Interesting Case of "Co-rumination"

I haven't written much about actual medical cases I see here at my hospital but this one intrigued me. Some details have been altered of course.

A 30ish female showed up in our emergency department complaining of a sharp, stabbing pain in her left neck (10 out of 10 in intensity) for several days along with a palpable mass over the area. The pain had been present for two to three months but not nearly this intense nor had the mass been as large. She also complained of fatigue, shortness of breath, tactile fevers (felt hot but hadn't actually checked her temperature), and a range of other symptoms. The intern who presented this case to me found absolutely nothing on physical exam: normal vital signs, no mass, lungs clear, etc.

My impression just from the presentation was that this was unadulterated BS (medicalese for "move along, nothing to see here"). How wrong I was.

When I walked into the exam room there were two healthy-appearing women sitting, both with the same look of overwhelming dread. Usually I'm fairly insightful but in this case, it took several seconds to determine which one was the patient. Seeing an "older" attending, the patient's friend whom I'll call "Patient #2" immediately unloaded Patient #1's symptoms upon me.

Patient #2 related in great detail every ache, every sensation, every pain, every bowel movement, indeed every agonized breath of her friends over the past three months. Certainly, it is not unusual for a patient's friend or family to function as an advocate and relate observations about the patient that may be helpful to clinicians.

It's rare however for such advocates to give detailed subjective descriptions of how the patient is actually feeling (at least when the patient herself is articulate, not shy or embarrassed, and for whom English is her native language). Between Patient #1 and Patient #2, I was barraged with with a torrent of imagined symptoms.

In examining Patient #1, I agreed with my intern that there was no mass, nor any other physical findings of note. In my most professorial and reassuring manner and despite the fact that my skin was crawling in much the same way as when I walk into a room with a patient believed to have scabies, I told her her symptoms were nothing to worry about, that medical science can't always explain what patients are feeling, that her problems would undoubtedly resolve shortly, and that we were always here in case she didn't get better...

Our patients were greatly reassured and they both thanked me profusely. I walked out of the room feeling I'd done some good.

The diagnosis? This woman (and her friend) turned out to have a severe case of co-rumination, a topic I've written about before. The problem was that, like many females, they tend to "share" far too much. By doing so, their anxieties spiral upwards out of control as happened here. Men seem much less likely to engage in this maladaptive behavior. Certainly, we'll see more of this with men as society continues to encourage us to explore our "feminine side".

Perhaps if I had been more upfront with my convictions, I would have also recommended they stop co-ruminating regarding each other's maladies.

But that might not have been cool.

The Top 10 Questions Patients Should Ask Their Docs (And That Docs Should Be Asking Themselves)

There's a very good article in MSN.com that's worth talking about. It lists 10 key questions to ask your doctor. Some are right on and some are problematic.

Click here for my scintillating observations!Here is a very good article on MSN.com entitled 10 Questions You Must Ask Your Doctor. The questions proposed are pretty good but I would like to throw my 2 cents in. It is MY blog after all!

First of all, I rather like the tone of the article. It recommends a reasonable, nonadversarial approach for patients to take with their physicians. Always a nice change from the usual How to Tell If Your Doctor is Screwing You Over pieces that I seem to run across.

So here we go:

1) Do I really need this test? Great question but the author is preaching not to the choir, but to the tree stump. It's pretty well documented that as far as the patient is concerned: "Nothing is too good for my health...as long as someone else is footing the bill." My feeling is that it's the patient that is the main driver to more extensive test-ordering. This is really a question the doctor should be asking until such time as patients are required to assume a greater personal responsibility for their routine medical expenses.

2) Where would you send your wife or children? Another great question. In fact, this is a version of a question I try to ask myself and that I try to teach housestaff to ask on their patients' behalf: "What would I do if this patient was my mother-father-child-etc.? Nothing focuses the mind like putting yourself in your patient's place.

3) How many surgeries do you perform each year? I would rephrase this as "How many of this type of operation do you perform each year?" As the article notes, There's an substantial body of literature that supports the notion that practice does indeed make perfect. This is true for both surgeons and for the hospitals in which they operate.

4) Can I schedule my surgery in the morning? I wasn't aware that outcomes for first procedures of the day were better but it seems plausible. The surgeons I know are mostly morning people. I'm ashamed to say that when I was a medical student, I definitely saw surgical cases rushed through because they were the last ones of the day.

5) If I get sick, will you see me in the hospital? Uh oh. And the author was doing so well. The fact of the matter is that hospital medicine has become so specialized that its best practitioners are those that do it the most. In fact, I point out (with some irony) his suggestion of the ideal response to question 3. In fact there's a large body of evidence to support the notion that hospitalists have better outcomes, shorter lengths of stay, and more cost-effective care than non-hospitalists. If a GP isn't admitting large numbers of patients per year, his skills are going to get a bit atrophied.

