Multimedia NYT: "Patient Voices"

A recent discovery--a late one--of this New York Times feature from 2009 called "Patient Voices," with personal audiovisual narratives from people sharing their experiences living with various well-known, and very un-well-known illnesses.  38 illnesses are included, to be exact, of everything from A.D.H.D., Tourette's syndrome, and stroke, to Lou Gehrig's disease, Charcot-Marie-Tooth disease, and sleep apnea. 

Couldn't resist passing along this must-see feature for med students, patients, caretakers, friends, family members--everyone, really.  NYT: Patient Voices

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Sex in Medicine--& a medical student's reflection

For the second consecutive year, medical students, faculty advisors, and a collaboration of a dozen student clubs at SUNY Downstate organized a series of lectures, discussions, and workshops on a topic often overlooked—and a facet often underserved—within American medicine.  In February, 2010, “Sex in Medicine Week” allowed participants and audience members to explore issues ranging from “Relationships, Sexuality, and Disability,” to sexual assault & the healthcare provider’s role, to the unique experiences of LGBT patients within a healthcare setting.  

What follows is a reflection written after attending a “Sex in Medicine Week” event. The author is a SUNY Downstate 2nd year medical student.

Conscientious Care for the Patient
By Alaina Burns

    Imagine that you and your life partner are about to board a cruise ship for a vacation with your three children when your partner suddenly suffers a massive stroke. Your partner is taken to the nearest hospital, but you are physically denied visitation rights; your partner dies eighteen hours later, and you are allowed entrance to the room only when the priest is reading the final rights.
    …Or imagine that you have been receiving care from your physician for a chronic medical condition, and one day, you happen to mention your partner. Your physician, who has been treating you for over a year, suddenly refuses to write you your next prescription.
    …Or imagine that you are a woman who has been receiving preparatory treatment for in vitro fertilization from the only in-network provider offered by your insurance plan. When, after a year, the staff at the clinic learn about your partner, they subsequently refuse to continue treatment.
    These cases might seem unbelievable, but they are all true; and they all took place in recent years, right here in the United States: in Miami, Washington state and California, respectively.  Welcome to the difficult reality faced by many lesbian, gay, bisexual and transgender (LGBT) patients who try to navigate the American healthcare system.
   Doctor’s offices and hospitals are often vulnerable spaces for all patients, but they can be particularly unpleasant for people who identify as LGBT. As part of SUNY Downstate’s 2010 “Sex in Medicine Week,” Dr. Maile O’Hara gave a talk, entitled, “Being a Good Doctor for ALL of Your Patients: Specific Needs of Lesbian, Gay, Bisexual, and Transgender Patients,”* in which she spoke about what medical professionals can do to provide more sensitive care for LGBT patients. Dr. O’Hara, a clinical psychologist at the Bellevue/NYU Program for Survivors of Torture, has worked extensively with the LGBT population.
    Among Dr. O’Hara’s recommendations for healthcare practitioners are these:

• Treat your patients who are LGBT with the same respect with which you treat all patients.
• Recognize that many LGBT people have had negative experiences with the health care system in the past.
• Ensure that your office has a nondiscrimination policy and that decorations and selections of items such as magazines and pamphlets are inclusive of the LGBT community.
• Treat the partners of LGBT patients as you would spouses, even if they are not legally married.

    In an era when most people can rest assured knowing that their civil rights are guaranteed, LGBT individuals, on the other hand, are made aware that discrimination can still lurk in the most unexpected of places. No national anti-discrimination law exists that protects lesbian, gay and transgender people, and among states, only twenty-one and the District of Columbia currently protect individuals from discrimination based on sexual orientation.
    Visiting the doctor, for any person, can often be stressful and scary for various reasons.  But for LGBT people, in an unwelcoming healthcare setting, the experience can be doubly terrifying. Educating yourself and being aware of the unique issues faced by people who are LGBT is the first step in providing conscientious care for all of your patients.

*To view the slides presented during Dr. Maile O’Hara’s talk, given at SUNY Downstate on February 25, 2010, please click on the “LGBT Q&A” link on the top left margin of this page.

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NYT: Wisdom on ankle injuries!

How to Fix Bad Ankles

By Gretchen Reynolds

July 8, 2009, 10:30 am

[Click on link above to NYT article for video on ankle exercises!]

