Lessons from the Donkey On Dealing with Difficult Patients

Lessons from the Donkey On Dealing with Difficult Patients

Dr. Neil Baum

Professor of Clinical Urology

Tulane Medical School

As a young doctor I tried very hard to please all of my patients.  I never wanted any patients to have a bad experience or to leave with negative feelings about myself or my practice.  As I matured as a doctor and saw that I was unable to make everyone happy, I learned better how to manage the difficult patient.

I would like to relate perhaps a fairy tale and how the message applies to healthcare.

An old man and his grandson were traveling with their donkey on their way to the market.  At the start of the journey, the old man sat on the donkey while his grandson walked and guided the trip.  A passerby saw the scene and said to the old man on the donkey, “You are a strong man; how can you let the little boy walk?”  The old man nodded in agreement and got off the donkey and the young boy climbed on top.  Another bystander saw the situation and said to the old man, “You are an old man and your donkey is very strong so both of you should get on the donkey and ride into town.”  And so they changed again and both the old man and the grandson mounted the donkey. Again, they passed another stranger offering advice who said, “Why don’t you both walk and give the donkey a chance to rest?”  As soon as they dismounted from the donkey, the donkey ran away!

The moral of the story is if you try to please everybody, you will lose your ass!*

This story leads me to a discussion on discharging patients that you don’t want to provide medical care. I have been in practice over 40 years and I can count on two hands the number of patients that I had to terminate from my practice.  Dismissing a patient can be a sticky wicket but there is a process involved, besides denying care, that must be followed when terminating a patient.

The discharge process must be conducted in writing and I suggest the letter be sent as a certified letter with a return receipt confirming that the patient did, indeed, receive the termination letter.  The letter does not need to provide a reason for the termination.  My letter merely states that “I feel that in the best interest of your medical care that you find another physician who can provide you with the medical attention that you require.”   The termination letter must give the date that the termination will take place, which is usually 30 days, and an offer to provide a copy of the patients’ records to either the patient or to the physician who will be assuming their care. I think it is important to offer to provide emergency care onlybetween the date the letter is sent and the date that termination will take place.  It is important to notify your staff and your colleagues in the practice that no appointment should be made for the patient and prescriptions that have been previously written will be refilled if appropriate to do so.

Finally, if the patient has a referring doctor in the community or other physicians involved in their care, I will often call the referring doctor and let them know about the termination. I want the referring doctor to hear about the termination from me and not the patient.

Bottom Line:  Terminating a patient is never a pleasant task, but on occasion discharging a patient must be done for the health and welfare of the patient, the staff, and, yes, even the doctor.  So remember the lesson from the donkey: try as hard as you might you can’t make all your patients happy and discharging an occasional patient may just prevent you from losing your “arse”!  If you have any stories, experience, or advice on terminating a patient, please let me hear from you.

*As told to me by Dr. Kendra Reed, Professor of Business at Loyola University

Why We Become Doctors-It’s Not the Money!

Dr. Neil Baum

Professor of Clinical Urology

Tulane Medical School

I know you’ve heard it many times before, doctors are rich and that’s why they have become doctors.  Dr. Kevin Pezzi has elegantly and graphically demonstrated that we don’t primarily become physicians because of the monetary reward.

There are jobs that are currently available that provide as much or even more income than that achieved by physicians with far fewer years spent in school and training required to become a physician. Who would think that a UPS driver right out of high school could earn more than a doctor?

The January 26, 2004 edition of U.S. News & World Report said that UPS drivers earn $60,000 per year. The average physician income is usually quoted as being $160,000 to $200,000 per year so it may seem preposterous to claim that UPS drivers can earn more than doctors. Just wait.

A UPS driver can go to work immediately after high school with no additional education required. In contrast, a would-be doctor requires 8-12 years of education for which he is paid nothing but actually incurs ~$300,000 in debt and loans after post-graduate training to pay back with interest over 20-30 years after entering practice.  As a result, UPS drivers are being paid while those who aspire to become doctors are spending thousands of dollars for the privilege of pursuing their dream.

