Patient Conversation of the Week

Excerpts from especially memorable patient encounters:

ME: So what made your back pain worse?

Patient: The Physical Therapy made is worse.

ME: Well, what did you do in PT?

Patient: What they told me to do.

ME: What did they tell you to do?

Patient: Things that hurt.

Excellent!

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Here Comes Google!

Google asks an open question about finding quality healthcare information. The post has serious implications about the future of how patients can learn about their conditions, doctors, and choices.
A while back I also observed a post on health information and evidence from Google. It is clear they are making a plan to be a source of quality health information. I suspect Google will probably change the way patients and doctors interact if able to “smarten-up” healthcare consumers. They want your feedback, so go drop them a line!

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Why Do They Smoke?

I started thinking about this the other day while hanging out with friends…who were smoking. I was wondering why so many young people I know smoke in light of such very strong evidence not to. I put the thought away, until a very nice conversation I had today motivated me to write about it.
This report confirms my personal observation, that even while overall smoking rates decline, the rate of smoking among young adults is climbing! I just can’t understand.
I guess I will not spend too much time trying to figure out this complex problem, but my message today will be:
In order to change behavior, sometimes more than just good evidence is needed. Often it takes a driving, deeply motivating issue to enact that change.

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Drug Companies Eat Zebras?

“Drug companies are like lions,” Dr. Grimm said of his sponsored talks. “For lions, it’s their nature to kill zebras and eat them. For drug companies, it’s their nature to make money. They’re not really trying to improve anybody’s health except if it makes them money.”

Those of you who regularly read my blog and know me at all, are probably very aware of my distaste for pharmaceutical companies and their perpetual courtship of physicians.

Here is an article that has some solid numbers behind it, including a couple instances of doctors receiving money from a drug company AND making guidelines for other doctors to follow that includes the drug they are being paid to promote!

Did you hear that? A doctor may make guidelines for how much and often a kidney patient receives a cholesterol medication even while being paid by the manufacturer of that medication. Outrageous!

How, in light of this conflict of interest, are we to trust any formal guidelines at all?

Does anyone else see a problem with this? This guy from Harvard does:

“When honest human beings have a vested stake in seeing the world in a particular way, they’re incapable of objectivity and independence,” said Max H. Bazerman, a professor at Harvard Business School. “A doctor who represents a pharmaceutical company will tend to see the data in a slightly more positive light and as a result will overprescribe that company’s drugs.”

This problem seems slightly more important than local North Augusta doctors, DEMANDING lunch for their entire office in order to speak to me…acting as the drug companies have conditioned them to.

Credits: The picture was observed here, in a nice lecture on the physiology of a lion-zebra chase!

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The Evolution of Rehabilitation

A series of blog posts led me to MedInnovationBlog, where I read a post: On Physical Therapists and Keeping Patients Moving.

That was nice to see and read about. Then came the comments. Physiatrists, upset that one could write about the profession of Physical Therapy and not give them credit. The blog author seemed pathetically apologetic in his response, and even went so far as to quickly credit Physiatrists for helping train Physical Therapists. Some clarification is needed.

The history of both Physiatry and Physical Therapy have very closely knit roots. In reviewing several sources of historical information on these professions, I find it interesting that neither mentions the other. Odd, because careful reading of these histories suggest each profession arose out of the same need and then developed independently.

Both professions start out with claiming roots to Hippocrates and the such….but let’s start at a more realistic date: World War I and 1917.

The Army, trying to deal with many injured soldiers, commissioned two physicians to create the Division of Physical Reconstruction upon recommendation from the Division of Orthopedic Surgery. The two physicians, Frank Granger, MD, and Joel Goldthwait, MD, signed on two Reconstruction Aides (read: Physical Therapists) who had already been trained and were helping patients with polio in Europe and the U.S. with rehabilitative modalities. They were Marguerite Sanderson and Mary McMillan. All four of these individuals eventually became influential in the founding and growth of the two professions in question. Each profession initially faced a struggle to become an accepted part of the current medical establishment.

Today, the two professions are largely separate, with unique educational programs and autonomy. The growing knowledge base of one is interdependent upon the other and each must yield respect accordingly. In my daily routine, I use the professional journals of each equally.

There is, however, one significant change upon us. For the first time, Physical Therapists are not dependent upon physicians for prescriptions, diagnoses, or treatment plans and are being educated to the doctorate level. It will be interesting to see how the relationship between these two mutually beneficial professions will continue to evolve in light of these changes.

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Google Searching for Back Pain

One of the things I think that Physical Therapists treat very well is the all inclusive “back pain” complaint. I’m quite proud of not only my personal skills, but the very helpful recent advances in research to support our practices. I wondered if the general public had any idea…
I was playing with the new, Google Trends (above), and queried: physical therapy (light blue), back pain (red), orthopedic (yellow), chiropractor (green), and manual therapy (the spec of blue on the bottom right). I wish manual therapy was more popular. So I continued…
I decided to search Google for “Physical Therapy” and “back pain.”
I was disappointed that the entire first page of results had exactly ZERO sources of information written by Physical Therapists or anything closely relating best/current evidence and no links to anything manual therapy-related.
I then searched a Google Custom search engine for the same term. The results were far better from a scientific perspective, but really not useful at all to a consumer. I wish the result of the search was somewhere in between the two.
I’m not sure what all this means, but I think it’s a marketing need and an opportunity.

