The Dehumanizing of Patients

When the first discussion took place in June 2012 and then when the Diagnostic and Statistical Manual (DSM5) was published in December 2012, I have been reading what has been published by other writers and psychiatrists and psychologists have been saying or writing. Finally, an author that I am able to understand and more importantly agree with has written a blog about topics covered in DSM. Much of the discussion on mental health really dehumanizes patients and throws medications at patients when this may not be the best.


I would ask that you read his blog for you own understanding, as I am biased and pleased that he sees his patients as humans and how they respond to positives given to them rather than just a diagnosis and another medication to solve the problem. Medications may be necessary for some mental health issues, but the wholesale prescribing of medications will only lead to dependence on medications and not a treatment, which will help the patient manage their lives in a positive way.


Because of the way Dr. Dan Peters describes things, much of the following will be quoted. “The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:


#1. Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
#2. Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
#3. If so, is there a “treatment” for every identified “condition?”
#4. Does it mean there is a treatment that works?
#5. Do you need a diagnosis to get help?


Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:


#1. Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
#2. Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
#3. Gluttony will be diagnosed as Binge Eating Disorder
#4. Grief will be diagnosed as Major Depression
#5. First time substance users and college partiers will get a diagnosis of Substance Use Disorder
#6. Everyday Worry will be diagnosed as Generalized Anxiety Disorder”


The following is important and very meaningful. “And what’s the number one treatment for all of these diagnoses? Medication. In my 20+ years of working with children, adolescent, adults, and families, I have found some simple and profound truths. First, if you talk to people about what is wrong with them and causally assign diagnostic labels to explain them, they feel badly about themselves and it plays into their low self-esteem, self-confidence, and self-worth. Next, if you help them to better understand their strengths and weaknesses, and help them to develop tools to cope with life, all of the aforementioned increases. Lastly, if you focus on their strengths, rather than their “deficits,” “disorders,” and “illness,” they become aware of neglected and unknown aspects of themselves that they can and do use to navigate life and meeting their goals.” Bold is my emphasis.


“I ask that all mental health and medical providers, educators, administrators, adults, and parents think critically when making or accepting a diagnosis.
Ask yourself:


#1. What is the purpose of making or accepting a diagnosis?
#2. Does it fit my or my client’s experience?
#3. How will I explain the diagnosis to my client?
#4. What does this diagnosis mean to me (client)?
#5. Will this diagnosis help my client (help me) achieve my goals?
#6. Does the diagnosis explain a normal human emotion or condition?
#7. What are all the possible helpful interventions? Can medication wait?
#8. What is right with my client? What is right with me (client)?


Those of us in the field of mental health and medicine have a minimal obligation to do no harm. Further than that, we have an obligation to improve the life conditions of our clients. Our current mental health and insurance system makes this very hard, but nothing in life that is worth anything is easy.”


I am very thankful he included “do no harm” in the above paragraph and from the tenor of his blog, I understand him to mean just that. Many of his colleagues may not care when they find it easier to pass out pills. Don't misunderstand me, some mental health issues do require medications, but as Dr. Peters points out, medication does not solve all problems or should it be the end-all for all mental health issues.

Are Laws Needed to Control Diabetes?

With the ever growing population of people developing diabetes, some are turning to legal remedies for stopping the tide and the role that law can play in serving as an effective health tool. Honestly, I had never thought legal remedies would be applied, but the more I read about this study the more I realized that some of the most useful legal remedies are not even mentioned in the press release. When the American Diabetes Association has legal tools available to use against discrimination, why should there not be other legal tools available.


I may be criticized for this, but without legal remedies to force doctors to become current in their knowledge, prevention, and diagnosis of diabetes, patients will continue to bang their heads against the wall. Doctors are the first line of defense and as long as they continue to ignore diabetes, this diabetes epidemic will continue. If stiff legal penalties are required to bring doctors into the twenty-first century, so be it.


The law can be a critical tool for health improvement as long as it does not jeopardize our freedom rights. Assessments reported in a new study published in the American Journal of Preventive Medicine indicates that federal, state, and local laws give only partial support to guidelines and evidence-based interventions relevant to diabetes prevention and control. Bold is my emphasis.


It is sad indeed that nearly 26 million people in the US have the disease and about one-fourth are not aware they have diabetes. Facing about 30 percent (about 1 in 3 people) having diabetes by 2050, it is time for action. Risk factors for type 2 diabetes include limited access to nutritious food, limited opportunity for physical activity, socio-economic conditions, and genetic disposition. While many well-crafted guidelines and recommendations for diabetes intervention exist, the incidence and prevalence of diabetes continues to escalate.


