TBTAM’s Healthcare Team Tips for New Players

In my last post, I complained that I sometimes feels like I am a one person health care team. What can I say? I had a bad week.

The truth is, the overwhelming majority of my patients are doing more than their part playing on our little healthcare team. In fact, they do most of the work keeping themselves healthy. They exercise, eat right, take their meds, and get their paps and mammograms and colonoscopies. And they ask me what more they can do to optimize their health.

With patients like these, all I am is a coach who doesn’t do much more than stand on the sidelines, occasionally acting as a relief pitcher or pinch hitter for them when the score gets close, sometimes bringing in reinforcements when our opponents are tough. We play well as a team, and usually we win the game.

If you’re just joining my team, I’ll need to know a little bit about you. Here are a few tips from the playbook so you know what I need. Feel free to ask me for what you need. After all, we’re a team.

TBTAM’s Tips for New Patients

1. If you are coming to see me for the first time, bring your old records. If it’s a big pile, that’s fine. I may not have time to review it during your visit, but I promise I will later when I have time.

2. Keep a current list of your medications. Include drug names and doses, and update it before every visit. Include herbs and vitamin supplements. An index card or word-document on your computer is fine. Give me a copy when you come in. Make sure your name, birth date and today’s date is on it. You don’t have to write it all down again on my intake form – just say “See attached” and I’ll know what to do.

3. Know when you last had a mammogram, colonoscopy, bone density and pap smear. If you brought your records, it will be in there. Keep track of these things on an ongoing basis.

4. Keep copies of all your test results. When you have a test done, I will send you a copy. Ask your other docs to do the same. After all, it’s your result.

5. If you are having a mammogram done at a new place, you’ll need to bring your old films. Just call your prior radiologist and ask for copies. Pick them up or have them sent to yourself, not me or the new radiologist. Then carry them yourself to your visit. This avoids things getting lost or misplaced.

6. Know your family history. Things you’ll want to ask your parents about are cancers in the family, birth defects or major pregnancy complications and diseases that run in families like diabetes, thyroid problems, hypertension, blood clots, strokes, heart disease and neurologic diseases. Write it all down somewhere so you’ll have it. If someone has had breast cancer, find out if it was pre-or post menopausal. If they’ve had colon cancer, find out how old they were at diagnosis. Not all families talk about these things, but find out what you can. It’s important.

7. Keep a menstrual calendar. If I ask for the date of your last menstrual period, the exact date is not so important unless you are pregnant, so just ballpark it for me.

8. Keep track of all your surgeries. Again, a card or printed word document list is fine. It really is important for me to know if your appendix and ovaries are in or out. If you ever have surgery, ask your surgeon for two things – the op note and the path report. If you had post op complications, the discharge summary from the hospital would also be helpful. Bring these with you to your visit with me and I’ll scan them into my chart. If we’re both lucky and your surgery was at my hospital, this is unnecessary as I now have it all ONLINE!

Which brings me to the topic of the online personal health record.

The Online Personal Health Record

Wouldn’t it make this entire post irrelevent and obsolete? Should you have one? The answers to these questionsa are “Yes” and “I’m not sure”.

There are multiple OHR’s cropping up out there. Here are just a few that I found googling “online health record”-

iHealth Record
Health Records Online
Microsoft’s HealthVault
Web MD’s Personal Health Record

And at least a dozen more. Not to mention the eagerly awaited Google Health.

From what I can see, these programs seem to be a very good way for you to organize your personal health information in one place.

But unless they interact with my EMR, they’re not going to save me much time and effort, except that they allow you to answer my questions more easily. I still need to organize your data according to my own EMR system. I know some EMRs have an an online patient component to them, but mine does not (yet). And so your online health record is unfortunately not a substitute for my well-taken medical history. But bring in print outs of what you’ve got, by all means.

I’m no tech expert, so I won’t speak to the issues and potential solutions related to privacy of these online records except to say that I started to fill one out for myself, then stopped almost as fast as I had started. I did not like the idea of having my personal health info out there on the Internet with some vendor. I know that most of it is out there already, but it’s scattered around at my hospital and my insurance company and you don’t necessarily know where that is. But you will sure know where it is if we all put it on Google, won’t you?

And that scares me just a bit.

