How a Psychologist Explained the Newtown School Shootings to His 7 & 8 Year Old Children

The shootings in at Sandy Brook Elementary School in Newtown, Connecticut have been traumatizing for the entire nation. While we have unfortunately become used to hearing about school shootings and other public mass shootings in the U.S., the brutal murder of 20 innocent elementary school children (all ages 6 and 7) is just too much to bear.

In fact, the moment I saw the picture above, it was impossible to hold back the tears any longer because the image of the little boy with the blonde hair reminded me of my precious 7-year-old son. 

In this day and age, I knew that he and his equally precious 8-year-old sister would probably hear of what happened next week in school and my wife and I decided that it would be best if they heard it from us first. This is because if they hear about what happened from their peers, children are prone to misinformation and exaggeration and I did not want them to be misinformed from the outset.  I also wanted to have some control over how and when the message was delivered.

As to the latter point, we had a family day planned with exciting activities scheduled that I knew would make the kids happy. I reasoned that it would be better to tell them the sad news first so that the good events of the day that were to follow would overshadow what I was about to tell them. After all, this is not the type of news one wants to deliver to a child at the end of the day or right before bedtime when they have a lot of time to dwell on it.

The way we have always raised our children is not to hide or shield them from the fact that we live in a dangerous world. They are aware that there are many nice people in the world but they also know that there are many “mean guys” out there who can do harm to them (which is why they know they should not go anywhere with strangers). We also talk to them and read books to them about dangerous things, places, and situations and how best to avoid or deal with such dangers.

So it was that context that allowed me to ease into the conversation somewhat. We brought the children into a comfortable room and we sat down together in close company. I reminded them about the discussions we have had about the world being a dangerous place sometimes and how there are mean guys around. They innocently looked at me and nodded their heads. I then told them that there was something bad that happened yesterday at a school that they may hear about on Monday and that it was best that they hear it from us first. They were told that the school is far away from where we live to make them feel safer. They were then told that there was a mean guy who went into a school with some guns and shot some adults and children and that some of these people died, including the principal. My guiding thought process was to explain the essential facts but not go into unnecessary detail.

After telling them such shocking news, I wanted to immediately counter this by letting them know something good, which is that the mean guy is dead and is not going to hurt them or anyone else anymore. Then came the first question, which was how did the mean guy die. My philosophy in responding was to tell the truth but try to keep it minimal. So my first response was simply that he was shot. The follow-up question was who shot him. The answer was that he shot himself. This is very strange to a young child and provoked a response that that is a very silly thing to do, which we all agreed with. Why would someone do that, my son asked. Again, to keep it simple for a 7-year-old, sometimes crazy people do crazy things that we would never do. While we don’t use the word crazy in clinical settings, you have to adjust the language when talking to children this young.

I then wanted to discuss another positive aspect of the tragedy, which is that there were teachers who saved many of the children’s lives by following proper lockdown drill procedures. My daughter immediately responded that she knows what a lockdown drill is and that they are scary. This reminded my son of the drill as well and they explained some of the things they have to do when one occurs. We explained why going to the corner or in a closet away from the door is the safe thing to do and they wound up having a better understanding of why they have to do these drills. They were reminded that if they have another lockdown drill in school that the teachers will clearly let them know that it is only a drill and not the real thing, so they are not too scared the next time it happens. But this real-life example of lives being saved helped to explain to them why practicing lockdown drills are so important. By practicing the drills, the teachers were much better prepared and lives were saved.

I then told them that I hoped one of the good things that will come out of something so sad is that our country finds a way to not make it so easy for mean guys to get guns. The hope here is that this would allow them to feel that something may happen in our society to make them feel safer. I sure hope this is not wishful thinking on my part because we cannot have another tragedy like this ever again. However, I could not tell them that there was no risk of this ever happening at their school. While I reminded them that dangerous situations can happen anywhere (even dad’s work, mom’s work, the mall, etc) there were told that school shootings are very rare.  Nevertheless, they were told that it is very important for us to be aware of our surroundings, to be as careful as we can, and to try to make smart decisions to keep ourselves safe. 

There were no further questions but they were told that their friends in school may tell them things about what happened that are not true and to check with mom and dad before believing it. We wanted to keep an open forum between us so they feel comfortable asking questions about difficult subjects. They readily agreed to check with us and to ask us questions.

The talk ended with a big family hug. We then proceeded to have a fun-filled family day and they did not bring the topic up once. We chose not to keep the TV news coverage on until they went to bed because we wanted to avoid chronic repeat exposure of this incident.

The difficult part about parenting is that there is no manual that exists on how to explain a tragedy like this to your children. I hope that example above is useful in that regard. Thank you for reading and give your children some extra big hugs.

Suggested reading: Why Kids Kill: Inside the Minds of School Shooters

Related blog entry: Society's Failure to Protect Children: 5 Ways to Improve

The Benefits of Electronic Medical Signatures

These days, more and more hospitals, doctor offices, and medical centers are transitioning from paper medical records to electronic (paperless) medical records (EMR). One of the motivations for this transition is a monetary incentive from the government, provided that certain criteria and reporting standards are met. However, there are other advantages to moving towards an EMR system.

One such advantage is that the days of sloppy, indecipherable, and forged handwritten signatures will be gone and replaced with a legible and secure electronic signature.

Online signatures in the pharmaceutical industry are particularly important because it is necessary to meet new standards set forth by the Food and Drug Administration and the SAFE-BioPharma Association. For electronic signature systems to be effective, they must be secure such as having systems in place to detect and prevent tampering. This involves utilizing a multi-faceted authentication process, which will vary according to the specific system and should be customizable.

