By Richard P. Holm M.D.
Before my junior year in high school, I returned from a Boy Scout canoeing trip to discover my sister had been killed in a car crash. I will never forget the sadness of the moment when I walked into the house, which was filled with what seemed like half the caring and wonderful town of DeSmet, to find my Mom and Dad there grieving. It was near the end of that summer, but the beginning of a long period of mourning for my family and me.
There were lessons that came to me after my sister’s death. I realized how important support from a community could be. Consolation came from our friends, neighbors, church community, as well as people who we barely knew. It seemed more about their presence, and not their words. I noticed there were people who had trouble themselves dealing with such loss, and they sort of disappeared.
Also I realized that a funeral is not exactly a time of closure for a family, but really just the beginning of a time to accept reality and forge ahead with the difficult changes that life can and does deal out. It took me years to think about my sister and relish in her memory rather than cringe from the pain of the loss. In that sense, I know I will never have closure and that’s good.
Some 14 years after her death, while I was on the faculty of a medical school in Georgia, I found myself having to advise medical students how to talk to patients or family about sad news. I reviewed the medical literature on the subject at the time, and concluded that there is no right way to do it except to be 100% honest, and to say whatever is needed with compassion. Through the years those guidelines have sustained me while I have had the burden of sharing awful news.
Bottom line, it is being there, more than words, that consoles. Never worry about what to say, just show up, be honest, and care.
Showing posts with label medicine. Show all posts
Showing posts with label medicine. Show all posts
Thursday, March 24, 2011
Tuesday, November 24, 2009
Corrosive Stomach Acid
By Shawn Vuong
A wise pharmacology professor once told me, "All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy."
This week Dr. Holm talks about drugs, particularly in the context of heart burn. In our pharmacology class, we are learning about how all types of drugs interact with the body. Prescription drugs, over-the-counter drugs, herbals, and even supplements all effect the body in different ways. The key to prescribing drugs correctly is weighing the risk of toxicity of a drug versus the benefit gained.
Each substance has it's own toxic effect when given at too high of doses. But we must make the dose high enough to see a benefit. In effect, we get a titer-totter like scenario where we are trying to balance the correct dose to see benefit while trying to limit toxic effects (also known as side effects). Some drugs are easy to give, since they have a high benefit but low toxic effects such as statins. Other drugs have medical health professions constantly walking that fine line between lethal effects and benefit to the patient such as chemotherapy agents or anesthetics.
So remember, every substance has toxic effects when given at incorrect doses. Even water can cause lethal effects if you drink too much. So, please work with your doctor to correctly dose your medications, because they can sometimes give you nasty side-effects.
_________________________________________________________________________
By Richard P. Holm MD
It has always amazed me that the stomach can produce large amounts of a very corrosive hydrochloric acid. Of course, we do that in order to breakdown food so our bodies can absorb nutrients.
In response to food stretching the stomach and esophagus, tiny proton-pumps in special cells that line the stomach make acidic stomach juice. The resultant strength of gastric acid during digestions can be not as corrosive as battery acid, but almost.
Fortunately, a special layer of mucus protects the stomach from the acid, and as food moves on into the small intestine, the corrosive juice is neutralized by sodium bicarbonate produced by the pancreas.
When something goes wrong: the stomach-mucus layer fails; the acid rolls up into the unprotected esophagus; or there is not enough sodium bicarbonate to neutralize the acid… then symptoms occur. People can be pretty miserable as digestive juices are eating away at their own tissue, rather than the food they just ate.
Fortunately we have very effective medications to reduce acid production when something goes awry. One group of antacids, which reduce acid quickly are the H2 blockers with ranitidine (Zantac) as an example. Another group, which reduce acid slower but more effectively, are the proton-pump inhibitors, with omeprazole (Prilosec) as an example.
These two types of powerful antacids have been a blessing for many people who truly suffer from excess acid stomach. A major drawback with both types of medicines, however, comes when trying to stop them, which can result in rebound acidity.
A recent study provided two months of omeprazole to people who at start had never been troubled with heartburn. When the medicine was stopped, however, the volunteers had rebound acid symptoms.
People need to be warned when using these stomach acid medicines that short-term use is safe and can be very helpful. However, getting off of them after prolonged use can be a challenge and may require a gradual reduction over two to three months. Certainly some people should never be off of them, but that should be discussed with your doctor.
Take home message: we have good medicines to counter the corrosive battery-like acid made in our stomachs, but they need to be used with caution.
A wise pharmacology professor once told me, "All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy."
This week Dr. Holm talks about drugs, particularly in the context of heart burn. In our pharmacology class, we are learning about how all types of drugs interact with the body. Prescription drugs, over-the-counter drugs, herbals, and even supplements all effect the body in different ways. The key to prescribing drugs correctly is weighing the risk of toxicity of a drug versus the benefit gained.
Each substance has it's own toxic effect when given at too high of doses. But we must make the dose high enough to see a benefit. In effect, we get a titer-totter like scenario where we are trying to balance the correct dose to see benefit while trying to limit toxic effects (also known as side effects). Some drugs are easy to give, since they have a high benefit but low toxic effects such as statins. Other drugs have medical health professions constantly walking that fine line between lethal effects and benefit to the patient such as chemotherapy agents or anesthetics.
So remember, every substance has toxic effects when given at incorrect doses. Even water can cause lethal effects if you drink too much. So, please work with your doctor to correctly dose your medications, because they can sometimes give you nasty side-effects.