A Team of One

Am I imagining it, or are my patients taking less and less responsibility for their healthcare, and leaving it all up to me? Here’s what happened this week, and you tell me –

Monday
Me: When was your last mammogram?
New Patient: I don’t know, isn’t it in their somewhere? (Points to computer)

Tuesday
Me: I notice that you haven’t written anything in the medication section of the interval history form. Are you taking any meds?
Patient: (Sweeps hand out in a dismissive manner) It’s all the same as last time.
Me: Okay, then, let me just confirm. (looks at computer) Prozac 40 mg?
Patient: No. My shrink changed me to Wellbutrin because my sex drive was lower.
Me: Lipitor?
Patient: Yes.
Me: Prilosec?
Patient: No, its’ Protonix now…
(You get the point…)

Wednesday
Me: You’ll need to have another sonogram next year with your mammogram. Just remind me when we order your mammogram, and I can order the sonogram up front so you don’t get called back again. That will save you the addtional visit for the sonogram.
Patient: Can’t you just write it down somewhere? I’m never going to remember that.

Thursday
Me: I’m happy to refill your Fosomax, but I’ll need a copy of your most recent bone density so I can be sure why I am prescribing it. Where was it done? We can call and get the report.
New Patient: (not stopping to think) I don’t know.
Me: Do you have a copy of it?
Patient: Somewhere.
(Pause)
Me: Would you be able to look?
Patient: I don’t know where it is.
Me: That’s all right . We can request records from your previous doctor, who probably has a copy in the chart…
Patient: (Getting annoyed) – Can’t you just order a new one?

Friday
Me: Let’s reschedule your mammogram. It looks like you missed the last one we scheduled for you.
Patient: Well, that’s because no one reminded me.

C’mon, ladies. Help me out here. This is a team effort, not a solo act.
____________________________________________________
Next post – Team tips for new players.

Cookies for an Afternoon Concert

Every year, my friend and pianist/artist Ellen Farren gives a recital at her apartment, a preparatory rehearsal for an annual performance she gives with New York Philharmonic violinist Fiona Simon.

It feels so special to be allowed into the private world of musicians, and to enjoy such amazing music in the comfort of a friend’s home. Fiona and Ellen played with untiring energy, tackling two lesser known pieces by Benjamin Britten and Dvorak, as well as a more familiar Schubert. When Fiona played a Bach violin solo, I felt transported back to the salons of Europe. The concert ended with an encore of Spanish music.

I wanted to do something to thank Ellen for the privilege of attending yesterday’s concert, so I brought some cookies. This is a variation on a raspberry cookie recipe from Irene, born out of necessity when I discovered at the last minute that I had no raspberry preserves but lucked upon a jar of fig jam in the fridge.

The combo of figs and chocolate was rich but not too sweet, and went well with the delicious array of cheeses, spreads and pates that Ellen served after the concert. I only wish I could have stayed a little longer to talk a bit more with everyone. And watch the Yankees -Red Sox Game, which Ellen made certain her husband turned back on as soon as the concert was over.

Wonderful music, good food, great wine, good conversation and the Yankees – Yep, I’d say that’s a really special New York afternoon.

Chocolate Fig Bars

¾ cup light brown sugar
1 cup all purpose flour
1 stick unsalted butter in 8 pieces
1 tsp. Vanilla extract
¼ cup Fig jam
2 oz. Bittersweet chocolate in pieces
2 large egg whites, at room temperature
½ cup blanched whole almonds
Confectioners’ sugar, for garnish

Preheat the oven to 350 degrees fahrenheit.

Process the lemon zest with ¼ cup brown sugar with the metal blade of a food processor until the zest I as fine as the sugar, about 1 minute. Add the flour, butter, and vanilla and process until the mixture resembles coarse crumbs, about 10 seconds.

Press into an ungreased 9-inch square baking pan and bake in the preheated oven until it begins to color, about 15 minutes.

Remove the crust from the oven and lower the temperature to 325 degrees.Let crust cool a few minutes to harden up a bit.

If the fig jam has large lumps of fig, pulse it a few times on the food processor. Then spread the jam on the cookie crust, leaving a ½ inch border on all sides.

Pulse the chocolate 4 times, then process until chopped finely, about 1 minute. Sprinkle over the jam.

Beat the egg whites in a clean, dry bowl with an electric hand mixer until stiff peaks form. Reserve.