Online signatures should also be simple to use for the health care provider such that all that is required to sign is a point and click of the mouse. The online signature system should also be easily accessible for the healthcare provider such that an electronic signature can be made from any secure internet connection. This can improve healthcare delivery because the easier it is to obtain a healthcare provider’s signature, the faster that services can be provided.

Time can also be saved with electronic signatures by allowing the health care provider to sign multiple documents at once and specifically directing the healthcare provider which documents need signing and which do not. This prevents packages of documents from missing needed signatures. Another benefit of EMRs is electronic notification of healthcare providers regarding a needed signature. Of course, reducing paper costs through electronic signatures helps save money.

In the future, the MedFriendly Blog will feature additional articles on various features or EMR systems and how they will affect the patient and provider.

Medical Jobs Specializing in Pregnancy

If you’re looking out to start a career in the medical field, you’ve got many choices. But there are some jobs that are directly related to childbirth, which are usually in demand. Childbirth is a special time for all parents. However, in order to have a safe birth, it’s important to take care during and after pregnancy which is why there are number of medical professionals involved in the 9 months of duration.
In the following article we look into a few careers that you begin with that are focused on helping pregnant women have a safe delivery...

Obstetric Physiotherapist

During the period of pregnancy and childbirth, the body goes through multiple changes. An obstetric physiotherapist works in the area of helping women deal with these changes. They help by teaching relaxation and breathing exercises, and also other activities that can be done during pregnancy in order to stay fit and healthy.

They also offer support even after birth, where they show how postnatal exercises can be done to help tone the muscles. If you choose to become an obstetric physiotherapist, then you will be playing an important role in your pregnant patient's life and helping them have a safe, healthy pregnancy.

Dietitian

Who knows what food is good to eat during pregnancy? A dietitian of course. The job of a dietitian is to mothers to be, find the right diet and let them know what food is bad for their health. Right from planning food/nutrition programs to teaching the right habits, they do it all.

In order to become a dietitian, you need to have a bachelor’s degree. As far as the choices go, you’re not limited to what you can major in. What’s more, since more and more people are getting health conscious these days, the profession of a dietitian will only grow with time.

Medical Sonographer

Ultrasounds or sonograms are commonly used to analyze the fetus in pregnancy. As a sonographer your job would be to assist patients in revealing the baby’s gender and have them see their baby for the first time.

The demand for sonography will definitely grow with time because one, sonography doesn’t use radiation and two, it’s cost-effective and non-invasive. You can receive training as a sonographer in a good, reputed institute such as the Sanford Brown Institute.

Pediatrician

A pediatrician is a doctor who is a child specialist. And a pediatrician whose specialty lies with dealing with newborn babies is called a neonatologist. The job of pediatrician is a sought after one since he is required to be there at the time of the birth in order to avoid any health complications in the baby.

A career as a pediatrician can be a rewarding one, knowing that there is a growing demand for it in the field. In order to become one, you will have to study medicine at a university and gain a bachelor’s degree.

The job options we discussed above may or may not be applicable to you but they definitely are worth considering if you want to build a career related to childbirth.

The entry above is a guest blog entry.

Five Ways to Handle When the Doctor is the Patient

It’s bound to happen if you are a healthcare provider. One day, you will evaluate a doctoral-level healthcare provider in your office, be it a physician or non-physician. Below is a series of tips for handling such a situation to increase the chances that the office visit will be a productive one.

1. Acknowledge the potential awkwardness of the situation during the initial visit: Doctors are used to being in charge and calling the shots (no pun intended). When a doctor becomes the patient, however, the roll is reversed. Now it is the doctor sitting in the waiting room, patient chair, filling out office and insurance forms, etc. When first meeting the doctor-patient, it is helpful to say something like, “Well, I understand that this may feel a little bit awkward, but I’ll do what I can to make the situation as comfortable as possible.” Doctors usually appreciate this and you may be surprised how many will quickly say something like, “I am here as a patient. You are my doctor. And that is how I would like it to be.” This is the best possible situation but in other cases, there may be more resistance. See the next few points for handling this.

2. Allow for some creature comforts: I usually ask doctors how they preferred to be referred to in the clinical note (e.g., Dr. Smith or Mr. Smith) which gives me a good sense of the degree of formalities that will be involved in the case.  Some doctors will insist on being called “Dr.” in the note and during personal interactions. While some evaluators may balk at this under the assumption that it blurs the doctor-patient boundary, the next point will show that this does not need to be the case. In my experience, this is typically not an issue worth having an argument about and is a good creature comfort to provide to help establish rapport.  Another creature comfort that doctor-patients enjoy is conveying their status in a more passive way during the evaluation, such as wearing their professional name badge and/or hospital garb during the appointment (some of which may say Dr. Smith on it). It is best to understand that this allows that doctor-patient to feel more comfortable rather than feeling offended or threatened by it.

3. Make sure that boundary levels are still maintained: While allowing for some creature comforts is ok, one has to be on guard against imbalances in the doctor to doctor-patient relationship. For example, while on may refer to the doctor-patient as Dr. Smith, the doctor-patient should not simultaneously be referring to the treating doctor by his/her first name only. 

4. Maintain control over the evaluation: This is related to point 3 and one of the most challenging aspects of the evaluation. Doctors are intelligent, fluent in medical jargon, and know how to discuss research findings. In fact, the doctor-patient is very likely to be more of an expert in some type of health care area than you are. This can be freely acknowledged in conversation in a way that makes the doctor-patient feel respected. However, always remember that the doctor-patient is coming to you for an evaluation because a) you have expertise in an area that he/she does not have or b) he/she cannot treat him/herself in an area of shared specialty (e.g., a neurologist treating another neurologist in the same sub-speciality area).  Be on guard for the doctor-patient requesting that you to do things (e.g., ordering certain tests, prescribing certain medications) that you do not feel is clinically appropriate given the facts of the case. While patient input should certainly be listened to and incorporated when possible, it needs to be established from early on that the ultimate person responsible for making diagnostic and treatment decisions is the treating doctor.  In cases where a conflict emerges about how to manage the case, the treating doctor will need to clearly convey his/her position with supportive evidence and proceed accordingly (see next point). 

