Saturday, January 19, 2013

Diabetes Treatment and Management

Despite extensive research, numerous medications that have come to market, and continued scientific advances, a cure for diabetes has yet to be found. However, there are numerous medications and forms of management equipment for diabetes and the future brings great hope for continued progress in the search for a cure.

Bringing new medications and disease managing equipment to market can be slowed by barriers within the pharmaceutical company industry. In addition, the FDA has a whole host of rules, regulations and legal barriers that slow down the research, creation and commercialization of cures. However, the American Diabetes Association is hoping to encourage research with their “Pathway to Stop Diabetes” program.

There has been research done that speculates that type 1 diabetes may be reversed by a tuberculosis vaccine. The vaccine is called bacillus Calmette-Guérin (BCG) and it stimulates production of a protein that kills insulin-attacking cells, according to a study published in PLOS One Journal. The study showed that 2 out of 3 patients given the BCG injection had signs of renewed insulin production. They are now planning on a larger study pending on funding.

No one knows what cures the future will bring. In the meantime, sufferers of diabetes type 1 and type 2 should continue maintenance treatments. The difference between type 1 and type 2 diabetes is how the body produces insulin. In type 1 diabetes, the body does not produce insulin. In type 2 diabetes, the body produces insulin, but it either does not produce enough or it does not utilize it properly. Untreated diabetes can lead to serious conditions such as heart disease, stroke, loss of limbs, and damage to the nerves, eyes or kidneys. A cure for this serious condition would help so many sufferers.

Blood sugar is monitored usually by a finger stick and a portable machine which you can learn more about at Such a device will read your glucose levels, indicating how much—if any—insulin is required. Patients should monitor their blood sugar levels at the same time every day for consistency.
Medication treatments include insulin injections or pumps and prescription medications. Common prescriptions include Metformin, Glipizide and Glimepiride.

Lifestyle and knowledge are important factors in treating and maintaining diabetes. Do your research. Be committed to maintaining your diabetes in hopes of a cure someday. Many suffers are overweight. Losing weight helps your body in many facets, including utilizing blood sugar. Eat a diet full of fruits, veggies, whole grains and limit bad fats such as saturated and trans fats. Some professionals recommend the Glycemic Index (GI) diet, which monitors carbohydrate-rich foods by how fast the body turns them into blood sugar versus the “no sugar” diet. Regular exercise is also extremely important. Aim for 30 minutes a day of aerobic exercise. 

You also want to keep up to date with eye and foot examinations, as these can be problem areas for diabetes sufferers. The sooner a problem is detected, the better.

The above entry is a guest blog entry.

Friday, January 18, 2013

The Stomach Bug/Flu in Children: What Works & What Doesn’t

You know of it as the stomach bug or the stomach flu (even though it is technically not related to the actual flu). Medical doctors refer to it as gastroenteritis because it involves inflammation (which is what “itis” means in Greek) of the stomach (gastro) and small intestines (entero). The small intestine is the part of the intestine that takes in all of the nutrients the body needs.

Regardless of what you call this condition, it is not something you want to have. Common signs and symptoms include diarrhea, stomach pain, stomach cramps, and vomiting.  It is a common reason for visits to the doctor, urgent care centers, and emergency rooms.

The stomach bug can occur in adults but it is very common in children. When it occurs in children, it is usually caused by a virus known as rotavirus.  By age five, nearly every child in the world has been infected by rotavirus at least once.

In a new review study published in Europe, researchers presented a summary of the best evidence for treatment of acute gastroenteritis in children. The authors found that oral rehydration (drinking fluids by mouth) is central to treatment.  Specific hypotonic solutions (composed of salt, sugar, and water) are used for this rehydration.  Although effective, oral rehydration is not always used because it does not decrease the amount of bowel movements, does not decrease the length of the illness, and the liquid is not something children enjoy due to the strong salty taste. There are continuing efforts to improve the taste and effectiveness of these liquids for children.

The authors found that the anti-diarrhea medication, Racecadotril  (acetorphan) can be an effective additional treatment along with oral rehydration. The authors also noted that a natural clay known as smectite can be an effective additional treatment to oral rehydration. However, neither smectite nor Racecadotril are available for use in the U.S.