Let’s analyze how this affects a physician’s net income. Most physicians will not appreciate any appreciable income until at least 8 years after graduating from high school.  Let’s look at total net income for physicians at year 8 (red arrow), once they graduate from medical school with an average debt of around $100,000.

It takes approximately 18 years (blue arrow) for a doctor to earn the same amount as a UPS driver working full-time.

Now check out the green arrow which shows that it takes about 27 years for a doctor to approximately equal the lifetime earnings of a UPS driver if the UPS driver worked the same 70+ hours a week which is the time most physicians work\week and the UPS driver received time and half for all hours worked after 40 hours.

In addition, to a respectable salary for the UPS driver, I am sure he never was called during the middle of the night because a package wasn’t delivered on time, nor did he\she have to go to the truck dispatch location to repair a malfunctioning vehicle. Requests and interruptions are part and parcel what every physician is confronted on a regular basis.

UPS drivers don’t have to go home after work and read journals or prepare for recertification exams every few years.  This time is necessary for every physician to stay current with all the progress and changes that are taking place in medicine.  All of this after-work hours is uncompensated time resulting in 60-80 hours of time dedicated to the practice of medicine.

Therefore, let no one tell us that we became doctors to earn lots of money.  Most of us became doctors in order to help others.  Unfortunately, an abundance of paperwork, adapting to new technologies such as EMRs, the risk of litigation, and a sacrifice of time with family and friends have tarnished the attraction of a medical career.  (Yet, there are a record number of applicants to American medical schools each year) I think if we just drop back and take a look at what we do on a daily basis and enjoy the gratitude and appreciation of most of our patients, we will be delighted and perhaps content with our decision to pursue a healthcare career.

Putting the “Care” Back in Healthcare by Showing That We Care-Advocating For Your Patients

Putting the “Care” Back in Healthcare by Showing That We Care-Advocating For Your Patients

Dr. Neil Baum

Professor of Clinical Urology at Tulane Medical School

There are so many occasions where an insurance company places the doctor in the middle of a coverage issue between the patient and the insurance company.  We all know that the insurance company and their medical directors are motivated to keep down costs and often deny coverage for medications, services, treatments, or durable medical equipment (DME) that are in the “gray zone”.

I would like to share one of my successful experiences as serving as an advocate for my patient. Shelly, that’s her real name and her name is used with her permission, was a quadriplegic patient from birth secondary to cerebral palsy.  She did not have use of her voice and could only make unintelligible sounds that were understood only by her parents and close friends.  She wanted to attend public high school but was not able to communicate with the teacher or her classmates.  With public funds she received a voice synthesizer (VS).  This is a computer program that is controlled by the patient’s mouth and allows him\her to select words that become audible and even digitalized so they can be used for homework and other assignments. Shelly received the voice synthesizer and learned to use it very well and was able to graduate with honors with her class.  Shelly’s parents requested that she be allowed to keep the VS program upon graduation so she might attend college.  The school board met and denied the request by using the comparison that the VS was kind of like a football helmet used by a player while he was on the team and that it was on loan and couldn’t be given to players upon graduation. The VS was not going to be useful to any other student and would remain in the school’s closet, gather dust, and eventually be thrown out.  The school would not make an exception and grant her the use of the VS upon graduation.

I suggested that her family request a VS device, which cost about $10,000, from the insurance company. The medical director quickly denied the request.  I contacted the medical director in order to obtain an explanation.  The medical director told me that this was a “creature comfort” and that the insurance company would not pay for the VS.  I wrote a letter on behalf of the Shelly to the medical director with a copy to Shelly’s father’s employer, UPS, requesting an appeal.  I was not able to attend the hearing in person but was there on a conference call along with Shelly’s parents.  The explanation that was given was that Shelly was born without a voice and, therefore, it wasn’t the insurance company’s responsibility to provide her with a voice that she didn’t have at birth.  They concluded that replacing her voice was not in the contract.  They offered up the comparison that if Shelly was born without a leg, they wouldn’t be required to provide her with a prosthesis. However, if she lost the leg after birth, then a prosthesis would be provided.

