Clinical Curbside

A blog for physicians, by physicians, offering thoughtful and thought-leading commentary on physician collaboration and diagnostic accuracy.

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   Andre Panagos
   Physiatry/ Pain Medicine/ Sports Medicine
   Spine & Sports Medicine of New York / NYU Lagone Medical Center
  @AndrePanagosMD  


I have always enjoyed stories and every day I am privileged to listen to the stories told to me by my patients. They are often stories of ecstatic delight or downright bone chilling fear and each and every day there is a new story to hear. Every once in a while I hear a different type of story from my patients, one which begins in frustration and despair, ends in relief and even humor, but can nonetheless cause cost, wasted time and possible harm. These are what I call “therapeutic misadventures.”

 Obliged to Image

 Late last week, at the end of a long day, a patient presented with lower back pain. Her pain was excruciating and she insisted on getting MRIs of her lumbar spine, hip, and cervical spine. She was worried that she had a severe injury following a fall.  I cautioned her against getting so many MRI studies but she was adamant that it was important to rule out “problems”.

The imaging studies came back with the suggestion of an unknown mass in her thyroid and upper lumbar spine area. On follow-up we reviewed the images and I was obligated to get even more imaging of her thyroid and thoracic spine to further clarify the previously visualized abnormalities.

Luckily, these imaging studies came back negative for any lesions and were otherwise unremarkable but this struck me as an interesting example of the “therapeutic misadventure”.  The patient responded well to our treatment which easily could have been delivered with one imaging study.

The Balance between Causing Harm and Avoiding Harm

I have always thought of adventures as an exciting time to step out of our normal daily activities to see something new in ourselves or in the world around us. In medicine, adventures can take very ugly twists and turns resulting in diagnoses and treatments that can be emotionally burdensome or downright deadly.

Hippocrates taught us to first do no harm, and so sometimes we are overcautious sending the patient a therapeutic misadventure.  However, what starts off as simple neck pain or a small imaging finding on an MRI can rapidly spin to become a therapeutic misadventure of several more imaging tests and multiple visits to specialists who divine no pathology in the patient.

It is worse if pathology is noted and a treatment plan is decided upon that makes the patient worse or is harmful. This not only increases costs, but also magnifies the adventure no one wants to take, talk about or even remember.

Listen to the Story to Help Write a Happy Ending 

Increasing productivity pressures of today’s modern medical care can be partly to blame.  I think physicians are very good listeners, it is just a question of having time to listen. While pressed for time when evaluating a new condition, we substitute time for laboratory work, imaging tests and referrals to super-specialists.

There will be patients that have very long stories to tell. You know these patients when they present to your office with hefty stack of progress notes, imaging reports and procedure notes as well as several imaging CDs. Once I had a patient bring along with her a large file box of past medical records.

However, to deliver the best care we can as physicians, it is essential that we listen. With the tectonic changes in medicine, only time will tell if we are given this opportunity to not only prevent these sometimes spectacular adventures but also bring those tales that are still being written to a happy ending.

Reference:

http://online.wsj.com/news/articles/SB10001424052702303426304579403041504577658 



  Eric Glazer
  Vice President, Physician Engagement
  Best Doctors, Inc

Illness is a great equalizer. The uncertainty and loss of control which accompany a serious medical condition universally breed fear, regardless of a patient’s age, social station or educational level. Illness even befalls physicians, despite their intimate knowledge of how to keep illness at bay.

Recently Dr. Danny Sands, co-founder of the Society for Participatory Medicine and, and co-author of Let Patients Help! (with David Dave deBronkart “ePatientDave”), became a patient himself.

The resulting blog post is a must-read for physicians, especially those lucky enough to have never before personally experienced a serious medical condition. As we move (slowly but surely) into an age of the “partner” patient, it’s important for physicians to remember that no matter how savvy, educated and engaged a patient may be, they are still facing circumstances that are scary, uncertain and raw.

On the Ultimate Loss of Control, Living with Uncertainty, Reflecting on the Future, and Being a Patient

image  Eric Glazer
  Vice President, Physician Engagement
  Best Doctors, Inc



Dr. Miguel-Angel Perales, Deputy Chief of Adult Bone Marrow Transplant Service and Director of the Adult Bone Marrow Transplantation Fellowship Program at Memorial Sloan Kettering Cancer Center, said recently on a webinar about online physician collaboration:

“It’s a responsibility of ours to participate in the online medical discussion because there is a lot of ‘bad science’ out there. As physicians, we need to participate and educate, and social media can help us do that.”

