Family Webicine

By Rod Moser, PA, PhD

“We are really sorry, but we can’t seem to find your chart.”

We often heard this in years past, but since the advent of EMRs (Electronic Medical Records), lost charts are uncommon. Instead, we hear: “I am sorry, but the computers are down. We cannot access your files.”

Many years ago, to augment my meager teaching salary with the University, I worked part-time in the Urgent Care at a local Air Force base. Lost charts were so commonplace that the excuse was expected., and pulling charts when the patient arrived sometimes took longer than the actual visit. Much to my surprise, a large number of patients came into my office, chart in hand. Why? The simple reason was that they never returned the chart to medical records after their last visit! They would keep it so it would not get lost. While this practice may have violated a dozen Air Force regulations, I just looked the other way and was glad they had their chart. Since it was the patient’s responsibility to take it back to medical records at the end of the visit, I really didn’t care.

The real problem with this practice was lab and x-ray reports. If there was a chart that could not be found, how would these reports be posted? Medical records would have to create a temporary chart, or perhaps the reports would be lost. Twenty years ago, at this same Air Force base, the ceiling in medical records caved in from the sheer weight of stacks and stacks of unfiled lab reports, x-rays, and charts. Apparently, a disgruntled airman, anxious to get home at the end of a busy day, removed one of the ceiling panels, and when he was ready to go home, he would simply toss the files up into the ceiling space. When reports were requested, he played stupid and claimed he never saw them. The number of tests that had to be repeated was enormous. Not only were frustrations and costs involved, some of the unfiled tests were abnormal. A delay in getting results may have caused unnecessary harm or worse. I heard that he was court martialed.

I wanted to see what a former urologist wrote in his notes since he did not bother to examine me, nor did an ER doc I saw. What would they record in the notes? Thinking they may lie about doing an exam, I reviewed my records. They did not lie. They did not write anything!

I am no longer allowed to read my own medical records. I can get my lab test results and a few other reports on line if I sign up for a service, but if I “break the glass” to access my own records, all kind of alarms sound. When we had paper charts, I would freely access my records, so what is the difference? Of course, my records (nothing to hide, incidentally) could be read by anyone in the clinic. Now, anyone who tries to read my electronic chart will be quickly identified.

What would happen if patients were required to keep their own medical records and bring them to each visit, like a passport? A recent study reported in the New York Times tried it out, fostering the concept of shared medical records. While many doctors, as you might imagine, voiced skepticism about this practice, the patients loved it. Over 90% of the patients felt that they would exercise more control over their own medical care if the saw and read their notes.

On the WebMD Ear, Nose, and Throat community board, I am often astounded at the number of postings were the patient was not even told their diagnosis! There was no discussion on any rationale or even a discussion on why they were given a certain medication. These patients were left hanging. If they could read their chart, then perhaps they would have many of those answers.

Here lies a problem. I take pride in the thoroughness of my chart notes, but I have to say that many of my colleagues write lousy notes. I write my notes knowing that I am not the only one who will read them. My chart notes are my only record of the visit, and my only defense should there be an unexpected outcome. I am proud of my notes and would happily give any of my patients a copy of their progress notes, but unfortunately, I am not going to have them completed by the end of their 15-minute visit. Since we have to type our own notes (not dictated and transcribed), I must complete them between patients, over lunch, or after clinic hours. I refuse to dilute my time with a patient by typing during the visit and having a computer screen create a barrier. If a patient wants my notes, they get them. I will email it to them, drop it in an envelope, or create an after-visit summary.

A patient deserves to have full access to their medical records. They shouldn’t have to beg for them (or steal them). They should not have to pay extra to get a copy of their records. I am merely a consultant in their care. They are already paying me for the service I provide (or their insurance companies). Legally, we have to maintain accurate medical records, but there is nothing in the law that states they cannot be freely shared with the patient themselves.

Further Reading

How to Get Your Medical Records

Is it a Good Idea to Have Access to Your Doctor’s Notes?

When Your Medical Records are Wrong

By Rod Moser, PA, PhD

It was bound to happen. Times are, indeed, changing. For the longest time, medical practices have been struggling with what to do about patients who miss appointments. The Washington Post recently printed an article about the growing trend of some doctors who charge a (non-refundable) down payment or put a credit card hold for medical appointments. You don’t show up, you forfeit the deposit. Will it work? Will it just anger patients in a competitive market? What about patients who are always late for their appointments? Will insurance companies pay for these missed appointments? Don’t count on it.

There are two sides to this story. For some reason, medical providers and their patients occasionally develop an adversarial attitude about appointments. Some arrogant doctors feel they can take their sweet old time and make patients wait…and wait, often for hours, sitting in a cramped reception area (I was going to say waiting room!).  A doctor that I knew in Southern California made his patients wait up to four hours. He felt that if they wanted to see him, they would wait. He felt that he was worth waiting for, and apparently most of his patients tolerated this attitude. A pediatric urologist in my area had block appointments. In other words, he would have a dozen or more patients come in at the same time. He would then see them one at a time, with the last patient waiting about three to four hours. Some savvy families, aware of his practice, would come prepared for the long wait with videos, books, and food for the kids. Since I hate waiting, I would have exercised my right to get up and walk out after a half-hour or so, unless I was given an explanation.

I feel really bad if I have to make a patient wait, so I always apologize and give them an explanation. If a patient is really ticked, I may even refund their co-pay or not charge them at all. It depends on the circumstances. If a patient still cusses me out or gets in my face for being late because I had a sicker patient in the previous room, we have a conundrum. I may not charge them for the visit and ask that they change medical providers in the future.