Ankles provide a rare opportunity to recreate a seminal medical study in the comfort of your own home. Back in the mid-1960s, a physician, wondering why, after one ankle sprain, his patients so often suffered another, asked the affected patients to stand on their injured leg (after it was no longer sore). Almost invariably, they wobbled badly, flailing out with their arms and having to put their foot down much sooner than people who’d never sprained an ankle. With this simple experiment, the doctor made a critical, if in retrospect, seemingly self-evident discovery. People with bad ankles have bad balance.

Remarkably, that conclusion, published more than 40 years ago, is only now making its way into the treatment of chronically unstable ankles. “I’m not really sure why it’s taken so long,” says Patrick McKeon, an assistant professor in the Division of Athletic Training at the University of Kentucky. “Maybe because ankles don’t get much respect or research money. They’re the neglected stepchild of body parts.”

At the same time, in sports they’re the most commonly injured body part — each year approximately eight million people sprain an ankle. Millions of those will then go on to sprain that same ankle, or their other ankle, in the future. “The recurrence rate for ankle sprains is at least 30 percent,” McKeon says, “and depending on what numbers you use, it may be high as 80 percent.”

A growing body of research suggests that many of those second (and often third and fourth) sprains could be avoided with an easy course of treatment. Stand on one leg. Try not to wobble. Hold for a minute. Repeat.

This is the essence of balance training, a supremely low-tech but increasingly well-documented approach to dealing with unstable ankles. A number of studies published since last year have shown that the treatment, simple as it is, can be quite beneficial.

In one of the best-controlled studies to date, 31 young adults with a history of multiple ankle sprains completed four weeks of supervised balance training. So did a control group with healthy ankles. The injured started out much shakier than the controls during the exercises. But by the end of the month, those with wobbly ankles had improved dramatically on all measures of balance. They also reported, subjectively, that their ankles felt much less likely to give way at any moment. The control group had improved their balance, too, but only slightly. Similarly, a major review published last year found that six weeks of balance training, begun soon after a first ankle sprain, substantially reduced the risk of a recurrence. The training also lessened, at least somewhat, the chances of suffering a first sprain at all.
Why should balance training prevent ankle sprains? The reasons are both obvious and quite subtle. Until recently, clinicians thought that ankle sprains were primarily a matter of overstretched, traumatized ligaments. Tape or brace the joint, relieve pressure on the sore tissue, and a person should heal fully, they thought. But that approach ignored the role of the central nervous system, which is intimately tied in to every joint. “There are neural receptors in ligaments,” says Jay Hertel, an associate professor of kinesiology at the University of Virginia and an expert on the ankle. When you damage the ligament, “you damage the neuro-receptors as well. Your brain no longer receives reliable signals” from the ankle about how your ankle and foot are positioned in relation to the ground. Your proprioception — your sense of your body’s position in space — is impaired. You’re less stable and more prone to falling over and re-injuring yourself.

For some people, that wobbliness, virtually inevitable for at least a month after an initial ankle sprain, eventually dissipates; for others it’s abiding, perhaps even permanent. Researchers don’t yet know why some people don’t recover. But they do believe that balance training can return the joint and its neuro-receptor function almost to normal.

Best of all, if you don’t mind your spouse sniggering, you can implement state-of-the-art balance training at home. “We have lots of equipment here in our lab” for patients to test, stress, and improve their balance, Hertel says. “But all you really need is some space, a table or wall nearby to steady yourself if needed, and a pillow.” (If you’ve recently sprained your ankle, wait until you comfortably can bear weight on the joint before starting balance training.) Begin by testing the limits of your equilibrium. If you can stand sturdily on one leg for a minute, cross your arms over your chest. If even that’s undemanding, close your eyes. Hop. Or attempt all of these exercises on the pillow, so that the surface beneath you is unstable. “One of the take-home exercises we give people is to stand on one leg while brushing your teeth, and to close your eyes if it’s too easy,” Hertel says. “It may sound ridiculous, but if you do that for two or three minutes a day, you’re working your balance really well.”

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NYT: New trends in practicing medicine!

If All Doctors Had More Time to Listen

By JULIE WEED

Published: June 6, 2009

(Dr. Lili Sacks moved to a clinic in Seattle that focuses on longer appointments. She now sees up to 12 patients a day instead of 25.--->)

(<---Dr. José Batlle invested in technology to reduce administrative costs, saving enough to move into a new office in Manhattan.)

