family practice issues and general life events

Archive for November, 2011

Allergies and Asthma

Allergies and Asthma.

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Allergies and Asthma

When you come in complaining of runny nose and congestion, I do feel bad for you.  Really I do.  I can sympathize.  Well up to a point.  If you tell me you just sneezed twice and it was intolerable, well I will try to help you, but that won’t equate to an emergency to me.  Heck it isn’t even a minor emergency.  And if you tell me taking an antihistamine is just too much trouble, well I may even become irritated.  I will try to hide it, but it will be there.  Why?  Because I probably have more severe allergies than most.  

I spent my childhood wearing long sleeve shirts when my eczema was so severe it looked to the untrained eye that I was attempting to shoot up.  Never mind that I was 8 or that I apparently had no regard for where the vein was when I was attempting to “shoot up”  In fact now my skin is tough in my antecubital fossa (crease of the elbow) that while my veins are close to the skin, you have to work to get to the vein when I have to get blood work done.  Additionally, I have spots that are now lacking any pigment at all do to damage that I have done. 

So please believe me when I discuss the importance of proper hydration of the skin, both topical and by mouth.  If I tell you that it will come back unless we can identify the trigger and avoid it.  And if you don’t want to avoid it, well that is fine, but the rash may come back and probably will.  Mine did throughout childhood, because well Pizza Hut pizza was worth it to me.  It is a trade off.

As for your runny nose, well you might have to take an antihistimine, Claritin, Zyrtec, Allegra, Benedryl, etc.  It may not require a doctor’s visit, they are all over the counter now.  Now if they are severe enough, maybe allergy testing and desensitization are worth it to you.  But if it is just once a year, when the flowers bloom it might not be worth it to you.  Sometimes you have to decide.  I can offer the tests, and can offer treatment, but you have to take it, consistently.

And I do apologize but there is nothing about your particular rash that will let me know what caused it.  (Assuming it is an allergy)  I don’t know if you changed detergents, soaps, or if you used that new lotion you got for Christmas.  I don’t know that you ate something new, and I will continue to ask all of these questions to help to identify the triggers.  And sometimes without allergy testing we may never know.  Sometimes it is obvious with questions, but not always.

And if I suggest checking you for asthma, realize that I am following current recommendations, and that the two processes are very similar.  However, I might not be able to tell you if your 2 year old will grow up with asthma.  First of all she is too young for the test, and secondly she may just have a cold today.  So please don’t try to insist that I do all the testing today.  I can’t. She cannot do the test.  Most kids can somewhere around 6, and even then depending on the asthma type and severity their test could still be normal.

What I can tell you is that you as a parent should stop smoking.  Sorry, but smoking in your bedroom travels through the vents of the house into the child’s room.  Those of you who say but I only smoke outside, well most people in cold weather smoke too close to their house to not be sucked back into the ventilation system, not to mention what is brought back in on your clothes.  And many of you neglect to realize that your car is a small enclosed space, and smoking in it regardless of whether the child is in the car or not harms the child all together.  It stays in the car, why do you think the resale value of cars that people smoke in are so much lower than those of nonsmokers?  It stays in the car.  And those who want to lie to me, well if I get secondhand smoke fumes by walking in the room, well you are probably affecting your child, just like me.

And those asthmatics who smoke?  Why?  You already have a hyper-responsive set of lungs.  Why are your introducing irritants that make your condition worse?  I know nicotine is addictive, and difficult to quit, but in addition to lung disease, it also contributes to heart disease, cancers that include not only lung and oral, but bladder, liver, and colon cancer.  If you are diabetic your risk for amputation increases significantly if you smoke, and healing of wounds is significantly impaired.  So much so I know back surgeons who will not operate unless you quit smoking for at least a week before and a month after surgery, and plastic surgeons who have included in their pre-operative consent that you understand that scarring and healing is worse and if you smoke, you will be responsible if the wound does not heal.