Medical providers get sick or have family emergencies and must re-schedule appointments. Medical providers occasionally run behind, mostly because they cannot anticipate the unknown. A patient makes an appointment for one thing, and then tries to maximize their visit by coercing the medical provider to handle about six other, undisclosed health issues. A patient may be in crisis or have a more serious health issue that takes more time. If the medical provider works on 15 minute appointments, that miniscule time allotment will quickly be depleted. They will be running into the next patient’s visit time. Multiply that by ten or twelve patients. The last ones are going to be very inconvenienced. If one patient is late, for whatever reason, you can run behind all day. Patients get angry, and angry patients complain. They may even come in late for the next visit on purpose to punish the medical provider, or worse, not show up at all.

I had one family in my practice that had a zillion kids. She had so many “no shows” that I wanted her discharged from the practice. The straw that broke the camel’s back was the day she no-showed for FOUR back-to-back appointments for her sick children. That is a one-hour hole in my busy day. She then convinced the receptionist to reschedule those four missed appointments in my coveted evening appointments, which I only reserve for very sick kids. She didn’t show up for those either – eight no-shows in one day, a new clinic record. The way I look at it, I could not see eight other sick kids that day because of her lack of consideration. If I could have charged her, I would have, but unfortunately, she was on state-provided insurance (Medicaid) and there no provisions to charge for missed appointments.

I have a personal policy not to turn down late appointments, but I do appreciate an explanation and I ask them to wait until I see a scheduled, on-time patient first. Most of the time, there are legitimate reasons for being late: a flat tire, a speeding ticket, traffic, lack of parking, or even an honest admission that they forgot. I forgive them and get on with my day. Perhaps because my wife is always late when we are going somewhere, I am more tolerant of tardiness.

A completely missed appointment is an entirely different problem. Sometimes, missed appointments are a blessing – a gift of time on a busy day. It gives me to time to catch up, make some phone calls, or even go to the bathroom! There are days when you absolutely have to get out on time, yet your schedule is impacted, and a few patients are late. A few times in my career, I have purposely put my own grandchildren at the end of my busy schedule, knowing they would not show up. I can’t believe I revealed that scheduling secret.

People have phones. They can call and cancel if they are running terribly late. I give patients a few “no-shows” because we are all human and forget, but repeat offenders are going to get a letter from me. Our office does track and monitor no-shows. We can’t charge for missed appointments (yet) but we do send them a letter. As a matter of fact, we have about four or five different letters, depending on how many no-shows they accumulated. Serious offenders can be legally discharged from our practice, but in reality, it rarely comes to this.

Medical provider time is valuable. Patient time is valuable, too. There must be some mutual courtesy here or someone may need to pay a price.

Want to hear more from Dr. Moser? Join him in our Ear, Nose, and Throat community.

By Rod Moser, PA, PhD

I had an extensive rotator cuff repair of my left shoulder a little over two months ago. This has been a longer road to recovery than I anticipated. At first, I only cancelled two weeks of patients, thinking I would be back at the clinic quickly. My orthopedist and a half-dozen other people have told me that it can take up to a full YEAR to return to normal.

Maybe I am impatient. Most medical providers are. I have been going to physical therapy regularly and showing improvement, but I still do not have full function of my left arm. As much as I think that I can function with just one arm in a clinical setting, I really cannot. I need both arms.

Being right-handed, I was always puzzled why my non-dominant arm had the tear, and not the dominant one. My right arm was apparently stronger and resisted injury, while my weaker left arm took the hit. It wasn’t long after having my left arm immobilized that I started having pain and limitations on the right arm. Feeling that it was just overuse, I let it go. One arm – even one that is somewhat painful – is better than having no arms.  As the weeks ticked by, my right arm (the ‘good’ arm) started getting worse. On some days, it hurt more than the arm that had surgery.

I waited but time did not heal anything. Last week, I underwent another challenging MRI on the right shoulder. I am not a big fan of closed spaces; I guess I am a claustrophobic. If you ever had an MRI, you know what I am saying. Even non-claustrophobic people have difficulty being inside a tube for 45 minutes of constant, loud hammering. The fact that I also have tinnitus did not help the situation, even with ear plugs. Thank God, I had a supply of Xanax to take before the MRI. Medication, combined with some extensive relaxation therapy, got me through…again.

As I suspected, the right shoulder has a small tear and considerable inflammation and swelling; lots of arthritic wear and tear. It was not as bad as the complete tear on my right shoulder, so another surgery may not be imminent. I don’t think I could emotionally handle having both arms out of commission at the same time. It would be a nightmare. How would I eat? How would I shower? How would I dress myself? Even worse…how could I go to the bathroom?

Today, my orthopedic PA injected steroid into my right shoulder joint, hoping to reduce the swelling and inflammation. An interim step, yes, but perhaps it will work and I will not head back to the operating room. If you are wondering if the shot hurt: it did. Of course, I am an admitted wuss. Steroids are typically combined with a short-acting anesthetic such as lidocaine. This numbs the area for a few hours so that you have time to get home before the pain kicks in again. It is now back with a vengeance. I was informed that it will get worse before it gets better.

If I don’t get back to seeing patient soon, I think I will go stir crazy. I can’t work outside, since I can’t lift anything, so all I can do is write. I even started writing a novel – one that I have been pondering for about 15 years now. And, of course, I have been prolific in posting on the Family Webicine blog. I thought I would enjoy the time off, but enough is enough. How in the world will I tolerate retirement some day? I suspect that I won’t ever retire, but semi-retirement would be great.