Chop the almonds finely with the remaining ½ cup brown sugar with the metal blade, about 15 seconds. Add the egg whites and pulse until just combined, about 3 times.

Spread on top of the chocolate layer and bake in the preheated oven until lightly browned, about 25 minutes. Cool. Sprinkle with the confectioners’ sugar, cut into squares and serve.

Note – For a thinner cookie, use a 9×12 inch glass pan.

Compost, Anyone?

Just when I start to wonder if winter will ever end, the light changes and the garden beckons. I am continually amazed every spring when, with no attention or effort on my part, the lillies return, the apple blossoms open and the lilac bush begins to sprout green leaves.

I can’t wait to dig in and get dirty, but first things first. Let’s get some compost!

Today, Mr TBTAM and I headed to the Fresh Kills Composting Site on Staten Island to get free compost from the NYC Compost Project. Here, Staten Island’s fallen leaves are brought every year, piled up into 10 foot high rows, then lovingly turned and areated with the backhoe till they become dark, rich loam called compost. (The front row of dark compost in the picture above is this year’s – the lighter colored back row is next year’s compost.)

On one weekend in spring, NYC residents are permitted to drive to the site, back their cars up to the rows of compost and fill their bags and bins with as much of the stuff as they want. We took away 6 quarter-filled yard bags full. (Note to self – use smaller bags next year. Lugging those babies up the staircase to the roof was no picnic…)

This will be our first year using compost instead of liquid fertilizer like Miracle Gro. I’m not quite sure how it’s all going to work, since adding 6 bags of compost to our container garden means removing the same amount of top soil from the pots. I guess that means carrying it all back down the stairs and out to the trash.

Hmm…..Somehow that seems to defeat the whole purpose of composting as recycling. Should we be taking the old dirt back out to the compost site? But that means gas and another $10 for the Verrazano Bridge. Which isn’t good for the environment either.

Maybe I should have stuck with the liquid fertilizer…

More on the Ortho Evra Patch and the FDA

The NY Times revealed on Sunday that Ortho, in reporting the results of a 1999 clinical trial of the contraceptive patch to the FDA, used a “correction factor” to adjust down the estrogen exposure in the patch by about 40%.

This adjustment was never part of the study protocol, a plan filed with the F.D.A…The company mentioned its decision to use the “correction factor” only once in a 435-page report filed with the F.D.A., and then only in a complex mathematical formula. When the study was published in 2002, there was no reference to the alteration.

The FDA recently updated the package labeling for the Patch to reflect the higher estrogen dosing and to warn users of the potential for blood clots from Patch. Ortho is now facing lawsuits from women who experienced blood clots they claim are related to the increased estrogen dose in the Patch.

According to the Times, the drug maker is attempting to block the suits, claiming that because the FDA approved the patch, Ortho should be immune to any lawsuits stemming from complications related to its use. It’s an argument that has made before, with recent success in favor of medical device makers.

If that’s the case, then doctors should be immune to lawsuits, since the Medical Board licenced us, right?

Somehow, I don’t think that’s gonna’ happen.
________________________________________________
My thoughts on the Patch

The Pink Patch – Irresponsible Advertising on My Space

If you visit My Space, you know what the Pink Patch is. Ads for this weight loss product are emblazoned atop web pages throughout this popular Internet community site. “Get Skinny with Pink!” “Be young and have fun with the body you’ve always dreamed of!”

My daughter and I stumbled across the Pick Patch on Kimya Dawson’s MySpace page last night. (Kimya’s music was featured in the movie Juno, so she’s a favorite among teenage girls.) Almost every 3rd hit on Kimya’s MySpace page will bring the Pink Patch ad back.

According to a 2007 survey, over one third of teens ages 12-19 report My Space as one of their most visited websites. And advertising unregulated diet medication to teenagers is just plain wrong.

What’s in the Pink Patch?

That’s hard to say for sure, since it’s an unregulated product. But these are the ingredients listed on the Patch’s website (though amounts are not listed):

Fucus Vesiculosus, or bladderwrack is a seaweed rich in iodine, which, if used in safe quantities, can prevent under-active thyroid in the same way iodized salt does. But too much iodine can be dangerous, and we don’t know how much is in the pink patch. In addition, research has found that bladderwrack can cause menstrual cycle changes and possibly kidney damage at high doses. Finally, bladderwrack can be contaminated with dangerous heavy metals if it is harvested from contaminated waters. Who knows where the pink patch gets its bladderwrack?