_________________________________________________________________________
By Richard P. Holm MD
It has always amazed me that the stomach can produce large amounts of a very corrosive hydrochloric acid. Of course, we do that in order to breakdown food so our bodies can absorb nutrients.
In response to food stretching the stomach and esophagus, tiny proton-pumps in special cells that line the stomach make acidic stomach juice. The resultant strength of gastric acid during digestions can be not as corrosive as battery acid, but almost.
Fortunately, a special layer of mucus protects the stomach from the acid, and as food moves on into the small intestine, the corrosive juice is neutralized by sodium bicarbonate produced by the pancreas.
When something goes wrong: the stomach-mucus layer fails; the acid rolls up into the unprotected esophagus; or there is not enough sodium bicarbonate to neutralize the acid… then symptoms occur. People can be pretty miserable as digestive juices are eating away at their own tissue, rather than the food they just ate.
Fortunately we have very effective medications to reduce acid production when something goes awry. One group of antacids, which reduce acid quickly are the H2 blockers with ranitidine (Zantac) as an example. Another group, which reduce acid slower but more effectively, are the proton-pump inhibitors, with omeprazole (Prilosec) as an example.
These two types of powerful antacids have been a blessing for many people who truly suffer from excess acid stomach. A major drawback with both types of medicines, however, comes when trying to stop them, which can result in rebound acidity.
A recent study provided two months of omeprazole to people who at start had never been troubled with heartburn. When the medicine was stopped, however, the volunteers had rebound acid symptoms.
People need to be warned when using these stomach acid medicines that short-term use is safe and can be very helpful. However, getting off of them after prolonged use can be a challenge and may require a gradual reduction over two to three months. Certainly some people should never be off of them, but that should be discussed with your doctor.
Take home message: we have good medicines to counter the corrosive battery-like acid made in our stomachs, but they need to be used with caution.
Sunday, November 1, 2009
Asthma
By Shawn Vuong
This post from Dr. Holm really hits home with me. In my late elementary school/early middle school years I was plagued with exercise-induced asthma. When I would play in PE class or recess, my chest would just feel like it was tightening up. The wheezing, the tightness, and the shortness of breath is very scary.
My parents took me to a pediatric pulmonologist and I was tested for asthma. Right then, the doctor prescribed me an albuterol inhaler, which became my life line. After that, any physical activity that I did was preceded by a couple puffs from my inhaler. I was too scared to have another asthma episode.
Asthma is not just something that is brought on by exercise, but can be induced by allergies, pollutants, smoking, chronic disease, infections, or even stress. Asthma can be deadly. If you think you have some of the signs or symptoms of asthma I encourage you to see your doctor.
____________________________________________________________________
By Richard P. Holm MD
A few years ago, a 40-something woman was walking across the farm yard when something in the air brought on wheezing, like gangbusters. She turned back to the house for her inhaler, but just couldn't make it, and collapsed in the yard.
While her husband was hurriedly driving her to town, she stopped breathing entirely. Her husband gave her mouth-to-mouth until the ambulance met them.
In the ER, we were able to place the breathing tube down, but her brain had been too long without oxygen. And a few days later, I will never forget how she gently escaped from this earth surrounded by her loving family.
This tragic death taught me how asthma kills. So what can we do to prevent a similar calamity?
First, recognize when you are at risk. Have you experienced an asthma attack that comes on fast and out of the blue?
Next: are you using your rescue-immediate-acting inhaler more often lately? I should add here that albuterol or any of the fast acting adrenaline-like asthma inhalers might cover-up or even cause worsening inflammation in the lungs. They only work for the short run-and increased use of these fast acting rescue meds is a big time danger signal.
Finally: know that when your asthma is accelerating you need to turn off the inflammation and our best tool to do that is a steroid. Not a body building type, but and anti-inflammatory which slowly turns off asthma for the long run.
That's the take home message: although fast acting rescue inhalers are good to have-they forecast danger. The real hero in this disease is the anti-inflammatory steroid inhalers.
So if you or your family member with asthma is using the rescue inhalers more than usual do not dally. You need to be talking to your doctor about anti-inflammatory steroids.
This post from Dr. Holm really hits home with me. In my late elementary school/early middle school years I was plagued with exercise-induced asthma. When I would play in PE class or recess, my chest would just feel like it was tightening up. The wheezing, the tightness, and the shortness of breath is very scary.
My parents took me to a pediatric pulmonologist and I was tested for asthma. Right then, the doctor prescribed me an albuterol inhaler, which became my life line. After that, any physical activity that I did was preceded by a couple puffs from my inhaler. I was too scared to have another asthma episode.
Asthma is not just something that is brought on by exercise, but can be induced by allergies, pollutants, smoking, chronic disease, infections, or even stress. Asthma can be deadly. If you think you have some of the signs or symptoms of asthma I encourage you to see your doctor.
____________________________________________________________________
By Richard P. Holm MD
A few years ago, a 40-something woman was walking across the farm yard when something in the air brought on wheezing, like gangbusters. She turned back to the house for her inhaler, but just couldn't make it, and collapsed in the yard.
While her husband was hurriedly driving her to town, she stopped breathing entirely. Her husband gave her mouth-to-mouth until the ambulance met them.
In the ER, we were able to place the breathing tube down, but her brain had been too long without oxygen. And a few days later, I will never forget how she gently escaped from this earth surrounded by her loving family.
This tragic death taught me how asthma kills. So what can we do to prevent a similar calamity?
First, recognize when you are at risk. Have you experienced an asthma attack that comes on fast and out of the blue?