My goal – if my right arm responds to the non-surgical treatment and my left arm heals – is to return to the clinic part –time at the end of the month. For the first month, I will extend my appointment times, work fewer hours per day, and modify the type of patients that I see, and how I see them.

From what I hear, the patients miss me, and I really miss them.

By Rod Moser, PA, PhD

Medicine can be a dirty business, when it comes to germ exposure and the potential to transmit germs to others. Most hygiene studies have focused on unwashed hands, perhaps the most contaminated area; however, hands are not the only problem. During a medical encounter, there are ample chances to be exposed to pathogens: the sign-in pen in the waiting room, the furniture, door knobs, faucets, exam tables, computer keyboard, and the various non-disposable medical instruments that are used during a typical examination. All of these areas can be crawling with disease-causing organisms. Sort of makes you want to stay at home!

I stopped wearing neckties about five years ago after a few research studies found them to be bastions of contagion. Many of my patients are babies, and it was not unusual for my necktie to drape across a snotty nose during an examination. If I was not paying attention, a baby would reach out and suck on the end of my tie. Yuck! To complicate matters, I accumulated a large collection of pediatric novelty neckties covered with cartoon characters which attracted their attention. So, I gave them up. They are now collecting dust in my closet.

I am a conscientious hand-washer, both to protect myself and others. I usually wash my hands three times with each encounter: once in front of the patients, once after the examination, and then again more thoroughly, after the patient leaves. I use hospital-grade antibacterial liquid soap and follow it with an alcohol-based hand sanitizer.

Patients notice dirty offices and they are not shy about commenting on breaches of infection control. If a medical provider doesn’t wash their hands, a patient will comment. If the office seems dirty, they will comment. Any and all efforts to clean up our acts goes a long way in patient comfort and confidence. A satisfied patient returns.

Although I should wear a lab coat to cover my street clothes, I do not, since the white coat tends to scare the kids. After a day of patient contact, my clothes go directly in the laundry. Ideally, we should all be wearing scrubs at work and take them off before going home. If the rest of the group did it, I would happily join in, but it is inconvenient to change back into street clothes when going out to lunch.

I am aware that our stethoscopes are contaminated. If I think about it (not with every patient, I have to admit), I will wipe it off with an alcohol pad. While alcohol can be an effective disinfectant, it requires a lot of surface time to work. Just wiping it off quickly doesn’t really do much, and is more for show. Even wiping off the skin with an alcohol swab before an injection is primarily for show. In order to completely sterilize the skin, you would have to rub that area for an hour or so. Over time, alcohol has the potential to ruin sensitive (and expensive) parts of the stethoscope head and even the tubing, necessitating their replacement.

How contaminated are stethoscopes? A study at the University of Arizona found that 100% of stethoscopes are contaminated with disease-causing viruses and bacteria – about 2,400 germs per square inch of surface space. In comparison, a toilet has 49 germs per square inch. Pretty gross, huh?

A new start-up company called Cleanint came up with a novel idea to decontaminate those nasty stethoscopes (appropriately named CleanStethoscope). A simple plastic holder containing a disposable sponge soaked in a safe and highly effective disinfectant is magnetically attached to a shirt or lab coat. After an examination the stethoscope, normally draped over the neck, is inserted into this holder so that it can be continuously disinfected. At about fifty cents a day, this little device could stop the spread of pathogens and ultimately save lives. For the bean-counters, these things can save money, too. Sick patients and sick employees end up costing more than a half-buck a day.

Along those same lines, Cleanint also tackled another “hot” item – the shared ink pen used to sign in before your appointment. Their CleanPen device uses the same technology to decontaminate the pen between uses. Although I do not use a stylus on a portable computer, they have a device for those, too.

These are simple solutions for serious problems. For a device of this nature to be successful in a skeptical market, it has to be (a) inexpensive, (b) durable, (c) easy to use, and (d) highly-effective. I feel that the CleanStethoscope and CleanPen nailed all four criteria –Kudos to this new company.

Look for them sticking to your medical providers soon.

Want to hear more from Dr. Moser? Join him in our Ear, Nose and Throat community.

By Rod Moser, PA, PhD

Two heads are better than one—or are they? What about three heads, or four, or a whole committee? When it comes to medical issues, especially complicated cases, many people seek or are advised to get another opinion.

Imagine this: a doctor tells you that you need surgery on your nose for a deviated septum. You are a bit puzzled since you really are not having a major problem with your nose, unless you have a cold. You don’t want to have surgery for an incidental finding, but here is a well-trained, authoritative clinician making a firm recommendation. Some people will agree to be scheduled for surgery, some will want to think about it, and some will be highly skeptical and immediately seek a second opinion. They go to another ear, nose, and throat specialist who totally disagrees. Now what do you do?  Do you believe the second opinion just because it was the last opinion, or do you leave totally confused?

A serious combination is an unassertive, uninformed patient who happens to have excellent insurance.  I am often appalled by the number of people who have had surgery that I considered unnecessary or, at least, borderline questionable. Many patients are justifiably skeptical about an economically driven clinician. This is not to say that a surgeon in private practice is not a good surgeon, or that his/her opinion is incorrect. Perhaps as a primary care clinician – a non-surgeon – I am more conservative. My fixed salary is not dependent on the number of cases I take to the operating room. As long as I am “paying my keep”, the bean counters in our non-profit medical group do not take notice.

Why do people seek second opinions?

1.       They did not like or disagreed with the first opinion, especially if it meant surgery.

2.       They want confirmation of their first opinion so they can make a more-informed decision.

3.       The clinician giving the first opinion had “no clue” as to what was going on.

4.       They did not care for the bedside manner, office staff, demeanor, etc. of the clinician giving the first opinion.

