how to communicate clearly with an MD?

I almost feel bad for Doctors, with the way our health care system is headed...

_almost_

 

I'm sorry for him. That's a pain. I myself have a herniated disc that causes me sciatic pain, and I've done the nerve block, the cortisone, had a surgeon tell me my only option was surgery (I've already had spine surgery once and will gladly avoid it if at all possible).

One fun/similar experience I had was with a specialist who treated me a few times in trying to find the best solution for my chronic pain... After the fourth or fifth visit to this guy, he came in one time holding my charts and said, regarding a CT scan evaluation that he had in his possession since my first visit with him, "Oh, it looks like you have a herniated disc at L-3/L-4... That changes things a little..." I had told him that exact information the first time I saw him, had previous MRI results sent before I visited, and he still ordered a CT scan and was surprised by this result... I didn't see him again.

On the bright side, I've found that the most effective way for me to deal with the condition is to exercise regularly, stretch using some stretches shown to me by my physical therapist, keep my weight down, but trunk muscle-mass up because trunk stability is really key in holding all your bits and pieces in place.

My condition was not the result of an injury, and I'm sure everyone's experience is a little different, but it's a slow semi-recovery(over a year for me) , and then a life-long maintenance schedule.

 

I actually have no clue myself yet (not enough experience)... but whatever suggestions that you guys come up with, I will keep in mind.

Desynch
I think you're wrong about feeling sorry for us docs. I love what I'm doing and would be very happy being paid 100K - with all the stress and everything going with it. Clearly, some fields in medicine NEED cuts... it's ridiculous how much some doctors are paid relative to the work others are paid. What I'm talking about is how pathetically primary care is paid in relation to specialty fields. If things go ok with healthcare changes (socialized medicine), patients will benefit. We have frakking private companies and the government nosing in our business... and I'd much prefer the self-regulated government to whackjobs just sucking up extra cash as the middlemen. Hopefully if medicine goes socialized, primary care docs won't be affected as much as specialty fields - and I will admit they make way too much money for what they do... while primary care, in general, work much harder.

(And for the first nutcase to say - well you're just jealous because ur not in that field - guess what? I'm near the top of my class.. I can get into most residencies in the nation)

 

<div class='quotetop'>QUOTE(galaxee @ Feb 28 2007, 04:52 PM) [snapback]398052[/snapback]</div>

Galaxee--
Don't shortchange yourself--these problems are not in themselves that complicated (though the solutions may be). Any good doctor should be able to explain the options in a clear and simple manner and follow thru with the treatment you've decided upon. Don't ever consent to have a procedure done that you haven't agreed to and that doesn't make any sense to you. OK, so I'm an MD (plastic and reconstructive surgery) and I deal with issues like this all the time. Your orthopedist should have gotten on the phone with you (not just the readiology fellow) and explained what was going on. Don't accept anything but full and complete communication.

As to the insurance and money situation--the only way to deal with them is by being as persistent and annoying as possible, unfortunately. Harrassment is the only thing that works. If you want specific advice I would be happy to help--PM me. And if you finally end up with a big bill with the hospital, these are always negotiable. So many bills are left unpaid that the hospitals will always settle for less if you'll pay right away.

 

<div class='quotetop'>QUOTE(Mirza @ Feb 28 2007, 06:45 PM) [snapback]398072[/snapback]</div>

If I had to deal with sick people everyday, coughing and sneezing and bleeding on me.. I don't think I'd last very long. My mother has been a teacher for many years and she is always coming down with something from the children.

I also don't like how those "Doctor Mills" are run.. You know, the health care clinics that cycle patients AND doctors in and out. Most insurance now-a-days, the insurance provided by your employer, are those ridiculous HMO's that pretty much force us to go to those "clinics".

When I was growing up I remember real doctors offices.. I had one doctor all throughout my childhood and teen years. It was his private practice.. He actually would remember who I was and why or when the last time he saw me! At these clinics, these doctors have no idea who I am, and they couldn't care less as to what my problem was - they just want to get me in and out so they can do the same thing to the next person.

I'm sure as a Doctor that has to be frustrating.

100,000K isn't enough for me to do that. I'm working my way up there and I sit behind my desk, lay low and chill.

 

If I had no insurrance and were paying for all this out of pocket I would have said NO and walked out.

Or I would have demanded to talk to MD on the phone.

They already did this and it didn't work.

They didn't do the procedure you went in for. They repeated a procedure you know didn't work.

This is a waste of your time and money.

I would have walked out.

I also would refuse to pay for this repeat procedure. May I assume the results were the same? Namely no improvement whatsoever?

I'd ream referring MD new one. Then I'd ream Hospital new one. Then I'd ream billing department new one. Then I'd repeat as necessary until pain subsides.