Next: are you using your rescue-immediate-acting inhaler more often lately? I should add here that albuterol or any of the fast acting adrenaline-like asthma inhalers might cover-up or even cause worsening inflammation in the lungs. They only work for the short run-and increased use of these fast acting rescue meds is a big time danger signal.
Finally: know that when your asthma is accelerating you need to turn off the inflammation and our best tool to do that is a steroid. Not a body building type, but and anti-inflammatory which slowly turns off asthma for the long run.
That's the take home message: although fast acting rescue inhalers are good to have-they forecast danger. The real hero in this disease is the anti-inflammatory steroid inhalers.
So if you or your family member with asthma is using the rescue inhalers more than usual do not dally. You need to be talking to your doctor about anti-inflammatory steroids.
Friday, September 25, 2009
An Old Dog’s Computer Quest
By Shawn Vuong
Technology. I love it.
I am a proud member of the millennial generation (aka Generation Y). While we aren't known for our humility or strong work ethic, we are known for our extreme integration with technology. As time goes on and more of the Generation Y hits the workforce, we will be expecting businesses to be updating to fully integrated all digital business schemes. In medicine this means the adoption of the electronic medical record.
While this seems like a huge step for older physicians still in practice (the baby boomer generation), this is hardly what we (as the Generation Y) envision as our ideal digital medical record. As time goes on, and our generation starts becoming the majority of the medical work force I for see the trend digital medical record becoming much more than some doctors could ever imagine. Fully integrated, international, digitally accessible and protected medical records. If I go to vacation in California and get hurt, I expect the ER doctor to be able to read my full history since my birth on his EMR at his/her hospital. If my child gets a test done at Mayo, I want to see the results online as soon as my physician gets them. We may have a long way to go before we get to this kind of integration. But I believe this is the future of medicine.
________________________________________________________________
Technology. I love it.
I am a proud member of the millennial generation (aka Generation Y). While we aren't known for our humility or strong work ethic, we are known for our extreme integration with technology. As time goes on and more of the Generation Y hits the workforce, we will be expecting businesses to be updating to fully integrated all digital business schemes. In medicine this means the adoption of the electronic medical record.
While this seems like a huge step for older physicians still in practice (the baby boomer generation), this is hardly what we (as the Generation Y) envision as our ideal digital medical record. As time goes on, and our generation starts becoming the majority of the medical work force I for see the trend digital medical record becoming much more than some doctors could ever imagine. Fully integrated, international, digitally accessible and protected medical records. If I go to vacation in California and get hurt, I expect the ER doctor to be able to read my full history since my birth on his EMR at his/her hospital. If my child gets a test done at Mayo, I want to see the results online as soon as my physician gets them. We may have a long way to go before we get to this kind of integration. But I believe this is the future of medicine.
________________________________________________________________
By Richard P. Holm MD
They say you can’t teach an old dog new tricks. Yet today I found myself in front of a Brookings Health System computer with a personal nurse tutor trudging through our new test version of an electronic medical record.
Indeed, for about a year we have been gradually getting used to seeing parts of the hospital record on computer screen. Finally this month we are about to take the leap of dropping our paper orders and progress notes, and going entirely paperless in the hospital.
We have to be prepared so that no patient is harmed by this transformation. That is why the physicians and PA/NPs have spent many meetings this spring developing orders sets, which are pre-defined orders for specific illnesses. That is why we have been having two hours a week of educational meetings all summer long on the topic.
It will be difficult for many of us to make this change, especially since we have been doing things on paper for so many years. At first it will take us all a lot more time. But the whole process is not only taking time, it means our hospital has to make a significant commitment both in personnel and money.
So why would we spend this kind of time and effort? Along with many who are so capably helping us through this, are two RN experts. Today I asked them both just what will result from all this effort, and their answers were straightforward. “It’s all about patient safety and accessing information.” Safety, for example means avoiding dangerous medication allergies and interactions. Access, for example means seeing the patient’s Problem List, prior test results, and medication list whenever needed.
Still, the electronic medical record cannot look into the eyes of a frightened person in pain, listen for a clue to solve a problem, provide for relief of suffering, and then find a way to healing and better health. That’s something this old dog better not forget.
They say you can’t teach an old dog new tricks. Yet today I found myself in front of a Brookings Health System computer with a personal nurse tutor trudging through our new test version of an electronic medical record.
Indeed, for about a year we have been gradually getting used to seeing parts of the hospital record on computer screen. Finally this month we are about to take the leap of dropping our paper orders and progress notes, and going entirely paperless in the hospital.
We have to be prepared so that no patient is harmed by this transformation. That is why the physicians and PA/NPs have spent many meetings this spring developing orders sets, which are pre-defined orders for specific illnesses. That is why we have been having two hours a week of educational meetings all summer long on the topic.
It will be difficult for many of us to make this change, especially since we have been doing things on paper for so many years. At first it will take us all a lot more time. But the whole process is not only taking time, it means our hospital has to make a significant commitment both in personnel and money.
So why would we spend this kind of time and effort? Along with many who are so capably helping us through this, are two RN experts. Today I asked them both just what will result from all this effort, and their answers were straightforward. “It’s all about patient safety and accessing information.” Safety, for example means avoiding dangerous medication allergies and interactions. Access, for example means seeing the patient’s Problem List, prior test results, and medication list whenever needed.
Still, the electronic medical record cannot look into the eyes of a frightened person in pain, listen for a clue to solve a problem, provide for relief of suffering, and then find a way to healing and better health. That’s something this old dog better not forget.
