Introducing Cancer Survivors New Normal with Dr. Linda

Dr. Linda as we know her is introducing her new video blog series that focuses on cancer survivors and the "new normal" that occurs after a cancer diagnosis. No one, I repeat no one can know what it's like to have cancer more than Dr. Linda Timmerman. She is a two time cancer survivor and a life long educator. Plus, she understands the pain, terror, and crisis that people feel when cancer enters their lives. Please help me welcome Dr. Linda to docdano.com.

When health care research meets Trip Advisor

This is the time of year just after spring break when I enter the stress zone of planning the summer vacation.

I'm always on the quest of making everyone happy.

Finding some place that I can afford, where the kids will have fun and maybe get to experience something new, is always a challenge.

So, I search the internet far and wide for good deals and destinations.  One site that I always check out is Trip Advisor.

This travel website is populated with information on hotels, resorts, air fare, deals, and even food and restaurants.  But the heart of the site is the traveler reviews. These often number in the hundreds depending on the location and are many times candidly verbose.

Visitors can even give a score which is tallied at the top of the review to help you sort through the list.

So what does that have in common with health care research?

Well, frankly, if you relied completely on Trip Advisor you probably would never travel any where.

Let me show you what I mean.

Last year I thought I planned the perfect vacation (turned out, I did according to the family).  We used every (I mean, every) frequent flyer mile I had and the four of us traveled to Kona, Hawaii, one of the most beautiful and mysterious places on earth.

We stayed at the Fairmont Orchid in Kamuela which is on a  grand beach on the west side of the Big Island.  The grounds are impeccable, the staff is always at your beck and call, and virtually every room has a nice view.  I'm a member of the President's Club so the kids were able to get free internet as well as discounts on beach gear.

From the turtles that lounge on the beach to the prettiest sunset in the world, I could live there. 

Now to Trip Advisor:  here are the top reviews currently --

"I have to say that while we love the Fairmont, the level of service has become uneven, if not somewhat mundane."

"The service was average - long waits and average staff at breakfast. Room was nice, but dated. I saw three cockroaches in the hotel. The grounds were lovely but the overall experience was not worth the cost."

"For the price of this hotel, the room was a disappointment. First of all we were on the bottom floor, with people walking by constantly, so there was very little privacy. The bathroom had dust and dirt on the shelves, and the wall was filthy. There were 2 moldy pictures beside the bed..."

The take home message here is that each person has their own experience, and it is impossible to make everyone's stay perfect. 

We live in a society where expectations often exceed reality.  There is just no way to make everyone happy and provide perfection no matter how much you strive for this level. 

That brings me to health care. 

I recently had a lengthy discussion with someone regarding online treatments for a medical condition.  He had done considerable research, wanted to know the ins and outs of every perturbation of treatment, and why some people reported good results and some did not.

He finally wanted my opinion, and wanted me to weigh in on making a further review of these treatments and these patient experiences.

He just couldn't understand why some patients didn't report perfect results with at least one treatment.

I told him that unfortunately it doesn't work that way.  Every patient will have a different experience with virtually every treatment or procedure.

Sure, there is an "expected" outcome.  But we are dealing with a human body that is dissimilar from every other one on earth.  You just can't expect similarity.

But to even be more accurate, we are dealing with humans and their own expectations of what a successful outcome should be.  And that is even more challenging than the biophysics and physiology.  Humans rarely agree on anything.

So the take home message here is that research on medical procedures and treatments can be very valuable, but you should always take into context the individual nature of the reviews.

Otherwise, you would never travel anywhere, and you would never make a health care decision that could improve your life.

The Blurry Line: When non-physicians practice medicine

It used to be that there were well defined roles.

Pharmacists dispensed medications on the order of a physician.

Nurses carried out care and healing as ordered by a physician.

Physical therapists helped patients heal their bodies on the order of a physician.

Physicians practiced medicine.

But that's all changing.  There is a hurrying pace to expand the scope of practice of non-physician providers to include elements of medical practice. The purported reason is the lack of availability of primary care physicians and access to care.

But, honestly, like almost all things in America, it's really not that altruistic.  It's about money of course.

And since it's about money, I've always been curious about the public's willingness to pay for information, time, or care from a non-physician provider at the same rate as if they were paying for a physician.

And when the stakes are high, like with your own health care, it looks like most people would only want the "best."

Now before I start getting hate mail or malicious tweets from the host of non-physician providers out there, I'm sure there are some in that group that practice good nursing, pharmacy, physical therapy, etc.  That's not what this is about.  I'm talking about medicine.

I'm sure if the airlines decide that airplanes have become sophisticated enough that flight attendants can be cross trained first as copilots and eventually as pilots, then the issue will become clear.

Someone once told me that to get hired by Southwest Airlines as a copilot in a 737 that it required 2000 hours in type and experience as pilot-in-command.  This is a hefty requirement but probably why the airline has one of the best records in the industry.

Now if you were to train a flight attendant with a fraction of that time, let's say 200 hours, would you feel as comfortable in seat 6B?  Even if your flight was on-time, everyone was friendly, and you had peanuts and a drink coupon?

