Monday, December 3, 2012

Changing the Paradigm for Outpatient Care

The present model has the primary care physician as the provider and gatekeeper of patient care. They evaluate the patient, obtain consultation, admit to the hospital (the hospitalists have taken over this role), and are the general coordinators of care. However, this model in theory works well; it has proven to be ineffective. This is no criticism of the concept but the complexity of modern medicine has made this very difficult for the average family practice unit.

Current Model
The family physician is supposed be the “gatekeeper” of resources and keep people out of other venues like Emergency Departments and urgent cares.

The problem is that the general public has voted “with their feet” that they prefer the family doctor when they are well, but the Emergency Department when they perceive themselves to be quite ill and the urgent care for quick, convenient care.  Call any doctor’s office and the first non-human response is: “If this is an EMERGENCY call 911 or go to the nearest Emergency Department.”

At the present time Emergency Department Services comprise approximately 2% of the nation’s annual healthcare expenditures.

Almost every ED has the built-in infrastructure to accommodate large number of patients which could be expanded. These are centrally located in most communities and already are the de facto safety net of the United States.

Make the ED the central piece of an organized system of emergency department, urgent care, family physicians with an integrated use of consultants.
New Model

Advantages are:
  • Lack of duplication of hard assets
  • Patients already prefer the ED
  • Coordination of care

Friday, November 2, 2012

How Medical Consumers Can Get More “Bang for the Buck”

One of the more interesting interactions between patient and provider occurs when the patient is asked, “What is the problem?”  The patient responds with “You’re the doctor,” or “You’ve got my records.”

This scenario highlights the opportunity the consumer has to achieve their goals in a quick, efficient, and potentially inexpensive way.

What can the patient bring to the interview to help the provider “GET IT RIGHT” the first time.

  1. Express your motivation for your visit. Such as:
    • I'm worried about a "stroke" or a "heart attack"
    • I need a work excuse
    • I'm out of meds
    • My spouse/relative made me come
    • I need a routine check-up
    • My concern "runs in the family"
  2. Provide a list of medications – best kept in wallet
  3. Provide a list of allergies
  4. Provide a list of past medical history and surgeries
  5. Share what has worked for you in a similar situation
  6. Don’t be afraid to say… “After Googling my symptoms, I got concerned about X…”
  7. Share your expectations
  8. Write a list of questions you have
  9. Be straightforward with your goals -- it saves a lot of time and money
  10. Reserve the right to say NO THANK You—I just wanted an educated opinion not a lot of tests and consultants.

All that said - and going back to our brief introduction of “you’re the doctor” -  what if you really don’t know.  That is, perhaps something is indeed bothering you, something is not right, but you cannot put your finger on it. 

Don’t be embarrassed.  

Doctor’s love these sorts of challenges, but they need to work alongside you to be effective at discerning the issues.  Just say it that way.  “Something is bothering me, something is wrong Doc, but I cannot put my finger on it.”  Then, you and the doctor can work together to figure it out.  And both of you feel like you have a partner in the discovery process. 

Tuesday, September 18, 2012

Using Risk Factors and Red Flags to Rapidly Identify Potential Serious Disease Processes

Identifying high risk patients from common chief complaints is an endeavor that needs to be cultivated and will significantly enhance one’s clinical acumen.

High Risk Patients can present with very subtle findings. An acute MI with ST elevation becomes readily apparent but the patient with the dissection can easily be misdiagnosed. High risk also includes illnesses that need to be treated in a specific time frame and bad outcomes leads to high liability.

Risk Factors are a combination of historical associations through family history, social history, genetics and red flags are positive responses to goal directed questions and physical exam findings that can lead to a higher suspicion of serious illness. Risk factors that are historical have been determined by longitudinal clinical studies over many years. They are a helpful guide but do not exclude serious illness in an individual patient.

The converse is also true. The majority of back pain chief complaints are musculoskeletal. How does one rapidly identify the patient that needs a more extensive evaluation?

The #1 Risk Factor is abnormal vital signs. Each abnormal sign must be addressed. If cannot be explained, further evaluation or monitoring is required.

See index below for some examples of risk factors and red flags associated with the following chief complaints. They are not all inclusive.