Very-Close-Veins
By Shawn Vuong
Failing leg veins are also known as varicose veins. In this post, Dr. Holm describes how people develop varicose veins, why they are a health risk, and how best to treat them.
Some times conservative treatment can fail, but one should not worry. Many other treatment options exists for varicose veins, although they are usually more invasive and expensive. Some of these options include sclerotherapy, laser surgery, vein stripping, ambulatory phlebectomy, and endoscope vein surgery. If you are having problems with varicose veins, it is best to see your physician to discuss the best treatment option for you.
________________________________________________________________
By Richard P. Holm MD
I’ve heard failing leg veins called everything from “spider veins”, or “a bag of worms,” to “very-close-veins.” Affecting more than fifty percent of people over fifty, these gnarled, distended, varicose veins represent a problem that, generally, only gets worse.
Arteries take blood out away from the heart, like a steel pipeline from a powerful pump station. On the other hand, veins bring blood back like a lazy river that works because of locks or valves located to prevent back flow. But there is nothing lazy about the job of returning all that blood up hill, against gravity, all the way back to the heart.
The trouble with leg veins usually starts during pregnancy, or with a job which requires lots of standing in one spot without walking, or with the increased venous pressure associated with obesity. Of course, some people inherit better veins than others.
When a few valves begin to fail, then veins gradually become distended and dilated, which makes more valves fail, and the problem swells. Common signs of failing veins include edema, redness, rash, fever, pain, and even hard to heal sores. What’s worse, when blood movement slows down, clotting can happen, and when clots spread the result can be life-threatening clots to the lung.
What can we do to prevent varicose veins? Muscles surround most veins within the leg, so when we walk or use our legs, the muscles contract and squeeze, acting like pumps. If the one-way valves are still working, walking and leg movement makes blood flow upward and in this way regular walking or rocking back and forth while we stand helps prevent varicose veins. And don’t forget to put the feet up whenever possible.
The next best solution is to wear compression stockings. Although they can be hard to put on and many people are hesitant to use them, the lower, knee-high stockings are easier to use, do the lion’s share of the job, are relatively cheap, and the results are well worth the effort. Some people absolutely swear by them since they prevent so many problems and feel so good.
There is a lot you can do if you stand to inherit those very-close-veins. Left alone, they only get worse.
Failing leg veins are also known as varicose veins. In this post, Dr. Holm describes how people develop varicose veins, why they are a health risk, and how best to treat them.
Some times conservative treatment can fail, but one should not worry. Many other treatment options exists for varicose veins, although they are usually more invasive and expensive. Some of these options include sclerotherapy, laser surgery, vein stripping, ambulatory phlebectomy, and endoscope vein surgery. If you are having problems with varicose veins, it is best to see your physician to discuss the best treatment option for you.
________________________________________________________________
By Richard P. Holm MD
I’ve heard failing leg veins called everything from “spider veins”, or “a bag of worms,” to “very-close-veins.” Affecting more than fifty percent of people over fifty, these gnarled, distended, varicose veins represent a problem that, generally, only gets worse.
Arteries take blood out away from the heart, like a steel pipeline from a powerful pump station. On the other hand, veins bring blood back like a lazy river that works because of locks or valves located to prevent back flow. But there is nothing lazy about the job of returning all that blood up hill, against gravity, all the way back to the heart.
The trouble with leg veins usually starts during pregnancy, or with a job which requires lots of standing in one spot without walking, or with the increased venous pressure associated with obesity. Of course, some people inherit better veins than others.
When a few valves begin to fail, then veins gradually become distended and dilated, which makes more valves fail, and the problem swells. Common signs of failing veins include edema, redness, rash, fever, pain, and even hard to heal sores. What’s worse, when blood movement slows down, clotting can happen, and when clots spread the result can be life-threatening clots to the lung.
What can we do to prevent varicose veins? Muscles surround most veins within the leg, so when we walk or use our legs, the muscles contract and squeeze, acting like pumps. If the one-way valves are still working, walking and leg movement makes blood flow upward and in this way regular walking or rocking back and forth while we stand helps prevent varicose veins. And don’t forget to put the feet up whenever possible.
The next best solution is to wear compression stockings. Although they can be hard to put on and many people are hesitant to use them, the lower, knee-high stockings are easier to use, do the lion’s share of the job, are relatively cheap, and the results are well worth the effort. Some people absolutely swear by them since they prevent so many problems and feel so good.
There is a lot you can do if you stand to inherit those very-close-veins. Left alone, they only get worse.
Thursday, April 16, 2009
Breast Cancer
By Richard P. Holm MD
I've heard it said that we should all have a close brush with death about once a year, in order to keep our priorities straight.
I spoke to a good friend the other day about her breast cancer experience, and the following story unfolded. During her routine monthly self-breast exam she found a nodule; an abnormal mammogram followed; and then she had a biopsy, which showed cancer cells.
Treatment began with a lumpectomy and then followed six weeks of radiation to the site. Finally gene testing showed how she had a very favorable prognosis and wouldn't require chemotherapy. The expression favorable prognosis is a sweet duet of words, which means that the future looks optimistic, with a very good chance that the cancer won't be back.
Now it's been three years of disease free survival and she tells me the whole experience changed her life dramatically. Considering the possibility of dying and realizing that her life will not go on forever made her live more in the present. She re-thought what was important in her life, and refocused on giving time to her family.
During this difficult time my friend sensed a rising spiritual presence accompanying her, and grew to feel that she was not alone. She told me that this experience would have been ten times harder without a faith in God.