Lead author, Anthony D. Moulton, PhD, Laboratory Science, Policy and Practice Program Office, Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, states, "Laws, including statutes, ordinances, and government agency rules and regulations, can support interventions to prevent and control disease in various ways."


Dr. Moulton continues, "Laws can help shape environments to reduce exposure to some type 2 diabetes risk factors and encourage preventive behaviors, and laws can authorize or require provision of prevention-oriented information designed to change the behaviors and cultural norms that affect risk."


“Investigators analyzed the laws further to determine whether they contained provisions that require, incentivize, or encourage healthcare providers, insurers, employers, schools, child care centers, restaurants, government agencies, and others, to take action consistent with a given guideline.
Investigators concluded that:

• Implementation of guidelines for evidence-based interventions for diabetes prevention and control is incomplete
  
• Many opportunities exist for exploring uses of law to improve adoption”
  

Dr. Moulton's conclusion is also worth quoting, "Laws that are demonstrated to be effective, designed to support proven public health and clinical interventions, and well implemented can give crucial support to strategies that address public health priorities and to wider adoption of evidence-based guidelines. Law is a key tool for scaling and sustaining effective interventions at the national level. Public health practitioners and policymakers nationally can intensify their exploration and evidence-based application of law to help slow and potentially reverse the accelerating threat posed by the diabetes epidemic."


Dr. Moulton does not state this, but I think until doctors educate themselves about diabetes and step up to the challenge, we will not achieve any reduction in the diabetes epidemic. Doctors that make statements, such as – “Watch what you eat, your blood sugar is a little high,” or “Curb your sugar intake,” should be penalized for not making a diagnosis or giving a complete description of what the blood glucose readings mean for the patient. ONLY then will we see a possible slowing of the number of diabetes cases. The 15 minute office visit or less, will do nothing to slow the diabetes epidemic and blaming the patient needs to end.

Obstructive Sleep Apnea When Having Surgery

If you suspect you have obstructive sleep apnea (OSA), and you are facing surgery, be sure to make this known to the anesthesiologist. This will alert this person to the possible complications you could develop from anesthesia. The following questions should give you some guidance to determine if you may have sleep apnea.


Answer the following questions truthfully. Remember that you will be the person suffering from anesthesia and unless you wish to spend time in the intensive care unit (ICU), it is wise to answer honestly and discuss this beforehand with the anesthesiologist. Going into an operation under anesthesia is a poor time to let vanity get the better of you.


#1. Do you snore loudly (loud enough to be heard through closed doors)?
#2. Are you often tired, fatigued, or sleepy during the daytime?
#3. Has anyone observed you stop breathing during your sleep?
#4. Do you have or are you being treated for high blood pressure?
#5. Is your body mass index > 35 kg/m2?
#6. Are you over 50 years old?
#7. Is your neck circumference > 40 cm?
#8. Are you male?


A person is considered to be at high risk for OSA if he or she answers yes to 5 or more of the 8 questions. This information has value beyond the benefits to anesthesia care. After being diagnosed with OSA, the patient can be referred to an internist or sleep physician to receive proper long-term treatment after the operation. Being a person with OSA myself, I know how important this is and I would not go back to my problems before sleep apnea treatment.


Having surgery done without knowledge of sleep apnea and in a hospital without an ICU may mean that you will not survive the operation. In the study, surgeons were not able to identify 90% of the patients with severe OSA. Anesthesiologists did not diagnose 53% of these patients. About one third of the patients with sleep study-identified OSA had only one or no cardinal symptoms of OSA. This indicates that these asymptomatic, "silent" patients are not going to be identified purely by history obtained by the physician.


One group of patients that is concerning to the anesthesiologist is surgical patients with undiagnosed OSA. Anesthesiologists also worry that such patients will be at higher recovery risk, especially when discharged home on opioids for pain. These patients may also have a higher incidence of difficult intubation, postoperative complications including delirium, increased admissions to the intensive care unit, and longer hospital stays.


If a patient is known to suffer from sleep apnea, then the anesthesiologist can be extra careful in properly managing opioids for pain relief and weighing other factors such as the risk for postoperative respiratory depression. This also opens the door for other combinations of analgesics or regional anesthesia to be considered. These patients warrant extra and longer monitoring in the recovery room. Initiation of continuous positive airway pressure (CPAP) perioperatively is also likely to be useful. A patient with undiagnosed OSA presenting for surgery would not receive such care if the diagnosis were unknown.

Connected Health – Generates Quality Care

This is a take-off of a blog posted recently by Nancy Finn on her site. I read her blog with interest as it was so much different from another article also posted recently on Medscape. Nancy's blog indicates an extremely large dollar savings while the Medscape article reports no savings.


