Thursday, July 12, 2018

Why Medicine Rarely Runs On Time

By Andrea Eisenberg, MD
Michigan Obstetrician-Gynecologist

This article originally appeared on KevinMD.com and Doximity.

“Sorry, I’m running late … sorry, to keep you waiting.” How many times a day do I say that? Sometimes it is every time I walk into a patient’s room as if it is a normal greeting. Sometimes patients respond with: “Oh, you aren’t late” or “I haven’t been waiting long.” I can be so obsessed with not being late that I don’t realize I’m actually running on time! But I know it is a common complaint that patients “always” have to wait to be seen by their doctor. One of my senior partners at work used to say “waiting for a good doctor is like waiting to be seated at a good restaurant, it is worth the wait,” and never worried about time. I admired how thorough he was with his patients — I don’t think any of his patients felt rushed or not heard and came to expect waiting for his care.

Come join me for a day and see for yourself why medicine rarely runs on time. It’s not because we don’t try or we sadistically want our patients to suffer waiting naked in an exam room. It’s because, well, stuff happens and as the day rolls on, the stuff gets bigger, like a snowball rolling down a hill. That snowball is filled with the inconsistencies of life and patient needs that can be unpredictable.

Let’s start our day — Monday at 7:50 a.m. I arrive at my office, turn on the computer to see my patient list for the day and put on my white coat. While walking down the hallway, my medical assistant greets me as she goes in and out of each exam room, making sure they are stocked. I go back to my station to take a closer look at my schedule. I usually have patients scheduled every 15 minutes, but sometimes the slots are double booked if patients need to be worked in for an urgent issue or emergency. As I look at my list, there is the usual variety of annual exams, OB patients, IUD insertions, and colposcopies. There are also new patients — some with specific issues, some for just a check up — post-op checks, ultrasounds, and consultations about getting pregnant or how not to get pregnant. Some patients I know will be fairly quick, not having any issues and some take a little longer. Hopefully, they will balance out each other out so I can run on time.

8:20 a.m. I still have not seen a patient yet; my first one is late. 8:30am —now my 8 a.m., 8:15 a.m. and 8:30 a.m. patients have arrived within minutes of each other. It’s like the bus arrived and in one fell swoop, I’m already running late.

Next thing I know, one of my receptionists is coming towards me quickly, “Dr. Eisenberg, I have a patient on the phone that is eight-weeks pregnant and bleeding. What should I do?” “Tell the patient to come in,” as I look at my schedule, “at, um … hmm … at 10 a.m.” I know she needs to be seen — I hope I don’t have bad news for her.

I’m starting to get in my groove — I just finished with a patient, another is ready for me, and another is getting undressed. I need to send in a prescription for birth control pills for the last patient and I know I will forget if I don’t do it right away. So I get on the computer, but the wrong pharmacy is showing on the screen. I have to get out of that window and search for the right pharmacy. As I’m doing this, I hear overhead “Dr. Eisenberg, Dr. Smith is on line three.” The receptionist is now coming down the hallway to give me the chart for the phone call. “The doctor wants to talk to you about a mammogram report,” she says. I get into my multitask mode and answer the phone while electronically sending in the prescription.

Now, back to the patients in exam rooms. I walk into the next exam room where the patient is scheduled for an annual exam. She is a young college student and is excited to tell me she is dating someone. After we talk a little about how they met and what he is like, I ask “Are you using condoms?” “Ah, no,” she answers. So I take some time to talk about birth control options and STI prevention. She also was recently diagnosed with a seizure disorder, so I have to take that into account in counseling her about birth control. She decides she wants an IUD and we finally get to the exam.

I walk out of her room, ask my medical assistant to give her a pamphlet on IUDs, and start opening the chart for the next patient. As I’m about to open the door, my receptionist is waving me down. “There is a patient in the waiting room that just walked in. She thinks she is in labor and she looks like it.” “OK, bring her back now.”