This response infuriated both the parents and myself.  Her father was fearful about causing a problem with the employer and was hesitant to pursue the matter any further and was considering taking out a bank loan to buy Shelly a VS so she might attend college.  With the permission of the family, I told them I would be their advocate and make an effort to help Shelly get her voice back.

I first wrote a letter explaining the situation to the insurance commissioner of the state where Shelly lived.  I sent a copy to the employer and to the medical director.  I received a meek response but without any offer to help the young girl get her voice.  I then wrote a letter to the family’s U.S. Congressman and their state’s U.S. Senators asking for their intervention.  I then wrote a letter to 60-Minutes telling them the story and offering to have Shelly and her family tell the story and give the name of the insurance company and the employer on national T.V.  Again, a copy of this letter to 60-Minutes was sent to the medical director and the employer.  One of the U.S. Senator’s sent a letter to the insurance commissioner of the state and to the medical director indicating that the U.S. Senator wanted a better explanation of the denial of the request for the VS.  Within one week of the U.S. Senator receiving a letter, I received a copy of a letter from the medical director that was sent to the family indicating authorization for the VS!

Shelly soon received a brand new VS.  Shelly went to college and is an author and working on a book about living with cerebral palsy and which includes a whole chapter on how she got her voice back.

That success of advocating for my patient was one of the highlights of my medical career.  There are so many instances when we receive a rejection from an insurance carrier who is motivated to keep down costs and denies an appropriate treatment or a device that restores people to good health, keeps them out of the hospital and doctors’ offices, and even gives them their voice back.

Certainly, I am unable to do this for every patient but I can find the most egregious rejections and serve as an advocate for my patients.  I can share with you that there is nothing in medicine that will give you more pleasure and satisfaction than standing up for your patient when you know you are right and your patient is made to suffer because the insurance company is focused on their bottom line and not on the patient’s healthcare and well-being.

I would like to hear from you if you have a patient advocate story.  (doctorwhiz@gmail.com) Perhaps we can write a book, Chicken Soup For The Patient’s Soul….and Voice!

The Latest Advice on Screening for Prostate Cancer

New Tests For Detecting Prostate Cancer

The concept of screening for prostate cancer is a moving target.  Screening for this common cancer in men has undergone significant changes in the past ten years.  This blog is intended to provide you with advice on whether you should participate in prostate cancer screening.

Another progress being made is that men with early-stage tumors have been spared the side effects of treatment, such as erectile dysfunction (impotence) and urinary incontinence, which can be devastating.  A recent report notes that 15 years after diagnosis, that 87% of men who underwent surgery and 94% of men who had radiotherapy were unable to engage in sexual intimacy.

So what do you need to know about prostate cancer screening?

Talk to your doctor about obtaining a PSA tests if you are at high risk for prostate cancer.  These include African American men who are twice as likely to be diagnosed with prostate cancer and have an aggressive form of the disease and 2.4 times more likely to die from it than Caucasian men.

Men with a family history of prostate cancer are twice as likely to have prostate cancer and to die from it.

New tests for prostate cancer

We have been looking for a test that will better predict prostate cancer than an elevated PSA level.  There are four new tests to enhance the diagnosis of prostate cancer.

A urine test, PCA3 looks for the presence of a specific prostate cancer gene.  This test is more accurate than the PSA test in deciding whether a man needs a prostate biopsy.

The Prostate Health Index (PHI) blood test evaluates three different components of PSA to determine whether the elevated PSA level is due to infection, benign prostate disease or possibly prostate cancer.

The 4K score blood test is similar to the PHI test but looks at four components which can predict a man’s risk of developing prostate cancer.