Now before I go further, the UK study was a once monthly telephone conference as a 1-on-1 health coaching session. Nancy covers a broader range of telemedicine. She brings in the internet, telecommunications, video technology, smart phones, robotics, digital sensors and scanners. This is all used to provide patients in remote, medically underserved areas, or those who are homebound, immediate quality care. This makes it easy to understand why the UK study was unsuccessful.


Enough about the UK study, Nancy's blog gives hope. Considering the range of services she is talking about, there is hope that her projected savings is possible and even if not met, large dollar savings should still exist. What I enjoy about Nancy's blog is the fact that her ideas are not limited by technology, but embraces technology to care for patients. From using an interface to hook up patients with appropriate healthcare specialists, speech therapy, and mental health counseling when and where it is needed. Also of interest is the assisting of patients with chronic diseases to manage there care remotely.


Nancy states, “The Center for Connected Health and Partners Home Care did a pilot where over 500 heart failure patients were monitored remotely. Home health nurses collected vital signs, including heart rate, blood pressure and weight, using simple devices in the patient’s home. The information was sent daily to a nurse, who could identify early warning signs, notify the patient’s primary care physician, and intervene to avert a potential health crisis. The program resulted in reduced hospital visits and improved quality of health care for the patients.”


This is the first I have read about a “smart” pill bottle being used to detect when a patient at home did not take their scheduled medication. The pill bottle would send a signal to an ambient orb in the patient's home to remind them to take that medication. I can see that this could reduce the chances of a medical crises and even an emergency room visit. This could alone save big dollars.


Using technology could make the workload for doctors' decrease and provide better care for patients. Now I will need to be alert to see if state medical boards will fight to prevent these technologies from happening and if doctors will welcome these technologies or try to say that it is robbing them of revenue when the Affordable Care Act becomes a reality. There are many areas in the US that could benefit from modern technology.

Are Doctors a Threat to Their Own Occupation?

Yes, according to Dr. Paul D. Simmons and he does not mince words. His final paragraph quite accurately sums up the whole argument, “If my professional organization, the AAFP (American Academy of Family Physicians), wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.”


According to Dr. Simmons, in recent months, AAFP president Reid Blackwelder has been up in arms about what he sees as the encroachment of nurse practitioners (NPs) and other mid-level providers on the practice of family physicians. Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.”


I do take delight is his term for specialist – partialist. These partialists are the ones that have slowly pushed the family physicians out of their practices by limiting what they are trained to do. Yes, it is not the NPs that have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. The culprit according to Dr. Simmons are their colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.


Dr. Simmons continues, “It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.”


Then he addresses the impending physician shortage by saying that there will not be enough family physicians to fill the gap. NPs he says will serve in that necessary role and do an excellent job. It will happen, it already has happened, and there is no way for the AAFP to prevent it. Good for Dr. Simmons.


This is also the reason I have written about the American Telemedicine Association calling for national licensing which medical associations and state medical boards are in full opposition. Then I also blogged about doctor bashing because this is happening because doctors will not make referrals when they are not current in an area. With the impending shortage of physicians, patients are going to become frustrated. If the frustration becomes large enough, the manure will hit the fan and the doctors opposing NPs, PAs, and pharmacists, plus other doctors who are qualified and could work across state lines may just find themselves hurting for patients. I hope this does not happen, but I would not bet against it. I just say let these doctors shoot themselves in the foot. Maybe the pain in one end will bring some sense to the other end.

PCPs Are Putting Themselves In a Bad Light

Primary care physicians are taking it on the chin, but in many cases are doing this to themselves. I think doctor bashing is too polite for the things I am reading about what the PCPs are doing. Dr. Michael Cetta cites even more cases where PCPs are damaging their profession. In some areas of the US the shortage is already being felt and people are reacting negatively to what they are doing.


I am even hearing about court actions against some PCPs for not doing what they are not letting others do. Yes, this is getting very upsetting in some areas. These doctors have smashed the pedestal they had placed themselves on, and people are hauling away the pieces. When primary care isn't available like the example covered in this blog, tempers become very short. I have heard from the fellow in this blog again and the doctors are dumping all patients working for the company because they could not wait for about six months for an insurance required physical. If the company was requiring the physical, then they should have waited, but the insurance company would give no extra time. The fellow said this is getting very nasty in the community. Two doctors that had insurance are without insurance because a division of the insurance company that required the physicals, canceled their insurance.


