Who Is Seeing The Whole Picture?

Who is Seeing the Whole Picture?

 

I love this image of a health care provider looking into a patient's problems. I can work with patients for a long time and realize I am only seeing such a small part of who they are and what ails them. Health care providers learn to look through the stuff that separates them from the patient, but only as a patient opens up. I am afraid modern-day medicine is retreating behind a thick wall to some degree. The beautiful art of medicine lies in the decoding process of all the pieces we are given. Recently I have been treating a patient named Stephanie. Because of how serious her injury is, I am really getting to know her due to our frequent visits, email, and phone calls. She has a nerve injury we are trying to sort out. She is getting many opinions on my recommendations. We talk, we e-mail, and we explore. I am so impressed at her strength, but understand her fear. Most health care providers want to see their patients face-to-face for every exchange, but it is not practical. The fragmented images of the patient's problem, are even more fragmented on paper, phone, or Internet, but it is just a new learning curve. I have learned to love the ease of using e-mail. But, since I am from San Francisco, I miss the hugs (probably why I got into medicine in the first place).

           The world is crying out for health care providers to be primary care doctors (where the buck stops!!) Not triage doctors who hear a complaint and just swish you around to various specialists. Every specialty should have super-specialists and general care specialists. I feel I do a decent job as the primary care podiatrist for my patients’ foot and ankle problems. By being the primary foot care specialist, the buck stops with me!! Even though I am sending Stephanie to various specialists, I gladly take full responsibility to help her decide her options, to wade through the complexities. If you have a foot injury, you should have a primary care foot specialist who takes care of you—and that can be a physical therapist, podiatrist, orthopedist, chiropractor, etc., someone who is committed to know what everyone is saying, and to see you through the injury to the end. Someone who will be privileged to see you at a deeper level. I know what you are thinking now, but I can dream can't I.

This was an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

 

Nothing Seems to be Too Wrong Syndrome

 "Nothing Seems to Be Wrong" Syndrome: Confusion created right at the start of treatment.

Many patients come to my office with a difficult problem and a pattern of treatment I would consider sub-par. This sub-par treatment may be performed by top physicians, physical therapists, and others in the health care system, all with good intentions. I am amazed so many times at the previous treatment given, and I think that the providers must have been burnt out when treating the patient. Why were these good clinicians giving patients such inadequate treatment? It took me a while to see a pattern in these patients. I call this syndrome of inadequate care "The Nothing Seems to be Too Wrong" Syndrome (although I still grasp for a better title).

Yesterday I saw Helen for the first time. Helen matches the profile of this syndrome well, and I even told her so. She has had a significant ankle problem for several years, and very inadequate treatment. The injury to her ankle is very disabling, she can not run or jump due to the injury, and she is only 21 years old!! Helen is cheerful, very positive in nature, bubbling in personality, walked into the office without limping, and looking vibrant and healthy by any definition. After examining her ankle, even though it was obvious she needed X-rays and an MRI, I had to force the words that she needed these tests out of my mouth. There is a psychological block to have the patient spend the money, time, effort, etc. to order these tests, since the patient outwardly seems to have nothing wrong (no bone is sticking out the side of the ankle). 

Yes, the patient is too healthy-looking with a persona beaming to have a serious injury. Does that make sense? No!! Anyone can get a serious injury. No health care provider actually wants anyone to have a bad injury, and the reasons at any one moment can be numerous. A bad injury denotes possible diagnostic dilemmas, possible difficulties in treatment reflecting poorly on the provider, possible requirements of effort that a burnt-out doctor, therapist, etc. may not want to expend . . . the list goes on. But, for the average clinician, a serious injury to an otherwise vibrant healthy-looking patient is just too sad on a human level, and so easily dismissed. The hope then shifts to a desire that the patient has something that they will recover from with ease. Should health care providers be allowed to be human in the twenty-first century? I hope so.