People want to get better and most are willing to spend good money, undergo surgical/anesthesia risks, and endure painful periods of recovery and rehabilitation to achieve a cure. If it takes a surgical procedure, then so be it.  If a surgical recommendation is not expected, however, the patient’s blood pressure and pulse rate rises in an anxiety response. In this case, it’s best to take some time to consider your options. After all, we avoid grocery shopping when we are hungry, and we should never be so hungry for a cure that we do not take the time to ponder a decision, or consider seeking a second opinion.

Doctor A recommends surgery. Patient freaks out (on the inside). Perhaps there is some more that can be done to avoid surgery? Some people will seek second (and third, and so forth) opinions from their non-medical friends. Some will hit the Internet chat rooms and consider opinions rendered by total strangers. Some will ask me in the comments. Since I have absolutely no way of delving into the complexities of their medical history, order or review diagnostic tests, or examine someone over the Internet, this is something that I could never do. Not only would rendering an official second opinion be against WebMD policy, it doesn’t make medical sense to blindly go where no clinician should ever go.  I do not blame people for asking. They are doing their homework and that is good.

Some people go 180 degrees and seek non-traditional, alternative care. Maybe a chiropractor can cure my chronic sinusitis or adjust my deviated septum? Maybe I should take vitamins and other supplements? Should I try homeopathic remedies? Home remedies? Acupuncture?  Massage?  Faith healing?  There has got to be something else other than surgery!

Patients may seek second opinions hoping to confirm the diagnosis or treatment plan of the first clinician. Two of the same opinions tend to tilt a skeptical scale. As long as the second opinion is not a friend or colleague of the first clinician, a validation of the first opinion may be unbiased and true.  If you are seeking a second opinion from a clinician who absolutely hates the first clinician, you may end up getting a biased, opposing opinion.  Now, you have a quandary: two different opinions. Do you get a third, a tie-breaker?

Doctors are like cooks. They all cook a little differently. One surgeon may love to head to the operating room, while another may be more conservative and only recommend surgery for the worst cases—those that are unlikely to improve without surgery.  Just because Doctor A recommends surgery and Doctor B disagrees does not necessarily mean one was wrong. They are simply offering different opinions. Of course, this does not help a desperate and confused patient one iota.

Not all medical providers are equal. Some will be tenacious and turn over every diagnostic stone until they get a definitive answer and a definitive solution. Some, unfortunately, will simply throw in the towel on the first visit. They may not take the time to explain their rationale to the patient, leaving them even more confused, more frustrated, and, perhaps, even angry that they wasted their time (and money).  People expect and deserve to have a thorough examination and a thorough explanation, but sadly, many leave an appointment unsatisfied.  I have heard (and experienced first-hand) about clinicians that will spend two minutes with a patient, look in the ear for a second, and simply say, “I don’t know. I guess you will have to live with it.”

Personally, I saw one particular urologist two times and was never once examined. I had an ER visit where the ER physician apparently forgot to examine me either. What in the world do they write in their medical records? Do they make things up (it happens), or do they simply not make notes? In both of these personal examples, they didn’t bother to write anything.

Medicine is unbelievably complex, as are the patients we see. Clinicians are merely paid consultants and not your boss. A medical provider who may be highly trained in the technical/surgical skills of medicine may have missed the classes on patient interaction. A patient should not have to choose between an arrogant, impersonal, highly skilled surgeon and the nice guy with borderline skills, but many choose the nice guy. He was good salesman.

Getting differing opinions is always a dilemma. Some insurances will not pay for a third opinion, and even if your insurance does, what if you get yet another differing opinion? My advice is simple: Select one. Select the opinion of the medical provider that took the time and effort to review your medical history, performed the best medical examination, and the one that respectfully responded to your questions.

Second opinions are often needed and they may be confusing. In the end you, the patient, will have to make an important decision. Choose your path wisely.

Want to hear more from Dr. Moser? Join him in our Ear, Nose, and Throat community.

By Rod Moser, PA, PhD

Teenage boys seem to eat non-stop. My grandson was visiting for the weekend and brought a friend. It was all that I could do to keep up with their insatiable appetite. Eventually, they took on the task of rooting around for food. Dylan found a box of macaroni and cheese deep in the catacombs of our pantry. I couldn’t even remember buying it, but he was elated. I gave the okay for them to prepare it. While cleaning up the mess, I noticed that the box expired about seven years ago. Can dry macaroni and cheese powder actually expire? Does it have a shelf life? According to the manufacturer, it did, but the boys experienced no ill effects.

Refrigerators can be havens for expired foods. I particularly watch dates on milk and yogurt. There is nothing like taking a drink of sour milk to ruin your day. There are jars of pickles and other condiments that are several years old. There are no expiration dates on them, so perhaps they preceded the law requiring them? Deep in the freezer, one might find mystery meat with the white appearance of freezer burn, or the Ice Man.

Medicines have expiration dates, but rarely do they deter anyone from taking them. Is this practice harmful? Perhaps, but it depends on the medications. Some will lose potency. Some will be completely ineffective. Some will be just as good as the day they were packaged. My pharmacist friend says that expiration dates are often randomly assigned: for instance, one year after manufacture. I have to admit that I have taken a few of those “expired” medications at times, but as a rule, I throw them out. That date really worries me.