5. Present scientific data when possible: Doctors are trained in the scientific method and are more likely to agree with diagnostic formulations and treatment recommendations when presented with reference to supportive empirical data. This can include reference to laboratory test values, diagnostic imaging results, published diagnostic criteria, empirically supported treatment recommendations, reference to specific research studies, etc.

Suggested reading: A Taste of My Own Medicine: When the Doctor Is the Patient

Non-Partisan Review of Obamacare Healthcare Reform

These days, it is difficult to read anything about health care reform on line without political spin. To help people who are interested in learning more about the important changes coming to the health care insurance industry in 2014 without the political spin, a detailed easy to read article has now been posted on MedFriendly.

The article is entitled "A Primer on Healthcare Reform (Obamacare)." If you find this article helpful, please pass it on to your friends, co-workers, and family.

Medical Equipment and Supplies for Your Home

Medical emergencies can occur at any time and often happen at home. Investing in home medical supplies brings added peace of mind to you and your family. Whether your family has young children or consists of just you and your spouse, your household may benefit from having the following supplies on hand.

Defibrillators

Each year, over 200,000 Americans die of sudden cardiac arrest. In many cases, the cause of cardiac arrest is ventricular fibrillation, a type of heart rhythm disruption.

While cardio pulmonary resuscitation helps in some cases, a defibrillator may be required to correct the heart rhythm and bring it back to normal. Defibrillators that are portable, also called AEDs, provide on-site defibrillation in these emergencies. Having an AED at home means that in some heart-related emergencies, you may be able to stabilize a loved one before paramedics arrive. These devices guide you through the process and senses if it's appropriate to give an electrical shock.

Glucose Monitoring Equipment

Diabetes has become a common medical condition in western society. Diabetics must keep a careful eye on blood sugar levels to ensure it stays within normal levels. When levels rise too high or fall too low, immediate action should be taken.

All who suffer from diabetes or hypoglycemia should have a glucose meter and test strips at home. Sometimes it is not easy to tell how high or low blood sugar levels are without testing.

Even if you have not been diagnosed with diabetes, it is a good idea to test your glucose levels on occasion. If you notice that your blood sugar seems abnormal, you can make lifestyle changes to prevent the onset of diabetes. Catching diabetes early may help prevent some common complications of this disease.

Blood Pressure Monitor

Blood pressure monitors have come a long way. Today, there are digital monitors available, and they are easier to use than ever. If you or a family member has high blood pressure, or borderline high blood pressure, you should consider investing in a blood pressure monitor.

It's important to monitor your blood pressure daily. A high reading is a sign that it's time to speak with your doctor about managing your high blood pressure. If you are already on medications for high blood pressure, high or overly low blood pressure readings indicate you may need a dosage change or a different medication.

Advanced First Aid Kits

Most simple first aid kits contain only basic supplies, such as ointment, bandages, sterile gloves and gauze pads. These only treat minor injuries. Be prepared for serious injuries, such as burns, sprains, allergic reactions and deep cuts.

Buy or create a first aid kit that contains sterile eyewash, burn cream, ammonia inhalants for fainting, splints, elastic bandages, antihistamine tablets and cream, wound wash and cold pack. For any serious illness or injury, you should always seek medical assistance. However, immediate home treatment of bleeding wounds, chemical splashes to the eyes, sprains, strains, breaks, and minor burns is also important for preventing further injury.

This entry is a guest blog entry.

Poop Transplants to the Rescue!

One of the worst types of infections someone can experience is C. diff, which is short for the bacteria, Clostridium difficile. It is known for causing signs and symptoms such as significant diarrhea with a distinctly foul odor, fever, and abdominal pain. It kills about 14,000 people a year.

Most cases are caused with the use of antibiotics in older people because the antibiotics kill off normal bacteria in the intestine, allowing C. diff to grow.   

C. diff bacteria can live outside of the body for long periods, which means that patients can ingest them accidentally and easily become infected, particularly if they are in a medically vulnerable state in a medical facility. There are various medications (e.g., antibiotics) that are used to treat C. diff, but they are not always effective (recurrence rate of 25 to 30%) and in severe cases, a person may need surgery to remove part of the colon (the major part of the large intestine).

However, there is a less drastic option available for treatment, which actually has a 90 to near 100% cure rate depending on the sample studied. Although most people are unaware of it, the name of this treatment is a fecal bacteriotherapy, which is also known as a stool transplant -- or to use a less scientific term, a poop transplant.

The technique involves taking bacteria from a health person’s feces (poop) and transplanting into the intestine of the patient with C. difficile. The technique works by restoring the normal balance of bacteria in the intestine so C. difficile can no longer thrive. If you are wondering, the poop to be transplanted is preferably collected from a close relative but can be taken from a stranger. It is then mixed with warm water, saline, or milk to reach the needed consistency.

Suggested reading: Clostridium difficile: A Patient's Guide

Five Ways to Get in to See a Medical Specialist Faster

So you have an appointment with that medical specialist you were told you should see. You heard great things about this doctor and have been told he/she is the best. There’s only one problem. The appointment is 3 to 6 months from now, you have pressing needs and concerns about your situation and want to be seen earlier.