Social media’s advantages in fostering patient-physician communication have been often and duly noted, but Dr. Perales’ quote can be applied to physician-physician communication as well. By connecting with peers on social media sites like Twitter and even LinkedIn, physicians can harness the “wisdom of crowds” to both learn from and advance the collective knowledge of the medical community.

Three Tips for Physicians Using Social Media Channels

If you’re interested in using public social media channels, like Twitter of Facebook, Dr. Garry Choy, Dr. Matt Katz and Dr. Ryan Madanick, all panelists on the webinar referenced above, recommend the following:

  • Start small.
    With so many social media channels out there, it’s easy to feel overwhelmed. Choose one, or maybe two, channels based on what you’d like to accomplish on social media.

  • Define objectives.
    Are you using social media to connect with other physicians, or to increase your practice’s visibility? Defining your objectives will help you decide which channel to use, and what messages you’d like to convey through it.

  • Be smart.
    Keep in mind that, while the social media channels available are fantastic tools for connecting you with peers and patients, it is always advisable to err on the side of caution when discussing professional matters on a public social media site.

This Physician’s Guide to Twitter can help you determine if that’s the channel for you, and there are several webinars on Best Doctors YouTube channel that can help you explore how best to use social media in your practice.

Benefits of Private Physician Forums

Private forums can help avoid some of the privacy concerns of social media. Cloud-based platforms like Medting, powered by Best Doctors, offer a customized, gated software solution to physicians for case collaboration and knowledge sharing. You can think of it as a LinkedIn group, but in a secure environment purpose-built for clinical collaboration.

In a private forum, doctors can curbside peers or give advice on challenging cases. They also offer the distinct advantages of purpose-built clinical collaboration tools, such as high-quality image sharing and viewing, and the ability to compile a dedicated case library for use in medical education or research.

But be careful: not all physician communities are created equal. Look for online physician communities that can deliver:

  • Focus on case collaboration, not just linking physicians socially in an attempt to be a “Facebook for physicians”
  • User profiles that are vetted and informative, meaning you know exactly who you’re collaborating with
  • Gated workgroups, managed by you or your healthcare organization, for collaborating on cases within your own community

This Physician’s Guide to Online Medical Communities can help you choose the forum that’s right for you.

If you’d like to learn more about Medting, contact me at eglazer@bestdoctors.com or 617.226.3623 and I’d be happy to give you a demonstration.

Asker Anonymous Asks:
How does Best Doctors, Inc. choose the doctors on their list?
curbsideconsult curbsideconsult Said:

Thanks for asking! Best Doctors are selected through a peer-polling process in which physicians nominate and vote for their colleagues. You can read more about it on our website: http://www.bestdoctors.com/about-best-doctors/our-doctors 



  Reza Michael Mozayeni, M.D.
  Ophthalmologist
  Selected Best Doctors in America® (2007-2014)
  Providence Eye & Laser Specialists
  Providence Eye | @Providenceeye


When you buy a house, they say location, location, location.  When it comes to patient care, I say communicate, communicate, communicate.  And to be clear, I mean two-way communication.

I spent nearly a decade studying to be a physician and, more specifically, a cornea-trained Ophthalmologist.  But in all those classes, labs and clinics, very little time was ever used to discuss, let alone, teach “communicate.”

Today as the Founder and surgeon of Providence Eye & Laser Specialists, an 11-year-old LASIK eye surgery practice in Charlotte, North Carolina, I know more than ever that communicating with patients is the key to providing excellent patient care.

As a physician practicing in today’s challenging medical world, we are all pushed to see more patients in the same eight-hour day.  And this does not take into consideration the additional demands that have been placed on physicians such as EMR implementation, documentation, and HIPPA requirements.

“So why should I take the time to communicate with my patients,” one may ask, “and how does that provide excellent medical care?”

Here are five reasons why you should have two-way communication with your patients:

  • Build Trust - Chat with your new patient for a minute or two; it will pay off.  This is a very important relationship and it needs to begin with trust.  Trust can only be built slowly and needs to start with some friendly communication.

  • Learn their Motivation - Listen and learn what is motivating your patient. With this bit of information you and your staff can articulate benefits that the patient cares about.  For example, if their motivation is to improve their golf game, they may not be concerned about their near vision as much as their distance vision.  Or, if they are an avid reader, they may be more concerned with near vision correction.

