I think that most patients do not understand medication allergies very well. Wrongly thinking that you are allergic to certain medications can limit the choices your doctor has in deciding which the best medicine for your current condition is. You could be given a costlier or less effective medication if you incorrectly state that you are allergic to a particular drug.
It is important to know the difference between an allergic reaction to a medicine and a side-effect from a medication. Some patients have been erroneously told by their doctors that a medicine caused an allergic rash when in reality the rash was caused by the underlying illness that the medication was prescribed for. Your doctor should know about any medicine that you have had an allergic reaction to or a side-effect from and should be able to differentiate between the two.
An allergic reaction to a medication occurs when your body's immune system reacts to a drug. The symptoms can include itching and a generalized rash. In severe cases an anaphylaxis allergic reaction occurs which can lead to life-threatening breathing and circulatory troubles.
The allergic reaction can occur even with medications that have been used without problems in the past. Once it occurs the medication will always cause reactions in the future, oftentimes escalating in the severity, unless an allergist desensitizes you to that particular drug by giving you tiny incremental amounts over several months. It will recur with medicines in the same class and sometimes with closely related medications. Just because a family member had an allergic reaction to a certain medication, doesn't mean that you will.
A side effect is not based on your immune system's response to a medication. It most commonly includes nausea, headaches, and drowsiness but can include many other symptoms such as dizziness and taste disturbance. These side-effects are annoying but seldom dangerous.
The side effect might improve with a dose adjustment or just over time with continued use of the same dose. It will usually recur if the same medicine is given in the future. It will sometimes occur with similar medicines but often is specific to a certain drug.
A common mistake a patient will make involves refusing to take a certain medication because of concerns of either allergic reactions or side effects. Unfortunately our pharmacist friends provide written handouts that are often misleading when it comes to warning patients against taking a particular drug if a prior reaction occurred with a similar but different medication. Three common situations are detailed below.
If you had an allergic reaction to penicillin in the past you are still able to safely take some, if not all, cephalosporins (Keflex, Ceclor, etc.). You and your doctor do need to be extra careful however if your allergic reaction to penicillin in the past was an anaphylactic one.
Many patients say they are allergic to codeine. That almost always means that they have a side effect of nausea and/or vomiting when they take codeine. That does not exclude you from taking hydrocodone for pain or a cough, if it is indicated. While you could coincidentally have a gastrointestinal side-effect from that, it is much less likely.
There is a difference between sulfa and sulfates/sulfites. The former is used as an antibiotic while the latter are included in many medications such as morphine and some diabetes pills. Many patients develop a rash with the antibiotic (much more so than with penicillin in my experience), but very few, if any, of them will have any reaction to the other medications.
You should tell your doctor which medications have given you which symptoms and let him decide if it was an allergic reaction or a side-effect. Only by doing this can you assure yourself of allowing your doctor to choose the most beneficial and cost-effective treatment for your condition.
6/27/07
6/19/07
THIS IS NOT BURGER KING
I think that some patients confuse a doctor's office with a supermarket. They come in with a written or mental list of what they want and are not happy unless they receive what's on that list. I will explain what a visit to a physician is and isn't.
A patient is paying for an evaluation and treatment of a medical condition. It would be a mistake to take your car to a mechanic and tell them you need a new water pump. If they replace it and the car still has the same problem, you would be upset. You should tell your mechanic that your car is overheating and let the expert determine if the problem is the water pump, the thermostat, the radiator or something altogether different. Certainly a car owner with a lot of knowledge about cars can provide thoughts as to what the problem is, but the diagnosis should be left up to the mechanic.
So too should the patient avoid going to the doctor and tell him that you need Nexium for your hiatal hernia. If you are just given the prescription without a proper evaluation and then have a heart attack, you would be upset. You should tell the doctor that you are having indigestion and let the expert determine if the problem is a hiatal hernia, ulcers, angina, or something altogether different. Certainly a patient with a lot of knowledge about health can provide thoughts as to what the problem is, but the diagnosis and treatment options should be left up to the doctor.