6) Do you earn bonuses based on performance? This is a tough one. The premise of this question is that, "Many hospitals pay their physicians bonuses based on how quickly they move patients out the door." First of all, there are very few settings where hospitals pay bonuses directly to hospitalists. That said, there are many situations in which hospitalist performance is evaluated at least in part on patients' average length of stay (ALOS). I don't know that many hospitalist groups are so crass as to pay a straight bonus on this basis but it can pretty much be guaranteed that ALOS is definitely looked at in reviewing their salaries. However, other quality measures are definitely examined as well: outcomes, bounce-backs, patient satisfaction, etc.

Should you refuse care from any physician whose income is in some way affected by the ALOS? If so, you may find yourself being cared for by the guy delivering the meal trays.

7) When did you graduate from medical school? The author cites a review suggesting that doctors more than 20 years out of medical school are 48% less likely to be on top of current developments in their fields. Like everything in medicine, the key question is whether your doctor is representative of the population studied. If you have confidence in your doctor, he explains things well in an easy-to-understand manner, and has a personality that clicks with your own; I wouldn't put too much weight on this finding.

Of course as one who will shortly approach that 20 year mark myself, this piece of commentary may appear curiously self-serving.

8) What the hell does that say? The point here is that "neatness counts" when penmanship is the issue. There have been countless cases of serious badness (as my infinitely more hip residents like to say) due to poorly written prescriptions and hospital orders. Reviewing your prescription with your doctor and making sure it's legible is obviously a good idea.

9) Will you remove that wedding ring? Hmm. The idea is that the risk of transmitting an infection to the patient is greater if his care providers are wearing rings. I don't know if this has ever been formally studied.

I pubmed'd "wedding ring" and found papers in the field of dermatology (eczema, allergic reactions to metals), emergency medicine and orthopedics (how to remove stuck rings, ring-associated injuries), and urology (don't even ask).

I also found a rather intriguing article in the journal Nature entitled Earth Science: The Extraterrestrial Wedding Ring. I'll definitely have to check out that one out.

The point is that I don't know if the evidence supports asking your nurse or doctor to remove his wedding ring. The study cited by the author didn't examine infection rates, only bacteria counts which in this setting may or may not have clinical relevance. Personally, I'd feel a little funny asking someone taking care of me to remove their wedding ring, particularly a woman. Who knows what she'd think!

10) What else can I do to treat my condition? It's true that physicians often lag in their familiarity with medical interventions if they don't involve man-made chemicals or sharp instruments. In fact there are studies that demonstrate the benefits of diet, nutrition, and exercise. Unfortunately, the data supporting them may not be as dramatic or as robust as you might hope. However, I've encountered many physicians who market their practices by emphasizing these more natural treatments.

I have no problem with that at all. Just make sure your doctor also knows about man-made chemicals and procedures involving sharp instruments.

All in all, I give this piece an 8.5. And some of that score has to be because the author raises compelling points that all of us, patients and doctors, should be asking ourselves.

Now your doctor can check your white blood cell count at his office in just 3 minutes!!!

Today, Medscape reported that the FDA has granted three new 510(k) clearances. This means that the companies involved will be allowed to market and sell their respective technologies. One of them, a gadget for surgically stabilizing the cervical spine (the neck), I'll defer to my orthopedic and neurosurgical colleagues to comment on.

The other two are worthy of comments by an internist.

The first one is a point-of-care (POC) assay of a patient's white blood cell count (WBC). This means that this test, which is normally done in a fancy lab will be possible at the doctor's office and the results will be available within three minutes.

WBC's are useful in a variety of clinical settings but I really question whether they need to be available as a POC study. When WBC's are high or low, that usually means infection of some sort or perhaps a malignancy. It's a very nonspecific test because so many things (including some non-disease states) can cause changes.

It is very rare however, that a doctor will need to know a patient's WBC immediately in his office to render a clinical decision. Truthfully, it'll take a doctor more imaginative than me to think of such a situation. If a patient is really sick, I'm going to admit him to the hospital; I don't need a WBC to tell me that. Some of us actually make clinical decisions based on talking to the patient and even examining them if you can believe it!

Don't get me wrong, WBC's are important. I order them all the time from clinic. I just don't need to know the results immediately. A day or two won't make a difference. On the other hand, if I have a sick patient in the emergency room, a "stat" WBC is often essential but hospital labs already are set up to do these quickly. In fact these results are far more useful because then, the WBC is part of a complete blood count which gives me more complete information. But in the E.R., I'm not ordering it to tell me that the patient is sick. I'm getting it because I need to know which diagnostic pathway to travel down next and I need to move fast.