I quickly go into the exam room I’m standing in front of, thinking I can see her before the laboring patient comes back. Luckily, this is a post-op check, and the patient is feeling fine, and after I review the surgery and pathology with her, she is ready to go. Next, I see the patient who thinks she is in labor. Her contractions are every five minutes, and she looks uncomfortable. I check her, and she is 4 cm dilated. “Time to go to the hospital,” I tell her. She is relieved that the pain is really labor. I leave the room, call the hospital to alert them as well as the on-call doctor who will likely deliver her baby.

By this time, I have completely lost track of time. I look at my watch. It is 10:30 a.m. and I have seen nine patients, written five prescriptions, answered two phone calls. My coffee’s cold, and now, I have a stack of lab results to go through in between seeing patients. I am running about 15 minutes behind — not bad. My 10:15 patient appears to be a no-show which helps me catch up a little. The early pregnancy bleeding patient hasn’t arrived yet.

Next up is a new patient. She is sitting in my office so we can talk. My medical assistant gives me a quick heads up as to why she is here and ends with “she has a stack of medical records.” She has a long history of issues with her periods, possible fibroids, heavy bleeding. It takes me awhile to sift through her story and her records. She ends with “I’m done. I just want my uterus out.” Once we are done talking, I tell her I need to examine her.

I walk out with her, show her where her exam room is and the bathroom. My medical assistant says, “You need to go into the ultrasound room next. The bleeder is in there.” When I enter the ultrasound room, the teary-eyed patient says, “Last night I had some spotting. I’ve never had this happen before when I’ve been pregnant.” I ask a few more questions, examine her and do an ultrasound. Fortunately, everything looks okay with the pregnancy, and the patient is relieved. “Thank you for seeing me today,” she said as I walked out of the room.

I continue on, and before I know it, it’s noon. Instead of taking my 30-minute lunch break, I use that time to catch up on charting patient visits and phone calls. I realize I haven’t even stopped to go to the bathroom, so I take a moment to do so and then pull out some snacks I have hidden under the counter. I have now seen 18 patients, answered five phone calls and electronically sent several prescriptions. I still need to call some patients about their lab results. That will have to wait for the moment, I have more patients to see and surgery after leaving the office.

I think you get the idea of how a doctor’s office flows, well, at least, at my office. We try to accommodate our patients’ needs and sometimes it takes a little longer than anticipated or a patient is scheduled for one thing and “oh, while I’m here, can’t you just also do …” Sometimes people have emergencies or urgent issues and need to be seen right away, even without an appointment. Sometimes people are late for appointments because of traffic or their babysitter came late, and then all patients after that get delayed. Sometimes patients call and need to talk to me at that moment instead of the end of the day. And sometimes, it is my doing — my cat throws up, my child is sick, I get a phone call walking out the door about my elderly parent, and I get to the office late. In the end, life gets messy and doesn’t run on time. Sometimes it helps me to I think of my schedule as more of a guide rather than a concrete time frame.

Believe me: As much as you want to be seen on time, I want to run on time. I like my day to flow smoothly, go home on time to see my family, make dinner, maybe even go for a run. But a doctor’s schedule is never nine-to five-because life doesn’t just happen between nine and five.

More importantly though, I want you to know that if you need extra time at an appointment, I will do my best to give it to you. And in return, I hope you understand if a patient before you needs that time, I will give it to her too and may see you a little later than your appointment time.

As I sit in my doctor’s waiting room for my check up, I too have to remind myself to take a breath, read a book, or play a game on my phone and be patient. I remember when I had an emergency, my doctor took the time to fit me into her busy schedule and address my urgent needs despite making her run late.

Dr. Eisenberg is a Michigan obstetrician-gynecologist. She blogs at Secret Life of an OB/GYN.

Monday, July 9, 2018

Too hot to handle? Dallas’ Parkland Hospital provides tips to avoid heat exhaustion, heat stroke

By Parkland Memorial Hospital

Editor’s Note: This summer, MeAndMyDoctor is focusing on several health hazards that can put a damper on seasonal fun. This week, Parkland Hospital in Dallas and TMA physician Alexander Eastman, MD, cover the dangers of rising summer temperatures and explain how to avoid heat exhaustion and heat stroke. 