In some cases, depending on what the ultimate diagnosis is (e.g., cancer), delaying treatment for months can negatively impact prognosis and can even be a matter of life and death. So, you have a choice:  a) find another doctor who can see you sooner but is not as highly regarded as the doctor you want to see, or b) find a way to get in to the doctor you want to see quicker. Here are five quick tips you can use to increase the chances you can accomplish the latter.

1. Ask to be placed on a waiting list. Cancellations happen regularly due to life circumstances (e.g., a sick child, death in the family, unexpected schedule conflict) and doctor’s offices maintain a waiting list to quickly fill in the appointment slot if a cancellation occurs. Some doctor offices will provide you the option to be placed on a waiting list but sometimes you will need to ask. Be sure to provide a cell phone number as a well as a land line to increase the chances you can be reached.

2. Check in once a week with the secretary. Getting on good terms with the appointment secretary is always a plus. If you call every day, you will not accomplish that goal, but calling once a week is a good idea for several reasons. First, it adequately conveys your desire to be evaluated, which can cause you to be moved up the waiting list when a free slot becomes available. Second, you may find that the secretary just got off the phone with someone who cancelled and since you just so happen to be on the phone, you may get chosen as the person to fill the appointment slot. I recommend using this technique mid to late morning to take advantage of an afternoon cancellation. You can still be on a waiting list and check in once a week.

3. Use your contacts. If you have a friend or family member who knows the doctor you want to see or someone who works at that office, use this to your advantage and see if that person can arrange for you to get moved up on the schedule.  You would be amazed how often this works and it can trim months off of appointment waiting time.

4. Ask the doctor who referred you to exert some pressure on the specialist. Doctors like to keep each other happy because they usually refer to each other. If option #3 is not applicable, the referring doctor is who you can reach out to try and expedite the appointment for you. This can be done with a quick email or phone call. 

5. Lastly, you can try to personally reach out to the specialist and convey why you feel that you or a family member should move up on the schedule. This can be done with a phone call although it will be difficult to reach the person directly. Best bet is usually to do an internet search for an enail contact by which to compose your message. If you know of other techniques, feel free to post that here.

Five Ways to Relax if You Think You May Have Cancer

At some point, it happens to most of us. One way or the other, you discover that there is something not quite right with your body and the doctor you first see about it tells you that more testing is needed to figure out exactly what is wrong.

Perhaps you found a small lump under your arm, maybe you were told that there was an abnormality on a blood test, or perhaps something came back looking unusual on a magnetic resonance imaging (MRI) scan or an ultrasound. Often, the major concern in these situations is that the abnormality may be cancer.  In many cases, a biopsy will be needed to make this determination.

The problem in this situation is that it often takes a considerable amount of time (e.g., weeks to months) before you can get evaluated by a specialist and then undergo the more specific diagnostic tests needed to make final diagnosis. During the interval, it is very common to let your imagination run away with you, especially when researching the issue over the internet, and become convinced that you have a serious medical condition with a poor prognosis. Here are a few tips to help you get through this time:

1. Tell yourself that you will worry when you actually have something to worry about. You may read this and think “but I do have something to worry about. I have a lump and I might have cancer!” The key word there is might, not definitely. Of course, this approach is not designed to reduce all anxiety about the situation because some anxiety is certainly natural. It is a technique, however, to decrease anxiety and remind oneself to focus on what is actually known in the present as opposed to what might happen in the future.

2. Be careful with internet research. While it is natural to type your signs and symptoms into a search engine to research what may be causing a particular problem, be aware that by doing this you are likely to focus on the worst case scenario possibilities as opposed to more benign explanations. Having some information at your fingertips is good, so you can ask knowledgeable questions to your doctor, but try to remember that the doctor will have the education and training to figure out which diagnosis is applicable to your situation and which is not. Of course, not every doctor is perfect or correct, which is why a second opinion can be sought.

3. Do not diagnose yourself. Many people spend weeks to months between appointments in a depressed, anxious, and/or irritable mood because they have been saying such things as “I know I have cancer” or “I know it is multiple sclerosis” without any solid evidence to support it. In many cases, this is a psychological defense mechanism to brace oneself for the worst possible news. However, wouldn’t a better approach be to focus on point #1?

4. Do something to keep you busy. Spending your time between diagnostic evaluations withdrawn, sleeping in bed all day, and isolating yourself from your friends and family only serves to increase depression and despondency. It will also make the time go by much slower. Better to keep yourself engaged in some kind of activity you enjoy that will make the time go by faster.

5. Talk to a trusted friend or family member who is positive. The worst thing you can do is hold all of your emotions in about the situation. Like a teapot filling up with steam with no escape route, the teapot will eventually explode. Talking to someone about your feelings and concerns during this initial stage can be quite a stress reliever and help you see a different side of the situation that you may not have thought about before. 

10 Ways Doctors Can Protect Themselves When Attorneys Try to Influence Patient Care

The prior blog entry discussed ways that attorneys try to control a patient’s medical care to win a case. Below are ten steps that doctors and other health care providers can take to prevent themselves being placed in such scenarios or deal with them more effectively when they occur despite attempts at prevention.

1. Awareness is key. When a  new patient arrives to the office or an existing patient arrives seeking medical treatment for a particular condition or injury, the first step is to determine whether the injury or condition is compensable in some way and whether the patient will be seeking compensation for it. In some cases, this will be easy to determine based on the insurance type (e.g., workers compensation, no-fault insurance) or if the patient acknowledges when asked that an attorney has been hired or that disability is being pursued. In other cases, a patient may deny pursuing compensation but plans to in the near future, is considering it, or is not being honest.  In such cases, consider the history. Was somewhat else alleged to be at fault for the injury (e.g., car accident) or is there someone the patient may blame for the injury/condition (e.g., a doctor misreading a brain CT scan in the ER as not showing signs of an acute stroke when it actually did, resulting in delayed care and worse signs, symptoms, and outcome)? Ask if the person is seeking disability.