Since this is a company town, this meant that 90% of their patients were gone and the remaining patients said no thank you and are looking elsewhere for a doctor. Then the owner of the building containing the offices of the two doctors served them with an eviction notice because he said they would not be able to pay the rent. One has already moved into another office about an hour away and the second will be joining him. What surprises this person is that the doctors are trying to prevent other doctors from moving into the town they were evicted from.


In some larger communities, Transition Care programs are beginning to take up the slack for PCPs to care for patients fresh out of hospitals. Because of the emphasis by the Centers for Medicare and Medicaid Services (CMS) of penalizing hospitals for too many readmissions, Transition Care programs are sending healthcare providers into the patient's homes. This is stirring up opposition from PCPs who don't want another care provider stepping in, or the PCPs don't understand the value. After all, (tongue-in-cheek) aren't PCPs supposed to have a proprietary right to oversee their patients' health.


The telling fact is disturbing because everyone does not have a PCP and about 50 percent of the Medicare readmission patients will not have been seen by a primary care physician between admissions. Of the $17 billion spent each year on only Medicare patients, 75 percent of those readmissions are considered preventable. Why aren't the PCPs taking care of them? Because they do not have office time to fit them in and some patients do not have access to a PCP.


Dr. Cetta has this example, “To solve this enormous problem, Transition Care programs need to work closely with PCPs. But right now, a large number of patients who could benefit most from Transition Care are weeded out of the programs because of PCP opposition. In one recent pilot program at a hospital in Maryland, roughly a third of all patients who otherwise qualified for Transition Care were weeded out because of their primary care doctor’s opposition.”


Turf wars are not pleasant for the patients and it is time to have patients take up the cry to PCPs saying if you don't have time to see me, then step aside, you will no longer be my doctor. Even caregivers are considering this, as they don't wish to see their people reenter the hospital so soon after discharge.

Another Reason to Be Careful of Hospitalists

On August 22, I blogged about hospitalists and what this can mean for you. Now another case of why hospitalists may not be the best. This hurts as it affects those of us with diabetes and those with hypertension. Hospitalists see it as their duty to fine tune our management of both. No matter the reason for being hospitalized, I would encourage all people with diabetes and/or hypertension to be careful what they allow the hospitalists to do to you.


The author of this blog relays information from the University of California, San Francisco about elderly patients admitted for an acute problem of pneumonia. They also have hypertension, diabetes, and other conditions that are unrelated to the reason for admission.


The well intentioned hospitalist may see the hospitalization as an opportunity to “tune up” the patient by intensifying the treatment of these conditions. The blog author continues, “This usually does more harm than good. Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving management to the outpatient doctor.”


An acute illness often causes problems in management of hypertension and diabetes while in the hospital. This is problem one, as control generally returns to normal after the acute illness resolves. But, when a hospitalist intensifies treatment in the hospital, the patient will then go home dangerously over treated.


Problem number two is that is impossible to determine the ideal regimen for blood pressure and glucose management in the hospital. It is just stupid (my words) to titrate medications for these conditions in the hospital. The acute illness may increase hypertension and make glucose management almost impossible until it is resolved. Then the patient is discharged and told this is what he/she must take and because the home regimen, diet, exercise, and other activities, is totally different than the hospital, this can cause all sorts of problems for the patient.

The hospitalist may have made the numbers look great while the patient was in the hospital, but clearly the numbers will be very different when the patient is at home. Hospitalists should think twice before trying to change established outpatient regimens for hypertension and diabetes in the hospital. Changes should only be made in consultation with the patient's normal doctor.


A local person with type 1 had his pump totally messed up by a hospitalist and needed to use multiple daily injections until he could get home and get help from the pump manufacturer. Then he needed to call his endocrinologist to get the settings corrected to what they had been before the hospitalist took charge. Since he knew he would be going back into the hospital two months from now, he has sent a registered letter to the hospital requesting that the hospitalist not be allowed near his room. In addition, the letter stated that under no circumstances was the hospitalist even to touch his insulin pump under threat of a lawsuit.


Since the hospital has refused, he and his doctor are investigating another hospital for the operation and they will go through the same procedure to limit what the hospitalist can do. Because of the location of the operation on his body, his wife will accompany him and take charge of his pump until after the operation is completed. Then he or his wife will reattach the pump to another area and start it. She will also have control of his testing supplies. His endocrinologist will see to it that he can use his own insulin.


Since hospitals are nefarious in allowing blood glucose reading to be maintained at 180 mg/dl to 200 mg/dl, his endocrinologist wants to help him heal faster and maintain his own glucose levels. His endocrinologist says that he should be able to manage having the hospital allow this especially since he has hospital privileges at the new hospital. He will also have a CGM for his use while hospitalized.