Even though the first “official day” of summer was June 21, Dallas residents saw 21 days in May and 27 in June with temperatures at or above 90 degrees Fahrenheit. And to make even the coolest dude break a sweat, the first triple-digit day was recorded on June 2, when the temperature climbed to 101 degrees. Though not a record-breaker, this was the first time in four years the temperature hit the century mark before July 1. And the city logged five more sizzling days in the 100-plus range throughout the month.

This extreme Dallas heat combined with strenuous physical activity and high humidity can be a recipe for danger, according to Parkland Health & Hospital System physicians.

From 1999 to 2010, 7,415 deaths in the United States, an average of 618 per year, were associated with exposure to excessive natural heat, according to the Centers for Disease Control and Prevention. Approximately 68 percent of those heat-related deaths were among males. Since 2010, Parkland Memorial Hospital has treated more than 430 patients with heat-related diagnoses in its emergency department.

“Even short periods of high temperatures can cause serious health problems. Doing too much on a hot day, spending too much time in the sun or staying too long in an overheated place can cause heat-related illnesses,” said Alexander Eastman, MD, medical director and chief of the Rees-Jones Trauma Center at Parkland and assistant professor of surgery at UT Southwestern Medical Center. “It’s important to use common sense — if you think you are overheated, you probably are.”

Heat exhaustion occurs when people are exposed to high temperatures and when the body loses fluids and becomes dehydrated. When heat exhaustion elevates, it may result in heat stroke, a life-threatening medical condition occurring when the body’s cooling system, which is controlled by the brain, stops working. The resulting high body temperature causes damage to internal organs, including the brain, and could result in death.

“People aged 65 years and older, infants, children, and people with chronic medical conditions are more prone to heat stress,” Dr. Eastman said. “Therefore it’s important for family or neighbors to visit an adult at risk at least twice a day and closely watch them for signs of heat exhaustion or heat stroke. Infants and young children, of course, need much more frequent watching.”

It’s also important for individuals who work outdoors to pay attention to signs of heat exhaustion or heat stroke, Dr. Eastman said. “Individuals including first responders, construction workers, landscapers, and others whose jobs require them to be outside need to be especially careful this time of the year,” he said.

Symptoms of heat stroke include thirst; red, warm, and dry skin; body temperature over 104 degrees Fahrenheit; fast breathing and heart rate; vomiting; muscle cramps; confusion or disorientation and coma.

“If you see any of the warning signs of heat stroke, you may be dealing with a life-threatening emergency,” Dr. Eastman cautioned. “Have someone call 911 for immediate medical assistance while you begin cooling the victim.”

Dr. Eastman offered the following tips to help a heat stroke victim before medical assistance arrives:

  • Get the victim to a shady area.
  • Cool the victim rapidly, but avoid an ice bath, using whatever methods you can. For example, place the person in a cool shower; spray the victim with cool water from a garden hose; sponge the person with cool water; or if the humidity is low, wrap the victim in a cool, wet sheet and fan him or her vigorously.
  • Monitor body temperature and continue cooling until the body temperature drops to 101-102 degrees Fahrenheit.
  • Do not give the victim fluids to drink.
  • If there is vomiting, make sure the airway remains open by turning the victim on his or her side. 


For additional information, visit www.parklandhospital.com.

Tuesday, July 3, 2018

Your July 4th Plans Should Include Mosquito Prevention

By Texas Department of State Health Services 

With outdoor activities on the holiday calendar for millions of Texans this week, the Texas Department of State Health Services (DSHS) is reminding everyone to protect themselves from mosquito bites and the diseases they can bring.

The best thing people can do to protect themselves and their families from mosquito-borne diseases like West Nile and Zika is to use insect repellent every time they’re outside. Plus, recent rains across the state mean it’s an important time to dump out standing water around homes and businesses so mosquitoes can’t lay eggs.

Several types of mosquitoes that can transmit disease thrive in Texas. Zika remains a serious threat because it can cause birth defects if women are infected during pregnancy, and West Nile can sicken hundreds of people a year in Texas, resulting in more than 3,500 illnesses and 167 deaths over the last 10 years.