WHEN Dr. José Batlle met his 93-year-old patient in her small Bronx apartment, she didn’t have much furniture beyond a small TV, a sofa and a wheelchair. What she did have in abundance were pills — 15 types from a variety of doctors, including a pulmonologist, a cardiologist and a gerontologist. He discovered that some medicines had expired, others were unnecessary and some were dangerous if taken together.

Sitting with his patient and her son, Dr. Batlle cut the number of her medicines to four. He also gave the family his personal cellphone number.

Before coming to see him, the woman had endured several emergency-room visits and hospital stays. With Dr. Batlle, she was able to avoid all of that.

Calling a doctor on his cell? No waiting for an appointment? It’s the type of service that Dr. Batlle tries to offer to all of his 1,500 patients. “I prefer to keep them healthy than treat them when they are sick,” he says.

The efforts of Dr. Batlle and other primary care physicians may get a boost at the federal level. The Obama administration is considering ways to persuade medical students to pursue careers in primary care by raising their pay, and is channeling them to work in underserved rural areas. And the White House has already set aside $2 billion for community health centers through the economic stimulus package.

But more far-reaching health care reform remains an uncertainty, and in the interim a small but growing number of doctors are trying to take matters into their own hands.

By stepping off the big-clinic treadmill, where doctors are sometimes asked to see a different patient every 15 minutes, Dr. Batlle has joined the vanguard of physicians trying to redefine health care. These doctors spend more time with patients, emphasize prevention and education to keep them healthy and can handle many medical problems without referrals to specialists.

In many cases, this kind of care can reduce a patient’s medical bills. That’s more crucial than ever: according to a study published online by the American Journal of Medicine, 60 percent of all bankruptcies in the United States in 2007 were driven by health care costs.

Exact numbers are hard to come by, but doctors involved in this movement, called “patient centered” practices, say its popularity is growing.

“I travel to a lot of medical conferences, and I’m meeting more and more doctors embarking on this path,” said Dr. L. Gordon Moore, who runs IdealMedicalPractices.org, a program to help small practices become more innovative and efficient. The Web site IdealMedicalHome.org has about 800 doctors who post and trade ideas, while more than 700 physicians have adopted methods from HowsYourHealth.org. Many of these doctors see fewer patients per day than they did before.
To make personalized care possible in an era when compensation is often tied to the number of patients they see, doctors use technology to streamline processes and reduce administrative costs. Dr. Batlle, for example, uses online appointment scheduling and manages his medical records electronically. He prescribes medications from his computer and offers virtual visits by phone and e-mail.

It cost Dr. Batlle about $25,000 to buy the technology to make all of this possible, but he estimates that he saves close to $100,000 a year in salaries and billing costs. And he has made enough money to begin renovations on a new office in Washington Heights in Manhattan.

The model seems to be working, according to a 2008 study by Dr. John H. Wasson at Dartmouth Medical School. His research showed that patients in patient-centered practices were more likely to say they were informed about how to manage chronic diseases and got the care they needed, compared with those in a national sample of medical practices. They also were less likely to say they had to wait for an appointment.

“If the goal is to deliver patient care when and how they want and need it, this is the way to go,” Dr. Wasson said.

Of course, even doctors in this movement acknowledge that it is not a panacea for the country’s health care problems. Privacy advocates warn that electronic patient records can be breached, and computer glitches can make patient records inaccessible for hours. Big clinics can be better for people who have several health problems and need easy access to a variety of specialists. Moreover, some doctors may not want to leave a big clinic because they feel they lack the technical or business skills they need — or because a salaried job there may be more stable in this economy.

And while the patient-centered movement is growing, the nation may not be able to afford to have all its primary care doctors reduce the number of patients they see. Across the country, primary care physicians are in short supply, in part because average salaries for family practitioners are the lowest of any medical specialty. According to a 2008 survey of physician salaries by the American Medical Group Association, their average annual salary is $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon.

“Medical school loans can be so high, you need to be a specialist to pay them back,” Dr. Batlle said. “But our country doesn’t need yet another sleep apnea specialist.”