The above is not a perfect analogy as diagnosing medical conditions is often an art and not an exact science. If the diagnosis turns out to be incorrect or incomplete on several occasions, you should find a new expert.
The two areas that often bring out the worst in patients are for prescriptions of antibiotics and pain medications. These are the two most frequent situations in which some patients insist on particular medications and will refuse others.
With antibiotics some patients insist on getting one even if they have a condition in which there is no benefit from it. I do not know why someone would expose themselves to the risk of allergic reactions, unnecessary side-effects, and the build-up of resistant bacteria in their system if antibiotics are not going to help them recover from their illness faster.
Other patients insist that they are immune to certain ones. It is often difficult to convince these people that while some bacteria are resistant to certain antibiotics, people are not. An antibiotic that might not have worked for a particular infection in one instance may very well be the best choice for a different infection.
It can be helpful for a patient to notify the doctor if they have had side-effects, allergies, good success, or bad success with a certain antibiotic for a similar infection in the past. The ultimate choice however, should be left up to the expert.
With pain medication, it is one thing to let your doctor know your past experience and results with particular drugs. It is quite another to insist on only one particular medication for your pain. You run the risk of being thought of as a drug-seeker if you are unwilling to try any medication other than strong narcotics.
Just as there are many different types of pain so are there different types of pain medications. One kind may be good for one pain while another might be better for another pain. Your doctor is in the best position to diagnose the cause of your pain and offer the most effective and appropriate medications for the situation at hand.
With any medication that your doctor prescribes, there is a chance that it will cause side-effects or might not be fully effective. That does not mean that the wrong medication was chosen. But your physician needs to be available to adjust a dose or change a prescription if the results are not satisfactory.
While a doctor patient relationship is a partnership, it is not an equal one. They each have their roles and responsibilities to achieve optimal results. The doctor should listen, examine, and advise. The patient should ask questions, choose among reasonable treatment options, and comply with the recommendations. Patients receive better care when they work with instead of trying to be their doctor.
A patient is paying for an evaluation and treatment of a medical condition. It would be a mistake to take your car to a mechanic and tell them you need a new water pump. If they replace it and the car still has the same problem, you would be upset. You should tell your mechanic that your car is overheating and let the expert determine if the problem is the water pump, the thermostat, the radiator or something altogether different. Certainly a car owner with a lot of knowledge about cars can provide thoughts as to what the problem is, but the diagnosis should be left up to the mechanic.
So too should the patient avoid going to the doctor and tell him that you need Nexium for your hiatal hernia. If you are just given the prescription without a proper evaluation and then have a heart attack, you would be upset. You should tell the doctor that you are having indigestion and let the expert determine if the problem is a hiatal hernia, ulcers, angina, or something altogether different. Certainly a patient with a lot of knowledge about health can provide thoughts as to what the problem is, but the diagnosis and treatment options should be left up to the doctor.
The above is not a perfect analogy as diagnosing medical conditions is often an art and not an exact science. If the diagnosis turns out to be incorrect or incomplete on several occasions, you should find a new expert.
The two areas that often bring out the worst in patients are for prescriptions of antibiotics and pain medications. These are the two most frequent situations in which some patients insist on particular medications and will refuse others.
With antibiotics some patients insist on getting one even if they have a condition in which there is no benefit from it. I do not know why someone would expose themselves to the risk of allergic reactions, unnecessary side-effects, and the build-up of resistant bacteria in their system if antibiotics are not going to help them recover from their illness faster.
Other patients insist that they are immune to certain ones. It is often difficult to convince these people that while some bacteria are resistant to certain antibiotics, people are not. An antibiotic that might not have worked for a particular infection in one instance may very well be the best choice for a different infection.
It can be helpful for a patient to notify the doctor if they have had side-effects, allergies, good success, or bad success with a certain antibiotic for a similar infection in the past. The ultimate choice however, should be left up to the expert.