2. Document acknowledged compensation seeking, receipt of compensation, and/or retention of legal counsel in the medical note. If the patient denies seeking compensation or having retained legal counsel, document this as well. This way, you have a record of what information was provided to you on this topic when treatment began. If the information changes at some point, document that as well.

3. Ask the patient whose idea it was for the evaluation. If the idea solely came from the attorney, explain to the patient that your practice (an insurance billing) is specifically designed for patients in which referrals originate from other health care providers or from the patient for the sole purposes of improving healthcare (as opposed to pursuing compensation). In other words, you perform clinical evaluations, not legal evaluations.

4. If the idea for the evaluation came from the attorney but was referred by another health care provider, contact that provider to discuss the issue. I have had several cases where I place such a call and the physician tells me. “I have no idea why I am sending the patient for the evaluation. She said her attorney wanted it, so I just ordered it.” In such cases, explain your position to healthcare provider and provide the patient and referral source with contact information of other providers in the area who perform medico-legal work (which is paid for by the attorney).  

5. If the referral was legitimately made by a healthcare provider but the patient is also pursuing compensation, explain that the medical records may be subpoenaed by an attorney/judge and used in a deposition, trial, or settlement negotiations. Explain that the findings may help the patient, have no impact, or negatively impact the compensation case. Explain that you will base your findings on scientific principles and methods and that your findings may be in perfect agreement with what the patients thinks is the problem and expects as a recommendation (e.g., disability status), may be in partial agreement, or that you may have a completely different take.
6. Go through the above information with the patient in an informed consent that you have the patient sign.  Make sure the form has a statement in it that says signing it means that the patient understands what is on the form, had the chance to ask questions, and that any questions have been answered to his/her satisfaction. Explain this out loud to the patient and provide the patient a copy when it is signed. This document can protect you in the future in case of a complaint. If the patient is unwilling to sign the form you can refer him/her to another provider.

7. While there is nothing wrong with clinically evaluating patients who are seeking compensation, make it clear that while you are open to hearing input that you are the one who makes the ultimate diagnostic and treatment decisions, decides how to word documentation, and what to say in a court of law. Be clear that this has nothing to do with ego or arrogance, but after all, you are the one with the health care license and health care degree.

8. While it is perfectly acceptable to advocate on a patient’s behalf, health care providers must be cautious to avoid blind advocacy in which there is an absence of evidence to validate compensation claims. This is especially the case when extensive attempts have been made to find such evidence. While it is true that absence of evidence is not always evidence of absence, many times it is.

9. Do not turn a blind eye to evidence that emerges which runs counter to the patient’s claims. In such cases, it is best to sit down with the patient, express your concerns, and adjust the case conceptualization and treatment plan accordingly. An example would include referring a patient for counseling if significant psychological distress appears to be the main problem as opposed to a mild injury. Do not send patients for indefinite treatments that show no improvement within reasonable time frames. Be sure to measure treatment progress over time.

10. If you eventually have to do a deposition or testify, try your best just to stick with the facts without getting caught up with trying to help one side win or lose the case. The outcome of the case is for the attorneys to handle and the jury to decide. The role of the witness is to assist the court/jury by providing honest testimony that is as objective as possible.

When Attorneys Control Patient's Medical Care to Win a Case

Consider the following scenario. A 40-year-old man arrives to your office seeking medical treatment for a mild personal injury suffered several weeks or months prior. Unbeknownst to you, the patient has hired a personal injury attorney who suggested that you evaluate him. Over the course of months to years, the patient reports no meaningful improvement in symptoms despite no objective biomarkers that any significant physical damage has occurred. In fact, the patient may even report getting worse despite all treatment attempts. 

Unbeknownst to the health care provider, the patient is regularly checking in with his attorney and receiving directives to request referrals for numerous therapy services (e.g., physical therapy, occupational therapy) to establish a record of a need for medical treatment to be used in settlement negotiations or an upcoming trial. Along the way, the attorney also directs the patient to make requests for diagnostic imaging (“Can you order an MRI?”), medications (“Can you prescribe me something for the pain?”), and specialty evaluations by someone known to the attorney (“Can you refer me to Dr. Smith?”). In health care, the attorney is said to be operating in stealth mode, although in other cases the attorney may be bolder and make these requests directly to the health care provider.

Unable to determine why the patient continues to report persisting symptoms, the health care provider accedes to these requests even though he/she may doubt that they will yield much, if any, benefit. Indeed, that is exactly what happens. For example, the therapists treat the patient but are also unable to provide any meaningful improvement and eventually inform him that no further treatment is indicated.  Within a few weeks, the therapists find out that the patient is back on the schedule for six more sessions, not knowing that the attorney instructed the patient to call the scheduling desk and do so.  The therapists see him again, as he now reports some new symptoms. Incidentally, when some of these patients are later asked why they continued to go to therapy sessions that were not helping, they will answer “Because my attorney told me I have to go.”

Eventually, the doctor who has been managing the patient’s care, receives a letter from the patient’s attorney, requesting a copy of all records and a time to talk on the phone to prepare for an upcoming deposition. The doctor may also be told something along these lines (taken from an actual email sent to me by a physician seeking my assistance on a case):

“The lawyer he (the patient) has hired told me that my response to a multi page letter from ‘independent’ reviewers needs to contain a rebuttal to their assertions that he has no claim. Whatever data I generate from the review of his file and references to papers will need to be made now because, if he does not win this appeal, only the information that I provide in a response can then be used in a subsequent law suit."

The doctor, wanting to advocate for his patient and not cause harm, writes a strongly worded rebuttal to the independent reviewers, clearing the language with the patient’s attorney before sending it in. A deposition, followed by trial testimony, is forthcoming.