LILI SACKS, a primary care doctor in Seattle, says she began thinking differently about her work on the day she realized she was beginning each appointment with the words, “Sorry I’m late.”
Scheduled to see as many as 25 patients a day at a large clinic, she lacked the time for thorough examinations and discussions. Because of this, she said, primary care doctors are often forced to order tests and send patients to specialists.

“Could I have helped some people without specialists and tests? Absolutely,” said Dr. Sacks. “Would it have saved the patient and the insurance company both money? Absolutely. Is the system set up for the best care and cost efficiency? Absolutely not.”

Dr. Sacks said she worried that seeing so many patients would lead to errors. Last year, she moved to a clinic that focuses on longer patient appointments, 30 to 60 minutes. This translates to 10 to 12 patients a day. Patients also communicate directly with her by phone or e-mail.
During those longer appointments, Dr. Sacks can perform basic lab tests and simple procedures, so patients see fewer specialists.

“I probably head off a handful of emergency-room visits and hospital stays every month because patients can see me as soon as they have a problem, and I can be thorough rather than rushed,” she said.

One patient who avoided the emergency room was Todd Martin, a store manager in Seattle who went to Dr. Sacks’s clinic on a Saturday.

“I couldn’t stop coughing and was having trouble breathing,” Mr. Martin said. “They were able to see me and give me a chest X-ray.”

Mr. Martin said he spent $40 for the resulting prescription but the rest was covered by a monthly fee he pays Dr. Sacks. “A weekend visit to the E.R. would have easily cost $1,000,” he said.

Dr. Sacks charges patients a direct monthly fee of $54 to $129 based on age, and she doesn’t take insurance. Her office calls its philosophy “direct practice” because it’s a direct contract between doctor and patient. But she advises patients to obtain insurance plans to cover large, unexpected health costs like those to treat cancer or a heart attack.

“We say it’s like having a car and paying for your own oil changes and tuneups, but getting insurance in case you need a big repair,” she said.

Dr. Garrison Bliss, who in 2007 founded the group where Dr. Sacks works, has offered direct-practice services since 1997. He says patients can save 15 to 40 percent of their medical costs by using this model, based on his examination of insurance rates and his belief that good primary care can fill most of a patient’s needs.

Insurance plans that cover every little thing can be very expensive, Dr. Bliss said. He said that a patient who paid an annual fee at his clinic and took out a higher-deductible insurance plan would usually come out ahead, even if the patient’s health needs meant that he or she had to pay the entire deductible.
Dr. Bliss’s office operates with just two administrative employees for seven doctors. He estimates that if he took insurance, one or two administrative workers would be needed per doctor.

Insurance administration costs can take a big bite out of a practice’s revenue. A recent Weill Cornell Medical College study found that a third of the money received by primary care physicians pays for interactions between a doctor’s practice and patients’ health plans.

Patricia Rogers Caroselli, a retired assistant principal who is a patient of Dr. Sacks, dreaded going to her former clinic. “The waiting room was always noisy and crowded,” she said. In the examining room, she felt that she should “get in and out and not waste the doctor’s time with questions,” she said.
In contrast, she said, she appreciates the friendly calm of Dr. Sacks’s new surroundings and the personal attention. “Everyone should have this kind of patient care,” she said.

Dr. Sacks said the financial mechanics of the direct-practice model match her medical goals. When she was compensated based on insurance, she was paid every time she saw a patient. Now, if she can use education and prevention to reduce office visits, she and her patients benefit, she said.

“Having more time to sit with each patient has made me a better doctor,” she said. “I had a disabled patient that I saw for 13 years. Until she came to my new clinic, I never had the time to learn the details of her accident and the resulting complications. I was always treating whatever the immediate concern was.”

TECHNOLOGY has helped many doctors reduce costs. Dr. Batlle says he has been building his arsenal of technology solutions one by one, with “lots of trial and error,” for eight years.
Recently, he saw a 52-year-old patient with hypertension. As he examined the patient, noting blood pressure and other vital signs, he entered the information into his laptop computer to add to the patient’s electronic medical record. He also typed in the codes for billing and insurance.

The patient wondered if he was due for a prescription refill, so Dr. Batlle checked his computer again, found that he was, and hit a button to send the refill request to the pharmacy. As the patient left, Dr. Batlle hit the keyboard to send the bill electronically to the insurance company.

“He’ll even go to the Web to schedule his follow-up appointment,” Dr. Batlle said. “I don’t pay a receptionist to sit and answer phones.”