Medical providers tend to have a lot of pharmaceutical samples lying around. Periodically, while digging through a pile of samples, I may discover that most have expired. It is now up to me to safely dispose of them. It is not a good idea to flush them down the toilet where they may end up in the water supply. My home is on a septic system and my water source is a well. I would like to just bag them up and give them to my pharmacist friend to dispose of, or I take them to work where we have a special receptacle for this purpose.

I get a lot of coupons in the mail or on-line for oil changes, pizza, and smog certificates. Most will have expiration dates. It is a guarantee that the coupon will be discovered after the expiration date. Some companies will honor them just to get your business; others will not. Some will even take expired coupons from their competitors, knowing that you may go elsewhere. Places like Jiffy Lube will put a sticker on your window to remind you of the next oil change. Like an expiration date, one starts to feel guilty when you drive beyond the recommended mileage.

Due dates on bills are a little different. You miss that due date; you are often punished by a hefty late charge. Credit card late charges can be brutal and overly punitive, but of course, they are somewhat justified. I once received a statement after the due date, so I spent hours on the phone complaining.

What about the ultimate expiration date? Life expectancy in the United States and other countries has risen progressively, but no one really knows when that day will come. The Mayans think it will be later this year for all of us. When someone is faced with a terminal illness, everyone wants to know: “How long does he have, Doc?” They hope that it’s not the traditional “six weeks”. What is it about six weeks or six months? People with terminal diseases more than often exceed their estimated expiration date.

I always thought if humans had expiration dates on them, we would be able to plan our lives more efficiently. Life insurance companies bank (literally) on our estimated expiration date and charge accordingly. We carry all kinds of insurance: health, auto, home, liability/malpractice, even pet insurance. We all pray that we will never need it.

Humans do have expiration dates. We will not be here forever. When you live a risky life, you are cheating death every day. If you don’t wear seatbelts, if you smoke, if you drink and drive, if you run with scissors, it will eventually catch up with you. Some people seem to live beyond an unwritten expiration date. They did everything wrong, embraced all the bad habits, yet their DNA allowed them to keep on ticking. Willard Scott often interviews centenarians who attribute their longevity to booze and cigarettes.

Life is also tragic and unpredictable. A guy gives up red meat, stops smoking, drinks moderately, exercises regularly, and visits his medical provider on a regular basis for check-ups. He avoids bottled water and toxic chemicas, takes numerous vitamins and practices relaxation and yoga. He seems to be the epitome of health, an example of perfection for all of us. One day, when he is jogging, he is hit by an overweight drunk driver trying to light a cigarette.

It happens.

My advice to all of you is to live your life each day like it was your expiration date, and then rejoice the next day when you wake up and are blessed with another. We can all choose to live a healthier lifestyle, or just sit back and wait for the Grim Reaper to knock. If you do find an expiration date somewhere on your body as you shower tonight, tear it off. It is safe and desirable to live beyond your expiration date.

By Rod Moser, PA, PhD

Although some medical providers like to consider themselves a different species from the rest of the population, doctors are human. Humans are imperfect; humans make mistakes. Someone once said that “Doctors bury their mistakes.”  This is a bit macabre, but sadly, it is true. Some medical mistakes are fatal. When medical providers make little mistakes, should they acknowledge them promptly and apologize? I think they should. A malpractice attorney may argue that an apology is an admission of guilt; one that cannot be easily defended. In many malpractice cases, all a patient really wants is an apology and some heartfelt compassion. When they don’t get it, they will settle for cash.

Earlier in 2011, I had a particularly large kidney stone wedged in my ureter that required surgery to get out. While I was being prepared for surgery, a nurse following orders was about to inject an antibiotic into my IV line – an antibiotic that has caused a serious, life-threatening reaction in the past, and one that was clearly “flagged” in red on my chart and on my wrist band. Did I get an apology? Nope.

For the third time this year, I had to undergo general anesthesia. My last surgery was to repair my torn rotator cuff in my left shoulder. There were a couple of big mistakes that time around: I was listed as a woman on my identification bracelet (which explains the letter I received about a week prior telling me I was overdue for my pap smear and mammogram), and the surgical tape used to keep my eyes shut during the procedure left me with cuts on both my eyes!

If you’ve ever had a paper cut on your finger, you know those little cuts can be painful. Now, imagine one on both of your eyes. The experience of a deep corneal abrasion is one that you are not likely to forget.

The first thing that should be done in this case is pain control. I needed some topical anesthetic for my eyes. A few drops would give me about fifteen minutes of pain relief until I could get my eyes carefully examined. No dice. The surgery center does not do any eye procedures, so they did not have any topical eye anesthetics or topical antibiotics available. Someone offered to go to the hospital pharmacy and get some sulfa drops. I have not prescribed (or personally used) sulfa eye drops for two decades. Why? They burn! The first time I used them for an eye infection, I immediately stopped using them for patients, especially kids. The anesthesiologist was busy on the next case, so he was not available.

I have to say that the painful eyes took my mind off of my painful, post-surgical shoulder. As soon as I was released, my wife immediately drove me to my optometrist. He is an old patient of mine who I consider a friend. When I called their office, they told me to come right in.

A quick exam revealed the corneal abrasions. The optometrist handed me some sample eye drops to use. I was allergic to the drops that he gave me, but I didn’t say anything. This was a “little mistake” since he did not double-check my chart. I had some drops at home anyway. Under the circumstances, I forgave him. As a matter of fact, I never mentioned it.

Later that evening, the surgeon called to check on me. I mentioned the corneal abrasion and he was very surprised. Apparently this had never happened before. He said that he would talk the anesthesiologist about it. I informed him that I was under care and aware that most of these abrasions heal in a few days. It took about five days before my eyes were pain-free and normal again.