  • Educate – Hopefully, your patient has elected to visit you because they feel you are an intelligent, excellent doctor.  You should still demonstrate that to them while understanding they are looking to you for answers.  Don’t assume they know everything just because they read your website or saw it on YouTube. Teach them about their specific situation, in their terms.

  • Set Expectations - Be clear and reasonable about expectations.  LASIK eye surgery has become so popular for some it is considered foolproof and the experience is same for everyone regardless of age, prescription, astigmatism etc.  This could not be further from the truth.  Every person’s eyes are different and LASIK can be extremely successful for most people, but you must clearly articulate what the patient should expect and when.  For example, patients with high prescriptions will see an immediate improvement when they sit up from the laser.  Those with a lower prescription may expect the same but that is not the case.  You don’t want your LASIK patient to ever be disappointed, so tell them what they should expect throughout the entire process.

  • Keep in Touch – Just because your patients have left your office, and they may even be “done” with their eye surgery procedure, does not mean you should stop communicating.  If you care, I mean really care, about them, ask for their opinion, read it, and act on it if necessary. There are several ways you can do this. For instance, you can send a simple e-mail or receive feedback through a survey. 

If you’ve built trust by communicating with your patient and have met their expectations, it is now time to ask for them to tell others. Encourage patients to visit your social media pages, write feedback and reviews and tell their friends and family.  If you’ve done your job as a great doctor and a great communicator, your patients will take pleasure in telling the world how great you are.  Just think of the return you will get all just by taking a few extra minutes to communicate.

Asker Anonymous Asks:
My father in law is a diabetic and on a cocktail of prescriptions for other conditions. He is 70 years old. Recently, he has been passing out after he gets up from the couch etc. His doctors are stumped cause they have done all kinds of tests and found nothing. His BP is ok. Pulmonary tests are good. This is not right. Who do we go to?
curbsideconsult curbsideconsult Said:

I’m so sorry we can’t make physician recommendations. It must be very frustrating for you to watch your father ail, and we sincerely wish him a recovery to full health soon.

image  

  Kelli Cleary
  Content and Programming Manager
  Best Doctors, Inc.

It’s been over a year since our last webinar on how social media can change the way physicians work together. In that time, the healthcare and social media (HCSM) rallying cry has grown louder, and also more nuanced. In an amazingly short period of time, we’ve seen online physician collaboration go from 140-character curbsides on Twitter to the development of gated, physicians-only medical communities which facilitate secure sharing and commenting.

Our recent physician panel discussion (and a re-launch im  of our HCSM webinars!) covers how real physicians (Dr. Garry Choy, Dr. Matthew Katz, Dr. Ryan Madanick and Dr. Miguel Perales) are using online medical communities in their daily practice, and how you can do the same to realize the real patient benefits of harnessing the wisdom of the medical crowd.

In the spirit of sharing HCSM information, I’ve put together these four articles which are HCSM must-reads for the progressive physician in this week:

Digital Health Is Nothing Without Communication

As the healthcare industry struggles to deal with ever-growing data and an influx of digital health innovation tools, it’s imperative to remember that the data and innovations should ultimately improve communication amongst doctors and between doctors and patients.

The Advent of Digital Health

It’s shaping up to be another record year of healthcare innovations, spurred in part by the Affordable Care Act, but also by patients and providers who are embracing digital health technology from web portals to body sensors.

How social media can combat chronic disease

A new eHealth Initiative report shows how social media and online communities are helping patient improve health but connecting patients and providers and allowing them to share health information, goals and results.

Survey: Despite risks, patients want to share data

It seems the patient is aboard the HCSM train, according to a PatientLikeMe survey which found 94% of adult patients were will to share health information on social media to improve their outcomes for others. Social is powerful, for patients and providers alike.

By the way, you can get HCSM content like this delivered to your inbox weekly but subscribing to our HCSM newsletter. Subscribe here!

   

   Garry Choy, MD, MBA
   Department of Radiology
   Massachusetts General Hospital

Dr. Matt Katz, a panelist on a free, upcoming Best Doctors webinar (eCurbsides to Tumor Boards: Real Patients and Real Benefits of Online Medical Communities) wrote earlier this month about the benefits of using online crowdsourcing tools to improve clinical trials.