With pain medication, it is one thing to let your doctor know your past experience and results with particular drugs. It is quite another to insist on only one particular medication for your pain. You run the risk of being thought of as a drug-seeker if you are unwilling to try any medication other than strong narcotics.
Just as there are many different types of pain so are there different types of pain medications. One kind may be good for one pain while another might be better for another pain. Your doctor is in the best position to diagnose the cause of your pain and offer the most effective and appropriate medications for the situation at hand.
With any medication that your doctor prescribes, there is a chance that it will cause side-effects or might not be fully effective. That does not mean that the wrong medication was chosen. But your physician needs to be available to adjust a dose or change a prescription if the results are not satisfactory.
While a doctor patient relationship is a partnership, it is not an equal one. They each have their roles and responsibilities to achieve optimal results. The doctor should listen, examine, and advise. The patient should ask questions, choose among reasonable treatment options, and comply with the recommendations. Patients receive better care when they work with instead of trying to be their doctor.
6/12/07
MAKE HASTE...SLOWLY
I think that patients need to have more patience. Some people rush to the Emergency Room for conditions that can safely wait to be evaluated by a physician in 24 to 48 hours. This waiting strategy can save you both time (if you have ever gone to the E.R. on a Saturday night with a non-life threatening problem you know what I mean) and money (if you have ever received a bill from the E.R. you also know what I mean).
As the summer is upon us, I will discuss several common conditions that patients often seek immediate care for but that can safely wait a period of time. These include sprains, cuts, and insect bites or stings.
Most people with an injury to a bone or joint are concerned whether or not there is a fracture. This is a reasonable concern as an untreated fracture or one not treated in a timely fashion can lead to long-term impairment or prolonged recovery.
Despite rumors to the contrary, being able to move a body part does not guarantee that there is no fracture. Many patients have walked into a doctor's office with a broken foot or ankle. An obvious deformity can make finding a fracture more likely, but unless you are Superman, you need an x-ray to detect a non-displaced fracture.
Fractures that require immediate attention include open fractures in which a bone is protruding through the skin and displaced fractures that compromise circulation. The former condition is readily apparent even to the untrained observer. The latter condition is detected when there is a decrease in pulse, coolness to touch, or pallor distal to the site of injury.
The vast majority of fractures can be managed with the use of rest, ice, compression, elevation, and over the counter pain medications until an office evaluation can be performed. Ideally this should be no later than 2 or 3 days after the injury.
Cuts require immediate attention if bleeding cannot be stopped with direct pressure. Otherwise relatively clean cuts can be sutured up to 19 hours after the injury. A longer delay increases the chances for infection.
A tetanus booster should be given within the first 24 hours of the wound if one is needed. A patient with a dirty or deep wound should receive this if more than 5 years have elapsed since the last booster while a patient with a clean or shallow wound only needs a booster if over 10 years have elapsed since the last booster.
Patients who step on a rusty nail should be seen immediately as these wounds should be anesthetized and thoroughly cleansed due to their extreme risk of infection. This prompt attention is even more important if the patient has a compromised immune system from diabetes or other chronic illness.
A bite from a mosquito or tick will take several days to cause symptoms if a disease has been spread. There is no known benefit from prophylactic antibiotics with these. If a fever or rash develops in the week or so following the bite, evaluation should be sought within a day or so.
A sting from an insect should prompt immediate medical attention if the patient has a history of severe allergic reactions to them in the past or if the patient develops hives or any breathing difficulties. Otherwise ice and oral benedryl can be utilized. If significant swelling or itching at the site of the bite occurs despite these measures, a physician can be consulted in a day or two.
While many common conditions are painful and frightening, the above guidelines can help the patient determine which ones require immediate attention from a doctor and which ones can be safely treated hours or days later. This knowledge will help avoid unnecessary trips to the emergency room after doctors' offices and urgent care centers are closed. The patient's patience can result in dramatic time and cost savings.
As the summer is upon us, I will discuss several common conditions that patients often seek immediate care for but that can safely wait a period of time. These include sprains, cuts, and insect bites or stings.