(After seeing a Chiropractor for piriformis syndrome {I'm *too* flexible} she recommended my primary care physician send me to get an MRI. He did. Turns out I have two herniated discs, L3-4 and L4-5. She addressed this at the subsequent Chiropractic visits. I've gone from 1 a week to 1 a month and am very much pain free compared to the constant pain in the a$$ {piriformis} and numbness in leg from physical therapists WRONG exercises. Cortisone shots in my piriformis did no good at all. I know you had bad experiences with chiropractor, but it couldn't cost more or be less effective than what you're going through now. Find a really good one and try it for three months.)

 

<div class='quotetop'>QUOTE(galaxee @ Feb 28 2007, 01:52 PM) [snapback]398052[/snapback]</div>

I have nothing useful to offer on this subject, but I just wanted to chime in and wish you both the best of luck in finding competent medical care and getting your DH cured of this frustrating condition.

 

I agree with daniel.

I do however have a family friend in Garner, NC that is an MD. If you would like, I can give you his name. PM me if you're interested. I know talking to another MD isn't what you had in mind, but it's what I can do from up here.

 

Another procedure I had done, in the interest of gorey detail, was similar to the epidural steroid injection in terms of how it was done: It was fluoroscopy-guided, but rather than injecting anything, the needle was placed near the nerve root, and then sent little pulses of electricity into the nerve. It made my leg seize or hurt or burn in various locations as the needle was moved around. When the doctor found a needle placement that excited the nerves connected to the part of my leg that hurt the most, the needle heated up, and sent out pulsed radio waves in order to nuke the nerve.

The doctor explained that pain nerves are smaller than motor control nerves, so I'd suffer no loss of motor function, but the pain would be reduced since the nerves were basically burned away.

This might be the "permanent" nerve block your doctor mentioned... there was a fancy name for the procedure that I don't remember, but my doctor did say those nerves would eventually grow back.

It did reduce my pain somewhat, but ultimately in my case the right exercises are what help me manage the pain.

I also heard a radio report this morning on a meditative practice that's being taught by some doctors in order to help manage pain. That's an area that's worth looking into. When I was in constant pain it tainted my entire outlook on life, and I was not fun to be around a lot of the time. So even if the pain can't be completely removed, there are ways to make life livable in spite of it. Best of luck to both of you.

 

He's in general practice, but he should still be able to at least come up with some additional names/options.

 

Who does a biopsy without local anesthetic? :blink:

Galaxee -- dang, I typed a book. Sorry to ramble on, but hopefully something here is useful to you.

You did the best you could. Remember that your DH was the one who chose to go through the procedure, despite your advice. You did the best you could, but you weren't the patient and the choice wasn't entirely yours.

Again, as has been said... I sympathize. I haven't gone through the kind of pain your DH is having, but I have seen and helped people try to deal with it. Please PM me if I can translate for you or help in any reasonable way, as I'd be very glad to.

Evan's right, in that MRI shows discs better (they are made of water mostly, and MRI shows watery structures best, and CT shows bone and spatial relationships best). That said, remember -- probably 80% of the time, in chronic noncancer pain, the MRI, CT, x-ray, and everything else look OK, but the pain is nonetheless there. Sometimes a person's pain corresponds to a particular damaged territory of nerve root, disc or facet joint, but often it doesn't, and there's no specific point to treat.

For me, one of the hardest parts of treating chronic pain in young people especially is resisting the pull from patients and families to pursue "doing everything," in that often there are options available that are likely not to be helpful. (And therefore possibly hurtful, certainly expensive, hope-destroying, and so on..) "Primum non nocere" means to help a patient avoid taking treatments that have no reasonable hope of benefit, too..

I agree with what Godiva says about the bill, except the part about "reaming." Be persistent, yes.. Oh, yes! But be polite and professional to a "T." No nastiness. Just firm, professional, and implacable. Being nasty will backfire, on levels you will either see or not see.

A side note, but relevant: I was listening to a CME audio about health literacy given by a great doc, Barry Weiss, who used to teach me when I was a resident. Barry talked about the overall literacy rates in America (which are astonishing to hear about!) and then about the specific problem of being able to assimilate and use health-related information, whatever one's literacy skills. Even very technically able readers and consumers of information (like you, or me) have variable ability to handle what is basically a second language.

The upshot of the CME was to remind people like me to AVOID MEDICAL JARGON and (to borrow from a FHOP thread) SPEAK ENGLISH to our patients. I pride myself on being a slow, patient communicator in my work, and being a pretty good listener... but there are times when I see myself leave my patients in the dust. Even worse, there are times when it happens and I don't see it.

It is incredibly, incredibly telling to me that I often have patients come to see me simply to spend a visit having me explain (from reading the specialist's notes) what a specialist actually said and to review the available choices! This is not meant as a knock at specialists, but it just underscores how often we don't successfully communicate to our patients. A lot of what a good primary care doctor does, and should do without complaint, is to be a guide. Not only what is the treatment, but is it a good idea, what can one expect from it, and what is the "big picture."