The above scenario, and variations of it, occurs with alarming regularity and it is a major cause of increased health care costs, costing millions of dollars a year or more. In such cases, much of the patient’s healthcare outwardly appears to be directed  by the health care provider but is actually being directed by the patient’s attorney . Despite this, years of medical bills are sent to the patient’s insurance company as opposed to the attorney’s law firm.  In addition, the attorney has obtained a free expert witness, taking advantage of the health care provider’s fidelity to the patient and fear that not helping with the legal requests will cause the patient to lose the case, thus causing "harm.". The above scenario raises many obvious ethical and legal pitfalls, the most important of which is the potential for insurance fraud. The next blog entry will discuss steps that health care providers can take to prevent themselves from being placed in these situations or manage them better when they occur.

If Andy Williams Drank Tea Would He Still Be Alive?

Today, legendary singer Andy Williams (age 84) died of bladder cancer, a condition he announced being diagnosed with less than one year ago (November 2011).  He had received chemotherapy treatment. One of the first things people ask when finding out that someone they know (or know of) has died of an illness, is what the signs and symptoms were and if it could have been prevented.

For most people, bladder cancer presents with blood in the urine, a sure sign that something is wrong and that you need to see a doctor ASAP. However, the blood is sometimes only detected microscopically, which is why regular check-ups with the doctor are important because periodic urine analysis studies are typically ordered.  Painful and frequent urination are also symptoms of bladder cancer as is a feeling that one has to urinate but being unable to when trying.  It is worth noting, however, that bladder cancer is only one of many reasons why someone can experience these signs and symptoms, some of which are more serious than others (e.g., dehydration, kidney stones, urinary tract infection).

Diagnosis of bladder cancer is typically made via a biopsy of selected tissue. At this time, there is no clearly effective screening test for bladder cancer. Thus, the focus turns to prevention. Some risk factors are controllable such as smoking and not exposing yourself to harmful toxic chemicals such as arsenic and those used in various manufacturing plants (e.g., paints and dyes). However, many of the factors are beyond one’s control such as genetics and being an old white guy. That may sound humorous but indeed, old age, being white, and being male are all factors that increase one’s risk of bladder cancer.

As a result of such incontrollable factors, people often try to turn to diet to tip the odds back in their favor. Enter the world of tea consumption, which has been touted as being able to prevent bladder cancer. Individual studies on the topic have been inconsistent. When this happens, one of the best ways to gain more clarity on the subject is to perform a meta-analysis. In a meta-analysis, the researcher examines all of the best studies available on a particular topic, treats each study as if it was a research subject, and looks to see if the claimed intervention is actually effective.

A new meta-analysis on this topic was recently published in the World Journal of Surgical Oncology.  The authors selected the 23 top studies on the topic and found no association between tea consumption and decreased bladder cancer risk. This held true regardless of the type of tea consumed (e.g., green, black), gender, or the type of research design used. Incidentally, this meta-analysis replicated the findings of a prior one on the topic (Zeegers et al, 2001), yet included 11 more recent studies.  Overall, regardless of how much tea Andy Williams would have consumed, he would have very likely still passed away from bladder cancer.

References:

Qin J, Xie B, Mao Q, Kong D, Lin Y, Zheng X. (2012). Tea consumption and risk of bladder cancer: a meta-analysis. World Journal of Surgical Oncology, 10, 172-(ahead of print).

Zeegers MP, Tan FE, Goldbohm RA, van den Brandt PA (2001). Are coffee and tea consumption associated with urinary tract cancer risk? A systematic review and metaanalysis. International Journal of Epidemioogy, 30, 353–362.

Treating Tonsil Abscesses with Immediate Tonsillectomy

In the current issue of Acta Oto-Laryngologica, Drs. Nicolas Albertz and Gonzalo Nazar summarized 10 years of experience in treating patients with abscesses around the tonsil region (known as peritonsillar abscesses). An abscess is a well-defined collection of pus that has escaped from blood vessels and has been deposited on tissues or in tissue surfaces.

One or both tonsils can become infected and develop an abscess. These types of abscesses are actually the most common infections in the deep part of the neck. A common form of treatment is to cut into the abscess and drain the pus. However, Drs, Albertz and Nazar provide evidence that immediate surgical removal of the tonsils (tonsillectomy) is a safe and effective alternative treatment based on reviewing 10 years worth of patients (total =112 people, average age = 24 years) with this condition who had one tonsil (28 patients) or both tonsils removed.

Of the patients who received the surgery, none developed sepsis, which is a potentially deadly whole-body inflammatory response to infection. Only four (3.6%) of the patients developed bleeding after the operation and of these, two resolved spontaneously. Only 29% of the patients had enough pain that they needed to use a pump to self-administer morphine after surgery for pain relief. The average hospital length was 3.4 days. Of the 28 patients who had one tonsil removed, four (14.2%) developed a strept infection of the tonsils. Two of the 28 patients (7.1%) were admitted to the hospital again with inflammation around the tonsil area on the side that was not operated on. Only one of these patients required drainage and removal of the other tonsil. The authors concluded that the complication rate of the immediate tonsillectomy in these patients was similar to that of scheduled tonsillectomies in adults and that this should be considered a first-line treatment for peritonsillar abscesses.

Reference: Albertz, A. & Nazar, G. (2012). Peritonsillar abscess: Treatment with immediate tonsillectomy –10 years of experience. Acta Oto-Laryngologica, 132, 1102-1107.

Japanese and American Differences in Modesty Eliminated by Money

New social psychological research from Japan is shedding light on differences is modesty between people from American and Japanese cultures and shows the powerful effect of financial incentives on behavior. In the experiment, Japanese and American participants each completed two tasks: an embedded figure test and a trustworthy judgment task.  The Japanese participants were found to be modest (self-effacing) when asked to evaluate their performance compared to peers in their age range when no reason for providing the evaluation was given.

