Missing the Call

I’ve had some pretty interesting jobs.  I used to set up balloon displays for weddings and bar mitzvahs.  I worked in organ and tissue recovery removing human parts for transplant.  I even worked, for short stints, on an ice cream truck, in a bank, in an amusement park and in late night food delivery.   From every job I learned something — some skill or lesson that I continue to use in my practice. 

This week, a patient told me he had gone for an MRI for a problem that I was not treating him for (a possible cartilage tear in his shoulder).  He was very upset that he did not have an appointment with his orthopedist for another 4 weeks.  An entire month of wondering if he would need surgery.  He wanted to plan a vacation but was hesitant to do so if he would need to save up his time off from work.  His family history of cancer was also worrying him; he wondered if the MRI had illuminated bone cancer as the cause of his shoulder pain.  He was worried, anxious and not sleeping well.

One of the jobs I had prior to chiropractic school was performing clinical testing for a medical device that measured early signs of breast cancer without ionizing radiation. (It looked kind of like an EKG for the breast and measured surface electrical potential which is different in cancer cells vs. normal cells).  This job required me to spend time in several mammography clinics around the world.

One of the things that stuck with me from this job was the way one particular radiologist ran her clinic.  It wasn’t sterile looking with tile floors and paper gowns.  Patients were treated with dignity.  Real pillows and sheets on the exam tables.  Carpeted rooms.  Women were given a mammogram and then went into a comfortable waiting area where they could have a cup of tea and wait.  The mammogram was read by the radiologist while the patient was still in the building and she would be given the results right then and there….that very day.  I had heard horror stories of women with breast lumps going for mammograms and not getting the results of their test for weeks.  That can make for a very long, sleepless time period.

I hear this too often.  Patients are sent home to wait.  No news is good news, right?  Wrong.  We should be actively giving patients their test results as quickly as possible.  Sure, we know it’s just a standard blood workup or x-ray or CT, but to the patient, we’re going to spot the same thing that wiped out their uncle Frank in his 40’s.  Every patient who has an x-ray has the same thought, if only for a second:  I have cancer or something horrible and this is the test that’s going to show it.  Some of them are correct but they have the right to know.   Be proactive to get test results quickly and call your patients with them.  Don’t even wait until the next appointment.  (And for Heaven sake, don’t call them and tell them you see something and they need to come in to discuss it in 2 weeks).   They’ll be back in to see you regardless and the goodwill you generate will outweigh any lost office visit fee.

Oh, what about my patient? I got those MRI results for him before he even hit the door to leave my office.  Negative for cartilage tear.  Just some inflammation.  Looks like that trip to Cabo is on!

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Dr. Brett L. Kinsler is a chiropractor practicing in Rochester, NY

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Deformed Consent: It Was a Million to One Shot, Doc!

Informed consent in healthcare is the process by which the provider informs the patient about the options for the diagnosis and treatment of the patient’s condition. In addition, the risks and benefits are described to the patient so that the patient can make a rational decision regarding what he or she wants to be done.

Informed consent is a good aspect of healthcare. Giving patients the information to make decisions about their health preserves their right to autonomy. Many people mistakenly believe that informed consent is simply getting a patient to sign a written form. It is more than that. It is a process of communication between the patient and provider that results in the patient’s authorization or agreement to undergo a specific intervention. Patients should always have the opportunity to ask questions to elicit a better understanding of treatments or procedures. Patients should always be able to make an informed decision to proceed or to refuse a particular intervention. All medical encounters should conclude with the patient agreeing that all his questions have been exhausted. And patients should be adequately advised patients prior to any procedure in order to exercise the patient’s right to choose which side of the risk/benefit table he would like to place his chips.