So... don't feel bad at yourself. But do formally, politely, and articulately complain. To the orthopedist and the hospital. Request a clarification of the error that was made. Any reasonable physician will admit when an error was made (not that we are all reasonable!) and will go farther than you might expect to try to make it right. These are your rights!

Terms:

The most common diagnostic procedures involving injections into the back, to sort out back pain, are epidural steroid injections (which are what your DH originally had, as I'm understanding this -- it's often abbreviated "ESI") -- and facet injections (injections into the nerves that go into the joints lining each side of the back) -- and level-specific nerve blocks.

There are also discograms -- which involve injecting straight into a disc to see if it manifests and worsens the pain a patient is having. If successful, a discogram that provokes symptoms identiical to a patient's complaint will be followed by "electrodessication" of the disc (frying it with a wire). This is a controversial and largely unproven technique.

There is also rhizotomy, which is frying nerves that go to facet joints. It, also, is largely unproven. (by good RCTs with a sufficient "n".)

- Seth

(PM me anytime if I can help you!)



<div class='quotetop'>QUOTE(galaxee @ Mar 25 2007, 10:55 PM) [snapback]412164[/snapback]</div>

(PS: No, you aren't asking too much... there's no reason you should have to go to the office for this kind of request...)

 

Something concise about how I think one sets the stage for success in a visit wth a doctor, of any speciality:

1. Make a list of specific questions for the visit. Bring it (along with everything you take, in their bottles, prescribed or over the counter) to the visit.

2. If your list is a long and complex one, revise it to the few things that matter most, so that you get real time for a real answer during that visit to the questions that matter most to you. If you ask your doctor to go over ten complicated issues, he will either treat each shallowly, or else will run an hour and a half behind -- and then you'll realize why you waited an hour and a half to be seen, and why you're already an hour late to get back to your job.

Example (fictional): I have had bad low back pain for a year, and have tried lots of treatment for it. I'm living with that pretty well, though, for now. I also have daily migraine headaches, I'm depressed, and there's a mole on my back that my wife is nagging me to show to the doctor. I decide that if my headaches would improve, that would be the priority. I'll spend the visit talking with my doc about that, and probably look at the mole since that just takes a second, and if she's worried about the mole she'll have me come back for a biopsy appointment anyhow. Next visit I'll probably tackle another one or two things on the list.

3. Don't pretend to understand anything you don't. Insist, politely, that your doctor make sense, and speak English without using medical jargon! Paraphrasing works well both ways here... you repeat back what your understanding of the problem and plan is, and then the doctor will know, for sure, whether you're on the same page or not.

4. It's often helpful to have a good friend with you at appointments that are complex (whatever complex may mean to you), so that you get someone else's take on the communcation.

5. If your doctor doesn't listen to you, and doesn't speak plain and understandable English.. or doesn't care enough to work harder at these things after you express concern about them ... Get another doctor!

 

Galaxee, my sympathies to you and your DH. I'm going through a similar issue now with herniations at L4-L5 and L5-S1, and foot drop in my right foot. The first MRI didn't show enough nerve compression to cause the foot drop, according to the neurologist, so I went to see the ortho department at UCLA (on the recommendation of a friend who had her surgery done by the head of the department there). He's on my insurance, so it works the same as my local doctor. You might check to see if the head of the ortho department at your nearest university is well regarded, and if he is on the insurance. Often they are, and you get the benefit of seeing one of the highest regarded physicians in the state just the same as the specialist in your area.

He recommended a "sitting MRI", since sitting seems to generate the back pain and aggravate the foot drop. Evidently, sometimes the disk protrusion into the nerve space is greater if you are not flat on your back. I had never heard that before. I'm hoping to get the results of that this week.

One of the best back pain forums I've found is at the Healthboards, at http://www.healthboards.com/boards/forumdisplay.php?f=18 But be warned, there are hundreds of opinions there from people who have been through it all, including some cases that truly look hopeless. You can get some clarity from people who have been through the maze, and some pretty good descriptions of the different procedures.

Before the foot drop, I actually got a lot of pain relief from a hokey program put out by a massage therapist and physical therapy aide called "Lose the Back Pain". They basically have the theory that most back pain is caused by "muscle imbalances" and they sell a workbook and program to identify which muscles are weak, and which are strong, and then provide some exercises to counteract the weaknesses. The idea is that muscles pull on the spine, moving it out of position, and by strengthening the counter-acting muscles, you get the spine straight again (as an analogy, think of the lines on a tent, as you tighten one side, the tent leans, but is finally OK when all the lines are in balance and the tent is standing tall). Hokey, and kind of like snake oil, I thought, but I spent the $99 and took the program to my doctor first. I had spent more than that on back pillows trying the make the Prius comfortable. He looked at the exercises and said "OK, you can do all of these, but don't do this one ..." which was an arching-back kind of exercise. I got rid of most of the back pain within about two weeks using their exercises, and at first, I thought it was a little silly. They are really mild exercises. But it did work for easing the pain. They are at http://www.losethebackpain.com/