What are the components that affect this syndrome? First of all, it is the physical nature of the patient. Secondly, and probably the most important, it is the positive personality of the patient. This positive personality, when the health care provider is collecting initial impressions, may steer the course of treatment away from a potentially negative diagnosis. How is a negative diagnosis avoided? One way is that the proper tests to make that diagnosis are never done. If done, the results of the tests may be minimized. If you match the positive personality of the patient (glass is half-full) with an otherwise positive (glass is half-full) doctor, trouble brews in setting the course correctly in developing a great treatment plan.

What does all this really mean? Patients who feel they may have a serious injury need to push these health care providers along gently (they are not machines). Assume that they are human and actually don’t want to learn any bad news about you. You, on the other hand, want your body to work correctly for many years to come and need their help to make things right again. How are things made right again? First step is always in ordering the right tests, and then moving the treatment through the roadblocks, and over the plateaus. 
Part of this syndrome is then matching the implied need of the patient to the implied need sensed by the doctor of the problem. Trouble happens when the patient and doctor can not agree on the present need of treatment. 
I have found as my long term patients have morphed into friends over the decades, I am very prone to this problem. I am glad I have partners to refer to for second opinions. I see my patients back regularly to check on their progress. I try to push through the psychological road block I put up myself for really not wanting this to be a bad problem. I recognize this in myself. Plus, I love the KISS principle (Keep It Simple Stupid). I must always ask if I am under treating for the patient, for me, or am I appropriately treating the problem. The Art of Medicine can be complex, and just take some extra thought. 

The following was an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist."

When the Pain is Superficial, Think Deep

When the Pain is Superficial, Think Deep

In medical school and residency training we are taught that superficial pain in a muscle/tendon/ligament may be secondary to deeper, more serious problems. The superficial structures may be sore for many reasons, including deep swelling that has surfaced (like after an ankle sprain), or muscle soreness from strain as they compensate to protect the deeper tissues. Hundreds of examples abound, including the diagnosis of Achilles tendinitis, only to later find out that there was a chip fracture in the back of the ankle requiring surgery. The diagnosis of Achilles tendinitis may have been followed with months of physical therapy, casts, orthotics, braces, and medications. A sports medicine practitioner works hard when superficial structures are identified as the cause of pain to at least consider deeper evaluation if the symptoms do not respond. This is where the patient can greatly help their own cause by asking questions about possible deeper structures involved.

Golden Rule of Foot: When the treatment is not progressing, think about deeper structures as the cause of the pain.

Another common scenario (of the reverse) happens all the time, and I will use Judy's story to describe it. In this case, Judy actually developed a superficial tendinitis on the outside of her knee called Ilio-Tibial Band Syndrome. The smart clinician looked deeper with an MRI and found arthritis in the knee. The decision was made, without proof, and not following KISS principles, that the arthritis must be causing the tendinitis, and that the knee required a knee replacement. The patient wisely chose the KISS principle and treated the tendinitis first (on advice from other physicians) to see if the pain would go away, and it did. I have had three major injuries in my life, and all three had a surgical option. Good people recommended good surgeries for me. But I chose to try rehabilitation first, and so far, I am fully functional and have avoided surgery. We owe it to ourselves to try rehabilitation first. In Judy's case, her pain was superficial, and surgery on her deeper arthritis was unnecessary.

The photo above shows the complexity of the knee joint and how soreness in one area may be caused by deeper problems, but perhaps not. So, deep injuries can be mistreated when the care is only directed at the secondary, more superficial soreness. And, superficial injuries with concurrent deeper, non-painful abnormalities can be mistreated when the doctor, therapist, and/or patient mistakenly blames the pain on the wrong structure.

Golden Rule of Foot: Allow time for rehabilitation to succeed or fail, so that you can possibly avoid unnecessary surgery or have the surgery you need with a firm conviction. 

The above has been an excerpt from my book: Secrets to Keep Moving

Philosophy of Treating Athletic Injuries (Part 2)

Philosophy of Treating Athletic Injuries (Part 2)

A patient should have already answered in their mind the following thoughts before coming to the initial visit (these can be sent to them in the initial email or fax of paperwork). These are:

1.     How serious do I think the problem really is?

2.     Do I want only home remedies or can I afford the time and expense of physical therapy done 2 or 3 times a week for 3 or 4 weeks?