I have observed many people walk this kind of journey through the valley of death. I am a physician, not a religious leader, but I know that people who get through this experience change how they value their family and friends. They seem to listen more, treasure the little things, and savor the tastes and flavors of each day.
Sometimes we don't know what we have until we almost lose it.
I've heard it said that we should all have a close brush with death about once a year, in order to keep our priorities straight.
I spoke to a good friend the other day about her breast cancer experience, and the following story unfolded. During her routine monthly self-breast exam she found a nodule; an abnormal mammogram followed; and then she had a biopsy, which showed cancer cells.
Treatment began with a lumpectomy and then followed six weeks of radiation to the site. Finally gene testing showed how she had a very favorable prognosis and wouldn't require chemotherapy. The expression favorable prognosis is a sweet duet of words, which means that the future looks optimistic, with a very good chance that the cancer won't be back.
Now it's been three years of disease free survival and she tells me the whole experience changed her life dramatically. Considering the possibility of dying and realizing that her life will not go on forever made her live more in the present. She re-thought what was important in her life, and refocused on giving time to her family.
During this difficult time my friend sensed a rising spiritual presence accompanying her, and grew to feel that she was not alone. She told me that this experience would have been ten times harder without a faith in God.
I have observed many people walk this kind of journey through the valley of death. I am a physician, not a religious leader, but I know that people who get through this experience change how they value their family and friends. They seem to listen more, treasure the little things, and savor the tastes and flavors of each day.
Sometimes we don't know what we have until we almost lose it.
Saturday, April 11, 2009
Three Cheers for Government Research
By Richard P. Holm MD
It was 1948, in Framingham, Massachusetts, when more than 5,000 people were first questioned about lifestyle, physically examined and blood tested. It was the beginning of the Framingham Heart Study, a government funded project, which has continued to this day. Every two years these same individuals are very carefully re-studied. In 1971 their children were added to the study, and in 2002 their grandchildren were entered.
Prior to this time little was known about the general causes for heart disease and stroke. In 1948, the rates of these conditions had been increasing steadily since the beginning of the century. How much is related to environmental factors and how much is inherited were the questions? Is it nurture or nature, and what can we do to make things better?
Over the years we have learned a lot from the Framingham data and we continue to discover from this large investigation why people develop heart disease and related conditions.
Now a similar survey called the National Childrens Study (NCS) is about to begin. The scope and diversity of the people in this research program is so much broader than from Framingham, however. It will involve 100,000 children, from representative counties all across the US, including right here in Brookings county. The NCS will follow these children from even before they are conceived until age 21.
It is important to note that, like in Framingham, no special interest group, such as the Pharmaceutical Industry or Medical Testing Industry, financially sponsors the NCS. Our government, specifically the U.S. Department of Health and Human Services along with the U.S. Environmental Protection Agency, is the fiscal supporter for this splendid and colossal effort.
I believe that our government should be much more involved in sponsoring research like the NCS and the Framingham Study; since industry sponsored studies, although important, have an inherent bias.
It is with the gathering of such information that we may finally learn what causes conditions like obesity, asthma, autism; or what influences intellect or mental health. Is it nurture or nature, and what can we do to make things better?
Monday, April 6, 2009
Are Two Heads Better?
By Richard P. Holm MD
Collaboration is a fancy word, which means two heads are better than one. It's the buzzword that always pops up when physicians are talking about Physician Assistants (PAs) and Nurse Practitioners (NPs). I believe that the art of collaboration, or knowing when and who to call for help, is about the most important and difficult challenge any PA, NP, or MD faces everyday.
Take for example the isolated over-busy practitioner who knows a lot about everything, but not enough about the specific problem troubling that individual patient. Hopefully that care provider has enough experience and depth of knowledge to recognize when to ask for help and collaborate with someone who knows more. Two heads can be better than one.
There is another side to that story. Last month Mr. X had a complicated problem and I sent him to the specialist in another community. Before he returned, three other specialists were consulted by the first, each adding another test, and medicine, and expense. I was faxed copies of all these consults, but basically kept out of the loop until the patient returned to my office. Here's a time when the big picture had been lost while focusing on all the tiny parts. Sometimes one head is better than four.
Many experts say that the cost and access problems we have with our health care in the US are because care is so fragmented. All the parts are not speaking to the whole.
In this time where it is likely major health care reform will occur, we must be very careful to construct a system that would encourage care that starts with a medical home. This would be when one very well trained primary care MD, PA, or NP would know when to refer, when not to refer, and expect a return of responsibility for the patient.
Collaboration is the name of the game.
Collaboration is a fancy word, which means two heads are better than one. It's the buzzword that always pops up when physicians are talking about Physician Assistants (PAs) and Nurse Practitioners (NPs). I believe that the art of collaboration, or knowing when and who to call for help, is about the most important and difficult challenge any PA, NP, or MD faces everyday.
Take for example the isolated over-busy practitioner who knows a lot about everything, but not enough about the specific problem troubling that individual patient. Hopefully that care provider has enough experience and depth of knowledge to recognize when to ask for help and collaborate with someone who knows more. Two heads can be better than one.
There is another side to that story. Last month Mr. X had a complicated problem and I sent him to the specialist in another community. Before he returned, three other specialists were consulted by the first, each adding another test, and medicine, and expense. I was faxed copies of all these consults, but basically kept out of the loop until the patient returned to my office. Here's a time when the big picture had been lost while focusing on all the tiny parts. Sometimes one head is better than four.