When oral rehydration is not feasible, another option is nasogastric rehydration. In this technique, fluid is directed to the stomach through a tube placed in the nose that connects it to the stomach. This technique is sometimes used over a 24 hour period but newer evidence shows that doing this rapidly over 4 hours is also effective. The authors found that nasogastric hydration can be an effective or better than intravenous hydration, which is when a needle is inserted through the vein and liquid enters the body.  For cases of intravenous hydration, evidence on the amount of fluid to administer was not consistent. The authors considered 20 ml/kg to be appropriate, which is standard intravenous rehydration.

Medications used to stop vomiting are known as anti-emetics. A common medicine used for this purpose is Ondansetron (Zofran). The authors noted that this medication does reduce vomiting in young children with the stomach bug but that there was no evidence that other medications were useful for this purpose. It was noted that the Food and Drug Administration (FDA) recommends heart monitoring in patients receiving Zofran who have potential electrolyte abnormalities (which someone with the stomach bug would) because it can lead to abnormal and potentially deadly heart rhythms. Electrolytes are chemical substances that are able to conduct electricity after they are melted or dissolved in water.

The authors reported on one European study that did not show that the element, zinc, was useful in treating gastroenteritis. Lastly, the authors found that some probiotics are helpful in managing diarrhea gastroenteritis. Probiotics are live microorganisms that provide health benefits to the host. Specific probiotics found to be helpful were Lactobacillus GG and S. boulardii but that others may prove helpful in the future as well as synbiotics. Synbiotics are combinations of probiotics and prebiotics. Prebiotics are undigestible food ingredients that promote growth and/or activity in the digestive system in ways claimed to be beneficial to health.

Suggested reading: Viral Gastroenteritis

Related blog entry: Preventing Rotavirus with Vaccines: Do They Work?

Reference: Pieścik-Lech M, Shamir R, Guarino A, Szajewska H. (2013). Review article: the management of acute gastroenteritis in children. Aliment Pharmacol Ther. 37(3): 289-303.

Thursday, January 17, 2013

Ovarian Cancer: Treatment with Avastin

Ovarian cancer is a serious disease diagnosed in over 20,000 women a year in the U.S. alone. Cancer is any of a large group of malignant diseases characterized by an abnormal, uncontrolled growth of new cells in one of the body organs or tissues. As the name suggests, ovarian cancer is cancer of the ovaries. The ovaries are a pair of glands that contain the eggs (female reproductive cells) and produce female hormones. Hormones are natural chemicals produced by the body and released into the blood that have a specific effect on tissues in the body.

Signs and symptoms of ovarian cancer are usually absent or subtle in the early stages of the disease, which is why it often goes undetected initially. Signs and symptoms typically include bloating, increased fluid in the abdomen area, pain in the abdomen, pelvis, or back, a mass in the abdomen, difficulty eating, weight loss, urinary difficulties, constipation, fatigue, and abnormal bleeding from the female reproductive area. Because the condition can go undiagnosed for so long, when the disease is detected in later stages, the prognosis is usually poor.

Treatment of ovarian cancer usually involves chemotherapy medication after surgery. There are many different chemotherapy options and combinations for women with ovarian cancer, which largely depends on the tumor type (when analyzed microscopically). One such chemotherapy medication is Bevacizumab (trade name Avastin). Avastin is known as an angiogenesis inhibitor, which means that it slows the growth of new blood vessels. This is important because tumors (cancerous masses) are highly dependent on blood vessel formation.

Avastin was first made commercially available for the treatment of colorectal cancer in 2004. At the time of this writing, Avastin is approved by the Food and Drug Administration (FDA) to treat additional cancers but is not yet approved to treat ovarian cancer in the U.S. However, Avastin is approved for ovarian cancer treatment in Europe.

Several clinical trials have been conducted in the U.S. to explore the role of Avastin in ovarian cancer treatment. This research was recently summarized by researchers in the medical journal, Advances in Therapy. The authors noted that adding Avastin as part of a first line treatment in advanced ovarian cancer and as maintenance therapy improves progression-free survival (PFS). PFS is the length of time during and after medication or treatment during which the disease being treated (e.g., cancer) does not worsen. Avalide has also shown benefit with respect to PFS in relapsed ovarian cancer that is sensitive to or resistant to platinum-containing chemotherapy.