Most people with an injury to a bone or joint are concerned whether or not there is a fracture. This is a reasonable concern as an untreated fracture or one not treated in a timely fashion can lead to long-term impairment or prolonged recovery.
Despite rumors to the contrary, being able to move a body part does not guarantee that there is no fracture. Many patients have walked into a doctor's office with a broken foot or ankle. An obvious deformity can make finding a fracture more likely, but unless you are Superman, you need an x-ray to detect a non-displaced fracture.
Fractures that require immediate attention include open fractures in which a bone is protruding through the skin and displaced fractures that compromise circulation. The former condition is readily apparent even to the untrained observer. The latter condition is detected when there is a decrease in pulse, coolness to touch, or pallor distal to the site of injury.
The vast majority of fractures can be managed with the use of rest, ice, compression, elevation, and over the counter pain medications until an office evaluation can be performed. Ideally this should be no later than 2 or 3 days after the injury.
Cuts require immediate attention if bleeding cannot be stopped with direct pressure. Otherwise relatively clean cuts can be sutured up to 19 hours after the injury. A longer delay increases the chances for infection.
A tetanus booster should be given within the first 24 hours of the wound if one is needed. A patient with a dirty or deep wound should receive this if more than 5 years have elapsed since the last booster while a patient with a clean or shallow wound only needs a booster if over 10 years have elapsed since the last booster.
Patients who step on a rusty nail should be seen immediately as these wounds should be anesthetized and thoroughly cleansed due to their extreme risk of infection. This prompt attention is even more important if the patient has a compromised immune system from diabetes or other chronic illness.
A bite from a mosquito or tick will take several days to cause symptoms if a disease has been spread. There is no known benefit from prophylactic antibiotics with these. If a fever or rash develops in the week or so following the bite, evaluation should be sought within a day or so.
A sting from an insect should prompt immediate medical attention if the patient has a history of severe allergic reactions to them in the past or if the patient develops hives or any breathing difficulties. Otherwise ice and oral benedryl can be utilized. If significant swelling or itching at the site of the bite occurs despite these measures, a physician can be consulted in a day or two.
While many common conditions are painful and frightening, the above guidelines can help the patient determine which ones require immediate attention from a doctor and which ones can be safely treated hours or days later. This knowledge will help avoid unnecessary trips to the emergency room after doctors' offices and urgent care centers are closed. The patient's patience can result in dramatic time and cost savings.
6/1/07
LOCUM TERRORS
I think that it's better to temporarily provide no service rather than poor service. That is why the Spiceland Pike Medical Center will be closed Sunday, June 3rd and not reopen until Sunday, June 10th. This will mark the first time in our 10+ years of business that we will be closed for more than 2 days in a row.
I pride myself on being the hardest working doctor in New Castle. I work more days a week, more days a month, and more days a year every year than any other area doctor. I do this because I love my work and I care for my patients and want them to have access to my services as much as possible.
In the past few years, I have opted to hire a "locum tenens" doctor. That is a doctor provided by a temporary agency. Unfortunately, that has been a disaster to varying degrees all three years. Despite the agencies assurances of the quality of the doctors, the locum agencies universally committed a cardinal sin of business by over promising and under delivering.
I explained to the agencies in great detail the type of practice I have and the skills and speed that are required of a physician to perform a competent job. The companies would then fax me resumes of "qualified", available doctors. I was then permitted to review the credentials of the doctors and have a phone interview with them ahead of time to directly and explicitly explain what was required of them. This only proved to me that anyone can talk a good game, but actions speak louder than words.
The first year we hired a physician who showed up late on his first day, worked incredibly slow, and took breaks to eat during the day despite a waiting room full of people that needed medical attention. His work quality at least was satisfactory.
When I talked with the locum agency upon my return, I was given a sympathetic ear. I was asked what I would like done to rectify the situation, I stated that I would like to be reimbursed for the time he spent eating instead of seeing patients and that I would like to leave a letter in his file to inform future clients of my concerns. Not surprisingly, while both requests were accepted, only the former was acted upon.