So how do we fully inform a patient? In order to be as fully informed as his doctor, must the patient be sent to medical school? Actually, yes. By committing even minor omissions, doctors fail to deliver a fully informed consent. After all, patients who do not have the same medical knowledge as their provider can never truly comprehend all of the risks of a given intervention in the same way their doctor does. And what of minor, but likely possibilities? Should we be required to tell a patient that he may get a papercut by handling an informed consent form? What if the patient refuses treatment, and in his haste to exit, gets a static electricity shock from the doorknob. No big deal, right? Not worth metioning, right? What if that shock shorted out his pacemaker? Ahh…bigger deal. Should we have provided the warning to this possible, but foreseeable event? Can you picture the huge disclaimer poster required to be put in medical waiting rooms informing potential patients of all risks and benefits of opening the door to the office hallway? And another poster in the hallway denoting all of the risks of entering the treatment room. I don’t even want to imagine the one in the restroom.

We would most certainly have to stop offering coffee and tea in the waiting area. I mean, right now, the cups come pre-printed with: CAUTION – CONTENTS MAY BE HOT. I am not sure there would be room on the cup for: CAUTION – CONTENTS MAY BE HOT, WET, CAFFEINATED, DECAFFEINATED or SWEETENED. MAY STING EYES, CAUSE DIABETES, CANCER, ANXIETY, HYPERTENSION or DROWNING. DO NOT INVERT OVER EYES, EARS OR PRIVATE PARTS. DO NOT INSERT RECTALLY. WARNING IS CONTINUED ON NEXT CUP. NO, NOT THAT ONE, THE BROWN ONE. And of course all written warnings need to be in 6800 languages in case someone who understands only Luxembourgish wants a cup of joe.

Informed consent is an excellent idea and one that healthcare should embrace…within reason. Patients have a right to the explanation of procedural or invasive risks in advance. Exclusive of emergency procedures in life threatening situations, informed consent should be made available whenever possible for significant risks with a high estimated likelihood of occurrence and tempered with the potential benefits and alternatives. Minor risks would take too long to explain, and would cloud even the most simple of procedures: “I’m going to draw blood from you now, Mrs. Smith. By inserting this needle in your arm, I am exposing you to the following 40,000 infinitesimally small risks which I shall explain in detail one at a time….” The delivery of informed consent would take hundreds of times longer than any actual procedure!

As for chiropractic, there are, of course, some common risks. These risks are usually temporary and minor, involving things like post treatment soreness. There are also a few major risks which, in terms of likelihood of occurrence, are more akin to choking on an aspirin tablet. To date, there is no warning on bottles of Bayer aspirin telling the user he may choke and die on the tablet. It certainly is a real risk with such a low likelihood of occurrence, it hardly warrants mentioning. If a patient asks if there is a chance of dying by choking on an aspirin, his doctor should address the concerns honestly and directly. I am not implying that doctors should skirt around any patient questions but a proactive stance for remote risks does neither the patient, the doctor, nor the entire field of healthcare any good.

In communicating with our patients, we should make sure they understand that which is likely and that which is serious. The operative action here is to communicate. If we strive to improve the doctor/patient relationship, and provide honest, open communication, we would do much to reduce the reasons informed consent has exploded into ridiculousness in the first place.

Brett Kinsler is an informed and consenting chiropractor in Rochester. NY

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500 Words About the Medical Conscience Rule

compassHave you heard about the governmental approval of a new medical “conscience protection” rule?  It allows health care workers to opt out of administering any form of medical care they feel is objectionable on moral or religious grounds. Hmm…sounds good in theory. People shouldn’t be forced to do things they find objectionable, should they?

A press release on the Department of Health and Human Services Web site says the law will “protect health care providers from discrimination.” DHHS secretary Michael Leavitt said that doctors have a duty only “to provide care that they are comfortable providing.”

But religion is a discussion hotbed and healthcare is a hot button on the front burner of that hotbed and I have a few questions and a somewhat queasy feeling about this rule.

The goal of this rule, supposedly, is to make sure doctors who are firmly against abortions aren’t forced to perform them. However, the new rule also permits emergency room workers to withhold information from rape victims about access to emergency contraception. It also allows doctors in federally-funded clinics to refuse to tell a pregnant woman that her fetus has a severe abnormality.