His application of the “wisdom of the crowd” theory is apt and timely. I’ve applied the same in the creation of radRounds with great results. When we first conceived a network of social media sites in healthcare and specifically radRounds in 2005, we wanted to bring radiology online, to create a site that connected physicians and healthcare providers around medical imaging.

Today, we have over 11,000 members and growing. The success is encouraging, but it’s the collaborative networks and relationships the site has helped establish which is the most satisfying. We’ve successfully built a reliable online medical imaging tool, and true to our vision, we’ve done much more than that: we’ve created a medical imaging community

We have been able to facilitate collaborative discussions around cases, the formation of new friendships and professional contacts, new research collaborations, and the education of radiologists globally.

Next Thursday (2/6, 8 PM ET), Dr. Katz and I will join Dr. Ryan Madanick and Dr. Miguel Perales as panelists on a Best Doctors webinar to share how you can harness the power of collaborative medicine with online medical communities.

We’ll show you how to:

  • Hold successful tumor boards without the usual time and resource constraints
  • Simply and easily share information that enables more effective collaboration
  • Expand your consultation network with trusted experts
  • Add another diagnostic tool to your arsenal, for when UptoDate just doesn’t have the answer

REGISTER HERE

We hope to see you there! The future of medicine will hinge on physician collaboration through online platforms. When doctors share and comment on cases in a secure, online environment, they pool their collective knowledge and offer unprecedented access to information unbounded by restrictions of time or geography.

(To register for a recording of this webinar, click here.)


   Jennifer Derebery, MD
   Associate at House Ear Clinic, Inc
   Clinical Professor, Department of Otolaryngology at the University of Southern          California School of Medicine 

Though dizziness symptoms are common, I consider diagnosing the cause challenging due to the complexity of their possible origins. When diagnosing dizziness, I like to use the “three-legged stool” approach that places the brain as the master center of balance or the seat of the stool; with the three legs supporting the seat refer to the dizziness’ origin. The three legs are as labeled:

  • Vestibular System – The sensory mechanism in the inner ear that detects movement of the head and helps to control balance
  • Proprioceptive System – The sensory receptors that are found in the skin, muscles and joints that are sensitive to stretch or pressure in the surrounding tissues
  • Visual System – The sensory receptors in the retina when affected send impulses to the brain that provide visual cues identifying how a person is relative to the other objects they are looking at

Using the “Three-Legged Stool” approach to pinpoint the high level sources of the dizziness, you can begin to refine your original diagnosis. I also, outlined three types of differential diagnosis:

  • Peripheral – Inner Ear
  • Central – The Brain
  • Systemic – Leading to a symptom                             

After going through the basics, make sure to incorporate the patient in the diagnosis.  It is essential to make the patient feel like they are contributing to their own diagnosis, so make it a point to ask the patient two important questions when diagnosing dizziness: 

  • What the patient means by dizziness
    • Does the patient feel they are “spinning,” as with vertigo?
    • Do they feel “drunk” or imbalanced?
  • Timing of dizziness-  Depending on the time frame, diagnosing the cause of dizziness can vary
    • Seconds of dizzy sensations could indicate benign positional vertigo
    • Minutes of dizziness could indicate a circulatory problem
    • Hours of dizziness could indicate Meniere’s or migraine
    • Days of dizziness could indicate viral labyrinthitis, and probably excludes the possibility of an inner ear problem
    • Constant dizziness probably does not indicate a primarily otolaryngological disorder
    • Whether the patient is experiencing  hearing loss problems in one half of the inner ear can often affect the other
    • The pattern of the hearing loss can also offer clues to inner ear problems
    • Presence of hearing loss symptoms, plus the timing of the dizziness, are two strong indicators in the source of dizziness

The severity of the diagnosis can be quickly made through a proper imaging study and physical examination. Determining whether it is a hemorrhage or a central nervous system problem can be accomplished with a simple exam or imaging study.

Recurring symptoms of benign positional vertigo can often indicate migraine. Keys indications are headaches or other forms of head discomfort, but also can include motion-induced dizziness such as spinning or imbalanced sensations, even if they haven’t experienced these symptoms in several years. Ask the patient whether they are bothered by light or loud sound: these symptoms would also indicate possible migraine. For treatment options, watch Diagnosing Dizziness: Tips for the Primary Care Doctor.

For more information on diagnosing dizziness, please check out the video below or watch the whole webinar here.