The second time I used a locum agency was worse. I was told a week before my scheduled vacation that the original doctor had backed out. But I was not to worry because they would find a new one in time. They had no answer for my questions of what would happen if they didn't and what would happen if this replacement was unacceptable to me.
A new physician was found and I was assured that the company would stand by her fully since they had used her before and received good reviews from her past employers. Well, this didn't turn out to be exactly true.
While she did exercise some questionable medical judgment at times and was incredibly slow, she did manage to work when she was supposed to instead of eating.
The bigger problem was that she failed to dictate on the office visits for many patients.
This creates two problems. I cannot submit insurance claims for patients if I have no record of what transpired during the visit and I cannot adequately address problems a patient might still be having if I don't know what was diagnosed and how that was determined.
The doctor blamed the equipment and initially refused to write out or re dictate the findings from the office visit. The locum agency was largely antagonistic and unhelpful in resolving this issue. Only after I refused to pay for her uncompleted services was the work done.
When I asked the company's representative whether there had been any other hiring physicians' complaints against her, they admitted that she had never worked for them before despite assurances to the contrary made earlier. I was transferred to their lawyer when I requested to speak with a supervisor. The lawyer made it clear that the agency had no interest in retaining me as a customer and did not care that I was unhappy with their last minute replacement physician.
The third time was going to be different. I was using a different agency and I was paying extra to hire a physician who could handle the sometimes hectic pace of a walk-in clinic.
What a relief when they sent me a resume of a doctor who already worked for them extensively as an urgent care physician. The best part was that the doctor had worked over the past month filling in at a local walk-in clinic.
Not wanting to take any chances, we called the local clinic and received glowing reviews on his speed and conduct. I had him stop into the office to personally talk with him and show him we ran things. The third time seemed like it would be the charm.
Not quite. He turned out to be the most unprofessional and irresponsible of the three. He would answer his cell phone to take personal calls while in rooms with patients. He would take frequent breaks to eat instead of seeing patients. He would dictate in front of patients about their "deviant lifestyles" if they were homosexual or had what he considered to be inappropriate or too many piercings. He would not treat anyone with a sexually transmitted disease. The list goes on.
When I voiced my concerns to the locum agency's representative I was told that if I was unhappy with his services I should have dismissed him. I asked them if they would have provided an immediate replacement. "We would have tried," was the response.
When I balked at paying the higher rate for a physician who could handle an urgent care volume I was told that he was an urgent care doctor because he stated that he was one. But calling a Nova a Cadillac doesn't make it so. After much arguing, the representative admitted that they had no obligation other than providing a warm body with a medical license. They were sorry that he had performed unprofessionally and unethically, but that was all.
I threatened not to pay the full amount. They threatened to sue. I retained an attorney and received a small discount. They still call back several times a year to ask if I want to use their services again. I think not.
So three strikes and I am out. These locum firms are interested in money, not customer satisfaction. They excuse the conduct of their physicians and do not properly screen them to provide suitable candidates for doctors like myself who are trying to provide continuous satisfactory care for patients.
I apologize for the inconvenience, but this year no physician will be available for one week. For your convenience however, a nurse will be available from 12:30 p.m. until 3:00 p.m. from Monday through Friday to answer questions, provide medical advice and provide refills when indicated. Thank you for your understanding of this difficult decision.
I pride myself on being the hardest working doctor in New Castle. I work more days a week, more days a month, and more days a year every year than any other area doctor. I do this because I love my work and I care for my patients and want them to have access to my services as much as possible.
In the past few years, I have opted to hire a "locum tenens" doctor. That is a doctor provided by a temporary agency. Unfortunately, that has been a disaster to varying degrees all three years. Despite the agencies assurances of the quality of the doctors, the locum agencies universally committed a cardinal sin of business by over promising and under delivering.