And if you come if sneezing and coughing and complaining if you can’t breath, don’t get offended if I tell you, that you need to quit smoking.  And don’t lie to me and tell me you don’t, when it smells like you have had a whole pack right in the room.  I will do what I can tell help you stop smoking if you want help.  But that is something you have to decide for yourself, or your kids.

Allergies and treatment options

This weekend, I started both my youngest son and I on a new therapy. Sublingual Immunotherapy Drops for our allergies. At the clinic I decided to start testing for allergies since the nearest place for many of our patients is 60 minutes away. And for a few we already give the shots. We might as well try to provide better care for those that don’t have the transportation to get where they need to go.

In being able to test, I will also be able to provide the therapy in 2 forms, drops and shots. While the drops are not yet approved by the FDA, they are still under study, I am willing to see if they are a viable and effective treatment for allergies. And it might also be that I am finally tired and desperate enough to find alternatives to the endless supply of antihistamines that I seem to purchase for both me and my youngest.

I have perennial allergies so for much of the year I am sneezing, suffering from congestion, runny nose and all manner of allergy symptoms. The best medication for me is Benedryl, unfortunately that puts me in a haze that if I am still conscious, I am not firing on all cylinders. So that does not make it useful for daytime. And I take a zyrtec (which is the best of the nonsedating/less sedating for me) during the day and still sneeze. I stopped taking it for two weeks to have the most effective of tests, and realized that it must be doing something because my symptoms worsened by about 10 times.

Now I went ahead and did the testing during our training. Might as well, if I am not willing to do something for myself, maybe I shouldn’t offer it to my patients. Assuming that I need it. I am not going to put myself through Humira injections, just because I have patients on it. Anyway, I had quite a few flare up.

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As this is a photo of me, I am not concerned about HIPPA violations and anyway I give myself permission.

This test was while not the most comfortable thing ever, it was a lot easier than the testing that I had done in high school. I remember that hurting like crazy. And itching. Which this did itch, but the duration was 15 minutes instead of 30 and as you can see there are definite areas where I had significant reaction.

I tested my youngest as well, and while he didn’t have as many large areas, he had more reactions, including horror of all horrors to chocolate. And while he did not appreciate the actual testing, he did tolerate it well, while watching an iPad

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After evaluating the tests, we sent off to the lab to prepare the samples, and less than a week later, we have our drops. So today is day three for me, day two for him. And we will see where this takes us. Hopefully it will result in less stuffy noses and congestion. I will let you know.

Testing oneself

This morning, I am focusing on getting myself ready to test for my black belt in Tae Kwon Do.  It has been a long time coming.  Do I have to do it?  Well that is a loaded question- Yes and No.  No I don’t have to do it.  There is no one forcing me to do so.  If I don’t test, nothing bad will happen to me, I won’t lose my house, my family, my job.  But in some ways I do have to test

Here is why- and part of the reason it has been a long time coming.  I started Tae Kwon Do about 3 and a half years ago- give or take six months, sometimes things in my memory get mixed together regarding time.  Any way I moved normally from white to orange, yellow, camo, green, purple, blue, brown, red and red black recommend.  No big deal.  For me, my husband tore his ACL shortly before testing for red and red-black but that cannot be my excuse.  Well I decided not to test on my first chance, was it a mistake?  I don’t know, I didn’t know what the next 6 to 12 months lay ahead.  I just wanted a little more than two months to prepare, so I made the choice.

However, summer came along, things got busy with the kids, and finances got back at work.  In other words, life got in the way.  I had a son with a broken leg- who still tested, a husband limping around refusing to admit he did anything to his knee, and only after someone else made him an appointment did he finally see a surgeon.  Was told that he not only needed surgery, it should be sooner than later, so he chose about 3 months from then.  (Doctors are terrible patients, though in his defense schedules are made 3 months in advance, so there is that)  Ok, so with balancing life, I got busy.  Missed testing opportunity number 2.  And most of the six months between opportunity one and two.