Routine mosquito surveillance has detected West Nile activity this year in the Houston, Dallas/Fort Worth, El Paso and Beaumont areas. The state has reported three Zika cases, all acquired while Texas residents were visiting other countries where Zika is being spread.

Some simple steps at home and while traveling will help people protect themselves and their communities from illnesses transmitted by mosquitoes:

  • Regularly apply EPA-registered insect repellent while outdoors.
  • Dump out all standing water inside and outside homes and businesses; scrub outdoor containers to dislodge mosquito eggs.
  • Use air conditioning or make sure window and door screens are in good repair.
  • Cover up with long sleeves and long pants to help prevent bites.

“These seem like small actions, but they make a huge difference in keeping people from getting sick or even dying from mosquito-borne diseases,” said DSHS Commissioner Dr. John Hellerstedt. “If individual Texans will take these steps, they will limit the spread of West Nile and prevent Zika from becoming established here.”

People should see their health care provider for possible testing if they experience symptoms of West Nile or Zika. The most common symptoms of Zika are fever, an itchy rash, joint pain and eye redness. West Nile virus can cause headache, fever, muscle and joint aches, nausea and fatigue. A more serious form of West Nile disease, in which the virus invades the nervous system, can cause neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness and paralysis.

DSHS has launched a revamped TexasZika.org website with easier-to-access information on Zika cases and precautions, printable prevention materials, and diagnosis and testing guidance for health care providers. Information about West Nile virus is available at TxWestNile.org.

Monday, July 2, 2018

Being a Neighbor in 2018

By Jason V. Terk, MD
Keller Pediatrician
Chair, TMA Council on Legislation
Committee on Federal Government Affairs, American Academy of Pediatrics

Fred Rogers dedicated his life to making a connection to the children around him by staying connected to the child within him. He knew how important it was to provide a mass media counterbalance of love and sensitivity to the detritus that otherwise existed in children’s television programming and child marketing at the time, and which still exists today. He knew how important early childhood experiences were to the ultimate end product of humanity that children become.

As a child, I watched Mr. Rogers’ Neighborhood and enjoyed the familiar safe and wonderful space that was created by that television show. Through my own childhood’s eyes, I witnessed a place where people talked about things in a way that kids could understand, and where helping kids understand clearly mattered to the people on the show. All of this was driven by Fred Roger’s deep desire to reconcile the pain of his own childhood by making the childhoods of others better.
Fran├žois Clemmons and Fred Rogers on the set of
Mr. Rogers' Neighborhood. Image via Wikimedia Commons.

As an adult, I revisited my memories of Fred Rogers through the recently released documentary “Won’t You Be My Neighbor”. And, what a counterbalancing message and life mission Fred Rogers provides in the year 2018. Our current season of distrust, nativism, and tribalism is so far removed from what Mr. Rogers was trying to teach us when we were kids. What an important time to hear from Mr. Rogers again!

As a pediatrician, I too have dedicated my life to the welfare and health of children. And, as the years have passed since the days of Mr. Rogers’ Neighborhood, science has come to an even greater understanding of how critical the experiences of early childhood are to the adults our children will become. I have seen so many examples of the wonderful effects of love and mentorship on children at crucial times for them. I have also seen the empty eyes of children who have been deprived of the message that they are good, important, and necessary persons among us…that they are nothing less than children of God!

Only by convenient compartmentalization can one justify the treatment that too many of our children are experiencing. Our children include the ones who have been cruelly separated from their parents as a part of our government’s border policy. Actions like this are essentially psychological and emotional shrapnel that these children will carry with them in one way or another for the rest of their lives as toxic stress. That stress will lead to social consequences in the form of maladaptive and unhealthy personal relationships and parenting. It will also lead to physical health consequences in the form of increased adult heart disease, hypertension, diabetes, and earlier death. Very truly, the cracks we make in our children will endure.