5-HTP is a serotonin precursor similar to Tryptophan, a product banned by the FDA when it was found to contain contaminants. Who knows if this stuff is contaminated?

Yerba mate is a stimulant that appears to slow gastrointestinal transit time, leading to a persistent sense of fullness and decreased food intake, as well as having caffeine-like inhibitory affects on appetite. An increase in certain cancers has been reported in areas with high intake of Yerba Mate, although other studies suggest that it may have antioxidant and anti-cancer properties. (Excellent review here.) In addition, Radioactive contaminants have been found in some brands of Yerba Mate, suggesting that they were grown with fertilizer from the area around the Chernobyl nuclear plant accident.

Flaxseed oil is an omega-3 rich oil. No problem there.

Guarana contains very high concentrations of caffeine, and therefore acts as a stimulant and appetite suppressant. However, irregular heart rhythms have been reported after use of Guarana. Seizures have been linked to high consumption of guarana containing energy drinks.

Lecithin is a fatty substance isolated from eggs. It’s safe.

L-carnitine is a nutrient that is involved in fat transport and metabolism. Its efficacy for weight loss is unproven, but it is probably safe. L-carnitine may interact with certain medications. (Good review here)

While some of the ingredients of the Pink Patch have properties that could lead to weight loss, well-done clinical trials have yet proven these claims. More importantly, there is absolutely no quality control or outside oversight on the manufacture or dosing of the products in the Pink Patch.

The Pink Patch is marketed directly to young women

The Pink Patch is blatantly marketed to teens and young women, with slogans like “Be the envy of every girl you know”, and comments about dining hall food and term paper stress.

Of course, you need a credit card to buy the Pink Patch, which limits its availability to older teens and college age girls. Fortunately, that’s just the market they’re going after.

Yes, this is America, and yes the FDA has no regulatory power over herbal products such as the Pink Patch.

But MySpace’s central place in teen culture imparts a responsibility to its owners to act responsibly in choosing advertisers. I notice there are no liquor or tobacco ads. They know that this would just not fly.

Well, it’s time for us to let them know that advertising unregulated herbal diet ads to teenage girls won’t fly either.

C’mon – Let’s see if we can get My Space to drop the Pink Patch Ads

If you already belong to My Space, go to Tom’s page (Tom is the founder of My Space, and that’s his page up there). Send Tom a message telling him what you think about the Pick Patch ads. Tell him it’s wrong to advertise unregulated diet medication to adolescents.

If you don’t belong to My Space, it’s easy enough to join. Tom will be your first friend. Then go to his page and message him.

If Tom isn’t taking email, then report this to the Myspace team as “abuse”, then choose “scams” from the drop down box. That’s what this is after all. A scam.

I’m already messaged Tom. Now I’m gonna’ head over to Kimya’s page and ask her to ask Tom to take the Pink Patch Ads off her page. Kimya seems like a really nice person, and she just had a baby girl.

I’m sure she wouldn’t want her daughter using diet pills and patches advertised on her own mother’s My Space page.
__________________________________________________________
I’m not the only one taking on the Pick Patch –

**********************************UPDATE********************************

Kimya messaged me back, and she is taking on the cause!! Here’s what she wrote to me –

holy s***. wow. thank you. this is super important. i will take drastic measures
this evening.

Go Kimya! The rest of you, Go buy her album!

A Hearty Grand Rounds

Dr Wes is hosting this week, and what a week it’s been.

I was stunned to read about what has been going on over at Neurodiversity – the blogger whose reporting into the legal machinations behind the vaccine-autism debate has led to attempts to intimidate her by subpeoena. A must read for anyone who believes in first amendment rights.

Head on over for this and much more. Truly the best of the medical blogosphere.

Just Thinking (I do that sometimes…)

So, here’s what I’ve been thinking lately.

We all have to die, right? Really. We cannot live forever, even if we think we can.

So no matter how good we get at health care and taking care of ourselves, we are all going to die of something. And there will always be a “#1 killer of women” and a “#1 killer of men” for us to be afraid of.

And a cause to fight or a new drug to sell or a headline to scare us or funding that is needed from the government for treatment and research.