A week later, I was sitting in the orthopedic waiting room waiting for my post-op appointment. I spotted another woman seated nearby sporting the same, identical sling. We introduced ourselves and shared our misery. When I mentioned my corneal abrasion, she informed me that she woke up with the same problem.  As a nurse, she knew it was caused by the taped eyes – eyes that were not patched prior to the taping. I encouraged her to mention it to the orthopedist, but she didn’t. When I had my post-op exam, I commented on the coincidence: two people, same surgery, same anesthesiologist, and same corneal abrasions.

Our medical group routinely sends out evaluation forms so that patients can comment on their experiences. Of course, I told the corneal abrasion story and rated the anesthesiologist poorly. Less than a week later, I received a letter of apology that stated (a) he tried to call me and there wasn’t any answer. I was home during this entire time; (b) this never happened to him before, and (c) I couldn’t have talked to the other patient with an abrasion since I was discharged hours before her procedure was finished. Apparently, he failed to realize that we didn’t meet in the recovery room, but in the waiting room a week later during our post-op visits.

I have been sitting on the letter, debating whether I should just “drop it,” or write back and correct some of his misconceptions about my comments. Did he think I lied about the other patient?  Clearly, I am going to set him straight. He has another letter of apology to write to this nurse.

His letter of apology was appreciated, but I would have rather had a face-to-face or phone dialogue. Had it happened to anyone else, perhaps he would be facing a nuisance, malpractice suit.

I will tell him to (a) be more careful from now on; put a soft eye patch over the closed eyes first and then the tape; (b) call and check on ALL of your patients within 24 hours, and (c) stock the recovery room with an eye tray containing a topical anesthetic and a selection of eye antibiotics.

I cannot believe that I was the first person ever to get a corneal abrasion after general anesthesia, but perhaps I was the first one who was knowledgeable and assertive enough to complain. Mistakes happen, but only a fool would consider this a rare event and not take the appropriate steps to make sure this never happens to anyone…ever again.

I will write a response to his letter today.

Do you have a question for Dr. Moser? Ask away in our Ear, Nose, and Throat community.

By Rod Moser, PA, PhD

The medical term for ear pain is otalgia, appropriately pronounced: Ohhhhhh talgia! Ear pain, regardless of the cause, can be severe and humbling for adults. When an adult gets middle ear pain, they usually want narcotics; the stronger the better. Children are also often the victims of ear pain, mostly from otitis media (a middle ear infection). Ear infections (middle ear infections) are among the most frequently diagnosed infections in the United States and the number one reason why children are given antibiotics. Sadly, ear pain is among the most frequently misdiagnosed conditions in America.

The ear has three main parts: the external ear (the part you can see, including the ear canal leading up to the eardrum), the middle ear (the air-filled space on the other side of the eardrum that is very prone to infections), and the inner ear (a tiny space that cannot be viewed on examination that contains the neurological connections for hearing and controls balance). Inner ear infections rarely cause pain but they do cause dizziness and tinnitus (ringing).

There are many causes of ear pain, and not all causes are due to infection. It seems that as soon as a medical provider hears the word “ear pain” they reach for their prescription pad and write the word ‘amoxicillin’ on it. While amoxicillin is still considered the drug of choice for middle ear infections it will not help an external or inner ear infection.

Ear Pain caused by Cold Temperatures

The external ear has an abundance of sensory nerves. One stimuli that can set them off may be cold temperatures. Don’t tell Grandma, but cold temperatures do not cause colds and do not cause ear infections. If you get ear pain while jogging in the winter, you can fix that by keeping your ears warm and covered. If you get ear pain swimming in cold water, then use protective ear plugs (or move to Hawaii). Surfers often get a condition called exostosis where the ear canal develops a painful lump due to cold water exposure. As a parent, if you put cold eardrops (inappropriately refrigerated) in a child’s ear, it is likely to cause a caloric response. Cold liquids in the ear will cause the eyes to twitch from side to side (nystagmus) and cause profound vertigo. People with vertigo tend to get nauseated and/or vomit.

Ear Pain caused by Q-tips and other instruments

Those touchy sensory nerves can also cause pain when they are scratched or irritated. Ear wax is a normal, protective coating for the external ear canal. It should NOT be removed no matter how yucky it appears. Not only do you risk rupturing the eardrum, you will predispose yourself to a painful infection (otitis externa) when this coating is removed. Otitis externa is exquisitely painful and is relatively easy to self-diagnose. If it hurts to move your pinna/auricle or push firmly on the tragus (the flap of tissue at the ear opening), then otitis externa is the most likely cause. One form of otitis externa is called swimmer’s ear. Frequent water exposure from bathing or showering can be as contributory as swimming. Otitis externa is treated with a prescription antibiotic eardrop, often containing a mild steroid to help with painful swelling. Minor infections may be prevented with a homemade solution of white vinegar diluted in half with water. Remember to instill those drops at body temperature!

Ear pain caused by blunt and barometric trauma

A slap on the side of the head or being hit in the ear by a soccer ball has the potential of rupturing the eardrum. Not only would the victim experience traumatic ear pain, a ruptured ear drum will tend to bleed. Ruptured eardrums should be medically evaluated. Most will heal without medical intervention, but they must be monitored.

Middle ear pressure causes pain. When you change altitude in a plane or even while driving in a car or scuba diving /snorkeling, you can experience sudden ear pain. Sometimes, the pressure variance will result in an eardrum rupture. Minor cases of barotitits (ear pain due to altitude changes) may resolve spontaneously as the Eustachian tubes try to equalize pressure, or may last several days or longer.