But the analogy fits very well with medicine.

Let's take nursing:  its become somewhat politically incorrect to consider nursing any longer as a support role in health care.  There has been considerable growth in the industry in the role of becoming primary care givers.

Many states leave the determination of the scope of practice to the state nurse licensing boards which gives them broad latitude in defining what nurses can and can't do.

Much of this depends on the definition of the "practice of medicine" which has always been understood as the "diagnosis and treatment" of disease.

So nursing boards have morphed a term now to include the title: nurse practitioner, or NP.  These "advanced practice nurses" usually have expanded training, mostly from other advanced practice nurses  and some physicians, in the area of diagnosing and treating basic ailments.

Supposedly.

I say supposedly because there are very few if any statutory limits on these advanced practice nurses.

Think for a minute that it might be one thing for a flight attendant to fire up the plane and taxi out to the runway, but it would be quite another to take off into the fog and rain of a messy evening.

So these APN's go into practice and begin to practice surrogate medicine.

The confusion abounds with patients who don't always know the difference from one provider to the next.  They just know their little girl has an ear infection and needs an antibiotic.

These lines even get blurrier when programs begin to offer "Ph. D." course work in nursing which then entitles the person to be referred to as "Dr. APN." Patients become confused:  just who is a "doctor" any more?

Now most of these non-physician providers are supposed to be either supervised by a physician or they are to practice under specific guidelines drafted and overseen by a physician.

But it is clearly not the same as having a physician see the patient or being immediately available for consultation.

(Think for a minute:  that flight attendant could always radio in for help....if they were to get into trouble...)

Many physicians like using non-physician providers of care because it increases through-put and therefore revenue for the practice.  These environments often deliver superb care in a team environment managing complicated patients.

Physician's assistants are one of the best examples of how the system can work well.  Usually these mid-level providers train directly with physicians, are regularly supervised, and have academic backgrounds that ground them in the basic science of medicine.

This type of preparation and apprenticeship is often lacking in other non-physician provider training programs.

But when advanced practice nurses want to open up a clinic and begin to practice primary care medicine, you really have to wonder if this is a good idea.

It's a slippery slope where most of the time no one gets hurt.

Pharmacists in many states can now give vaccinations and maybe even adjust the dose of someone's insulin to treat their diabetes.

Physical therapists may be able to diagnose a knee strain and begin corrective exercises and rehab.

Advanced practice nurses may be able to diagnose a sore throat in a 3 year old and start antibiotics.

So where does the slope end?  Despite the fact that medicine is becoming even more technical, the number of drugs is expanding at an unbelievable rate, and patients are generally sicker now than in the past (particularly with the economy challenging access to preventative health care services), there is a growing feeling that we need more non-physicians delivering health care.

And because of the purported need for access to primary care, legislatures are changing the statutes and regulations to expand the scope of practice of these non-physicians.

Physicians in the United States on average have completed a four year basic science undergraduate curriculum, four years of medical school, and typically 4 to 5 years of post graduate training in an internship and residency.

Most advanced nurse practitioners complete about 5 to 6 years of training total -- at least of three of which is spent solely in nursing.

So can a legislature obviate the need for medical school just by changing the law?  Of course not, but that is what is happening in many states around the country:  nurses, and other non-physician providers, are seeking independent practice.

This independent practice would remove even cursory physician supervision of their treatment of patients.

If lowering the standards was all that was necessary,  then one solution for the crisis in primary care access would be to shorten the requirements for physicians going to medical school.  I know, that's absurd.

With the technological advances in medicine and particularly surgical procedures and medication treatment -- the course of study cannot be condensed.

But to complete the tale of a story gone wrong, many advanced nurse practitioners never practice primary care. Instead they take up the practice of aesthetic medicine such as treating patients with cosmetic drugs like Botox or lip fillers.

To be fair, all of these non-physician providers in the proper setting offer advantages in our current health care crisis.  Working in a team under the supervision of a physician, health care delivery can be enhanced, access can be improved, and patients can get better service.

There is no better example than that of physician assistants.  This relatively new type of non-physician provider is probably the model that needs to be followed in expanding the scope of practice for medical providers.

Physician assistants usually complete a six year curriculum and even then there is typically a post graduate practicum or   on-the-job training program directly with a physician.  These professionals work hand in hand with physicians in caring for patients, have privileges to write prescriptions and perform some surgical procedures, and can help the physician in coordination of care for the patient.

In most states they are even supervised by the physician licensing board.

But as a rule, they don't have independent practice.  It is the perfect model to expand access of quality care.

Now, I'm usually a self-described progressive, and I'm always open to new ways to educate and treat patients.  But the last thing I want to do is to put patients in harm's way.

We shouldn't allow the access argument to blur the lines of right and wrong so much that we allow the training of our health care providers to be diminished.

If you want to practice in a support role working hand in hand with a physician to provide quality care, I'm all for it, and will work and lobby to make it happen.