So when does it stop?

I mean, what happens when we’ve cured cancer and found the perfect statin or perfect diet? What will we do when the word “plaque” only refers to a thing you get to hang on your wall ? Or when diabetes is discovered to be from a virus and we get the vaccine, and when stem cells make Alzheimer’s and Parkinson’s obsolete…will there be anything left to die from?

Or will we all live forever?

And if we don’t live forever, how long will we all live? To 120 years old? 150?

At that point, will there be a group of people who are living to 150 and still look great but a whole lot of people will still be dying at 95 from heart disease because they can’t afford the best health care?

But that’s already happening, isn’t it? Just on an earlier scale.

I mean, here we are, just plowing ahead curing everything right and left, leaving many of us to live longer and longer while women and children are dying at young ages from thing like malaria, measles and infant diarrhea. Diseases we in the developed world left behind in the history books years ago.

Really, really think about that. While we sit here worrying about which statin to take because we won’t get off our fat ass to exercise, kids are dying all over Africa from malaria and measles.

That’s because there’s no master plan. There’s no prioritizing where the money is going on a worldwide basis.

Now I know those laisse faire capitalists out there are saying “Leave it alone. Let it evolve. It’s working, just not at the pace everyone wants it to. And not equally everywhere, but give it time. We’re figuring it out…”

But are we figuring it out? Or are we just figuring out best how to make money doing it?

Because if it’s really all about making money, then we should not be surprised that we spend so much on it. And we should all just shut up and spend the money and see where it takes us.

But we really don’t want to spend the money, do we? We want our cash for other things, like I-phones and HDTV and oil guzzling minivans and movie downloads.

Of course we can’t say that, so we talk about the uninsured and the poor who can’t afford health care.

But really, how much would it cost for us just to take care of those folks? Not much compared to what we are paying overall for health care we would rather get for free so we can spend our money elsewhere.

And certainly pennies compared with the billions we spend trying to hang onto every last second of life because we really haven’t come to terms with the fact that we all have to die. And that if that death happens to be unexpected, it doesn’t necessarily mean that someone did something wrong and we have to find someone to blame.

How many times have I heard people speak these words – “Why haven’t they found the cause of … yet?” or “Someone has to have figured this out by now” or “”How come they don’t know …?”, all spoken with the expectation that it’s someone’s responsibility to have figured these things out, and if it’s not done, then by god, someone’s not doing their job!

All of which leads to lawsuits and raises the costs of health care even further.

Or do I have it all wrong? Maybe health care costs so much because the system isn’t free market enough. After all, the price of most things goes down with time – like I-Phones and laptops. But health care just keeps getting more expensive.

Maybe the answer is to just set the beast free. Get rid of insurance companies and go back to the days when folks just paid the doctor. Then who knows what health care would look like? Maybe I’d become obsolete because someone else has figured out how to deliver health care more cheaply.

Uh, oh. This thought train is taking a turn I don’t like. I think I’ll stop and make some soup.

A Clorox Moment

A woman I know has a second home in the mountains that she rents out when she and her family are not using it. In the house, they keep a guest book for renters to sign and write remarks, thank you’s, suggestions etc.

Recently she and her family were at the house and she decided to look through the guest book. In doing so, she came upon this entry from a recent tenant which read something like this –

“We had a wonderful stay at your lovely home. It will always be part of our family memories. While we were here, I gave birth to my third child while in the jacuzzi overlooking the mountains. It was an experience I will never forget.”

Neither will my friend, after spending an hour cleaning the afore-mentioned birthplace with clorox before she would let her kids use it that weekend.

I don’t know if there are any rules of Jacuzzi Etiquette, but if there were such a thing, this has to violate it. Plus, I thought “home” birth means you do it in your home, not someone else’s.

Time to add some new language to the rental agreement…”No home births, please.”

Employer-Based Health Clinics – The Next Big Thing?

While Hillary and Obama are debating how to save health care and we all rail against the drugstore clinics, a quiet revolution in primary care delivery is happening right under our noses.

I’m talking about employer-based health clinics. In-house clinics operated on site at the job, usually staffed by mid-level practitioners and maybe a doc, sometimes including a pharmacy.

What got me thinking about workplace clinics?