The ultimate message from Mr. Rogers to the adult children like me who enjoyed his neighborhood is to remember for a quiet moment the person or persons who made a critical difference in our own lives, and to try to be that person for each other and our children. In an intensely beseeching appeal, Fred’s message is to love one another and care about each other in meaningful ways and to remember we are all — each one of us — children of God!

Friday, June 29, 2018

Cyclosporiasis: A Summer Hazard to Your Health

By John T. Carlo, MD
Dallas Physician
Chair, Texas Public Health Coalition

Editor’s Note: This summer, MeAndMyDoctor is focusing on several health hazards that can put a damper on seasonal fun. This week we cover the potential dangers of cyclospora, a parasite that commonly sickens people in summer months. 

Summer’s heat entices us to eat fresh summer fruits and veggies, but these summertime delights can sometimes bring a decidedly undesirable plight — cyclosporiasis.

Texans, cyclosporiasis (an intestinal infection caused by a parasite) is not just a problem outside of the U.S., it’s becoming more and more common here, especially during summer.

Recent outbreaks of the disease in the U.S. have been due to contaminated fresh produce such as raspberries, basil, snow peas, mesclun lettuce, and cilantro. Cyclosporiasis can also occur after drinking water contaminated with feces.

Symptoms vary, with some infected people not having any symptoms at all. Others can experience significant symptoms including watery diarrhea, low-grade fever, vomiting, nausea, and fatigue. Special laboratory testing through your doctor’s office must be done in order to diagnose cyclosporiasis. More info on the test can be found here. Treatment for cyclosporiasis is typically trimethoprim-sulfamethoxazole (known by the brand name Bactrim®).

Preventing infection is possible by taking such steps as washing all fresh produce, keeping up with any contamination or product recall notices, and avoiding drinking untreated water. As always, it’s best to check with your physician if you or your children experience systems which may indicate a cyclosporiasis infection. For more information, visit https://www.cdc.gov/parasites/cyclosporiasis/index.html.

Physicians and other health care providers should consider cyclosporiasis infection in patients experiencing watery diarrhea that lasts more than a few days, relapses, or occurs along with a sudden lack of appetite or fatigue. Travel outside of the U.S. to areas known to have high rates of infection is an important risk factor, but many recent cases of cyclosporiasis have been reported without a recent history of travel.

Friday, June 15, 2018

A Proactive Approach Can Ease Alzheimer's Burden

By Troy Alexander
Director, TMA Public Affairs

This will be my first Father’s Day without my dad, who passed away October 16, 2017. A few weeks prior I went for a walk with my 81-year-old father around the pond near his home in Pearland. It was not something I had a chance to do often in the last few years, especially just the two of us. I knew it was a precious time because my father was in the late stages of lung cancer and dementia with Alzheimer’s disease. As we walked, I advanced ahead of him around a corner. I heard him raise his voice, “Hey, Troy – wait up.” And of course I did and we finished our walk together.

In the past few years as my dad’s Alzheimer’s worsened, I noticed he could have conversations with me, but he never addressed me by my name. That moment during the walk when he called my name — it mattered. I felt like it had been years since I’d heard my own father say my name. There’s just something special about hearing a father address his son by the name he gave him.   

The author's father on his 80th birthday celebration (left), and playing baseball with his sons (right).


Alzheimer’s attack on a person’s memories makes stories of sons like me all too common. My father’s condition was detected around two and a half years before his death. Looking back now, I can see instances where the disease was noticeable before we knew a diagnosis. I know many families endure many more years on average with the disease.