While benefit to using Avastin in ovarian cancer treatment has been demonstrated, the authors noted that the medication is not without its side effects. Nevertheless, the authors concluded that Avastin represents a new option in treatment for ovarian cancer.

Suggested reading: Memoir of a Debulked Woman: Enduring Ovarian Cancer

Related blog entry: Ovarian Tumors in Children: They Happen

Reference: Heitz F, Harter P, Barinoff J, Beutel B, Kannisto P, Grabowski JP, Heitz J, Kurzeder C, du Bois A. (2012). Bevacizumab in the treatment of ovarian cancer. Adv Ther. 29(9):723-35.

Wednesday, January 16, 2013

Anti-depressants in Pregnancy: What are the Risks?

Women with major depressive disorder often become pregnant and women who are pregnant often develop major depressive disorder (referred to as depression going forwards). While the safest form of treatment for depression is counseling (usually with a psychologist) another common form of treatment is anti-depressant medication.

Anti-depressant medications, like all medications, have side effects and there is controversy about whether these medications should be used during pregnancy.

Researchers recently published a critical review of the scientific literature on anti-depressant medication use in pregnancy in the journal, Acta Psychiatrica Scandinavica. The authors found that no single type of birth defect has been consistently observed across research studies with any anti-depressant medication that is commonly used.  Some studies suggested associations between some specific birth defects and anti-depressant use in pregnancy but the findings were not consistent. 

These specific medications in which such inconsistent association were noted was in a class known as selective serotonin-reuptake inhibitors (SSRIs). SSRIS work to block the re-uptake of a chemical messenger in the brain known as serotonin. This makes more serotonin available, which improves mood. SSRIs are among the most commonly prescribed anti-depressant medications and are the most studied anti-depressant medications in pregnancy. Since all SSRIs cross the placenta, they can transport increased levels of serotonin to the fetus. The placenta is an organ in the uterus (a hollow organ in which a baby develops) that links the blood supply of the mother to the developing fetus and by which the fetus can release wastes.

Another finding was that postnatal adaptation syndrome (PNAS) occurs in up to 30% of neonates exposed to antidepressants in late pregnancy. PNAS is a cluster of signs and symptoms in infants that includes irritability, lack of energy, decreased activity, decreased feeding,  abnormal rapid breathing, abnormal crying, tremor, and difficulty breathing. PNAS usually lasts for days to weeks (up to 6 weeks) after delivery.  Some studies suggested a small association between persistent pulmonary hypertension of the newborn (PPHN) but others did not (the evidence is inconclusive). Pulmonary hypertension is when more blood than necessary is pumped to the lungs.

The authors cautioned that when evaluating research studies on this topic it is important to consider whether researchers took into account diagnoses of the mother or other factors that can confound the study outcome, whether they used adequate control groups (e.g., infants exposed to no medications or another class of medications), whether the infants were systematically  assessed, and whether those rating the infants knew if they were exposed to anti-depressant medications.

The authors suggested that doctors should have individually-tailored discussions with each pregnant woman about these issues who are considering anti-depressant use during pregnancy. They noted that past medication trials, previous success with symptom remission, and women’s preferences should guide treatment decisions.

Suggested Reading: Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting

Related Blog Entry: Preventing Post-partum Depression in Adolescent Mothers

Reference: Byatt N, Deligiannidis KM, Freeman MP. (2013). Acta Psychiatr Scand. 127(2):94-114. Antidepressant use in pregnancy: a critical review focused on risks and controversies.

Tuesday, January 15, 2013

Breast Cancer Staging: PET Scans, Ultrasounds, and Biopsies

Breast cancer continues to be a major health problem throughout the world and requires accurate staging to determine the most appropriate treatment and to estimate prognosis. Cancer staging describes the extent or severity of the disease. One way that cancer staging is determined is to assess if the cancer has metastasized (spread) to the lymph nodes. Lymph nodes are small egg shaped structures in the body that help fight against infection. The first lymph node (or group of nodes) that cancer spreads to is known as the sentinel lymph node.

There are multiple ways to assess for lymph node metastasis. The most definitive way is to perform a biopsy of the lymph node(s) where cancer spread is the most likely. A biopsy is the process of removing living tissue or cells from organs or other body parts of patients for examination under a microscope or in a culture to help make a diagnosis, follow the course of a disease, or estimate a prognosis. In breast cancer, the lymph node(s) biopsied are one or more (usually one to three) of the axillary lymph nodes, which are located under the arm pits. A more intensive surgical process is an axillary lymph node dissection, which involves removing at least six of the lymph nodes and having them analyzed at a laboratory to be tested for cancer. In most cases, if the sentinel lymph node biopsy shows metastasis, then a lymph node dissection follows.