Chief Complaint:

        i.           Chest Pain
      ii.            Shortness of Breath
    iii.            Ob-Gyn
    iv.            Back Pain
      v.            Headache
    vi.            Syncope
  vii.            Allergic reaction
viii.            Abdominal Pain
     ix.            Testicle pain

This list is extensive, however evaluating the patient with knowledge of these risk factors and red flags will limit your liability and allow benign processes (tincture of time) to heal most patients without extensive cost , radiation, side effects of unnecessary treatments.  When artificial intelligence is fully developed and placed in EHRs, these items will be sent to the provider in real time to enhance their clinical decision making.
More details available upon request.


i.                    Chest Pain

         Risk Factors for Acute Coronary Syndromes:
o   Past Hx of CAD
o   Family Hx of CAD
o   Age: Male >33 Female >40
o   Diabetes
o   Hypertension
o   Smoking
o   Increased Lipids
o   Sedentary lifestyle
o   Obesity
o   Postmenopausal
o   Drug use- cocaine

Risk Factors for Pulmonary embolism (PE):
o   Prolonged immobilization
o   Surgery >30 days 3 months
o   Prior DVT or PE
o   Pregnancy
o   Lower extremity trauma
o   Oral contraceptives
o   Smoking
o   CHF
o   Chronic obstructive pulmonary disease
o   Obesity
o   PMH or FH Hypercoagulability

Risk Factors for Aortic Dissection:
o   Hypertension
o   Congenital disease of the aorta or aortic value
o   Inflammatory aortic disease
o   Connective tissue disease
o   Pregnancy
o   Arteriosclerosis
o   Smoking

ii.                  Shortness of Breath

                          Risk factors for Acute Coronary Syndromes:
           See list above

                        Risk factors for Pulmonary embolism (PE):
o   See list above

 Risk factors for Pneumothorax:
o   Hx Pneumothorax
o   Valsalva maneuver
o   Chronic lung disease
o   Smoking

iii.                Ob-Gyn

             Risk Factors for Ectopic Pregnancy:
o   Abdominal pain
o   Abnormal tenderness
o   Positive hCG test

 Ovarian Torsion
o   Pregnancy
o   ovarian cysts
o   ovarison hyper stimulation syndrome
o   tumors

Pelvic Inflammatory Disease
o   STD exposure
o   Abdominal pain
o   Fever
o   Vaginal discharge
o   Pelvic pain
o   Multiple sex partners

iv.                Back Pain

          Risk Factors for Abdominal Aortic Aneurysm:
o   Abdominal pain
o   Back pain
o   Age >50

  Red flags:
o   Numbness
o   Dizziness
o   Motor Weakness
o   Syncope
o   Paresthesias
o   Fever
o   urinary retention

v.                  Headache

          Red flags:
o   Syncope
o   Loss of Consciousness
o   Mental State
o   Speech Difficulty
o   Seizure disorder
o   Focal weakness
o   Dizziness
o   Gait Abnormal
o   Numbness
o   Paresthesias
o   Fever
o   Polycystic kidneys
o   Osteopathic manipulative treatment

vi.                Syncope

            Risk Factors for ACS:
o   See above

Risk Factors for Pulmonary Embolism (PE):
o   See above

Risk Factors for Abdominal Aortic Aneurysm:
o   See below

Risk Factors for Drug Syncope:
o   Drug use
o   Polypharmacy
o   Drug interactions

Risk Factors for Ectopic Pregnancy:
o   See above

Family History of Sudden Death

CHF (Congestive Heart Failure)

vii.              Allergic Reactions

          Red flags:
o   Allergic to ace inhibitors
o   Allergen exposure
o   Allergic to bee stings
o   Bug bites / stings
o   Allergic to shellfish
o   Allergic to soap/detergent
o   Allergic to pets

viii.            Abdominal Pain

         Risk Factors for Ectopic Pregnancy:
o   See above

Red Flags for Abdominal Aortic Aneurysm:
o   Abdominal pain
o   Back pain
o   Age >50

 Risk Factors for Mesenteric Ischemia and Ischemic Bowel Disease:
o   Age >55
o   Hx Cardio Vascular Disease (CV)
o   Hx Congestive heart failure (CHF)
o   post-myocardial infarction mural thrombi
o   Congestive heart failure (CHF)
o   Shock
o   hypercoagulable state
o   pain is out of proportion
o   coagulable state
o   arrhythmias
o   Sleeping impairment

Risk Factors for Acute Coronary Syndromes:
o   Past Hx of CAD

 Red Flags for Acute Appendicitis:
o   Anorexia
o   Right lower quadrant pain
o   Fever

ix.                 Testicle Pain

             Age <40

Thursday, August 23, 2012

Closing the Deal

How does one efficiently, safely, and compassionately make the disposition on a patient in a busy ED?

