Clinical Curbside

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

Opinions reflected here are those of the physician authors and are not necessarily endorsed by Best Doctors, Inc.

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  Bruce Friedman, MD
  Medical Director, Critical Care, Best Doctors, Inc.
  Critical Care and Co-Director, JM Still Burn Center


Over the past 30 years, hospitals have become acute care centers. In order to be admitted to most hospitals, the patient is often very seriously ill, requiring various monitoring devices, multiple diagnostic and other interventions and, in many cases, needing some level of intensive care.

The vast majority of these patients present not only with their acute admitting diagnosis but with multiple premorbid conditions. The combination of an acute disease or injury state with the complexity of these comorbid, multifaceted diagnoses leads to significant challenges for the hospital-based physician and their treating teams.

Compounding these individual challenges, the Hospitalists or the Intensive Care physicians must manage as many as 20-30 patients per day, all of whom are at various levels of acute critical illness. This, despite excellent support systems including physician extenders, nurses, fellows, residents, ancillary staff and other physician consultants, can be a daunting and overwhelming task.  

The Toll of Diligent Care

When faced with a patient who is substantially critically ill the critical care practitioners must begin the arduous task of source control: the preemptive and constant management of the complications that a patient often encounters during their critical illness. This includes the interventions that might prevent further deterioration in the clinical picture such as infectious disease prevention and management, continued nutrition support and analysis, and the multiple efforts that are required to help the patient return to as normal a state as conceivably possible within the limitations of their total injury. 

It’s an enduring effort that extends beyond the first few days of the injury or complex disease presentation. The patient requires diligence to maintain what I call “providing a net.”  These are strategies to preserve source control far into the patient’s course of illness from tactics used in the acute hospitalization to those stretching throughout the long-term acute care (LTAC) facility, rehabilitation phase and even the initial outpatient recovery period.

Best Doctors: A Support Solution

The complexity of today’s hospitalized inpatient population and the increasing numbers of critical care cases straining our modern-day health care system present a phenomenal opportunity for the Best Doctors model in the critical care arena.

Our Critical Care team and multiple cadre of designated experts can evaluate patients presenting acutely with a severe trauma or critical illness within in the first few perilous days of their injury or complicated disease state. The rapid provision of this initial and comprehensive overview, summary, and suggestions and recommendations provides a solid foundation to building effective source control.

This second opinion, that complements the already thorough care plan initiated at the treating facility, offers a channel for enduring dialogue that can proceed throughout the acute hospitalization and into the rehabilitative and recovery phases. Evidence-based data has not only shown that we can reduce direct and indirect healthcare costs, but more importantly, this “source control” prototype has touched and influenced individual lives and families throughout our nation as well as globally. 

By offering well-referenced and detailed suggestions in areas such as pain management, wound, orthopedic, surgical and neurosurgical care, nutrition support, respiratory interventions and other organ system preemptive prevention strategies not withstanding the all-important infectious disease collateral damage control; the Best Doctors critical care synopsis provides solace to desperate, scared and confused family members as well as collegial, non-threatening and collaborative information that the overburdened treating team most often welcomes. 

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  Leana Wen, MD
  Emergency Medicine 
  George Washington University
  @DrLeanaWen www.drleanawen.com


From an early age, I knew I wanted to be a doctor. In medical school, my mother was misdiagnosed for a year before she was finally diagnosed with metastatic cancer. Through this experience I learned how important it is to learn to be your own best advocate. Getting to the right diagnosis is so important because if the diagnosis is wrong, then so is everything else that follows. The story and history behind one’s illness is critical to getting to the right diagnosis. Best Doctors and I have synergistic messages, stressing the importance of a second opinion and speaking up when something isn’t right.  

For more Best Doctors videos, click here

For more information on Dr. Leana Wen’s recently published book, click here

   


  Kevin Campbell, MD, FACC
  Cardiologist at Wake Heart & Vascular
  Healthcare Consultant
 @DrKevinCampbell | DrKevinCampbellMD.com

This originally appeared in Dr. Campbell’s personal blog on May 24, 2014

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

For physicians, the possible applications of tablet technologies are endless.  Ultimately, I believe that these mobile technologies will revolutionize medicine and allow for care to be provided to patients who have previously been underserved.  Tablet based electronic patient encounters are on the horizon.  As physicians we must ensure that we continue to embrace technology and we must not resist change–medicine remains both a science and an art.  We must continue to strive to incorporate BOTH technology and human touch into our patient encounters.  Change is coming–we must adapt and embrace these technologies in order to provide our patients with the healthcare and caring that they deserve.




  Kevin Campbell, MD, FACC
  Cardiologist at Wake Heart & Vascular
  Healthcare Consultant
  @DrKevinCampbell | DrKevinCampbellMD.com

This originally appeared in Dr. Campbell’s personal blog on May 11, 2014

The digital age of medicine is upon us.  This past week at the opening Plenary session at the Annual Heart Rhythm Society Meetings, we heard Dr Eric Topol and others tell us that we must embrace social networking in order to engage patients and improve care.  The Affordable Care Act has now changed the landscape of medical practice in the US–we must do more to focus on preventative care and work harder to curtail costs.  More patients are insured and a primary care shortage is upon us (according to data from the AAFP).  In fact, it is estimated that we must create an additional 65 training spots in primary care every year for the next 10 years in order to keep up with the demand–this is assuming that the AAFP estimate of a 25% growth in workforce will be needed to meet the growing pool of insured Americans.  In addition, preventative services will require frequent follow up, patient engagement and support services.