Due to the invasiveness of these surgical procedures, there has been increased interest in developing non-invasive ways to detect breast cancer spread to the lymph nodes. One method is to use ultrasound scanning. Ultrasound scanning is a procedure that uses high-frequency sound waves to produce images of internal body structures. Another technique is a positron emission tomography (PET) scan combined with computed tomography (CT). When combined, this is known as PET/CT and can be used to scan the entire body. A PET scan involves injecting the patient with a small radioactive chemical and being placed in a machine that detects and records energy given off by the substance. The computer translates the energy into 3D pictures which provides information about how cells in the body are functioning because normal cells react differently to the chemical than healthy cells. CT scanning is an advanced imaging technique that uses x-rays and computer technology to produce more clear and detailed pictures than a traditional x-ray.

In a recent study published in the medical journal, Acta Radiologica, researchers compared the diagnostic utility of PET/CT scans to ultrasound scanning in detecting axillary lymph node metastases. The authors found that PET/CT scans were more accurate than ultrasounds in evaluating axillary lymph node metastases. The PET/CT scan also detected lymph node metastases in seven out of 91 patients (8%) that had not been detected by another imaging modality. However, because the PET/CT scan still has a low sensitivity (54%) for detecting axillary lymph node metastasis, it was noted that it cannot serve as a substitute for sentinel lymph node biopsy.

Suggested reading: The Mayo Clinic Breast Cancer Book

Reference: Riegger C, Koeninger A, Hartung V, Otterbach F, Kimmig R, Forsting M, Bockisch A, Antoch G, Heusner TA. Acta Radiol. (2012) Comparison of the diagnostic value of FDG-PET/CT and axillary ultrasound for the detection of lymph node metastases in breast cancer patients. Acta Radiologica, 53(10): 1092-8.

Monday, January 14, 2013

Contraceptive Use in Women with HIV

If you are a woman with HIV (human immunodeficiency virus), preventing unintended pregnancy is important to preventing the transmission of HIV to a baby. While abstinence is the best option to prevent further spread of HIV, some individuals choose to use hormonal contraception.

However, there has been speculation that use of hormonal contraception in women with HIV will lead to worsening of disease progression.

 In an upcoming article in the journal, AIDS, researchers conducted a systematic review of the literature to determine if women with HIV who use hormonal contraceptives are at increased risk of disease progression compared to women who do not use contraceptives. Eleven total studies were reviewed.

The authors found that most of the evidence showed that women with HIV can use hormonal contraception without needing to worry that it will result in increased disease progression. Disease progression was measured by mortality (death), increased viral load, time to beginning anti-retroviral therapy, decreased CD4 cell count, and time to CD4 count below 200). CD4 cells are types of white blood cells that help protect the body against disease by fighting infectious organisms. When these levels go below 200, it is an important marker of disease progression. Anti-retroviral therapy (ART) refers to medications designed to suppress HIV and disease spread.

Suggested reading: The First Year: HIV: An Essential Guide for the Newly Diagnosed

Related blog entry: Increased Risk of Sudden Hearing Loss in HIV

Reference: Phillips SJ, Curtis KM, Polis CB. (2013). Effect of hormonal contraceptive methods on HIV disease progression: a Systematic Review. AIDS, in press.

The image above shows HIV (yellow) attacking a human cell. Credit: National Institutes of Health.

Sunday, January 13, 2013

"My Child is a Picky Eater!" Is it Normal?

Many parents are familiar with the routine of sitting down with their young child for a meal and finding that the child refuses to eat it for one reason or another. Sometimes, the child does not like a certain ingredient, does not like the taste, does not like the texture, does not like the temperature, or a combination of these.

It can be extremely frustrating the more this happens, particularly when the parent puts a lot of time into preparing the meal. Sometimes, the child may simply be more biologically sensitive to certain tastes and textures and so meals need to be planned around these particular likes and dislikes. Forcing the child to eat these meals while he/she is crying or clearly being repulsed by it (e.g., gagging) is usually counterproductive. Finding a suitable alternative that the child will agree to eat is often the best solution.