Dr. Batlle says other doctors could outfit an office for less than the $25,000 he spent on technology.
“Most doctors think they need to hire two receptionists, a billing person and two nurses to run a primary care office,” he said. “But they can learn about these technologies from other doctors, and the software salespeople do some training.”

Some physicians hire consultants to find and install the right equipment. Doctors who want to switch to electronic health records may also receive financial support from the government through the stimulus package.

By using new technology and streamlining processes, small primary care practices can reduce their costs to half of what a typical practice pays, from about 60 percent of income down to 30 percent, Dr. Wasson said. He said that doctors who focus on reducing their costs can see fewer patients without sacrificing income. Dr. Sacks said she and her colleagues didn’t have to take a pay cut when they moved to Dr. Bliss’s practice.

As Congress and the Obama administration begin to focus more closely on health care, some primary care doctors are weighing in. Dr. Bliss, for instance, has been to Washington twice in the last month to share his ideas with legislators. He knows he’s in a debate with powerful voices, especially insurance companies and hospitals. So he and other doctors are encouraging patients to speak up as well.

“We need to bring the patients to the barricades with us,” Dr. Batlle says.

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NYT: "Exercise more, Eat less (sugar)!" Add this reason to your persuasion toolbox

Blood Sugar Control Linked to Memory Decline, Study Says

By RONI CARYN RABIN

Published: December 31, 2008

(<---High glucose seemed to affect the dentate gyrus, part of the hippocampus (shaded).)

Spikes in blood sugar can take a toll on memory by affecting the dentate gyrus, an area of the brain within the hippocampus that helps form memories, a new study reports.

Researchers said the effects can be seen even when levels of blood sugar, or glucose, are only moderately elevated, a finding that may help explain normal age-related cognitive decline, since glucose regulation worsenswith age.

The study, by researchers at Columbia University Medical Center and funded in part by the National Institute on Aging, was published in the December issue of Annals of Neurology.

“If we conclude this is underlying normal age-related cognitive decline, then it affects all of us,” said lead investigator Dr. Scott Small, associate professor of neurology at Columbia University Medical Center. The ability to regulate glucose starts deteriorating by the third or fourth decade of life, he added.

Since glucose regulation is improved with physical activity, Dr. Small said, “We have a behavioral recommendation — physical exercise.”

In the study, researchers used high-resolution functional magnetic resonance imaging to map brain regions in 240 elderly subjects. They found a correlation between elevated blood glucose levels and reduced cerebral blood volume, or blood flow, in the dentate gyrus, an indication of reduced metabolic activity and function in that region of the brain.

By manipulating blood sugar levels in mice and monkeys, researchers said, they tried to confirm a cause-and-effect relationship between the glucose spikes and the reduced blood volume, Dr. Small said.

Bruce S. McEwen, who heads the neuroendocrinology lab at Rockefeller University in New York and was not involved in the research, said the study’s findings were “compelling,” with important implications not just for the elderly but for the growing number of overweight children and teens at risk of Type 2 diabetes.

“When we think about diabetes, we think about heart disease and all the consequences for the rest of the body, but we usually don’t think about the brain,” he said. “This is something we’ve got to be really worried about. We need to think about their ultimate risks not only for cardiovascular disease and metabolic disorders, but also about their cognitive skills, and whether they will be able to keep up with the demands of education and a fast-paced complex society. That’s the part that scares the heck out of me.”

Previous observational studies have shown that physical activity reduces the risk of cognitive decline, and studies have also found that diabetes increases the risk of dementia. Earlier studies had also found a link between Type 2 diabetes and dysfunction in the dentate gyrus.

Sheri Colberg-Ochs, an associate professor of exercise science at Old Dominion University in Norfolk, Va., said her research has found that regular exercise, even light physical activity, can offset the potentially negative effects of Type 2 diabetes on cognitive function. It is not clear what the mechanism is, she said, but may have something to do with the effect of insulin.

“This new study is interesting in that it allows for a greater understanding of which region of the hippocampus is likely most affected by poorly controlled diabetes,” she said.

But the elevations in blood glucose seen in the new study are more subtle and would not be considered a disease state, Dr. Small said.

“It’s part of the normal process of aging, much like wrinkling of skin,” he said. “It happens to all of us inexorably, and it worsens progressively across the life span.”

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