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Calculator Day

A pound of body fat (see image) equates to approximately 3500 calories. So a calorie deficit of 500 calories (meaning that you burn 500 calories more than you eat each day) you would lose approximately one pound per week:

500 x 7 = 3,500
A calorie deficit of 1000 calories would mean that you’d lose approximately two pounds per week. That’s a good number to remember, because two pounds a week is commonly accepted as the maximum rate of weight loss that is healthy.
Here are some exercise-related calorie calculators to experiment with:
Activity Calculator taking into account body weight
Another one, with adjustable definitions.
A very cool, simple Daily Expenditure Estimator
A Disease Risk Calculator from Harvard University. (very cool)

Body Mass Index Calculator (now losing respect as a measure of obesity)

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Pay For Performance, An Overview

For those of my readers who work in the medical field, perhaps the title of this post caused a slight shudder or tingling in the spine. Understandable, indeed, as we have become accustomed to health insurers devising ways to reduce payments under the guise of improved quality of care. But, as a provider interested in improving my performance and having “Quality” be a marketable part of my services, I can see potential value in the concept.

For those who have never heard of Pay 4 Performance, an quick overview is indicated:

Insurance companies, Medicare included, are developing systems of payment for medical services based on performance, or quality. For example, a Physical Therapist that reports the risk of falls for each patient would be eligible for improved reimbursement. A physician who screens for cervical cancer would benefit likewise.

A good overview is available via this article, last week in The LA Times. It talks about a state-wide pilot program in California. California is the state where managed care and HMO’s came from too.

While improving healthcare quality is a vitally important part of reform, healthcare providers are nervous that these initiatives will become mandated before the details are worked out.

Details like:

  • Currently, there is no agreed upon measures of what “Quality” practice consists of.
  • Physical Therapists worry about measures having anything to do with PT at all, instead just being a poorly translated medical-based measure.
  • How will the system compensate for those times when quality measures don’t make sense i.e. measuring for fall risk in a bed-bound or wheelchair bound patient.
  • The list of concerns goes on.

In short, this change is coming, but everyone in concerned that it might just be more hoops to jump through to get paid, and that healthcare quality will not improve because of it. Careful planning is needed if quality is to improve. Either way, the insurance companies are gaining a tool to withhold more payments, and presumably, increase their bottom line. Personally, I hope it works out…maybe we could weed some of the detractors of quality out of our profession.

Here are some links:

Health Provider Report Card

Board of Directors of IHA, a leading institution behind this measure (note insurance bias of board)

Wikipedia Explanation

Medicare Page

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The Galapagos Islands and Huntington's chorea

Ahh, Blue-Footed Boobies!

One of my favorite authors, Kurt Vonnegut, wrote about Huntington’s Disease in the great book, Galapagos. The main character’s pending and inevitable onset of neurological wasting intrigued me. I tried to imagine what that must be like.

Since Mr. Vonnegut wrote that book, researchers have identified the gene in question that causes this disorder, and tests are now available for only a couple hundred dollars for people who are at risk. Today’s New York Times, had an excellent piece on Huntington’s Disease, Facing Life With a Lethal Gene.

I no longer have to imagine what it must be like to have it. The article really lays it out with the story of Ms. Moser, a young Occupational Therapist who carries the gene.

To circle this wagon back around, tonight, the National Geographic Channel is having a special called, Galapagos, “It’s like no where else.”

So what am I really talking about here? Evolution. It’s everywhere!

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More Media Confusion

The tag-lines went something like this: “Watch NBC tonight and find out why the way we do CPR has changed.” So I then changed the channel, only to find the same teaser on another station. By the end of this week’s news cycle, an unassuming viewer could be convinced not to perform rescue breaths as part of CPR.

I’m sure you know what I’m talking about, a new study released this week in The Lancet, a well respected peer-reviewed journal. In observing survival rates of over 4000 individuals, it found no benefit to those receiving both breaths and compressions. In fact 22% of those without rescue breaths survived, while only 10% with rescue breaths survived. Time to jump on a single study bandwagon???

Not yet:

  1. The study looked at older CPR guidelines (15:2), not the current 30 compressions to 2 breaths.
  2. The study only looked at cardiac-related cardiac arrest. Non-cardiac causes of arrest include drowning, trauma, choking.
  3. The study only looked at adults, who have much less sensitivity to lack of Oxygen than do children.

And this is why, despite presumably hundreds of calls from the media, The American Heart Association has decided not to change its CPR Guidelines.

News Watcher Beware!

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