A lot of creativity may be required to find ways to get the child to eat nutritious meals, but it can be done by sneaking in small amounts of food into a larger product the child likes (e.g., putting a small amount of pureed carrots in the child’s favorite sauce), creatively building off of foods that the child is known to like (e.g., making a hot Panini sandwich with the same ingredients that the child likes on a cold sandwich), using cookbooks to experiment with certain meals, or giving meals creative names (e.g., Mickey Mouse meatballs for turkey meatballs) based on something the child likes or the food looks like.

Sometimes, parents might rightfully wonder if such eating problems are abnormal and signal a more serious problem. In and of itself, however, eating problems are common in young children, as was recently documented in a study released in the medical journal, Acta Paediatrica, in which researchers in Germany questioned the parents of 1,090 children (544 boys) between ages 4 and 7. Specifically, the researchers found that 53% of children were reported to avoid eating certain foods. This was more common in children who were underweight. Underweight children also ate less food, which makes sense. Twenty-three percent of children were reported to have selective eating preferences (i.e., eating a narrow range of foods) and 26% showed aversions against trying new foods.

The authors found that they were able to differentiate three groups of children in the study. Group 1 (61%) was classified as normal eaters who avoided certain foods, had normal weight, and did not show a high level of anxiety or oppositional behavior. Group 2 (32%) were selective eaters and/or restrictive eaters.
Restrictive eaters are those who eat smaller amounts of food, do not have interest in eating, and do not enjoy eating. Group 3 (5%) were children who were worried about their weight. It was this third group that was most prone to being anxious and to engage in oppositional behaviors.  In the absence of significant weight loss, behavior problems, or emotional problems, the authors concluded that selective eating should be seen as normal in children. If these problems are present, advice and treatment should be offered, such as a referral to specialized outpatient programs to prevent the development of chronic eating problems. In this way, medical doctors and psychologists can play an important role in the early detection of eating and behavioral problems.

Suggested reading: The No-Cry Picky Eater Solution: Gentle Ways to Encourage Your Child to Eat—and Eat Healthy

Reference: Equit M, Pälmke M, Becker N, Moritz AM, Becker S, von Gontard A. (2013). Eating problems in young children - a population-based study. Acta Paediatr. 102(2):149-55.

Saturday, January 12, 2013

Treating Sleep Problems in Multiple Sclerosis: An Update

In the current edition of journal Acta Neurologica Scandinavica, researchers presented a comprehensive up to date literature review on the clinical assessment and management of sleep disorders in multiple sclerosis. Multiple sclerosis (MS) is a condition in which people develop multiple areas of abnormal patches (also known as plaques or sclerosis) in the brain and/or spinal cord (depending on the stage of the illness).

There are many others conditions that co-occur with MS, including sleep disorders. The most common sleep disorder in MS is insomnia but others are present as well such as hypersomnia (conditions that causes excessive sleepiness), sleep-related movement disorder (e.g., restless leg syndrome), sleep-related breathing disorders (e.g., sleep apnea), parasomnias, and circadian rhythm disorders. Sleep apnea is a disorder in which the person does not breathe for periods of time while sleeping. Parasomnias are abnormal and unnatural behaviors, feelings, perceptions, or dreams that occur while sleeping, falling asleep, awakening, or between sleep stages. Circadian rhythms are internally controlled biological processes (e.g., sleep) over a 24-hour period.

It is important for doctors to assess for and treat these sleep disorders because they can negative affect the quality of life and functioning for patients with MS. In fact, in their literature review, the authors found that sleep apnea caused by obstructions in MS patients was associated with significant morbidity and mortality (disease and death).  This is why when patients with MS complain of fatigue and daytime sleepiness, a sleep study is recommended by the authors as a matter of routine. However, fatigue in MS can have many other causes such as depression (which is also common in MS) or as a result of the MS-disease process itself.

Common treatments for insomnia and obstructive sleep apnea include techniques that do not involve medications. For insomnia, one example of this is cognitive behavioral therapy (CBT), in which the patient is taught how to change their feelings by altering the way he/she thinks. This, in turn, can improve sleep. In obstructive sleep apnea, a common treatment in continuous positive airway pressure (CPAP) in which a mask is fitted over the face at night so a continuous pressurized airflow can be provided to the body. The authors note, however, that in some cases, a different treatment approach (e.g., steroid treatment) may be needed for patients in which a lesion (abnormal area) is present in the brain that is associated with the particular sleep disorder. Determining if this is the case requires detailed investigation.