So January comes, hubby has surgery.  So I have to take care of him, his patients, my patients, hospital, kids, … for about 2 weeks.  Then I am back to normal, my patients and kids.  Maybe valid excuses, but excuses, none the less.  And then there is an explosion on the business end.  (Not an actual explosion, but one of patients due to physician leaving town.)  So my thoughts of maybe this testing turn to …well, maybe not, maybe next time, I am just not ready yet.  May comes and goes.

Now we are 6 months later.  Life is still going.  Life will continue to go.  Work is good, though turned over an entire office, gave my first lecture at a national convention, two kids science fair projects, wiped the tears of my oldest when he missed breaking the board at the last test.  And up until last weekend, I was still on maybe and I will try.  However, Sunday night I realized that I have to test.  Time will continue to pass, and there will always be excuses.  And how can I expect my kids to put forth the effort and try, if I don’t get back in the game. And my oldest told me he believes in me and that it is only important that I do my best.

So today, I will go and give it my all.  Because if I don’t test, I am more afraid that I never will.  And that is what life is about testing oneself, improving oneself.  I just have to have faith that I know it, and give it all that I have got.  Wish me luck

Do we overmedicate?

I saw a child the other day, a patient.  He was brought in for routine medication, one he didn’t want and didn’t feel he needed.  His parents weren’t sure either but the school was demanding it.  This actually is not too terribly uncommon.

The diagnosis of ADHD has become so used and diagnosed, it makes me question whether all the diagnosis are valid.  I try to do the right thing, I make sure all my newly diagnosed patients are formally tested, but over the last 6 months to a year, I have found that all of the tests are coming back positive.  That makes me question, am I only sending those that I already know have ADHD, or is something else going on?  In fact, some that I sent more for developmental delay came back positive as ADHD.  This was not the case two years ago, and I was using the same people to do the test.

Is the problem becoming overly epidemic or all some of the tools becoming misused to put more children on stimulants so rather than having to engage the children in their work they are merely medicated so that their job is easier.  What if the decreased concentration has more to do with the children being bored because of lack of stimulation, than to do with true ADHD?  I can calm any child down with Ritalin/Adderall and other stimulants, but to what cost?  And now the American Psychiatric Association is discussing with their DSM -10 changing the lower age limit down to 4.  How many of you had a calm 4 year old?

I have grave concerns for this trend.  I thought it was improving briefly and there are definitely times when medication is needed to help the child succeed in school and life, and even some adults sometimes need it.  But are we trading in our children’s health and well being for well ordered classrooms?

One of parents greatest complaints is that sometimes their children seem like zombies on their medication.  That child is overmedicated, but when we decrease the dosage a little, there seems to be complaints from the school.  I don’t know about you, but I went into a local school about 2 years ago, and was horrified by what I saw.  In the time before classes began there were more children on the wall in time out than there were sitting at the tables in the cafeteria.  This was before classes had started. And I saw one teacher send another student that way for merely asking another student for a pencil.  So my question is, whether the ADHD epidemic is true, or is it manufactured from our one size fits all education system.  Are we forgetting that 5 year olds need to be stimulated?  Maybe we need to sit down and look a little closer at where the problem is coming from.

As for me, I am stuck between a rock and a hard place.  What do I do for that child?  Is medicine the best choice?  Maybe, maybe not.  But him getting kicked out of school definitely isn’t.  So I write the prescription, and we discuss things to help him function better in school, and I will see him again, in the next room, or tomorrow.  Unfortunately in some cases, I don’t have the answers, only the questions.

Why I really like electronic medical records

As a physician, I am not supposed to like electronic records. Or at least it seems that way. That doesn’t mean that I think that the is one ideal system. There is not one that’s perfect, but I think overall they are a good thing. I know regulations are forcing them on the providers and there is a natural resistance to that, but I believe that the market would eventually switch to electronic health charts. It would be a slower process and would probably be easier, but it would happen.