Early detection matters for families. Here’s some reasons why:
  1. Science continues to rapidly advance treatment of this disease. Early detection affords the opportunity to access treatments that may alleviate symptoms. 
  2. It influences decision-making about how you spend your time. I am so thankful that right after his diagnosis we planned a family road trip with my parents to Colorado. I treated it as a memory trip with my kids. I also remembered many road trips my dad had taken us on when I was a boy. I even created special song playlists from those early days of music I could recall my dad liked. We went back to a place he loved in the mountains and even travelled Route 66 for part of the trip.  
  3. Early detection can help families deal with other disease conditions the family might face. When my dad’s cancer appeared about one year later, the realities of his Alzheimer’s impacted our choice of treatment for him. 
  4. Earlier detection helps to facilitate planning. When my dad’s diagnosis occurred he was still driving and very lucid in many ways. He was able to make decisions on his vehicle and ensure other financial and advanced directives were taken care of the way he wanted. 
  5. Early intervention provided us the ability to alter lifestyle changes for him that permitted my parents to remain in their home and in their daily life. 
June is Alzheimer’s Awareness Month. Here are some things you can do for your dad (and mom) this year:
  • Ensure your loved ones have a primary medical home, like a family doctor, to coordinate their care. 
  • At the first sign of possible symptoms, seek neurological testing to establish a baseline for future comparison should disease manifest.
  • Encourage regular exercise and a balanced diet, as evidence points strongly to the link of obesity and tobacco with the disease.

For more ideas and information, visit the Alzheimer’s Association website

Wednesday, June 13, 2018

Mosquito Bites Can Lead to Deadly Diseases

As summer heats up, you may find yourself swatting that occasional seasonal annoyance, the mosquito. For most people, the bite is just a temporary irritation; but for some, it can be life-changing — even life-threatening.

Mosquitoes, ticks, and fleas can spread diseases like Zika and West Nile virus, and some lesser-known ones like dengue fever and murine typhus. Texas’ warm climate makes the state a hotbed for these diseases spread by those insect “vectors.”

“Texas is probably the most vulnerable state in the union to these diseases,” said Peter J. Hotez, MD, head of the National School of Tropical Medicine at the Baylor College of Medicine in Houston.

Despite disease surveillance by the Texas Department of State Health Services (DSHS), the June issue of Texas Medicine magazine reports vector-borne illnesses are underreported. Complicating that is the difficulty in diagnosing some of the diseases, which can look like other illnesses.

Zika is a good example: The virus’ symptoms often look like the flu — fever, joint pain, and rash. And tests for the disease aren’t always accurate or easy to interpret.

To even be tested, patients must first feel sick enough to visit their physician, said Dr. Hotez. The physician then must recognize the symptoms could indicate a tropical disease and arrange appropriate tests, which can be more complex than a simple lab test. “It requires all three stars to align before you can diagnose somebody,” said Dr. Hotez.

A study released by the Centers for Disease Control and Prevention in May found the number or people in the United States who experienced insect-borne diseases tripled to 96,000 between 2004 and 2016. In addition, nine new vector diseases were discovered or introduced during that time.

Regulatory and commercial roadblocks have sidelined vaccines that could help prevent the diseases. Texas’ best short-term defense, say the experts, is better disease surveillance, mosquito control, and education.

House Bill 3576, passed by the 2017 Texas Legislature, calls for DSHS to track, study, and prevent the spread of Zika and some other communicable diseases. DSHS now tests pregnant women in nine Texas counties along the U.S.-Mexico border where Zika is most likely to spread. DSHS and the local health departments follow up on positive results.

Mosquito control is erratic because some Texas communities don’t have the resources to support it.

Better physician and public education is needed. Many doctors don’t have a lot of firsthand experience with vector-borne diseases, said Scott Weaver, PhD, principal investigator for the Western Gulf Center of Excellence for Vector-Borne Diseases at The University of Texas Medical Branch at Galveston. Knowing which ones are common in their area and advising patients about those diseases can help, he said.

“Physicians in Corpus Christi know murine typhus in their sleep,” said Jane Siegel, MD, a Corpus Christi pediatric infectious disease specialist and chair of TMA’s Committee on Infectious Diseases. “People who haven’t seen it a lot have to ask for information about it.”

She says physicians need to routinely ask patients about their travel in and out of the country, and consider the potential for seeing vector-borne illnesses in their patients.

“When we’re in the height of an outbreak, like Zika in Dallas, we [physicians] tend to ask about it. But then we tend to relax. Somehow it needs to be standardized and incorporated into our practice,” said Dr. Seigel.
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