Finally, the prostate MRI or magnetic resonance imaging test which can accurately diagnose aggressive prostate cancer.

If any of these four tests are positive, then the next step is a prostate biopsy.

Bottom Line:

I suggest a baseline PSA test for all men at age 50 and for higher risk patients at age 45.  Men with very low PSA levels, less than 0.7ng\ml at baseline can have the PSA test every 5 years, and those 60 and older with levels less than 2.0ng\ml or lower may be able to avoid future PSA testing for the rest of their lives….as long as they remain symptom free.  If you have any questions, check with your doctor.

 

 

To Screen or Not to Screen For Prostate Cancer-That Is the Question.

Helping to answer the questions of screeing for prostate cancer

Prostate cancer is one of the most common cancers to affect men and is the second most common cause of cancer death in men following lung cancer.  There are over 30,000 deaths in the U.S. each year from prostate cancer.

Screening for prostate cancer has been controversial for the past few years.  A U.S. Task Force recommended against screening all men for prostate cancer.  This task force felt that there were too many false positive tests, too many prostate biopsies and too many men receiving treatment such as radiation therapy and surgery which result in complications such as erectile dysfunction\impotence and urinary incontinence.

Now that same Task Force released new recommendations that men aged 55-69 consider screening after a discussion with their doctor about the risks and benefits associated with screening and then the men and their doctors should decide on the best course of action regarding proceeding with a screening PSA test.

It is true that screening offers a small potential benefit of reducing the chance of dying of prostate cancer.

The same Task Force recommends against screening for men 75 years of age and older.  As many of these men will have slow-growing prostate cancer and will not likely succumb to the cancer but likely will die of some other cause.

My advice for men with a family history of prostate cancer, that is a man with close relative such as father, brother, or uncle with prostate cancer strongly consider having a PSA blood test as there is an increased likelihood of prostate cancer and an increased risk of dying from prostate cancer in men with relatives who have the disease.  The same advice also applies to African-American men who also have an increased risk of developing prostate cancer.

Bottom Line:  Not every man needs to be screened for prostate cancer.  However, every man should have a discussion with their doctor and review the benefits vs. the risks of screening and then make the screening decision.

Magnetic Resonance Imaging (MRI) Instead of a Prostate Biopsy

For several decades I have ordered PSA testing as a screening test for prostate cancer, the most common cancer in middle aged men and the second most cause of death, following lung cancer, in men.  The PSA test is now controversial as a result of the U.S. Preventive Services Task Force recommended five years ago that men forgo the test because the blood test led to too many inaccurate prostate biopsies, which in turn resulted in diagnosis  of insignificant prostate cancer or cancers that were so slow growing that no treatment was required and also resulted in many men who received treatment and had side effects and complications that significantly impaired their quality of life.

Now, however, there is true progress in prostate cancer detection, bringing a new era of minimal intervention yet maximum accuracy of diagnosis and treatment. The single most important factor in this change is the addition of multiparametric MRI (mpMRI) before having a prostate biopsy. There is compelling research-based evidence, both in the U.S. and abroad, that mpMRI can help determine if a biopsy is not yet necessary. This means sparing men from conventional TRUS-guided biopsy that has a discouraging track record of inaccuracy. On the other hand, if mpMRI detects a suspicious area, a real-time MRI guided targeted biopsy facilitates pinpoint diagnosis and treatment matching.

According to a newly published article, “Prebiopsy MRI followed by targeted biopsy” appears to have the ability to overcome the limitations of the standard 12-core template [biopsy]. The authors of the review point out that both the American Urological Association and the Society of Abdominal Radiology have confirmed the utilization of MRI prior to biopsy.

I hope you have found this blog helpful.  If you have any questions about managing your elevated PSA, please let me hear from you.