Why you ask. That is say, doctors graduating from medical school grew up with computers in their home from birth. While I am old enough to remember the Apple2 and riding with my dad to take a pile of punch cards to a mainframe there are those now graduating who never heard of such a thing. They grew up with a personal computer in there home and Internet. Probably dial up for the current class, but there are high school students who would not believe that someone would use dial up

But as to why I like them… Do they make me a better doctor? As far as diagnostic skills, no. Computers don’t improve bedside manner, and in many cases hinders it. At least in some cases, especially during the install or conversions. But it does help with drug interactions, it helps remind that the patient is due for certain steps, and everything is there. And it is legible.

That is probably the best thing. I have specialists that have terrible hand writing. I get a report or a copy of their visit note and I cannot read it. So despite having their notes, it doesn’t help since I cannot read it and still have no idea what it is.

It also has helped with coding. Since converting I am coding visits higher than I ever did by hand. While you still have to look at what the codes say, because I am responsible for whatever I code or the computer does, it has been accurate and for the most part increased my reimbursement. My software includes everything, scheduling, billing, chart notes, so once I sign off, it gets billed and sent off to a clearing house and then to the insurance companies. I don’t have to fumble through charts, cause it is all threat my fingertips.

I have a system that reminds me to look for test results, consults and other items after it has been too long. So the reminds in itself is nice

As for the theory that patients don’t like their doctor turned around typing with their back towards them,well I wouldn’t either. I have tablet, that at one point had a pen, so there was little difference between writing on a chart or writing on a computer tablet. And if I would prefer to type, well I can do that too.

Overall, I think that electronic records are great. There are bugs that need to ironed out, and some of the requirements from CMS are pain to meet, but the concept itself is a winning one. And as technology continues to advance so will these systems, which will help to take better care of patients.

Unexpected lessons

I was going to blog about something today, I don’t remember what, but my ideas disappeared when I read a blog from a high school classmate of mine. I haven’t talked to her since we graduated, but a link to her blog popped up on one of our mutual friends page, and I opened it. It’s contents shocked me. What I remember her from high school is that she was one of the strongest people I knew. In fact that would probably be the word that I would have described her if I had to give a one word description. And in the blog she revealed she had been diagnosed with breast cancer- it stopped me

I hope she won’t take this as a method of self indulgence, she has given me a gift. Something as a doctor, while we know and think about (or should) it is not always a look we see. The ivory towers of medicine instruct you on diagnosis, tests, and treatments, it does not train you how to feel what the individual does. In residency, people do become their diseases, right or wrong. There might be cases that stick with you, whether you made a mistake or not- but they are not personalized.

And in private practice, these are your patients. As a family practice doctor, I have told several patients about their cancer, I have sat with them, I have cried with them. They teach you that once the word cancer is introduced, everything else is forgotten. And Toni reminded me of this in a more personal way.

Her honesty is the reason, we always try to bring a family member with the diagnosis, and yet how much do they remember after the “C” word. And the public, while there are references to cancer and cancer research everywhere, how much of it helps the one with the disease. The one undergoing treatment. It reminds me of the rubber bracelets which are now a fad that say “Boobies” do those wearing them understand the significance or are they just a way for the teenaged boy to get away with wearing “boobies” on his wrist. I hope it is the former, but I have my doubts.

Any way Toni, I wish to say thank you, thank you for the reminder. The reminder that people are more than their diseases, which I try to remember everyday. That people with cancer are more than their disease, and more than the marketing blitz you see on the television. I send you my prayers, and send you what strength I can, and I thank you for the gift you gave me with your blog. I think what you wrote helps me to remember why I am a doctor, not that I forgot, but you have helped to make it clearer today. And I hope that I carry that forward with my patients. And maybe it will help me do better when I have to give that dreaded diagnosis to another

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