3.     Could I totally rest from my sport if advised? Would that devastate me physically, financially, and/or emotionally?

4.     Do I need to know exactly what is wrong on the first visit, or can X-rays, bone scans, MRIs, etc., wait if initial treatment does not work?

5.     Do I want to take the necessary steps to prevent recurrences if lifts, shoe inserts, daily exercises, prolonged therapy is recommended, or do I think of this as a one-time occurrence?

6.     Is the cost of care a big issue? What does my insurance cover? What is my deductible?

Without knowing the answers to these questions, the doctor or therapist may make some wrong decisions with regard to your care.

So, you have an injury and want freedom from it. Some of the basic Golden Rules that everyone must follow are:

1.     No running, dancing, etc., if you cannot walk without pain.

2.     Never exercise with pain; if you have an injury, you cannot do anything that keeps producing the pain cycle.

3.     If there is swelling, you must work on that daily to reduce it as soon as possible with compression, massage, elevation, contrast.

4.     If there is stiffness, full return to activity is restricted until the stiffness is greatly improved.

5.     If the decision to start your activity has been made, and you are experiencing a return in symptoms, you must rest again for minimum of two weeks. You are just not ready.

6.     Alternative activities to cross-train are normally encouraged to maintain cardiovascular fitness.

With some injuries, the sequelae of scar tissue accumulation and muscle weakness, joint instability and stiffness, chronic swelling and nerve hypersensitivities, all can play a role in a slow return to normal activity. Rest alone may not help some injuries, and treatment may be prolonged in addressing these issues. Of course, no athlete wants to deal with that. If there has been permanent damage as a result of the injury, only partial rehabilitation may occur. It is so important to quickly produce a pain-free environment (0-2 pain levels maintained). How to get there normally dictates some of the early treatment.

For most injuries, reversal of the cause is often helpful, and even mandatory. Without finding the cause, the injury may chronically recur over and over. But for many injuries, that can be overdone or misused. For example, flat feet can cause knee pain, or prevent knee pain from getting better. So, should all patients with knee pain and flat feet get corrective inserts? If you realize that most patients with knee pain get better without correcting the flat feet, you can perhaps see that treating flat feet in all cases of knee pain would be improper. The clinician needs to select only those patients that really need a certain treatment. This is not always a simple task to accomplish. Temporary orthotic devices, like Power step or Sole, which can be modified for greater support if needed, have created a wonderful diagnostic test to see which patients may need permanent corrective devices. The patient's response to the insert will help make the decision on custom orthotic devices easier. But, this is just a small example of cause reversal. With every injury, there are a myriad of common causes, and some not-so-common causes, which may need to be treated as treatment goes along.

So the doctor and therapist must have free communication with the patient each step of the way in rehabilitating the injury. The patient must understand the doctor's or therapist's plan of attack, and help advise on the limitations of time, expense, and energy. The patient should be given clear guidelines on the present activity level allowed, the proposed treatment plan, and options for further treatment if needed. With this communication, injuries can become a learning process for the patient, and a guideline for further injury prevention.
The above is from my book: Secrets to Keep Moving. 

Philosophy of Treating Athletic Injuries (Part 1)

Philosophy of Treating Athletic Injuries (Part 1)

The treatment of athletic injuries is based on many principles that must be applied to the individual with his/her injury. Of course, the same principles that are used on athletic injuries can be applied to non-athletic injuries and pain syndromes as well. The experience and knowledge base of the doctor and therapist become very important to the patient. The decisions of diagnosis, cause, when to cast, when to X-ray, when to inject, and when to stop all activity must be carefully thought out. This is why this is not a cookbook lesson plan to be easily followed by any doctor or therapist. Understanding the individuality among athletes is the key to understanding the complexity of treatment of athletic injuries. Each similar injury has a different set of circumstances associated with it. There may be differences in, among other things:

·       severity of injury

·       severity of the cause

·       length of time that the injury has been present

·       amount of residual weakness, swelling, scar tissue accumulation, or stiffness

·       suddenness of the injury

·       individual’s sport

·       individual’s physical, psychological, or emotional need to return to activity

·       previous treatment

·       speed of return to activity

·       pain tolerance

·       multiplicity of the problem(s)

Does this give you a hint of the complexity? The patient is a stranger to the doctor or therapist on the first visit. There is sometimes a limited amount of time to sense the patient’s problem, frustration, cause or causes, and possible treatment plans, etc. Many decisions are then made. The patient’s main goal is to rid himself or herself from the problem as soon as possible, with no recurrence. The health care provider’s main goal is to safely rid the patient of the problem with no recurrence. Should the patient rest a day, two days, two weeks, three months? Should the patient self-treat the problem at home to save expenses, or be seen in therapy daily, weekly? Should an elaborate work-up on the cause be pursued? Should every ache and pain be X-rayed, bone scanned, MRI’d, casted, or injected? Should every possible cause be treated, even if this would entail months of treatment and huge expense to the patient? The purpose of this conversation is to bring the patient closer to the doctor/therapist in making decisions on treatment care. It is a joint venture, and both must know what the other is thinking. This TEAM approach is unique to sports medicine, but slowly spreading to other disciplines as well.

There are a few common athletic injuries where the doctor or therapist must immediately realize that the patient’s problem is very serious. The crack or snap that is heard, the amount of sudden swelling, the severe intense pain, the total inability to walk without pain, the inability to bend a joint without severe pain, the history of years of pain without relief, can all signal the doctor/therapist to regard this injury as special and definitely serious. Complete investigation should be performed in all of these cases. Fortunately, these are the rare injuries. Definitely, five percent or less of all athletic injuries fall into this category. Most of the time, the injury was gradual, with no to minimal swelling, only moderate aches (level 5 pain at most), with no limping when walking, running, skating, dancing, etc. All body parts are freely movable. The symptoms have existed for three months maximum. Should be easy to treat, right? Sometimes that is the case; but there are so many variables that play a role in the difficulty or ease of treatment.

     The doctor or therapist must have basic rules that guide them in their treatment of  injuries or pain syndromes. A starting place for the treatment of most injuries develops from there. For each doctor or therapist, these basic rules are very different. Hence, the reason that some are successful at treating sports injuries, while others are not.

But even the best doctor/therapist cannot put all the pieces together all the time for every patient. And, of course, the patient feels let down, misdiagnosed, ripped off, etc. Can this be prevented? Sometimes it can. If the basic trust in the doctor and therapist is there, the patient will communicate his or her frustrations. This forces the health care provider to re-evaluate the course of action and accept failure, change direction, etc. Usually the doctor/therapist is busy actively treating many patients at any one time, all in different stages of healing, without the ability to individually check on the progress of each patient. The patient must follow up, inform if there is no change for the better, and positively help in the healing. There can be physical reasons a treatment regimen fails.

We must avoid failure from patient frustration and lack of communication and distrust in the doctor/therapist and patient relationship. Fortunately, 90 percent or more of patients get better when communication is free flowing.

Here are some basic principles in the treatment of athletic injuries. The first priority right at the initial visit is to decide on the severity of the problem. The two important categories are major and minor. A major injury needs no guesswork in treatment philosophy. The patient may develop permanent injury if not treated quickly, accurately, and intensely. This is the first type of injury we discussed, when there is the inability to walk, severe and intense pain are present, etc. Diagnosis is important. X-rays are taken, and MRIs or other tests are considered quickly. Physical therapy is initiated. Expense, time, and risk of radiation become minor concerns or no concern of all. These, in a way, are easier to initially treat. Cookbook teaching is present for most. Follow the book and success in treatment is usually obtained. It may take months or even years to rehabilitate, and the patient may never run or ski or dance again, but the doctor is the hero. He/She prevented it from getting worse, taking longer, etc. Hopefully, you are completely cured in the process and can resume all activities.