The U.S. Conference of Catholic Bishops praised the new rules, saying medical workers “should not be required to take the very human life they are dedicated to protecting.” The rule is scheduled to take effect the day before President Bush leaves office.  Coincidence?  Sure, like cops with white powdered sugar on a dark colored uniform.

But a large number of medical groups oppose the rule.  Wacko fringe groups?  Not quite.   The American Medical Association, the American Nurses Association, the American Academy of Family Physicians, the American Academy of Pediatrics, and 27 state medical associations. Democratic House Representatives Diana DeGette (Colorado) and Louise Slaughter (New York ) plan to introduce a Congressional resolution rejecting the Bush administration’s last-minute rules.

Perhaps they have questions like me.  Perhaps they, too, are the teensiest bit afraid of Dr. Government.  Perhaps they are wondering:

Does the law mean a doctor can refuse to treat someone who is gay? Or refuse to prescribe medications for someone who is gay and has HIV because they feel that homosexuality is wrong?

Can care be refused to someone who overdosed using illegal drugs because the doctor doesn’t approve of drug use or of illegal activities?

How about refusal of treatment of an unwed mother because they disapprove of premarital sex or having children out of wedlock?

Wait a second! What if the doctor is anti-gun? Does the law permit withholding treatment to someone who was injured by a gun?  What if it was the patient’s own gun that went off when he was cleaning it?

Should medical professionals be permitted to refuse to treat a member of any particular group who they deem as immoral?

Of course not. This is a dicey, ill-conceived last minute plan to slip in a policy that makes sense to some people on isolated religious grounds but the risks if its implementation are too great and far reaching.

 

Dr. Brett Kinsler is a chiropractor practicing in Rochester, NY who does not support the conscience rule….and no, wiseguy, this does not count as part of the 500 words.

One Pill Makes You Larger And One Pill Makes You Lie

 

A person critical of chiropractic recently told me he believed the only reason chiropractic showed any effectiveness was entirely placebo effect.  He was wrong.  I’m not getting into that in this article.  However, it looks like he could have made a similar statement about many medical practices and not been too far off the mark.

It turns out, according to a recent study published in the British Medical Journal (BMJ), almost half of U.S. medical doctors use placebos with their patients.

If your doctor has prescribed antibiotics for the flu or told you to try B-12 vitamins for fatigue, those treatments were just a placebo — an unproven therapy offered with the hope you would feel better if you took something…anything.

Treatment with placebos is far more common than you might think, according to the national survey about 58 percent of U.S. physicians admitted using placebos regularly. Only 5 percent said they tell patients explicitly that they are doing so. The survey was sent to 1,200 internists and rheumatologists with a response rate of about half of them. 

Classic examples of placebos are sugar pills, saline injections and other treatments that seem to inspire confidence even though they are inert. But the physicians surveyed were far more likely to use active agents as placebos, including over-the-counter painkillers, vitamins, sedatives and antibiotics.  What classified them as placebos was the context. If the recommended treatment hasn’t been shown, physiologically, to work for the condition in question, then it was a placebo.

Two years ago, the American Medical Association said it was wrong to use placebos without a person’s knowledge.  But some make a case for what they call “benevolent deception” — letting a patient believe she’s getting a useful treatment because, paradoxically, it might work.  I think that when placebos involve medications like antibiotics and sedatives there is a line that has been crossed.  Furthermore, when the AMA code of Ethics states that “a physician shall … be honest in all professional interactions” I don’t see the wiggle room in there to tell Mrs. Smith that the garlic tablets you gave her will have a chance at curing her cancer.

So what’s to be done with patients who insist on a prescription for something they don’t need?  I say, educate them, don’t lie to them.  Tell them why they don’t need an antibiotic, give them a lollipop and send them home.

What do you think?

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