Well, a few days back, a young patient who I had not seen in 3 years arrived for an appointment, abnormal pap smear in hand, requesting a coloposcopy. She had been referred back to me by the nurse practitioner at her job, where she had been getting free pap smears since I had last seen her.

That same day, I hear that Walgreens has bought both I-Trax, Inc (CHC-Meridian) and Whole Health Management, two of the county’s largest operators of workplace health clinics.

“These announcements mark an important strategic initiative for us,” said Walgreens Chairman and CEO Jeffrey A. Rein. “Walgreens Health and Wellness division will marry our store clinics and pharmacies with worksite health centers and pharmacies. Our unique offering will allow large employers and health plans to provide care to employees and plan members at their worksites, and to dependents and retirees through our Take Care Health Clinics at local Walgreens drugstores.”

Are you thinking what I’m thinking?

Two Ways to Look at it

Now, there are two ways to looks at the situation. The first is to believe all the press releases and see this as a win – win for both patients and employers. Employees get inexpensive, on-site, convenient health care. There is opportunity for development of long term relationships with patients, which enhances interventions to treat chronic diseases, especially those that have a lifestyle component. Combine this with on-site fitness centers such as those offered by I-Trax and Whole Health, and you have a model for the development and maintenance of a healthy workforce.

Of course, the cynical way to look at it is to say that Walgreen’s acquisition of employer-based clinics is just another way for them to capture the prescription drug market. In this regard, it will be very interesting to see if Walgreen’s keeps I-Trax and Whole Health’s employer-based fitness center products as part of their business model. I suspect that they may not. A recent survey of employer based clinics found that while older clinics were more likely to include physical therapy and mental health benefits, newer ones were more like to to offer pharmacy benefits.

Workplace-based clinics have the potential to destroy ongoing doctor-patients relationships that employees may have outside the workplace (as happened to my patient and myself). Not to mention that they are gleaning the healthier patients, leaving the community-based docs to deal with the sickest patients while losing the revenue generated from primary and acute care.

One might also argue that this is more of what NHS Blog doctor calls the “dumbing-down of health care” – the shift away from highly trained and experience doctors towards lower level, cheaper providers. Because the truth is that most workplace clinics are staffed by mid-level practitioners “supervised” by an MD, who may or may not be on site. Thus, in return for convenience, employees will receive the bulk of their primary care from someone other than a doctor. Of course, that’s the way it is anyway in most managed-care primary practices these days (except of course, Dinosaur Doc’s ), so maybe this will be nothing new.

How big is the movement to employer-based clinics?

According to a recent article in the Milwaukee Sentinal, 23% of 600 large companies surveyed reported that they were providing health care on site for their employees. These include companies like Sprint/Nextel, Qualcomm and Pepsi, just to name a few.

Walgreen’s is not the only company getting in on Employer-Based Clinics. Some medical centers offer on-site care to large employers, guaranteeing their continued place in the provision of primary care and a nice referral base for their hospital and specialists. Individual physician practices may also contract with local employers to provide on site care.

What happens next?

Something tells me that pharmacy run employer-based health care is fraught with conflict of interest that may not necessarily be aligned with those of the employers or employees. But I think the business model is making sense for employers, at least from what I’ve gleaned in my readings on the topic. And if I were a medical center, or a primary care practice in an area with a big employer, I’d be thinking about scrambling to get those employer contracts for myself before Walgreen’s snatches them all up.

As for my patient, I was more than happy to do her colposcopy, and she decided she would stay with me rather than go back to her employer for follow up.

Still, I called her workplace nurse practitioner, gave her the biopsy results and sent her some of my cards. I figured at least I might be able to get a few more referrals before she puts me out of business.
______________________________________

Other Blog reactions to Walgreen’s announcement

Healthbeat Blog – “Health care is a public good, and as such, should be delivered by non-profit organizations overseen by government organization that reviews quality and is accountable only to the public.”(via Kevin, MD)

Brian Kleppert – if the physician community remains scattered and dis-united, it could spell the end of medicine as a cottage industry, and the next big phase of true corporate medicine in America.”

Listen to an NPR story on Employer based clinics

EMR Purgatory – Not a Bad Place to Be

It’s been 21 months since I was forced to convert to an electronic medical record, and I have just now reached the point where I can say that the EMR has had a positive impact in my practice.