Patients are more connected than ever–most patients now go to the internet to prepare for office visits and come armed with lots of information.  Office visits are already now dominated by keyboards and EMRs–it only seems logical that the next step will be virtual access for physicians and patients.  With growing primary care shortages and an increasing pool of patients needed access to care, telemedicine is likely to play a much larger role in the future.  The concept of telemedicine is not new–remote areas and hospitals have been utilizing telemedicine consults in order to provide specialist support for primary care physicians with limited access.

This week, the Wall Street Journal’s Belinda Beck reported on the growing telemedicine business–doctors seeing patients via computer portals from nearly anywhere in the world.  Several web based companies are now regularly hosting virtual doctor visits online where physicians and patients interact via phone and internet.  Patients describe symptoms and discuss issues with their virtual doctor and are then prescribed therapy–all for a cost of only 40-50 dollars.  Most visits are completed within 15 minutes and no travel is required for either doctor or patient.  Advocates argue that for simple straightforward problems telemedicine visits are much more cost effective and also provide high quality efficient patient care.  Critics have voiced concerns over the quality of care, lack of doctor-patient relationship and the over-prescription of antibiotics.  Some argue that when a virtual visit occurs, diagnosis is made more difficult due to a lack of physical exam.  In addition, data obtained by the Wall Street Journalfrom Rand, indicate that virtual visits are more likely to result in the prescription of an antibiotic.

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(Graphic from JAMA Internal Medicine and Published in the WSJ)

As you may expect, guidelines from regulatory agencies and medical boards are currently in the works.  Virtual physicians will be held to the same standards as in person office visits and continuity of care is being encouraged by allowing patients to choose their virtual doctor rather than have the provider randomly assigned.  In addition, the Federation of State Medical Boards is now recommending that all virtual doctors are licensed in the state in which the patient that is treated resides.  However, this particular requirement for licensing does not really make good sense if the objective of telemedicine is to provide care to those with limited access to physicians.  Virtual medicine has the potential to meet significant primary care needs in remote, rural and underserved communities and may be an alternative to in person treatment of simple, straightforward medical problems.

As we continue to reform the US healthcare system, many challenges must be met and overcome.  Providing affordable, high quality, efficient care to a growing number of insured Americans is a significant task.  With the advent of digital medicine and advancements in mobile technologies, it is now possible to provide care to patients who may otherwise remain unserved.  Wearable sensors, mobile devices that can obtain real time electrocardiograms and other technologies in development make it possible to receive diagnostic data from remote locations. In order to be successful, we must embrace change and utilize the digital tools that are now available to provide care to those who so badly need it.





  Mark Lewis, MD
  Assistant Professor in General & GI Oncology, MD Anderson Cancer Center
  marklewismd

"Are we still friends?" 

It’s the half-joking question I pose as I walk into the exam room of the patient to whom I have just administered chemotherapy. The first treatment is always instructive and clarifying for both of us, preceded by the hazy prophesying of informed consent. I like to mock the television commercials for prescription drugs, so artfully composed by the pharmaceutical companies, who run a breathless audio description of their product’s most fearsome side effects with deliberate incongruity beneath video of smiling attractive couples on adventurous vacations. But if I’m honest, I’m guilty of the same salesmanship, rushing through the litany of potential outcomes (and similarly likely to mention death as fleetingly as possible) before advising my patients to sign on the dotted line with the assurance that, in my professional medical opinion, the benefits likely outweigh the risks. For all the talk of darkness, the future looks bright. 

How differently things can seem at our next encounter, ideally meeting again during a scheduled office visit but sometimes in the ER, on the hospital ward, or in the ICU. That laundry list of possibilities with which I deluged them at our prior appointment has now been narrowed, distilled into a present reality that might include intractable nausea, cholera-like diarrhea, or febrile neutropenia. Clouds have intruded on a sunny forecast, and it’s time for the weatherman to accept blame. 

I do my best to survey the damage, even quantify it (although I have yet to meet a patient who describes their disabling paresthesias as grade 3 neuropathy); make adjustments (I have great empathy for the coach whose team is losing badly at half-time); and then move on, mingling my regret with the sincere hope that things will be better the next time, learning from the past lest we be doomed to repeat it.

So when I ask the patient if we’re still friends, it’s a feint towards an admission of guilt. I recognize this is the life cycle of an abusive relationship: I inflict harm, I ask for forgiveness, I try to re-establish trust, and then I do it all over again. We even number the chemo treatments in cycles, reminding ourselves of time’s flat circle, the not-so-merry-go-round. Along another axis, it can be seen as a roller coaster: a plunge into toxicity, an ascent back to baseline, and then another precipitous decline. 

The ethics lessons from first-year medical school resound accusingly in my head: primum non nocere —  First, do no harm. As a student this seemed a self-evident, easy morality (and boy, don’t I sound sophisticated saying it in Latin?!). But it turns out to be a precept that’s extremely hard, if not impossible, for a medical oncologist to follow. I am a blunt instrument, and I cause collateral damage despite my best intentions to take careful aim at an often-elusive target inside another person. 

In truth, this is not friendship but it is undeniably intimacy. I have a fiduciary responsibility to these people who were unfortunate enough to fall under my care, who tell me their secrets while wearing flimsy gowns in cold rooms, who make their lives and bodies an open book to me that I might help them. In return for their faith and transparency, I try to make their lives longer, or at least better. I just wish I didn’t have to make it hurt so much. With friends like me, who would want friends?

 


   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.