Now there are some useful POC tests. I like getting blood sugar tests right then and there. They help me make immediate decisions on how to modify someone's diabetic care. The same is true with HemoCues (a POC test for anemia). This is sometimes helpful in managing certain problems such as iron deficiency because it allows me to know if therapy is adequate and if I need to modify treatment. There are other examples.

Unfortunately, I don't think WBC's fall into that category. I seriously doubt that most primary care providers (PCP's) will pick up on this subtlety. A lot of them will probably purchase this technology, a lot of them will make money running the test, and a lot more useless WBC's will be performed. Guess what? This will become one more factor in rising healthcare costs and with very little to show for it.

Also, more useless WBC's being ordered means a higher percentage of falsely abnormal test results. This inevitably leads to more clinical testing, more diagnostic dead-ends, more needless patient anxiety, and more wasted healthcare dollars.

Who knows, maybe I'm wrong. Maybe insurance companies will balk at paying for it and when patients are told they'll have to pay out-of-pocket, they'll ask the hard questions that should be asked of all forms of medical technology: "How much does it cost and what will this really do for me?"

I can dream can't I?

I'll try to blog about the third technology approved by the FDA another time (a POC blood test for the virus that causes genital herpes).

Patient Advocates to protect you from your healthcare system

KevinMD posted this entry about the newest brand of overpaid consultants, "patient advocates".

It is amazing to me that modern healthcare has gotten to the point where there is a general perception that we need to pay people to protect us from our doctors and other healthcare institutions.

Most surveys of patient satisfaction, contrary to popular belief, actually show that patients usually like their doctors and feel confident in their care. It's the nature of the parameters that they work under that makes people feel the need for protection.

For example, the article in the Boston Globe that Kevin linked talks about hiring private nurses to attend to patients while they're in the hospital. This is undoubtedly because of the very real concerns patients and families have about medical errors. Unfortunately, and I'm sure most patients are unaware of this, there have been a number of tragic cases of poor care that arose because of inattentive, poorly screened or incompetent private nurses whose presence gave the hospital's nursing staff a false sense of security and fostered less dilligent care.

The article was amusing on one level in that it described the work of one advocate, a Dr. Gwendolyn Stritter, who runs a telephone-based advocacy practice. She's an anesthesiologist who decided to "branch out" into clinical advocacy. She charges $300 for an initial two-hour visit, reviews cancer patients' medical records and finds the latest treatments for them:

"She reviews their medical records, combs six to eight online physician databases to find the latest research, then talks to the researchers who've done the studies. She also attends major cancer conferences with her patients in mind."

Maybe it's just me, but if the patient's own oncologist isn't doing the legwork himself (and with the benefit of a subspecialist's added experience), that patient needs a lot more than a "patient advocate"...how about a new doctor (or at least a second opinion)?

Electronic Alerts to Improve Hospital Outcomes

Here is the reference to an article that appeared in the New England Journal of Medicine. Basically it describes a very innovative randomized study that evaluated an "electronic alert" system. These alerts were computer-generated to notify admitting physicians that inpatients of theirs meeting specific criteria were at high risk of thromboembolic events (e.g., blood clots in the legs or lungs).

Half of the patients were subject to the alerts and half were not (the standard of care). These alerts reminded the admitting physician that it might be advantageous to place such patients on some type of prophylaxis such as anticoagulants, compression stockings, etc. The physician could then elect to apply such prophylaxis or not depending on his preference. Hospitalized patients can be at risk for such events for a variety of reasons and the amount of morbidity and death is significant.

It turned out that physicians taking care of the patients subject to the alerts were more likely to place their patients on prophylaxis then with the control group. More importantly, those patients did better and were 41% less likely to actually have an actual adverse event then the control group.

So this relatively simple, easily engineered computer program had a marked impact on patient outcomes.

As a hospitalist (one who specializes in taking care of inpatients in acute care facilities) attempts by hospitals to initiate such interventions have always been annoying to me. While admitting patients with certain medical problems, I have often been confronted with pre-printed admission orders for given diseases used to gently prod me to address specific issues.

I had always found such pre-printed orders annoying. I felt that I as an experienced physician, I knew how to take care of my patients and the last thing I needed was the product of some bureaucratically entangled "forms committee" to tell me how to manage patients. Nor was my (occasionally pig-headed view?) rare among doctors.

Studies like this with such dramatic results are very hard to ignore. There is no doubt that as physicians involved in patient care, we are going to see a lot more of this type of intervention. It may be annoying (and perhaps personally embarrassing to admit to ourselves that we missed something) but after all, it's the patient outcome that matters.

Measures such as this can make hospitals safer places to be.

(I violated my usual rule of never updating my posting because I wrote a really stupid sentence construction!)