If you want to practice medicine independently, then go to medical school.

My skin cancer script: what I tell patients 40 times a day on how to recognize skin cancer

Moles are like stars.

And patients are like constellations.

And the number of these lesions is like the number of stars in the universe.

There is no way to see every mole, document every mole, or even have every mole examined by a dermatologist.

So patients play an important role in skin cancer diagnosis and recognition.  Teaching and educating patients on discovering these lesions is essential.

We have to make melanoma astronomers out of our patients.

So here's what I say:

1) "The most sensitive sign for a melanoma is a mole that is changing in size and color -- not specific, but sensitive.  So call me if you see a mole you are concerned about that is changing in size or color."

2) "Look for 'ugly ducklings.' That is, don't focus on your moles as individual lesions -- rather look at them as a group.  Look for moles that are ugly ducklings and don't look like their neighbors.  If you see one of these ugly ducklings, then bring it to my attention."

3) For non-melanoma skin cancer:  "You don't need to see me every time you get a pimple.  But if you get a non-healing wound or sore that lasts longer than six weeks, then we probably need to take a look."

The three steps are simple, but they represent good advice in finding skin cancer, particularly melanoma, early.

Your health records: more like a blog, or more like Twitter?

For over a decade I traveled 30 miles south to a rural clinic along I-45 in Fairfield, Texas. There I met one of those physicians that people always think of when they think the word "doctor."

Dr. John Keller is a community icon.

Born south of this small town, he practiced medicine there for over 50 years. Now he's retired, and the community is at a loss.

Though certainly not the cause, his retirement coincided with the roll out of a new electronic medical record, or EMR (sometimes AKA EHR).

This reminded me of a story from Dr. Keller that he related to me over a decade ago. He told me that when he first went into practice records were kept on 3"x 5" note cards.

As someone who has served in various administrative capacities over the years, I've always remembered Dr. Keller's initial non-electronic medical record. And I suspected that his care was super, despite the limitations of space on that card.

Today, EMRs are becoming more and more common. There is still significant resistance from some physicians because of the lack of a unified national standard of connectivity.

That is, one system still can't talk to another.

Plus there is the cost of implementation. Some estimates put this near $60,000 per physician in a practice.

In this day of declining reimbursement it's hard for many medical practices to take the plunge and invest in this new technology.

Plus there is the whole slew of resistance remarks that range from "it'll slow down my productivity," "I'm too old to learn," "there isn't one for my specialty," and on and on.

Personally (albeit I'm a self professed techno-nerd) I haven't seen any of these problems.

We use a nice cloud based system from AthenaHealth which allows us to limit our on site technical requirements and back up, is constantly up to date, and can be accessed anywhere. Patients can even log in to check their test results, pay their bill, or ask me a question.

The electronic prescribing is phenomenal. I haven't written more than a handful of paper prescriptions in a year or so.

But even with all this technology, I'm not sure that we practice medicine any better today than Dr. Keller did fifty years ago. We just document a whole lot more information.

But is it useful?

We're pretty good at not generating a ream of electronic information every time a patient comes in. Some EMR systems accomplish this task (conventional wisdom is that it might help with coding and therefore reimbursement).

But, we chart way more than Dr. Keller ever did. I hope it's still pertinent to our patients complaint.

What's amazing to me is that as we have advanced in our technology we have become more verbose in our ability to describe it.

You could say that we are "health care bloggers" in the patients' medical record.

Whereas Dr. Keller was more like Twitter. He kept his comments to probably less than 140 characters -- and he did just fine.

So Dr. Keller may have been ahead of his time. Maybe we should "follow" him.

How a dying child tells his parents he's ready to die

My good friend and Fort Worth pediatrician Gary Floyd relates this telling story about working with a family through the death of their child from cystic fibrosis.  Gary's story is compelling, really...downright tear jerking.  This video is part of a series from the Texas Medical Association that began as project from their creative social media guru Steve Levine.  Check out other videos from that series here.

Injections: Does hurting children now, hurt their health care decisions later

For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.

Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.

But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.

The children, though, turned, ran, and cried to their mother.

Ruby commented to me that this was a common but unfortunate occurrence for her.

She was the "shot lady."

Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."

Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.

Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."

Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.

But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.

(Just for the record, I'm opposed to corporal punishment.)




Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."

Well, it never hurts me.

Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.

Like a bee sting.

That one always makes me calm down.

"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."

You're calm now, aren't you?

Brute force is sometimes an option, particularly if it's a young child.

There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."

Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.

This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.

Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.

Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)

You see with injections there's really no "compromise." So negotiation is doomed from the beginning.

You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.

But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.

So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?

Particularly if the primal image of your first health care experience is clouded with pain.

Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.

I think many patients do.

Going to the doctor is often a painful experience. Some things just hurt.

But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.

I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.

Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.

Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.

Their fear is gone and what comes with it is a learning that water can be safe.

Health care is no different for children.

If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.

Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."

Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.

Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.

In our office it  is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.

I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.

And I don't want children to run away crying when they see me at Walmart!


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Location:Dallas, Texas