Converting to the EMR is not easy. This conversion is not like getting dunked in the river and seeing the light. It’s more like going through Dante’s Inferno. It’s taken me almost 2 years to ascend through the Circles of Hell and I am in Purgatory right now – things aren’t perfect, but I can see Paradise in the distance, and I’m glad I’m here.

Here’s what’s happened, and what is different.

1. When things get hectic, I no longer reach for a pen.

This change took about a year, because you have to get to the point where you don’t have to think and everything is automatic. Now I just head to the computer and type like a madwoman.

2. I am getting really good at typing while looking at my patient.

And at spell checker.

3. Most of my visits are now closed by the end of office hours.

When you are converting to an EMR, every patient is like a new patient, because you need to input their history into the computer at their first visit on the EMR. There was no time to do this during office hours, so I would catch up at the end of the day, evenings or weekends. Since most of my patients only come once a year or so, it’s taken this long to get everyone in.

This is the largest and final circle of EMR hell. But the payoff for all that hard work is that now visit documentation is a breeze – just update the meds and history, click on the exam elements, type in my notes and I am done.

4. Most of my patients’ prescriptions are now in the system.

I can bang though my refills in a few minutes by just pointing and clicking. Pretty soon, those refills will be going straight from my computer to the pharmacy, though for now my secretary is still calling them in. Cleaning out meds lists, though, is becoming a little maintenance chore.

5. My colleagues are helping me (and vice-versa).

About once or twice a day I see a patient who also sees another member of our faculty, and that doc has already completed the history, meds and allergies. That just makes me smile.

6. The EMR is changing my referral habits.

I’m starting to learn which of my colleagues uses the EMR the way I do, and which just short-cut their way through.

When you first convert, it’s extremely tempting to just start creating text notes using the text editor and macros, ignoring the custom fields for history, meds and allergies. It gets your charts closed faster. But if you just use the EMR as a fancy word processor, you’ll never see its true benefits. Plus you’ll make my life harder.

So, if I need to refer a patient to a colleague in another specialty, all other things being equal, it’s going to be the one who uses the EMR the same way I do. The docs who update the history and allergies and clean out the medication and problem lists once in awhile.

7. EMR creates transparency between practices

This is something I had not anticipated with the EMR. More often than not, I am impressed with the care my colleagues are giving. And I’m discovering some great new docs this way who I had previously only known by name.

8. Communication between docs is a snap

Just forward on lab and path reports with a brief note. No more phone tag. I even messaged my own doc to ask for some refills to mail in to my online pharmacy. Cool!

9. Of course, things aren’t perfect.

  • I need our nursing staff to update meds and manage the overdue results box. (Staffing issues…).
  • They need to figure out a way to input radiology appointment dates so that every mammogram I order months in advance doesn’t come into my overdue box a few weeks later.
  • The lab and radiology have different systems, and the interfaces can be tricky. This means that my staff still needs to print out radiology referrals and lab slips.
  • The EMR is getting too large. In another few years, negotiating through a patient’s chart is going to become a nightmare. Just scrolling down a list of visits can be time-consuming, not to mention filtering out the ones that matter, like doc encounters, from the ones that don’t, like refills. This is a job for the programmers – finding a way to have information retrievable but not in your face at all times.
  • I still need a sticky note function.

10. Because of the EMR, I’m making more money.

Gotcha! (Check the date of this post.)_____________________________________________

To read my previous posts on the EMR, go here.

Silicone Treatment for Scars

It’s been 3 weeks since my Mohs surgery, and I’m becoming addicted to this little tube of silicone gel that my plastic surgeon gave me to use.

“Apply this 2-3 times a day to prevent scarring and redness” he said, uncapping the tube, smearing it’s contents on my newly-healed Moh’s incision and then gently rubbing it in. “Rub it in, pressing down to the bone. Let it dry, then you can apply make-up over it.”

As I left, his nurse commented – “Ah – I see you got “The Tube”. He loves that tube!”

It’s pretty cool that I can actually do myself to help the healing process along. It’s also oddly comforting to stroke my scar and feel the silicone covering on it. But the other night, as I applied the silicone gel, I found myself curious as to how this stuff worked. Was it just a little plastic surgery witchcraft or was it really doing something to prevent scarring and redness? So I headed to Pub-Med and did a little reading.