Ear pain caused by middle ear infections

Most middle ear infections are preceded by a stuffy cold. Children from six months old to six years, and especially those in group daycare are very prone to middle ear infections, but they can happen at any age. The Standard of Care in the past was to immediately start antibiotics, but study after study has proved this to be an over-treatment. Most middle ear infections – over 90% – will resolve without antibiotics if you give the body’s immune system a few days to work. Parents are often so bothered by the ear pain that they rush to get antibiotics, circumventing the body’s natural response. Treating ear infections too soon may actually make a child more prone to subsequent infections. Deciding not to immediately treat a middle ear infection (with antibiotics) does not mean the pain should be ignored or trivialized. Remember that ear pain can be severe and humbling. It needs to be treated appropriately, from over-the-counter medications to prescription pain meds, depending on the child’s tolerance. Europeans tend to hold the antibiotic for a week, but U.S. medical providers are not following this recommended “wait-and-see” approach. Old habits are hard to break, so parents can play a vital role by not allowing medical providers to do this. It is appropriate to just treat the pain and wait three days or so, unless your child has special medical needs.

I have long recommended that parents learn how to use a home otoscope so they can examine their child’s ears at home. A simple $30 investment can save hundreds of dollars in unnecessary medical costs and unnecessary antibiotics, and help prevent those misdiagnoses. I feel that medical care – ANY medical care – should be highly participatory. Your medical provider should be regarded as a partner in your care, not necessarily the leader.

By Rod Moser, PA, PhD

Someone once told me that the best boss is one that can step on your toes without ruining the shine on your shoes. It is not easy to give constructive feedback…to a child, to your spouse, or to a co-worker. It is, indeed, an art.

My first experience in getting evaluations was at a university where I was a professor. While it is true that you cannot please everyone all of the time, reading your course evaluations at the end of the semester can be eye opening. You think you did a good job, but when you get the student feedback, the amount of negativity is gut-wrenching. Faculty members often share comments. I vividly remembering a very nice female faculty reading: “I felt that [Professor X] made my life a living hell!” Of course, no one reveals their names, so she spent the better part of the next month comparing handwriting to identify the culprit!

All of those comments, positive and negative, go into your reappointment package. If you have too many negatives, the Dean will call you in for a talk.  As much as we hated to admit it, the students’ tuition paid our salaries, and they knew it.

Faculty quickly learned that handing out the evaluations after finals is not a good idea. To students, there is nothing called a “good test.” Exams are a key tool for evaluations, but no matter how much time you spend on writing good questions, a certain percentage of the class is going to call foul. I once taught a review class where I promised to give the answers to three of the questions on the final if students paid attention. At the end, I told them that three answers were: A, C, and None of the Above. I never promised them I would give the corresponding question to those answers, so it sort of explains a lot of complaints that I received that semester.

Large medical groups, like the one that I am in, send out evaluations to nearly all of our patients. This is done through an unbiased third party now. In the past, evaluations were left in exam rooms for patients to complete after their visits. At least one of the doctors in my group admitted to filling out his own evaluations. Obvious, they were exemplary.

The medical group now mails a written evaluation after random office visits, or may actually call patients on the phone.  Then, the several hundred medical providers in our group are ranked by popularity, if you can believe it. One of our providers was gloating about her perfect 100% score, accepting kudos from other providers.  We were puzzled, since she had been on leave for most of the year, so we checked her “n” column – the number of responses that determined her score. The number was two; only two patients responded to the survey and both of them loved her. This gave her a 100% approval and moved her to the top of the popularity list. If only one of the two had complaints, she would have scored 50%; indicating that half of her patients disliked her!

High rankings on these evaluations convert to cash for the medical group, often paid by insurance companies. The medical groups are financially rewarded for their high marks, and in turn may give bonuses to the individual providers. The message is: Be nice for a price.

Personally, I think ALL medical providers should be nice. People (or their insurance companies) are paying big bucks for care. An office visit in the U.S. can cost well over a hundred dollars or more now. Specialty consultations are two to three hundred dollars for the first visit. For that kind of money, medical providers would be remiss not to be nice, but being nice does not always imply a good visit.

Some medical visits can be touchy, so to speak. If I smell cigarette smoke on someone’s clothes and comment about their smoking, it may annoy them. Upset patients give bad evaluations. My wife brought up a teenager’s weight (too much) and it came back to haunt her on the evaluations. The teen’s mother was livid that my wife would address her weight problem, so she complained. My wife ranked lower on the popularity scale as a result and it really hurt her feelings. I seriously doubt she will change her practice style over this one incident, but it makes you feel that not giving a patient what they want is going to be detrimental.

The federal government has been tweaking the medical profession for years, and groups that conduct these evaluations get financial rewards and other acknowledgments, such as being considered “one of the best hospitals in America.” Most patients are not aware that groups that have switched to electronic medical records have done so for the financial incentives offered by our government. Granted, this is an expensive venture, but the medical group does not have to bear the entire cost of the conversion.

A good medical provider “tells it like it is,” but should do so with sensitivity and finesse. If your medical provider hesitates before bringing up a sensitive health issue, try not to be upset. A bad provider may simply ignore them. If you are given an opportunity to give feedback on an evaluation, don’t do so in anger. Think about it first. Medical providers have feelings, too, and they may have just been doing their jobs. If you want to make your doctor’s day, write a nice letter or card for something good they have done for you.

The most important part of health care is the “care” part.  It goes both ways.