Delayed Ejaculation-The Other Sexual Dysfunction

Unlike premature ejaculation—usually defined as ejaculating 3 minutes or less after penetration—there isn’t a set amount of time that constitutes delayed ejaculation.

Still, you may have it if you can’t orgasm within 20 minutes after penetration.

Statistically, that time frame is far enough away from the average guy’s norm of about 5 minutes.

Sound like you? Here’s everything you need to know about why it may be taking so long to finish in bed, and how to treat the condition.

What Causes Delayed Ejaculation?

Ejaculation is a complicated process that involves your brain, nerves, and muscles in your pelvic region. Your nerves send a signal from your brain to your pelvis muscles telling them to contract and release semen.

But when your nerves aren’t communicating properly—whether from a disease like diabetes or multiple sclerosis, or from aging—that “ejaculate now” message from your brain can get lost in translation.

Some drugs can also delay your ejaculation, especially those that affect your central nervous system.

Selective serotonin reuptake inhibitors (SSRIs) for depression, certain muscle relaxers, and anti-smoking meds may manipulate the neurotransmitters in your brain, which can postpone your ejaculatory response.

Then there are your hormone levels: Guys with low testosterone or low thyroid hormones may be more at risk for delayed ejaculation.

Psychological issues like anxiety, depression, performance anxiety, relationship conflict, or sexual shame, or even the fear of becoming a father can also hinder or delay an ejaculation.

Finally, if these problems pop up only when you’re with your partner, consider the way you masturbate. If you use an atypical technique—like rubbing your penis against a certain object, or sticking it into a vise-like device—your partner’s may not be able to replicate it.

Although endless sex sounds awesome, but many men with delayed ejaculation complain that the sustained effort makes them feel physically exhausted during the act. As a result a lot of men will actually have to stop sex before they orgasm.

Also, delayed ejaculation can be mentally draining. Men can start to feel depressed or anxious that they’re taking too long to finish.

The explanation is that if you stress about how long it’s taking orgasm, your body produces more of the hormone adrenaline and more adrenaline restricts the blood supply to penis resulting in difficulty holding or maintaining an erection thus contributing to a delay in ejaculation.

Treating delayed ejaculation begins with an appointment to see a urologist—preferably one who specializes in sexual medicine. The urologist will most likely order a full workup, including tests for testosterone, thyroid, and blood sugar levels.

At the present time there is no medication to treat delayed ejaculation. However, there are drugs that have been shown in small studies but without FDA approval to treat delayed ejaculation. These include cabergoline or oxytocin, which act on certain chemicals in your brain whose levels have been disrupted.  However, the most successful treatment includes both medical intervention and sexual counseling with a certified sex therapist.

Bottom Line: Delayed ejaculation is a common problem especially in middle aged and older men. Although no medical treatment is available, you can be helped and can solve the problem with a discussion with your doctor and perhaps a referral to a counselor or sex therapist.

Xiaflex for Peyroine’s Disease, Caveat Imperator (or let the buyer beware)

Peyroine’s disease is a common malady of penile curvature that impedes normal sexual intimacy and affects millions of American men. One of the treatment options for Peyroine’s disease is Xiaflex. Xiaflex can cause serious side effects, including penile fracture, which is a medical emergency often requiring surgery to repair the fracture. After treatment with Xiaflex, the erection tissue in the penis may break during an erection. This is called a penile fracture.

After treatment with Xiaflex, blood vessels in your penis may also break, causing blood to collect under the skin which is referred to as a hematoma. This could also require a procedure to drain the blood from under the skin

Other serious injury to your penis may include a popping sound or sensation that may occur with an erection, sudden loss of the ability to maintain an erection, pain in your penis, purple bruising and swelling of your penis or even difficulty urinating or blood in the urine.

I suggest that you call your urologist if you have any of the symptoms of penis fracture or serious injury to the penis.

The manufacturer of Xiaflex recommend that you not have sex or any other sexual activity between the first and second injections of Xiaflex.
The manufactures also recommend that you not have sex or have any other sexual activity for at least 2 weeks after the second injection of a treatment.

