Clinical Curbside

  Diane Radford MD, FACS, FRCSEd   @dianeradfordmd   www.DianeRadfordMD.com

Whenever I watch an awards show like the Emmys or the Oscars, I wonder why we don’t have such awards for physicians. So many professions have recognition for a job well done, an accolade, and a confirmation that the training, the effort, the long hours, the toil, has been recognized. In industries ranging from film to theatre to the culinary arts, there is an effort to reward those who are remarkable. Even my father — a tailor —was honored by Tailor and Cutter Magazine for his bespoke skills. He won the Donegal Trophy for craftsmanship in Ladies’ Suits and the Medal for Ladies’ Couture. My mother was lauded as an excellent teacher.

In sports, too, outstanding performance is hailed by winning the Heisman trophy, Olympic medals, the World Series, and the Super Bowl. Who holds the Heisman trophy for surgery? Or the lifetime achievement award for nephrology? Who wears le maillot jaune for primary care?

Recognizing Medical Excellence

Our patients’ confidence in us and their thanks is oftentimes our award. The folder full of cards and hand-written notes from patients is the equivalent of my People’s Choice Award. We don’t do what we do because we want a trophy. We don’t seek a gold star.

To me, Best Doctors® represents the physician equivalent of the Oscars. Members of the Academy of Motion Picture Arts and Sciences vote for the Oscar winners. Peers voting for peers. I am honored that I’ve been chosen by my peers to be listed on the Best Doctors® rolls every year since 1996 — eighteen consecutive years. Eighteen years on the red carpet. Eighteen years of recognition. Eighteen years in the August edition of St. Louis Magazine, which features the Best Doctors in America® List.

I thank those who voted for me, and I thank my parents — the tailor and the teacher— who taught me never to give up. If they were still alive, I would mail them a copy of the August St. Louis Magazine, so they could see their child followed their example of striving to do my best in my chosen field.

  Eric Glazer   Vice President, Physician Engagement and Social Media   Best Doctors, Inc.

In Part 1, we looked at some of the barriers that physicians face related to diagnostic error. Now let’s explore a few solutions to help improve diagnosis.

 The reporting of diagnostic errors has always been inconsistent. Not surprisingly, in a profession that all but demands 100 percent accuracy, the culture can frown on physicians admitting any level of fault.

 When offered choices as to which action would most encourage the reporting of diagnostic errors, a majority (55 percent) of physicians felt confidentiality was an important enticement: Three out of ten (30 percent) physicians felt “incentives for hospitals from state and federal lawmakers to participate in confidential misdiagnosis data gathering and reporting” would be most helpful; 25 percent selected “confidential reporting/data-sharing on misdiagnosis as part of hospital accreditation.” 

Some physicians believe that “increasing the number of national events and conferences devoted to misdiagnosis” (17 percent) would most encourage reporting, while others saw a strong need for “a national voluntary misdiagnosis reporting system” (17 percent). Only 11 percent thought “a local champion that would encourage reporting” was the most beneficial action.

 Although encouraging physicians to report diagnostic errors is an important first step in elevating the issue, preventingerror is even more essential.

 When physicians were asked what they believe would be useful in improving diagnosis, the top three answers selected were “education about commonly misdiagnosed conditions”, “providing clear diagnostic algorithms for critical conditions” and “development of a secure online environment for collaboration with peers on challenging cases.”

These promising solutions to improve diagnosis will form the backdrop for the Diagnostic Error in Medicine 7th International Conference in Atlanta, September 14-17. Organized by the Society to Improve Diagnosis in Medicine (SIDM), the conference will bring together physicians, patients and public policy leaders to focus on topics including:

Reducing Diagnostic Error Through Improvement of Laboratory Test Utilization

Error, Overconfidence and Inadequate Feedback: Prospects for Systems Improvements

Clinical Decision Support — Bedside Tools for Better Diagnosis

Understanding and Misunderstanding Diagnostic Testing: A Source of Diagnostic Error

Placing Diagnosis Errors on the Policy Agenda

  Eric Glazer   Vice President, Physician Engagement and Social Media   Best Doctors, Inc.

In the March 2009 Journal of the American Medical Association, David Newman-Toker, MD, Ph.D., and Peter J. Pronovost, MD, Ph.D., of Johns Hopkins University, cited an estimated 40,000 – 80,000 US hospital deaths result per year from misdiagnosis. To help put an end to this preventable harm, Best Doctors surveyed more than 1,300 physicians in specialties ranging from allergy and immunology to vascular surgery to get their perspective on this problem and how to solve it.

In general, the study found that doctors are very concerned with misdiagnosis (a diagnosis that is wrong, missed, or could have been made much earlier): over 7 out of 10 doctors (71 percent) view the problem as “extremely important” or “important” compared to other adverse patient outcomes. Only 3 percent of physicians reported that a misdiagnosis was “not at all a problem.”

However, many physicians don’t see diagnostic error as an issue in their practice but rather a problem in other doctors’ offices. In fact, 20 percent cite a misdiagnosis in their practice “almost never” occurs while 39 percent estimate it happens “once a year.” Still, some physicians (34 percent) say a diagnostic error occurs in their practice “about once a month.” It’s often difficult to pinpoint the reasons behind a misdiagnosis. It’s certainly not about a physician’s ability, nor does it mean a doctor doesn’t care. Rather, there are a variety of factors that can contribute to a misdiagnosis. When physicians were asked to choose the most significant barrier to improve diagnostic accuracy, the results confirmed problems that have existed for too long in the health care industry. The top reason chosen by 35 percent of physicians was “fragmented or missing information across medical information systems” followed by “inadequate time for patient evaluation” (30 percent) and “incomplete or inaccurate medical history provided by the patient” (19 percent).

Check back here Thursday for part two and see what physicians feel are the most useful ways to help improve diagnoses.

  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. 

        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. 

      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.

  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.

(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.

  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. 

     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:

  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 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.

  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.

  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. 

     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.

       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.

   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.