Many experts say that the cost and access problems we have with our health care in the US are because care is so fragmented. All the parts are not speaking to the whole.
In this time where it is likely major health care reform will occur, we must be very careful to construct a system that would encourage care that starts with a medical home. This would be when one very well trained primary care MD, PA, or NP would know when to refer, when not to refer, and expect a return of responsibility for the patient.
Collaboration is the name of the game.
Wednesday, March 25, 2009
Expensive High-Tech Medicine
By Richard P. Holm MD
In this country the health care system is sick. There are 47 million uninsured people and the number is rising; med students as well as PA and Nurse Practitioner students are choosing fields other than primary care; and the massive numbers of baby-boomers are getting old. Worst of all, we cannot seem to get a handle on the spiraling cost of health care.
Why is it that in this country health care costs are twice as high as the rest of the developed world? Experts explain that it comes from the excessive use of high-tech medicine, which yields only minimal benefit at a very high price.
It seems that much of the spiraling expense comes from excessive and unnecessary use of imaging such as CT scans and MRI; from very high-priced and borderline-helpful types of radiation and chemotherapy for cancer; and from costly techno-heavy procedures that are not proven to significantly improve the patient's condition.
Others have explained that the out-of-control cost of care is due to over-ordering these items since the patient and family expect and demand the latest and greatest, and threaten a lawsuit if the doctor is reluctant, or anything goes wrong.
But alas, insurance companies and the government have tried desperately to get a handle on these costs and have not been able to control the ever-escalating expensive technology. All efforts with preauthorization and oversight have simply not worked.
The solution must begin with patients being financially encouraged to seek proven methods for diagnosis and treatment. Also, everyone must have access to a primary care provider, which means we must find a way to encourage students into this field. Finally the provider must not be pushed by patient, lawsuit, or financial incentive for unproven technology. Value and quality should be the watchwords, and high-tech methods should be used only when it is part of that equation.
The health care system in our country is sick, and the cure should start with a primary care doctor, not with a CT scan.
Wednesday, January 21, 2009
The Warm Light
By Richard P. Holm MD
A man more than 90 years of age came into my office one day following a spell in the hospital for severe pneumonia. While I was examining him, he stopped me, looked into my eyes, and said, "I need to tell you that I think I died one night when I was so sick. Then I came back."
He spoke about a scroll unrolling rapidly before his eyes, re-running all the experiences of his life. Then he found himself walking through a meadow beside a large lake, towards a warm light, along with others coming from somewhere else, all walking in the same direction. The comforting warm light then told him was not ready, and shortly after that he woke up in the hospital as his fever broke.
I have heard similar stories several times in the thirty-five years since I started interacting with patients. It's been interesting and reassuring that the people who have had these "life after death" experiences often have talked about losing their fear of dying after the experience.
What happens to the soul after death is the great mystery about which all religions seem to turn. In this way they give important support to people as we struggle and suffer in this often tough world.
I should add that, in my opinion, differences in religion or belief systems, about what happens after death, should not be used to separate people. Rather, I believe such questions should help draw us together as human beings.
I see it as an honor that my job as a physician often brings me to be there at the bedside of a dying person, when the spirit lifts up from the body, and passes to another place. So it happened with my ancestors before me, and so it shall be when my turn comes to walk toward a warm light.
A man more than 90 years of age came into my office one day following a spell in the hospital for severe pneumonia. While I was examining him, he stopped me, looked into my eyes, and said, "I need to tell you that I think I died one night when I was so sick. Then I came back."
He spoke about a scroll unrolling rapidly before his eyes, re-running all the experiences of his life. Then he found himself walking through a meadow beside a large lake, towards a warm light, along with others coming from somewhere else, all walking in the same direction. The comforting warm light then told him was not ready, and shortly after that he woke up in the hospital as his fever broke.
I have heard similar stories several times in the thirty-five years since I started interacting with patients. It's been interesting and reassuring that the people who have had these "life after death" experiences often have talked about losing their fear of dying after the experience.
What happens to the soul after death is the great mystery about which all religions seem to turn. In this way they give important support to people as we struggle and suffer in this often tough world.
I should add that, in my opinion, differences in religion or belief systems, about what happens after death, should not be used to separate people. Rather, I believe such questions should help draw us together as human beings.
I see it as an honor that my job as a physician often brings me to be there at the bedside of a dying person, when the spirit lifts up from the body, and passes to another place. So it happened with my ancestors before me, and so it shall be when my turn comes to walk toward a warm light.
Blizzard On the Journey Home
By Richard P. Holm MD
This last month while driving home from a distant city after holiday feasting with family, we ran into a blizzard. Intermittently the powerful wind and new snow would explode between passing shelterbelts, other vehicles, and especially big trucks. Suddenly all vision of what was before us would be gone.
The idea of coming to a stop during such blinding snow was not an option, as moving vehicles were coming upon us from behind. So we pressed on as carefully as we could, white knuckled, leaning forward, staring hard out onto a here-and-gone-and-here-again prairie highway, until we finally arrived home safe.
Being able to see what is in front of us is one thing most take for granted. But this will change for many as aging occurs. It's one of those unhappy surprises about growing old that many will have to face.
If we don't lose our vision from a bottle-rocket, cataracts, glaucoma, diabetic retinopathy, or other condition, many will develop age-related macular degeneration. Although this type of vision loss only affects two percent of those over 50, it climbs to 30 percent in those over 75. It's like winter snow that turns into a blizzard as we get older.