I explained to the agencies in great detail the type of practice I have and the skills and speed that are required of a physician to perform a competent job. The companies would then fax me resumes of "qualified", available doctors. I was then permitted to review the credentials of the doctors and have a phone interview with them ahead of time to directly and explicitly explain what was required of them. This only proved to me that anyone can talk a good game, but actions speak louder than words.
The first year we hired a physician who showed up late on his first day, worked incredibly slow, and took breaks to eat during the day despite a waiting room full of people that needed medical attention. His work quality at least was satisfactory.
When I talked with the locum agency upon my return, I was given a sympathetic ear. I was asked what I would like done to rectify the situation, I stated that I would like to be reimbursed for the time he spent eating instead of seeing patients and that I would like to leave a letter in his file to inform future clients of my concerns. Not surprisingly, while both requests were accepted, only the former was acted upon.
The second time I used a locum agency was worse. I was told a week before my scheduled vacation that the original doctor had backed out. But I was not to worry because they would find a new one in time. They had no answer for my questions of what would happen if they didn't and what would happen if this replacement was unacceptable to me.
A new physician was found and I was assured that the company would stand by her fully since they had used her before and received good reviews from her past employers. Well, this didn't turn out to be exactly true.
While she did exercise some questionable medical judgment at times and was incredibly slow, she did manage to work when she was supposed to instead of eating.
The bigger problem was that she failed to dictate on the office visits for many patients.
This creates two problems. I cannot submit insurance claims for patients if I have no record of what transpired during the visit and I cannot adequately address problems a patient might still be having if I don't know what was diagnosed and how that was determined.
The doctor blamed the equipment and initially refused to write out or re dictate the findings from the office visit. The locum agency was largely antagonistic and unhelpful in resolving this issue. Only after I refused to pay for her uncompleted services was the work done.
When I asked the company's representative whether there had been any other hiring physicians' complaints against her, they admitted that she had never worked for them before despite assurances to the contrary made earlier. I was transferred to their lawyer when I requested to speak with a supervisor. The lawyer made it clear that the agency had no interest in retaining me as a customer and did not care that I was unhappy with their last minute replacement physician.
The third time was going to be different. I was using a different agency and I was paying extra to hire a physician who could handle the sometimes hectic pace of a walk-in clinic.
What a relief when they sent me a resume of a doctor who already worked for them extensively as an urgent care physician. The best part was that the doctor had worked over the past month filling in at a local walk-in clinic.
Not wanting to take any chances, we called the local clinic and received glowing reviews on his speed and conduct. I had him stop into the office to personally talk with him and show him we ran things. The third time seemed like it would be the charm.
Not quite. He turned out to be the most unprofessional and irresponsible of the three. He would answer his cell phone to take personal calls while in rooms with patients. He would take frequent breaks to eat instead of seeing patients. He would dictate in front of patients about their "deviant lifestyles" if they were homosexual or had what he considered to be inappropriate or too many piercings. He would not treat anyone with a sexually transmitted disease. The list goes on.
When I voiced my concerns to the locum agency's representative I was told that if I was unhappy with his services I should have dismissed him. I asked them if they would have provided an immediate replacement. "We would have tried," was the response.
When I balked at paying the higher rate for a physician who could handle an urgent care volume I was told that he was an urgent care doctor because he stated that he was one. But calling a Nova a Cadillac doesn't make it so. After much arguing, the representative admitted that they had no obligation other than providing a warm body with a medical license. They were sorry that he had performed unprofessionally and unethically, but that was all.
I threatened not to pay the full amount. They threatened to sue. I retained an attorney and received a small discount. They still call back several times a year to ask if I want to use their services again. I think not.
So three strikes and I am out. These locum firms are interested in money, not customer satisfaction. They excuse the conduct of their physicians and do not properly screen them to provide suitable candidates for doctors like myself who are trying to provide continuous satisfactory care for patients.
I apologize for the inconvenience, but this year no physician will be available for one week. For your convenience however, a nurse will be available from 12:30 p.m. until 3:00 p.m. from Monday through Friday to answer questions, provide medical advice and provide refills when indicated. Thank you for your understanding of this difficult decision.
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