This was the case even though the responses were done via an anonymous questionnaire. By contrast, the Americans (especially the men) showed a self-enhancing tendency when evaluating themselves when no reason for providing the evaluation was given. However,  these cultural differences were eliminated when the participants were offered money for providing the correct self-evaluation. That is, the Japanese and the American groups both enhanced their self-evaluation ratings when offered a monetary awards. The findings show that the stereotypical differences in modesty between Japanese and American cultures were entirely dependent on context.

The authors believed that the results showed that modesty is a default reaction in the Japanese culture designed to avoid offending others. This default reaction was described as a social mandate that is advantageous to avoid being excluded from the group relations they encounter in everyday life. However, the study shows that default cultural behavior can be altered significantly with a monetary award because there is a strongly motivating factor present to override it.

Reference: Yamagishi, T., H. Hashimoto, Cook,  K., Kiyonari, T., Shinada, M., Mifune, N., Inukai, K., Takagishi, H., Horita, Y., Li, Y. Modesty in self-presentation: A comparison between the USA and Japan. Asian Journal of Social Psychology, 15, 1, 60-68. The entire study can be read here.

Want to Boost Your Health? Try Healthy Supplements

Are you looking to improve your health? You've probably started by getting more exercise and switching to a healthy diet full of fresh fruits and vegetables in order to get more nutrients from your food. This is a great start, but the reality is that it's extremely challenging to get all the nutrients your body requires from your food alone.


Fruits and vegetables derive their nutrients from the soil in which they are grown. Unfortunately, our soil is becoming depleted, which means that today's fruits and vegetables as well as other foods have lower nutritional content than in previous years. The animals that eat foods that are grown in depleted soil also have fewer nutrients available, which means that the pigs and cows that we consume in the form of pork chops and steaks also have a less favorable nutritional profile.

While obtaining nutrients solely from food is ideal, to get the rest of the nutrients your body needs, you can add nutritional supplements like the ones found on this site. Not only do nutritional supplements help build up your levels of important vitamins and minerals required by your body, they also provide complementary nutrients that help your body to better absorb and assimilate the vitamins that you are able to obtain from your foods.

As an example, you probably drink milk in order to meet your body's daily calcium requirements. Unfortunately, without enough vitamin A and vitamin D, your body is unable to properly use the calcium that is found in your milk. While milk is often fortified with these vitamins, they are typically not enough. According to a study published in the Archives of Internal Medicine, vitamin D deficiency is dramatically on the rise and is being blamed for an increase in such diseases as cancer and diabetes.

Additionally, if your digestive system isn't working properly, you will have difficulty absorbing nutrients properly. Many supplements contain ingredients that help your digestion run smoother so that you can get more benefit from the foods that you eat. Adding a supplement containing probiotics to your diet is a great way to boost your gut health. Probiotics help restore the natural flora of your gut, which is easily damaged by taking antibiotics yourself or by eating meat that has been overly treated with antibiotics.

Adding nutritional supplements to your diet is a great way to improve your health. When your body is properly nourished, you will look and feel your best.

This entry is a guest blog entry.

How Too Much Exercise Can Harm You and Your Heart

A regular normal amount of exercise is known to reduce many diseases and improve heart health. However, some people have taken the “Let’s Move” and exercise suggestions to the extreme. Examples include running hours a day and training for grueling marathons and triathalons. By all means, people should feel free to do this if they want to, but they should do so knowing that there are potential serious health risks involved.  People may be surprised to hear this, especially after hearing day after day about the need to exercise, exercise, exercise. This has led some people to believe that if exercise is good, then very high amounts of exercise must even healthier. But that is not always the case, as recently pointed out in a review article in Mayo Clinics Proceedings (reference below) that did not receive much media attention.

The authors of the review paper found that long-term exercise endurance can cause abnormal structural changes in the heart and large arteries. This is especially true for people who train in marathons, ultra-marathons, ironman distance triathlons, and very long bicycle races. Initially, this could cause short-term overloading of the heart, decreased heart pumping efficiency, and elevations on blood tests that are indicative of heart damage. The good news is that these transient effects return to normal in one week.

The bad news is that if this process of excessive repetitive exercise continues over months to years, it can lead to heart disease such as abnormal thickening of the heart valves and abnormalities in the heart muscle leading to stiffening of the heart tissue.  This can also lead to abnormal heart rhythms. Other problems that can be caused by excessive exercise include coronary artery disease and stiffening of large arteries.  Some of the risk factors are considered hypothetical and like most research areas there are some inconsistent findings. However, it is probably wise to consider the words of the ancient Greek philosophers to do things in moderation.

Reference: O'Keefe JH, Patil HR, Lavie CJ, Magalski A, Vogel RA, McCullough PA. (2012). Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clin Proc., 87, 587-95.

Also of Interest: How Jogging Can Kill You

Can Hyperbaric Oxygen Therapy Improve Achilles Tendon Tears?

Hyperbaric oxygen therapy (HBOT) is the application of 100% oxygen in a specialized chamber to treat medical conditions, most commonly decompression sickness. Decompression sickness is  the formation of gas bubbles in the body from being exposed to extreme depths or heights.  However, scientists continue to research whether hyperbaric oxygen can be used to treat other medical conditions.