Suggested reading:
Say Good Night to Insomnia

Related blog post: Improving Sleep in Intensive Care Units

Reference: Lunde HM, Bjorvatn B, Myhr KM, Bø L. (2013). Clinical assessment and management of sleep disorders in multiple sclerosis: a literature review. Acta Neurol Scand Suppl., 196, 24-30. The article is freely available here.

Tuesday, January 08, 2013

The Medical Miracle of Microbubbles

For the uninitiated, micro bubbles are bubbles that are 50 microns or less (which is several orders of magnitude smaller than traditional bubbles); and it is their remarkably small size and resulting unique physical composition that gives these bubbles their inherently amazing properties. Although micro bubbles can be more or less easily created, they possess many unique properties. For one, their characteristics are not shared with traditional bubbles.

Various physical forces interact with these micro bubbles differently because of their size. A deep understanding of these physical properties has resulted in applications that are far reaching and extraordinary. Micro bubble research is rapidly becoming an applied science in fields such as medicine, manufacturing and wellness. However, the medical advances demonstrated by these tiny miracles are the most promising.

Changing Medicine

Medical uses of micro bubbles are plentiful, yet are just being discovered. They have been proposed for use in cancer treatments, specifically as a drug delivery instrument that penetrates into a cell and implodes, delivering its internal contents. They are also being tested as contrast agents in ultra-sounds as well as in a technique used to detect the early warning signs of heart disease. Per the CDC, about 1 of every 4 people who die in the United States every year die from heart disease. While that may seem like a lot, when extrapolated, it comes out to a staggering average of 600,000 people every year! These numbers reveal that heart disease is the main killer in the United States. Thankfully, micro bubble technology is being tested in order to help combat these incredibly large numbers. Dr. Isabelle Masseau of the University of Missouri has conducted a study to test the feasibility of using micro bubbles to detect the early signs of heart disease. So far, this process has successfully been used to help better detect artery inflammation in pigs and has promising implications.

If Dr. Masseau is able to expand on her existing research and bring this procedure to realization in humans, then early inflammation and other warning signs for heart conditions and diseases could be detected, treated, and then maintained. This would drastically reduce the number of people killed each year. This process seems both simple and amazing at the same time. The process that Dr. Masseau has pioneered involves attaching antibodies to micro bubbles that are then injected into the bloodstream of pigs with heart disease. Because of the inherent properties of micro bubbles and these enhanced antibodies, they are able to better target artery inflammation. By using ultrasound, Dr. Masseau could pinpoint the locations where the bubbles congregated, as the gas within those bubbles reflected back the ultrasound signal. While these early breakthroughs are staggering, the future of micro bubbles looks even brighter.

The above entry is a guest blog entry.

Tuesday, January 01, 2013

MedFriendly Publishes Comprehensive Scientific Review on Asperger’s Disorder and Violence

In response to the frequent discussion in the media and elsewhere on the association (or lack of an association) between Asperger’s disorder and violence/planned violence, I decided to write an objective comprehensive review of the peer-reviewed published scientific literature on this topic. The review begins with an introduction and then lists and summarizes the relevant studies, which are divided based on study format and year of publication. At the end of the review, ten conclusions are listed based on the current state of the scientific literature. I believe that this is the most objective and up to date comprehensive review of this topic presently available.

As more research on the topic is published, it will be integrated into the article. When updates are made, I will mention it in the comment section below. Others can also feel free to post comments (e.g., suggest other articles for inclusions) but be aware that comments are closely moderated and that inflammatory comments will be rejected.

Click here to access: Asperger’s Disorder & Violence: A Review

Sunday, December 16, 2012

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

Wednesday, December 12, 2012

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.

Saturday, December 08, 2012

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.


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.


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.

Tuesday, November 27, 2012

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

Tuesday, November 13, 2012

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.

Saturday, October 27, 2012

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.


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.

Monday, October 22, 2012

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

Friday, October 19, 2012

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.

Monday, October 15, 2012

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. 

Friday, October 05, 2012

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.