Xiaflex is a prescription medicine used to treat adult men with Peyronie’s disease who have a curve in their penis greater than 30 degrees when treatment is started.

Bottom Line: Peyroine’s disease is a plaque formation in the penis that results in bending or curvature of the penis that can impair the ability to engage in sexual intimacy with your partner. One option is Xiaflex injections into the plaque. However, these injections are not without risks ad complications include penile fracture, which is a medical emergency. For more information speak to your doctor.

 

 

Wipe Away Premature Ejaculation

Premature ejaculation (PE) is one of the most common sexual problems affecting men, especially younger men. Nothing is more embarrassing to a man than a problem of rapid ejaculation.  Men are interested in satisfying their partners and when they ejaculate\cum too soon, it is a source of embarrassment and anxiety for every man and a source of frustration and lack of fulfillment for every partner.

Premature ejaculation (PE) is a problem that plagues 36,000,000 men and is defined as ejaculation in less than 5 minutes of penetration. It is important to point out that premature ejaculation depends on the satisfaction of the partners.

The exact cause of PE isn’t clear, but it is felt to be a lack of control of the receptors to the nerves from the spinal nerve to the prostate gland and the seminal vesicles, the two organs behind the prostate gland that store the sperm prior to ejaculation.

A list of treatments that have been shown NOT to be beneficial includes:

1. Long-term psychoanalysis.
2. Getting drunk.
3. Use of one or more condoms.
4. Concentrating on something other than sex while having intercourse. (i.e. Baseball line-ups, or state capitals)
5. Biting one’s cheek.
6. Frequent masturbation.
7. Testosterone injections.
8. Tranquillizers.
9. PD5 inhibitors such as Viagra, Levitra, or Cialis

Now a new treatment option is available containing benzocaine wipes may help men with premature ejaculation.

In one study, men with premature ejaculation (PE)—those who lasted two minutes or less during sex, were unable to delay their orgasm, and were distressed about it—used a benzocaine topical wipe, a local anesthetic, compared to men with PE used wipes without benzocaine before sex.

After two months of using the benzocaine wipes, the men lasted on average of four minutes longer during sexual intimacy

They also reported a greater improvement in distress and control over their ejaculation, as well as greater satisfaction with sex.

The average guy lasts just over 7 minutes during sex, a study in the Journal of Sexual Medicine found. But a man with premature ejaculation? They tend to last about 1.8 minutes on average.

That’s because benzocaine can make sex less pleasant for her—using benzocaine on your penis and then having sex without a condom can numb your partner’s vagina, making sex feel uncomfortable for her.

Bottom Line: Premature ejaculation is one of the most common sexual problems impacting millions of American men. Now there is a topical wipe containing benzocaine which has demonstrated significant improvement in delaying orgasm in men who are suffering from PE.

GERD Medication and Kidney Disease

Millions of Americans take proton pump inhibitors (Prevacid, Prilosec, Nexium, and Protonix) for heartburn or gastroesophageal reflux disease or GERD.  Data show that more than 15 million Americans suffering from heartburn, and acid reflux have prescriptions for PPIs, which bring relief by reducing gastric acid. Many millions more purchase the drugs over-the-counter and take them without being under a doctor’s care.

A recent report in a medical journal has shown that taking popular proton pump inhibitors (PPIs) for heartburn for prolonged periods has been linked to serious kidney problems, including kidney failure resulting in the need for dialysis or kidney transplantation.

Many patients who use PPIs may not be aware of a decline in kidney function as kidney function can deteriorate very slowly without any symptoms or warning of decline in kidney function.

Since many of the PPIs are over the counter and don’t require a doctor’s prescription, patients should tell their doctors if they’re taking PPIs and only use the drugs when necessary.

Bottom Line:  Your doctors should pay attention to your kidney function if you are using PPIs, even when there are no signs of problems.