Sometimes the choices involved are complex, and for any given patient, there is always more than one tactic. In the end, the best approach will always consider the unique characteristics and circumstances of the patient & family in question.

Get in the habit of asking yourself whether you have been able to:
  1. Provide quality care. (Even if “you and your staff’’ are the only ones to appreciate true quality.  It is good to remember that even when the patient/family doesn’t get it, your staff does.) 
  2. Deliver a reasonable diagnosis or problem identification in layman’s terms.
  3. Provide decent discharge instructions. My bias is an electronic document with highlighted advice with very time specific advice.
  4. Show the patient team the x-ray. (This move is a subset of a number of actions that serve to “involve” the patient/family in the diagnostic decision process. Other actions of the same type may include a more detailed discussion of lab or consultants findings).
  5. Set reasonable expectations on the timing and course of illness. (From this, the patient/family should be able to discern if things are going as expected;  or, if not going as expected, recognize that they need to return and/or execute your safeguard follow-up instructions (see #6)
  7. Explain why this disposition is best for them, given the present information.  Clearly state why they need to be admitted, to be transferred, to be sent home, or to see a specialist for more testing, treatments and evaluation. This is a good time to mention any known risks to this disposition approach, state them clearly, and state alternative disposition options.
  8. Try to identify the type of patient you are dealing with.  You might have seen, during your discussions, the principle means through which the patient processes information. Is this visually? (e.g. show the x-ray, lab tests, Wikipedia), and/or through hearing? (I hear what you are saying), and/or with a strong emotional dimension? (I feel your concern/ pain).
  9. Try to discern, finally, whether you have met the patient/family needs, especially whether you have succeeded in establishing their trust in your evaluation and plan.

These steps work most of the time. However, like diagnosis and treatment, effective disposition is an art form that has to be developed over time. It helps to be mindful of the psychological processes that are present.  While for you  it is a closing (you are closing the deal, after all; usually while attending to multiple other patients whose deals you would similarly like to close), for the patient, this moment may very well be a beginning.  Your recognition of the patient’s viewpoint and needs are best communicated when you give evidence of your interest in their outcome, follow-up, and other further care. 

Tuesday, August 14, 2012

The 5-Minute Focused History and Physical Exam

Speediness has become a necessary virtue in EDs and urgent care settings, where providers, without exception, are expected to provide accurate, efficient, cost-effective care quickly.  While it may often feel that such expectations are not realistic, it is still nevertheless true that perceptions of promptness and efficiency are major factors in determining patient satisfaction.

Therefore, achieving a balance between speed, quality of care, safety, and efficiency, requires that each provider refine and polish a personal approach that facilitates rapid, complete, assessment in a minimum amount of time, using whatever tools are at hand.  In most cases--even in complex presentations--this can be accomplished in 5 minutes, or less, and is facilitated when using an EHR with the capacity to present information succinctly.


MINUTE 1:  45 seconds- review pertinent data; 15 seconds- establish common ground, put patient at ease.
MINUTE 2:  30-60 seconds- Allow the patient to speak. Listen.
MINUTE 3:  15-30 seconds - Discover the patient’s motivation (reason) for the visit. You will have already gotten the main clues, but make sure you also understand the driving forces behind the decision to come to the ED… Did the family drag them in? Are they worried about a stroke? Etc.
MINUTE 4:  30- 60 seconds - Ask very specific chief complaint driven high risk questions to identify the seriousness of the problem
MINUTE 5:  30- 60 seconds - Perform a goal directed physical while simultaneously restating the patient’s story. This reaffirms confidence in you as the provider, gives an opportunity to correct any overlooked concerns, and gets the key physical elements examined.

If you have an electronic order entry system at the bedside, you may be concurrently clicking off initial orders while gathering information during minutes 4 and 5. 

This system is very effective.  It allows you to keep with the patient flow and concentrate on treatment plans and dispositions (creating space for the next encounter. Additionally Patients immediately perceive that you are concerned about them, engaged, and “on their team” concerning their medical issues.

The next blog will be on how to “close the deal”.