The macula is the central element of the retina. It provides for that concentrated part of our eyesight necessary for threading a needle, painting the lips of the Mona Lisa, finding a lost button, or seeing excitement on the face of your grandchild as she discovers a new thing.
The prevention of this age related blindness comes with all the same things that would prevent premature aging, heart attacks, and stroke; namely regular exercise and the avoidance of smoking and sleep apnea.
Other possible preventatives include eating oily fish and ground golden flax seed, taking regular vitamin D, and maybe special zinc and oil supplements. I hold mostly with the staying physically active and eating a balanced and perhaps fishy diet.
Growing old has it's challenges, like coming home from a long wonderful trip, and finding oneself in the middle of a South Dakota blizzard.
This last month while driving home from a distant city after holiday feasting with family, we ran into a blizzard. Intermittently the powerful wind and new snow would explode between passing shelterbelts, other vehicles, and especially big trucks. Suddenly all vision of what was before us would be gone.
The idea of coming to a stop during such blinding snow was not an option, as moving vehicles were coming upon us from behind. So we pressed on as carefully as we could, white knuckled, leaning forward, staring hard out onto a here-and-gone-and-here-again prairie highway, until we finally arrived home safe.
Being able to see what is in front of us is one thing most take for granted. But this will change for many as aging occurs. It's one of those unhappy surprises about growing old that many will have to face.
If we don't lose our vision from a bottle-rocket, cataracts, glaucoma, diabetic retinopathy, or other condition, many will develop age-related macular degeneration. Although this type of vision loss only affects two percent of those over 50, it climbs to 30 percent in those over 75. It's like winter snow that turns into a blizzard as we get older.
The macula is the central element of the retina. It provides for that concentrated part of our eyesight necessary for threading a needle, painting the lips of the Mona Lisa, finding a lost button, or seeing excitement on the face of your grandchild as she discovers a new thing.
The prevention of this age related blindness comes with all the same things that would prevent premature aging, heart attacks, and stroke; namely regular exercise and the avoidance of smoking and sleep apnea.
Other possible preventatives include eating oily fish and ground golden flax seed, taking regular vitamin D, and maybe special zinc and oil supplements. I hold mostly with the staying physically active and eating a balanced and perhaps fishy diet.
Growing old has it's challenges, like coming home from a long wonderful trip, and finding oneself in the middle of a South Dakota blizzard.
Tuesday, December 30, 2008
Creative Listening
By Richard P. Holm MD
We all know people who are never happy. Contrast those with individuals who almost always seem interested, satisfied, and enjoying life. What is it that makes the difference?
Numerous studies have shown that people find self-fulfillment when they have strong social support, sense a spiritual meaning to life, and last but not least, are able to find time to be physically and creatively active. I think it's that creative element for many that is so elusive.
Obviously we would all be better and happier if we allowed for our creative parts to come out, but how does one do that in a loud and cacophonous world? All the noise out there makes it difficult to create music of our own. I would submit that true creativity begins not with making more clamor, but with very concentrated listening. For example, the improvisational jazz sax is best when played in sync with piano and base.
As a med student I had a physician teacher, he was a cancer specialist, who taught by example on how to find fulfillment by creatively approaching patients with ears wide open, listening with all concentration. He was known as one who could perceive the nuance, the hidden pain, the color of the mood, sensing the broken heart& He said the creative person is one that is open-minded and listens.
I remember learning about his reputation as a true healer, one who creatively found a way to bring the patient back to health relying not only on the knowledge of medicine but also of human nature. He had the capacity and confidence to know when to cure, and when to move to comfort, to let go, to sing the lullaby&
Whatever job or talents we possess, each of our lives could be so full and balanced if we learned to let go of unneeded and rigid rules and fears, opened our minds, and creatively listened, truly listened with all of our might.
We all know people who are never happy. Contrast those with individuals who almost always seem interested, satisfied, and enjoying life. What is it that makes the difference?
Numerous studies have shown that people find self-fulfillment when they have strong social support, sense a spiritual meaning to life, and last but not least, are able to find time to be physically and creatively active. I think it's that creative element for many that is so elusive.
Obviously we would all be better and happier if we allowed for our creative parts to come out, but how does one do that in a loud and cacophonous world? All the noise out there makes it difficult to create music of our own. I would submit that true creativity begins not with making more clamor, but with very concentrated listening. For example, the improvisational jazz sax is best when played in sync with piano and base.
As a med student I had a physician teacher, he was a cancer specialist, who taught by example on how to find fulfillment by creatively approaching patients with ears wide open, listening with all concentration. He was known as one who could perceive the nuance, the hidden pain, the color of the mood, sensing the broken heart& He said the creative person is one that is open-minded and listens.
I remember learning about his reputation as a true healer, one who creatively found a way to bring the patient back to health relying not only on the knowledge of medicine but also of human nature. He had the capacity and confidence to know when to cure, and when to move to comfort, to let go, to sing the lullaby&
Whatever job or talents we possess, each of our lives could be so full and balanced if we learned to let go of unneeded and rigid rules and fears, opened our minds, and creatively listened, truly listened with all of our might.
Monday, December 15, 2008
Medical Education
By Shawn Vuong
The decision to go to medical school is a big one. Dr. Holm brings up a good point, why do people chose to go to medical school? I think there are many reasons why a person would want to pursue medicine, but Dr. Holm hit the big one, "to help people."