What I found was that this stuff really does work. Numerous controlled trials have shown that silicone sheeting treats hypertrophic scars or keloids and prevents such scars in the first place if used prophylactically. There is less data on silicone in other forms, such as gels and creams, but several studies suggest that they work as well as the sheets. My tube is just one of many brands of silicone products that now sell over the counter. I don’t know if there’s a difference between brands, thought I suspect they are probably all the same.

How do silicone sheeting and gels work to prevent scars?

No one knows for sure, but here is the current thinking – When a wound heals, the new skin that is made is immature and not as good an osmotic barrier as older skin. Thus, water is lost from the deeper layers of the skin. It is theorized that water loss from the stratum corneum leads to production of cytokines, which in turn increases the amount of collagen laid down by the fibroblasts there. (Collagen is the stuff of which scars are made.)

Silicone sheets and gels are thought to create an osmotic barrier that prevents evaporative loss of water from the wound, thus leading to decreased collagen and scar formation. Silicone sheets are the most studied, but are harder to use on the face where visibility is a problem and on joints where movement dislodges them. Silicone gels have the advantage of being easy to use, and the gel dries nicely to create a countered covering. Some specialists recommend using the sheets at night and the gels during the day.

Can’t I just Use Vaseline?

Nope. Apparently, Vaseline does not work to prevent scar formation. Nor do plastic sheets and other occlusive dressings. There is something about the osmotic barrier in silicone sheets and gels that makes it “just right” for the job. That something may not be the actual silicone itself, but the vehicle or matrix that it forms. Indeed, more recent studies using some non-silicone gels have shown similar efficacy to silicone, suggesting that the gel’s the thing.

What about steroid injections?

The other well-proven treatment for hypertrophic scars is steroid injections. But steroid injections are used on already formed scars, as opposed to silicone gel, which can be used to prevent scarring.

How about the rubbing?

The rubbing that I am doing is also helping my wound heal prettily by preventing the formation of collagen bands in the scar.

This young girl, whose parents have a wonderful site showing the evolution of her cleft lip and palate from birth through repair to age 10, rubbed cocoa butter on her scar. She looks great – a testimony to the use of pressure and rubbing (or 10 year old skin…)

Comments? Corrections?

This is my own little foray into a completely different field of medicine from that for which I was trained, so I hope that I have not made any glaring errors. I would love to know what my plastic surgery colleagues think about this topic (RL?). I don’t know, for instance, if one brand or type of gel is better than another, or what one should look for in a gel to be sure it will work.

That’s it? No shocking photos of scar tattoos?

Oh, all right – here. Just don’t say I didn’t warn you.
________________________________________________

Part 5 here

The Power of the Medical Blog

Dr Crippen has managed to get the BBC to change a headline, merely by criticizing it in his blog. He then got an apology from the writer of the article in question, which was about how MRI has a high false positive rate. This, of course, is not news. It is why MRI is not yet ready for prime time breast cancer screening. But like any good news outlet, the BBC had managed to make this piece of information sound utterly frightening, with the headline “Mri scans commonly wrong”.

This is not the first time the BBC has responded to Dr Crippin’s criticism by changing a story.

I find this entire episode amazingly encouraging. Our voice can matter, folks. Keep writing, keep taking on the powers that harm, and we will be heard.

Decorating Update

I promised photos of the paint job, and here they are.

The final color we chose was Benjamin Moore’s Richmond Gold with Cream Froth for the trim and contrast walls. (It’s really hard to get a photo that captures the color as it looks in real life, so I’m putting up a few to give you the idea. The first one below is in daylight and all the rest are in the evening.)

And then I saw this amazing wallpaper, and had to have that too.

I have to admit that as the paint was going up, I was a little scared that I did not like it. But as soon as things got up on the walls and the rugs down, I knew we had made the right choice.

Our prior color had been yellow, which I loved, but I think this new look is better. Look at the before photo below to see what I mean. (Don’t think the place looked this good before we painted – that before shot is almost 10 years old…)

Here another shot…

Need to get a runner for that back hall…

The living room is still a work in progress. We’re looking for something new to hang on the wall over the sofa. And a wood coffee table. And some new lamps. And a bigger rug. And another big comfy chair…

Thanks again for everyone’s suggestions and support through this process. I feel as though I’ve given birth.