By Rod Moser, PA, PhD

Why did Humpty Dumpty have a great fall?  Answer: To make up for his lousy summer.  As I have mentioned many times in the past (Annus Horribilis), I had a lousy 2011 and have been anxious about the turn of the New Year, hoping that 2012 would be a better year for me. Today, I got my regular newsletter from my good friend and former neighbor, Shawn Anderson, a noted author and motivational speaker.  Shawn and I have been sort of motivating each other for years, but I was particularly thrilled by his latest newsletter topic: Five Ways to Guarantee a Crummy 2012. I have taken the liberty of reprinting his tongue- in-cheek topic. It is just too good not to share.

1. Set less-than-spectacular goals.

Set your sights low. Who needs goals…right? Or…here’s an alternative option: Be bold! Create a wish list for what you want different in your life. Albert Einstein shared, “Imagination is everything. It is a preview to life’s coming attractions.” If your imagination is dull for what you want out of life…how can you truly live a life that you’ll love?

2. Be afraid of taking risks.

Want more of the same limited success this year? Then don’t jump. Don’t risk anything. Just keep walking the exact same status quo road. Or…here’s an alternative option:

Jump! Ray Bradbury wrote: “Sometimes you’ve got to jump off cliffs and grow wings on the way down.” Sure there are no guarantees, but if you don’t take risks, how is anything great ever going to happen for you?

3. Watch a lot of TV.

Want to be sure to stay stuck? Flip the TV on! Undoubtedly, there will be a ton of mind-draining shows on that will absolutely allow you to waste your time. Or…here’s an alternative option:

Kick it into gear! Take one baby-step forward on one of your goals every day. Maximize time, and remember that when you put yourself into motion and take action, you initiate the possibility of putting into motion something great.

4. Act like a victim.

It’s gotta be somebody’s fault you aren’t where you want to be…right? Go ahead and blame your boss for not paying you enough. Blame your spouse for you being unmotivated. Blame your parents for how you were raised. Blame the government for not having a program to help you. The reason you are stuck in life must be because of one of them! Or…here’s an alternative option:

Move forward! Quit blaming others for your “bad luck.” Instead, take responsibility and improve your life from the inside out. Start a daily self-improvement program: 1) exercise, 2) read motivational books, and 3) join an empowering organization. We become what we do and what we think.

5. Give up.

You’re too old…too broke….too everything to start over now, so don’t even try. Just quit. And point fingers. And watch TV. Or…here’s an alternative option:

Make your life count. As long as your heart is beating, you can still go for it! You can still make a difference. You can still influence others. You can still create adventure and success for yourself. It is all about choosing to make your life count until the end.

The biggest obstacle in creating more of what we want in 2012 is ourselves.  If we don’t change attitudes, plans or actions…neither will the success we experience change. Hey…if your 2011 was crummy, who wants more of that? Right?

So what do you say? How about raising our glasses to a year of spectacular goal-setting, bold risk-taking…and our best year ever.

Cheers! Shawn Anderson

To these five great suggestions, I would like to add five of my own for my Family Webicine readers:

6.  Ignore your health

Making lifestyle changes is perhaps the most difficult challenge that many of us will undertake. Stop smoking. Lose weight. Start an exercise program. Eat better. I suspect all or some of these were on your list of New Year’s resolutions. If YOU do not take the initiative to make these life-saving and life-extending changes, you should not expect it to happen.

7. Expect to Die

In the end, we will all die, so what’s the point? It has been said that “Good Health is the slowest form of dying.” If you are impatient to see what is on the other side, just keep doing what you are doing. Don’t break those bad habits that are killing you. Life is short, so let’s just keep it that way.

8. Pleasure first.

People smoke because they like it. They don’t stop smoking because they do not want to deprive themselves of pleasure.  People stay fat, and even get fatter, because they do not want to deprive themselves of sweet culinary pleasures of life. If you exercise, it takes time and effort. You sweat. You stink. You hurt. Why do any of these things? They are not pleasurable.

9. Beauty is only skin deep. Ugly goes all the way to the bone.

None of us look the way we did when we were teenagers or in our adult youth. We can chose to age with dignity, or just simply let ourselves go. If you don’t like looking in mirrors, just get rid them.  If you don’t like stepping on a scale, throw it away. Ignorance is bliss. We glance at our naked bodies and jump back with revulsion. We blame our clothes for making us look terrible, but it is what inside that needs to change. A positive attitude must occur before any positive physical changes can occur.

10.  Think only of yourself

The most important person on this planet is you. Everyone else comes last. You have the right to deprive your family of a father (or mother). If you die prematurely, you will not to get to know your grandchildren. So what? Your spouse can just fend for themselves after you are gone. If your health results in disability instead of death, someone else will care for you. You have the right to be grumpy and to make other people dislike you because of you negative attitude. You do not have any friends.

No one really goes through life alone.  We all started with two parents even though many of us grew up with only one (or none). We make friends and we form our own families. Our families are not necessarily blood related. Our families are our friends (and some relatives, of course).  Friends are friends because they care about you. They do not want to be mourners at your funeral, but rather people that you can count on for help while you are alive. Life is rarely easy, and it is not something we can usually do alone. Unless you are a hermit living in a cave, you have friends or relatives out there that care for you, even if you think you do not.

Friends are good medicine, but they do require nurturing. You have to call them; don’t just expect them to call you. You have to tell them how much you appreciate them in your life. You have to ask for help if you need it, or even if you think you don’t.

Life is short and you do have the power to make it shorter and more uncomfortable if you want, but you also have the ability to make then necessary changes.

Be a better YOU in 2012 and your life will improve. I guarantee it.

Have a question for Dr. Moser? Ask it in the comments below, or join the discussion in our Ear, Nose and Throat community.