In a new study referenced below, researchers attempted to find if HBOT could improve early healing after Achilles tendon tear and subsequent repair, in rats. The Achilles tendon attaches the calf bone to the heel bone and is often torn as a result of athletic activity. The researchers took two groups of rats (28 per group) , surgically tore the tendons, and sutured them. Before surgery, one group’s Achilles tendon was injected with a steroid medication (betamethasone ) and the other group’s Achilles tendon was injected with a saltwater solution. Fourteen rats from each group were treated with HBOT and the others were not. The Achilles tendons were removed, evaluated for how well  they moved, how strong they were, and what their features were like under the microscope 11 days after surgery. The researchers found that the group treated with HBOT showed improved healing of the Achilles tendon in terms of movement, strength, and formed more fibrous connective tissue.  The results cannot yet be generalized to humans because it is based on rats but many will view the findings as promising.

Reference: Kuran, F.D., Pekedis, M.P., Yildiz, H., Aydin, F., & Eliyatkin, N. (2012). Effect of hyperbaric oxygen treatment on tendon healing after Achilles tendon repair: an experimental study on rats. Acta Orthopaedica et Traumatologica Turcica, 46 (4).

Improving Sleep in Intensive Care Units

Intensive care units (ICUs) are not fun places to be. By definition, people placed on such a unit need intense medical care for a serious medical condition (which is often life-threatening). While on the ICU, the body needs to rest in order to heal and the best way to do that is through the restorative powers of sleep.

 RECOMMENDED BOOK: Say Good Night to Insomnia

With worse sleep in the ICU, it will take longer to leave the ICU, the patient may develop delirium, and worst of all, the chances of dying increases. Delirium is a state of fluctuating mental confusion that develops over a few hours or days. Some studies have shown that people in ICUs have sleep problems characterized by frequent awakening, abnormal biological clock rhythms, and/or a decreased length of time in the 3rd and 4th stages of sleep.

To address this problem, treatment of sleep disorders in critically care patients are needed. However, in a newly published review article in the medical journal, Acta Anaesthesiologica Scandinavica, researchers found that there was not good scientific evidence that existing treatments of sleep disorders in the ICU setting worked. The authors suggested large multi-center studies to address this problem with larger groups of patients that were more alike as a group.

The authors also suggested some specific possible changes such as: 1) improving the ICU setting, 2) not using as many medications known to cause sleep problems, 3) use of melatonin pills (a chemical that is used naturally in the body to promote sleep), and 4) using more types of mechanical ventilation to improve synchrony between the patient and the ventilator.

Related blog entry: Treating Sleep Problems in Multiple Sclerosis: An Update

Reference:  Boyko, Y., Ording, H., Jennum, P. (2012). Sleep disturbances in critically ill patients in ICU: how much do we know? Anaesthesiologica Scandinavica, 56, 950-958. 

Michael Clarke Duncan Turns Vegetarian, Loses Weight, and Dies of a Heart Attack

On 9/3/12, famous actor, Michael Clarke Duncan, died after complications from a heart attack that he suffered on 7/13/12. Some people may not be surprised because they remember him from his roles as an imposing figure in The Green Mile. Duncan was 6 foot 5 inches tall but before he became famous, he weighed up to 315 pounds.

I have yet to see anyone comment on the irony of his death given that he became a vegetarian in 2009, lost about 45 pounds, and became a spokesperson for PETA, touting the health and strength benefits of vegetarianism. As I have made clear many times on this blog, I have no objections at all to people wanting to be a vegetarian. However, I don’t like when people continuously try to convince and badger others that they should not eat meat if they are perfectly content doing so.

As I have also pointed out, the notion that eating a diet full of fruits of vegetables is going to provide some sort of guarantee against sickness and death is completely misplaced. In Duncan’s advertising campaign for PETA, he pointed out how elephants are powerful and strong despite only eating vegetables. However, the real King of the Jungle is the lion and the lion feasts on meat.  I also once saw a nature show documenting a group of hungry tigers attacking and eating an elephant when provoked by hunger.

The bottom line is that there are pros and cons to vegetarian and non-vegetarian diets and each person needs to make their own individual choice. However, the choice should be made based on realistic expectations. In other words, if you really love meat but chose not to eat it because of reported health benefits, you may regret not having the occasional hamburger or hotdog after being diagnosed with a terminal illness and should not be surprised if this occurs. If you truly love being a vegetarian though, won’t regret it when facing your own mortality, and won ‘t be shocked if you are diagnosed with a serious illness (e.g., cancer) then enjoy those fruits and veggies.

Related Blog Entries:

1. When Fruits and Vegetables Kill
2. How Fruits and Vegetables Killed Steve Jobs
3. Exercise and Eat Fruits and Veggies All You Want: You're Still Going to Die

EXTREME Body Parts: Part 4

The most popular feature of the MedFriendly Blog is back: the world's most extreme body parts. If you have not seen this interesting feature, see the original article, part 2, and part 3. Without further ado, here is part 4.

1. World's Largest Hand: This is the hand of Lui Hua, who suffers from a condition known as macrodactyly. This rare condition is defined as abnormally large fingers or toes from birth due to overgrowth of underlying bone and soft tissue. The left thumb was 10.2 inches and the index finger was close to 12 inches. In July 2007, he underwent radical surgery to have 11-pounds of flesh removed.

2. Most Fingers and Toes: Another abnormal condition that can affect the fingers and toes is polydactylism. There are two people known to have 25 fingers and toes (Pranamya Menaria, Devendra Harne). Devendra is shown below:

3. World's Largest Female Beard: This is Vivian Wheeler, a woman born as a hermaphrodite. The longest hair was 11 inches and 27.9 centimeters.

4. World's Longest Eyebrow Hair: This record goes to Frank Ames from Saranac, NY, who has a 3.7 inch eyebrow hair.

5. The World's Largest Tongue: The world's longest tongue belongs to Steven Taylor from England. It measures 9.8 cm (3.86 cm). For the female record for the longest tongue, see here.