   

   Shabbir Hossain
   Internist, Stony Brook School of Medicine
   @ShabbirHossain | Shab’s Sanatorium

This post also appears on the Stony Brook Internal Medicine Unofficial Blog

I’ve been on Twitter for almost a couple of years now and when I talk to people about it, I still get a healthy dose of skepticism.

So I’ve put together a top ten list of why as a physician and medical educator, I use Twitter.

10: Connecting with Leaders

To be lead, you must know what your leaders are thinking. Twitter has made leaders accessible. Now, instead of spending time looking for their opinions or hoping to catch a handshake or meeting at a conference, they send their thoughts directly to me, in small increments of 140 characters, everyday!

9: Connecting with Followers

As physicians, you are a leader. Whether it ‘s in your office, your patient panel, your learners, your colleagues, your academic society, you have the opportunity (and responsibility? ) to lead and lead effectively. Twitter allows you to share your thoughts in small increments, reach a vast audience with minimal effort. Quoting #10, “To be lead, you must know what your leaders are thinking.”

8: Networking

The importance of professional networking cannot be understated. Twitter easily connects people with similar interests. In less than 2 years, I have been able to access a vast network of people interested in things that are important to me such as Primary Care, Medical Education, Social Media, Evidence Based Medicine and Healthcare Technology. In the past, networking for me occurred in spurts, at pre-determined locations over a finite period of time. With Twitter, networking happens 24/7, with little effort no matter where you are (and in your pajamas, while watching tv!).

7: It makes me an active learner

All through my education I took notes. Writing things down helped solidify that piece of knowledge. A notebook was also useful for exams, reviewing and reinforcing information. Now instead of a notebook, I have a tablet and instead of a piece of paper, I use twitter. The 140 character limitations forces me to be succinct which makes my virtual notebook very easy to review.

6: I can educate the world

This is a grandiose statement, but Twitter makes it real. As a Medical Educator, I take pride in being able to influence the learners in my immediate proximity. With Twitter I can take all those notes  (See reason #7) and broadcast it to learners in other cities, states, countries and continents! Currently I’m using the the hashtag #sbmgr to broadcast what we’re learning in our Internal Medicine Grand Rounds every Wednesday 8:30 to 9:30 AM.

5: I can attend multiple conferences simultaneously, year round

Until human cloning technology advances, Twitter is the best way to be at multiple places at once.  I wish I could attend every medical conference out there. But thanks to people who prescribe to reason #7, I can virtually attend other conferences through my smart phone, all throughout the year. There are thousands of people out there like myself, live tweeting from conferences. This year, I personally attended ACP and APDIM live tweeting from both. But in addition, while being back home, I followed the tweets from Kidney Week and Chest in the past couple of months.

4: It’s a forum for debate

Healthy debate is part of our lives as physicians. New guidelines and treatments are always coming up, and Twitter I get immediate access to viewpoints from a wide variety of people. I often get immediate feedback on my own opinions.

3: My mom taught me to share

We are all online, all the time. As a physician, I’m always finding a great journal article, an interesting blog,  or an important news article. Before twitter, I had no mechanism to share that, besides e-mailing to a small set of people or writing it down somewhere and hope that I have an opportunity to suggest it to people. Now, every website has a Twitter link. You see something cool, you can share it with a large audience with just a few clicks.

2: The world at any given moment

Whenever I have a free moment, Twitter  is my go to activity. In 2 minutes, I can scroll through a myriad of messages and get a burst of information from a network of my choosing.  So it’s whether pumping gas, waiting for an elevator, a 15 minute lunch, a commercial break during the football game, Twitter helps me use these small snippets of time, constructively.

1: It broadens my mind

In patient care we are emphasizing a team-based approach that values the roles of every individual in a healthcare team. The same can be said for my continuing medical education. I think I have something to learn, from everyone. As a result I follow folks in Internal Medicine, sub-specialties, family medicine, psychiatry, surgery and so on. I follow nurses, physical therapists, social workers and patient advocates. I follow patients (not my own) sharing the story of their medical conditions. I am learning something from everyone from the palm of my hand.

If this doesn’t get you interested in Twitter, here’s a a blog post from someone who’s listed 140 Health Care uses for Twitter:

http://philbaumann.com/140-health-care-uses-for-twitter/

In addition, here’s another post to help you make the leap.

Top Twitter Myths and Tips

This is written by Dr. Vineet Arora who is Director of GME Clinical Learning Environment Innovation and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago.