative informed me that the patient in question didn’t qualify for the CT sinus study because they hadn’t been on antibiotics for 2 months. “Aren’t we supposed to use antibiotics judiciously?” I asked. But my troubles today were just beginning. Continue reading

#medical-society, #medicine, #tulsa

Don’t ask….don’t tell!

If patients don’t think you as a doctor are open to discussion about complementary medicine, guess what? 

Ask your doctor about complementary medicine–don’t be silent any longer!

They won’t talk!  This web site is to prove that the Federal Government is interested in “bridging the gap” between traditional medicine and the complementary approach.  I would advise you to visit with your doctor about complementary medicines and treatment for allergies & asthma. 

NCCAM website

#alternative, #alternative-medicine, #asthma, #health, #medicine, #national-center-for-complementary-and-alternative-medicine, #physician, #united-states

Why Can’t I just get medication OTC?

It’s allergy season and we should all be taking antihistamines–right?  I don’t think that would be the best approach and here’s why…  For allergy patients, getting medication OTC only may not be helpful.  But don’t just listen to me, USA Today would also agree about OTC.


#health-care, #medicine, #nursing, #pharmacy, #usa-today

If there’s one thing I’ve learned….

I always tell me nursing staff, that I learn something with every “face-to-face” visit with a patients.  Maybe it’s what they don’t tell me, but show me using body language.  At times patients will disclose medical symptoms just as I’m leaving the room…causing me to stop and reconsider.  In any event, virtual medicine’s time has come…..


#american-telemedicine-association, #health-care, #medicine

Does the Tail Wag the Dog in Medicine?

This is a great story for all to read.  We (myself included) tend to become very negative about healthcare, especially with the elections heating up.  Grab your favorite beverage and enjoy reading how taking care of patients with empathy & concern will never go away regardless of healthcare legislation! 

Relax! and enjoy some good reading.

The Patient Will See You Now

Citation: Krueger J. The patient will see you now. J Participat Med. 2011 Dec 28; 3:e53.
Published: December 28, 2011.
Competing Interests: The author has declared that no competing interests exist.

In 1992, I graduated from college with a degree in business and enrolled in the National Marrow Donor Program, never really expecting to match. But, a few months later, a phone call came from the Red Cross; I had “matched.” Would I come in for screening?

I was informed that the identity of the person to whom I might be donating could not be divulged. I envisioned a patient and family as they waited, hoping for their opportunity. I imagined their prayers and their anxiety. “What if it were me or my family?” I wondered. “Would someone care for us?”

After weeks of tests and exams, another call came; we had matched! Then, several days before the transplant, it was cancelled because the patient was too ill. That night, I penned a letter to the patient, saying, “I hope you pull through. I want to be of help. If you can, just get stronger, I’m still willing to do it.” I gave the letter to the Red Cross coordinator, who promised to pass it on anonymously if the patient’s family agreed.

Several weeks later the patient had recovered and was ready for a transplant. Blood and bone marrow were taken through two punctures in my pelvis. Meanwhile, my original letter had touched off an avalanche of letters, pictures, and stories from the patient and his family. Through them, I was afforded the extraordinary opportunity to become a part of Larry’s story.

I learned Larry’s story — about his children, his wonderful wife, his amazing family, and his gracious and loving friends — and, through this, became connected to their lives. Larry was able to return home, visited his favorite restaurant again, took family trips, was a father to his kids and spent time with his wife – all the things leukemia had robbed him of during the previous 16 months. “I” was along every step of the way, as my bone marrow took hold.

By now, inspired by Larry’s story and our relationship, I had begun studying for medical school. And as I dreamed of what kind of physician I wanted to be, there was no doubt; it was a doctor who would care for patients like Larry.

One day, another call came. Larry was very sick. His body was rejecting my bone marrow. I penned another letter to him and his family, and prayed. But alas, Larry died several days later, surrounded by family and friends. I grieved as if it were the death of a family member or close friend. I still felt strongly connected to Larry and his family.

I received a letter from Larry’s wife, telling me how much Larry had enjoyed his last months of life. “He really lived and enjoyed living,” she said. She said thanks and that she hoped I didn’t consider my contribution to Larry’s care to be in vain. She said one of the things that Larry looked forward to the most was reading my letters, and it made him feel proud to know he had inspired me to study medicine.

I went on to become a physician, naively thinking that most of my experiences in medicine would be as inspirational as those I had with Larry and his family. But “health care,” as I would come to experience it as a medical student and physician, was very different than I had imagined it. When I heard patients complain about their medical care, it was hardly ever about the lack of technical care or competence. Instead, it followed a common theme: “He just didn’t seem like he cared.”

During medical school education, the patient’s story was relegated to the category of “poetry” or “essay.” Healthcare valued technical competence more than these stories. As I listened and learned, becoming increasingly proficient in medicine, I kept looking for what had inspired me to become a physician in the first place. And I was having trouble finding it!

As I entered practice, the more the pressures of a busy medical office competed for my ability to participate in the patient’s story, the less effective I found myself as a healer and the less joy I found in medicine. Practicing rural family medicine helped me discover that patients often come to physicians with much more than just medical problems. They brought legal, marital, spiritual, financial, educational issues, and more. I discovered that I could solve as many health problems with a car ride, phone call, letter, or chain-saw as I could with penicillin.

My eyes were opened to the story of the patient, and what care they expect and need at this moment in their story. My fascination grew with the idea that the patient’s life is a story in which health care only intermittently plays a role. Care meant something more.

Though I became skilled at negotiating the clinical protocol, patients often came to the office seemingly indifferent to my agenda. I pushed to accomplish the checklist, worried the patient might suffer through an oversight on my part. Whether it was just a need to visit or ask a question about life, my agenda usually didn’t allow enough time to fully accommodate the patient’s story.

Though medicine is necessarily standards driven, we often thrust these on patients without their full understanding or engagement. And this approach tends to set up a dependent relationship. If it occurs without kindness, caring, and respect, patients may even perceive it as a form of harm, and either avoid care or disengage completely.[1] And when it is unwelcome, it creates antagonism, yet another form of harm.

But, with my hand on the doorknob, the simple “Oh by the way…” offered up by the patient at the conclusion of an office visit invites me to delay my agenda and just listen. I am offered a chance to become a part of the patient’s story, where the patient is at the center and I am being asked to care. It is in the “oh by the way” moment when I discover that a “normal appearing” woman is abused by a model citizen husband; a spouse’s alcoholism is driving a family apart; a teenager has been taking her mother’s pain medications; and I learn how depressed and close to suicide the seemingly carefree successful father of three is as his business descends into bankruptcy and his marriage into divorce.

Pressure that physicians feel to maintain a good business model threatens to overlook a critical part of our “product.” In health care, the patient’s story and the relationship have ironically become the obstacle, rather than the objective. The consultative visit, the one place where the patient can discuss what is important to them with a trusted healer and confidant, is relegated to an agenda and a timeline by the need to see enough patients in a limited time to pay the bills.

Pauses such as the hand on the doorknob can be transitional points to discovery and relationship. In these pauses, I often felt the connection with the patient that is missing from the hamster wheel of a busy clinic or ward. In the pause, the agenda becomes the domain of the patient. In the pause, I often find myself uniquely free to listen and participate in the patient’s story. And in the pause, I’m able to suspend my assumptions and just listen.

Last year, I underwent my own extended “pause” as I left my clinical practice to attend a fellowship at the Institute for Healthcare Improvement (IHI) in Boston.

During the year, as I listened to patients talk, I discovered that many considered our health care system to be completely out of step with their lives. Patients spoke of their sense that health care just no longer cared. They reminded me that caring is not just about being nice to others. It is about an awareness and consideration of the true needs of others cultivated by a relationship between patients and those who provide care.

An article by Emeril Szilagy, “In Defense of the Art of Medicine,” captures the nature of this relationship between healer and patient, and between health and care. “A man stricken with disease today is assaulted by the same fears and finds himself searching for the same helping hand as his ancestors did five or ten thousand years ago. He has been told about the clever tools of modern medicine, and somewhat vaguely, he expects that by-and-by he will profit from them, but in his hour of trial, his desperate want is for someone who is personally committed to him, who has taken up his cause and who is willing to go to trouble for him.[2]”

Health and care transcends position and location. I also discovered that most care delivery is actually self-care.[3] As much as I might think I affect health outcomes, most are influenced by factors other than “me,” and are outside the four walls of medical delivery. Socioeconomics, biology, geography, education, literacy, temperament, environment, and networks all play a role in outcomes.[4]

Through listening to patients, I began to realize that health care’s focus on controlling the access to and location of the diagnosis and treatment of disease, without empowering connections and relationships, displaced any opportunity for breakthrough improvements in health and care.

Health care providers must embrace the goals of improved safety, efficiency, effectiveness, and timeliness, but must also realize that health care does not own health and care. If it is owned by anyone, it is owned by patients. We need to include patients as we listen, learn, and redesign our current systems of care with them and for them. Care must become a community metric where all who work in service participate and understand the impact and importance of their role in the health of others.

Though metrics are important, a thermometer cannot measure despair, a Hemoglobin A1C is not an experience, and a blood pressure is not a heart-to-heart chat. If the connections and relational aspects of medicine are minimized or eliminated, health care and medicine become commoditized, and care becomes relegated to the status of a drive-though oil change which, even if technically competent, is soulless. If treatments and tests are ingredients, relationships and stories are the meal. Making the mistake of preserving one at the expense of the other lessens the potential of both. This is the essence of high-touch medicine, and it is why the pervasive need for the injured and hurting to seek healing from caregivers has endured across the millennia.[5]

It is critical to get this right if we are ever going to restore the idea of “health” to health care. “Patient-centered” health care must not just “put” the patient at the center — a controlling and somewhat paternalistic concept. Patient-centered care [6] must mean that the patient elects to determine his or her location within health and care, and implies that we need to work with patients to develop a system for their needs. This might mean that we aren’t the biggest part of their story in some cases, and it behooves us to recognize when health care adds value and when it’s just in the way. Through a better understanding of the patient’s story, we can begin to see how we can truly help patients.

Increasingly, patients are self-directed. They are blogging, writing on “walls,” and forming self-help communities. But for each of these, there are others whose stories elude us, and they may struggle to find outlets to express themselves. These are the stories the health care system has never fully discovered. For them, systems supporting health and care must reach out to better understand their story and determine how we can best care. To accomplish this, systems of care must incorporate ways for all who provide care a way to truly “see” the patient; in so doing, patients can, in turn, “see” us.

It took a year away from patients for me to finally realize that the major impact of my relationship with Larry was not the “medicine” I was able to provide. Though important, it was ultimately not successful. The real value occurred in the relationship that afforded, if only for a while, an opportunity to care for another person and their family. As such, it allowed me to really “see” Larry and for him to “see” me. This is a mutually restorative process for healer, patient, and family.

Health and care will only become patient-centered when patients are allowed to design the “center” they want and need. A “center” based on a story. This one’s for you, Larry. Thanks for teaching me what it means to care and for allowing me to participate in your story.

The patient will see you now. Are you ready?

#bone-marrow, #education, #health, #health-care, #medicine, #national-marrow-donor-program, #patient, #physician

Michael Jackson’s Trial

Michael Jackson

Now that the verdict is public with Michael Jackson’s trial, what does propofol really do?  This is a summary from The Medical Letter (October 2011) in response to a reader who asked for a review on the use of propofol

First marketed more than 20 years ago, propofol has a rapid onset of action (patients usually lose consciousness in less then one minute) and a short duration of action with a rapid recovery (3-5 minutes) that makes it highly suitable for brief ambulatory procedures.  This means any endoscopy for your colon may very well use propofol to sedate you for the procedure. 

Propofol use is not uncommon; in fact, it is the most widely used parenteral anesthetic in the US. 

 The main problems with its use have been pain on injection and bacterial contamination, both related to how its kept in solution.  The lipid emulsion formulation gives it the white, milky consistency. 

Milky color of propofol

Propofol has a narrow therapeutic window; this means there is a small difference between the “usual” dose and the toxic one.  Overdosing can readily induce states of deep sedation and general anesthesia, which could result in respiratory depression and loss of protective airway reflexes.  It appears this is what happened to MJ. 

 The following is a quote from The Medical Letter: “After years of use by emergency physicians and nurses, nurse anesthetists and gastroenterologists, among others, the Centers for Medicare and Medicaid Services (CMS) issued a memo in 2010 (soon after the propofol-related death of Michael Jackson) that has generally been interpreted as limiting the use of propofol for procedural sedation to anesthesiologists. This CMS guideline for Medicare and Medicaid patients has had a ripple effect on hospital emergency departments, where propofol has been widely used for intubation, and on endoscopy suites; patients who may have had endoscopies for years without receiving bills from anesthesiologists are receiving them now.

 The mortality rate associated with brief use of propofol is so low that few data are available comparing the safety of use by non-anesthesiologists with that of use by anesthesiologists.”

I like this list of references:  Most readers can pull articles of interest from PubMed–

1. Propofol. Med Lett Drugs Ther 1990; 32:22.

2. PM Patel et al in LL Brunton et al, eds, Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 12th ed., New York: McGraw-Hill 2011, p. 536.

3. LB Cohen et al. A randomized, double-blind, phase 3 study of fospropofol disodium for sedation during colonoscopy. J Clin Gastroenterol 2010; 44:345.

4. TJ Gan et al. Safety evaluation of fospropofol for sedation during minor surgical procedures. J Clin Anesth 2010; 22:260.

5. DK Rex et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009;137:1229.

6. H Singh et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; 4:CD006268.

For the full Medical Letter review, click on the link.

#anesthesiology, #death-of-michael-jackson, #health, #medicine, #michael-jackson, #propofol