Fortunately, most athletic injuries do completely recover!!!

And, fortunately, few injuries are considered in this major category.

The patient's outlook on their injury varies according to:

·       outlook on severity: major or minor problem to them

·       expense of possible treatment

·       time and energy of possible treatment

·       speed of recovery desired

Therefore, with 95 percent of all injuries considered minor in consequences, the doctor/therapist must come to grips with the patient's perspective. The doctor or therapist then maps out a plan of attack after the initial evaluation. Always important to have, this plan of attack has different variables. These are:

·       Further diagnostic testing—now, or only if not getting better

·       What type of pain is the primary source at present: mechanically induced, inflammatory, or neuropathic?

·       Initial treatment plan—physical therapy, home exercises, medications, casts, lifts or other shoe inserts, training adjustments (i.e., rest, alternative exercise), taping and other treatment modalities

·       Back-up treatment plan—if patient does not get better, if patient is better but wants faster relief, and if patient wants insurance to prevent re-flares (Golden Rule of Foot: Always Have a Plan B)

Patient Education Advice—the patient needs to know how to prevent recurrence of injuries by knowing the cause of a particular injury (and the causes of most injuries). This is so crucial in preventing the same injury from just coming back. It is one of the key reasons podiatry is so successful with athletics because we can find a cause to reverse. As the doctor or therapist maps out the proposed treatment plan, it is based on what the majority of patients with the same or similar problem became better with. I try to point out all the possibilities of diagnosis, cause, and treatment, and then allow the patient to decide how much expense, time, and energy he or she wants to build into the rehabilitation plan. Most patients are started on a home exercise program and other self-help ideas. X-rays are not routinely performed, since 90 percent of the time the injury is limited to soft tissue. Casting is done when walking is difficult, but removable casts/boots have revolutionized the process (if you have to get one, look into the Ovation Medical ones). Much less muscle atrophy is seen with removable casts/boots than the traditional permanent casts. Cortisone shots should be limited to only mandatory situations due to their possible weakening effects on the soft tissues. Never have tendons injected with long-acting cortisone since possible ruptures can occur. 

Patients are advised what the next step would be if the injury is not responding to treatment. Sometimes there are so many possibilities of treatment that they all cannot be covered in the initial visit. Surgery rarely is needed for a particular problem, so it is not normally mentioned at the initial visit. The doctor or therapist tries to discuss with the patient:

·       His/Her immediate concerns at the full diagnostic examination (if the diagnosis is still questionable, does the patient want/need X-rays, MRIs, etc.)

·       The patient's ability to begin therapy now, speeding up the process of healing (I can think of very few injuries, primarily neuropathic pain syndromes, which would not be helped by therapy)

·       Their concerns for a rapid (as fast as possible) recovery

For some health care providers, it will seem strange that some patients do not want the "best" fastest care. The problem is that with this "fast" care comes expense, time, and energy. These are commodities some patients—most patients—are short on. Most of the time we settle on slower, but still effective, courses of action.

Problems arise when the doctor treats the patient on a slow course, cutting expenses, when the patient wants to be cured today, or even yesterday. Some patients must face reality. If they want the best, more effective treatment of their problem, they must give the time and energy and expense to accomplish it. Medical care costs are getting out of control, and paying for it more of a burden.

It is important to minimize the amount of patients going elsewhere when their treatment is slow or recurring. Again, communication is the key. The doctor or therapist must respect the patient as a person, and the patient must view the doctor/therapist as someone truly concerned. Sometimes, there are no good answers to a problem. I try to limit those to a small percentage. I find that if I can communicate with a patient, treatment goes well. If the patient never trusts me, communication will not go well, and the treatment will be shaky, with constant problems. Broken trust between doctor/therapist and patient is rarely fixable.

To be continued (this was an excerpt from my book "Secrets to Keep Moving").