If you're interested or have a child who is interested in pursuing medicine that's great. But remember doctors are not the only ones who work in the health care field. Physician assistants do similar work to that of a physician and have a lot of autonomy, schooling is also much shorter. Nursing is a great career choice for those who want to work directly with patients. Nurses are more involved in direct patient care than physicians, and if that's what gets you up in the morning consider nursing school. Also, with nursing school there is a lot of room for growth with nurse anesthetist programs, LPN programs, and many others. And there are much more than nurses and PA's, consider social workers, psychologists, dentistry, physical therapy, occupational therapy, and many others.
If you are interested in helping people, there is a wide variety of options out there not just medical school.
Why Go To Medical School?
By Richard P. Holm MD
Why do we choose the paths that we take in life? Certainly some of it is just happenstance, a chance occurrence that came about for no particularly reason. I believe, however, that often we are influenced to take on challenges by seeing other people fulfilled by doing good things.
I remember, as a kid, watching on black and white television, a Hallmark-Hall-of-Fame version of Arrowsmith, by Sinclair Lewis. This was a 1920's story about a Midwest boy who goes to the East coast to med school, comes back to practice medicine in a small town, and there develops a special interest in infectious diseases.
The hero goes on a quest to halt an epidemic on a tropical island, has a tragic love with great heartbreak along the way, and then, of course, saves the day in the end. There was something about the compassion this physician had for using science to help people that intrigued me.
Growing up in a small community I experienced the typical cuts and colds, bumps and bruises of a kid. There the good doctor, who was also a respected community leader, cared for me. One day during my high school freshman biology class while dissecting a frog, it came to me, "Maybe I should be a doctor!"
It was at that moment I started pointing in this direction, and here I am 45 years later, still thrilled by the challenge.
What is it that triggers a person to apply to medical school? Is it an idealistic wish to make a difference in the world; the intellectual challenge to use science to discover something new; or the model of someone who provides one-on-one caring and healing to the sick or dying?
I would say almost 34 years after graduating from medical school, that practicing medicine is a little bit of all those things, but mostly it is about trying to do what you can to help people, and the reward in knowing that sometimes you are able to help.
Whatever the experience, or example, or dream that moves a kid down the road toward a health care profession, I would call it a very good thing.
Why do we choose the paths that we take in life? Certainly some of it is just happenstance, a chance occurrence that came about for no particularly reason. I believe, however, that often we are influenced to take on challenges by seeing other people fulfilled by doing good things.
I remember, as a kid, watching on black and white television, a Hallmark-Hall-of-Fame version of Arrowsmith, by Sinclair Lewis. This was a 1920's story about a Midwest boy who goes to the East coast to med school, comes back to practice medicine in a small town, and there develops a special interest in infectious diseases.
The hero goes on a quest to halt an epidemic on a tropical island, has a tragic love with great heartbreak along the way, and then, of course, saves the day in the end. There was something about the compassion this physician had for using science to help people that intrigued me.
Growing up in a small community I experienced the typical cuts and colds, bumps and bruises of a kid. There the good doctor, who was also a respected community leader, cared for me. One day during my high school freshman biology class while dissecting a frog, it came to me, "Maybe I should be a doctor!"
It was at that moment I started pointing in this direction, and here I am 45 years later, still thrilled by the challenge.
What is it that triggers a person to apply to medical school? Is it an idealistic wish to make a difference in the world; the intellectual challenge to use science to discover something new; or the model of someone who provides one-on-one caring and healing to the sick or dying?
I would say almost 34 years after graduating from medical school, that practicing medicine is a little bit of all those things, but mostly it is about trying to do what you can to help people, and the reward in knowing that sometimes you are able to help.
Whatever the experience, or example, or dream that moves a kid down the road toward a health care profession, I would call it a very good thing.
Monday, November 17, 2008
The Hot Toe
By Richard P. Holm MD
It was 1972 and I was a green sophomore med student spending my summer shadowing a doctor in Watertown. As soon as we walked into the patients room, my hero-teacher told me the patient was suffering from an acute attack of gout.
The crusty old German doctor explained we were seeing the classic signs of inflammation. He said that the great Celsius, a physician living in the first century, described inflammation with four cardinal signs and the definition still applies.
"In Latin it's rubor, calor, tumor, dolor," is what he said. "Commonly inflammation means infection, but in this case there is no infection. Rubor is redness, calor is heat, tumor is swelling, dolor is pain, and add to that loss of function." There it was, a red, hot, swollen, painful toe. And the patient said, "It hurts so bad I can't stand for my wife to look at it."
The patient was a 45 year-old man with a tendency to drink too much, a prior experience of similar bouts of severe single joint inflammation, and he came from a family many of whom also experienced this same condition. He was moderately over-weight, quite sedentary, and was taking a water-pill for high blood pressure.
"This is the classic picture of gout," my teacher told me. "His body suffers from too much uric acid, partly because of dehydration from the water pill, partly because of his weight and lack of exercise, maybe a little from eating too much protein, but mostly because he inherited the tendency. Too much uric acid causes the formation of needle shaped crystals in the joint fluid, and then comes inflammation."
"We need to treat the inflammation first, and then later get at reducing the uric acid level, or he may destroy his joints, develop kidney stones and destroy his kidneys," he instructed.
The complex treatment of gout made our patient better. It was the perfect lesson from a great teacher.
Take home lesson:
1. Inflammation is characterized by redness, heat, swelling, pain, loss of function, and can be due to reasons other than infection.
2. Gout most often presents as recurrent episodes of a severely inflamed single joint, most often involving the big toe but it can effect other joints as well;
3. This condition results from the formation of uric acid crystals in joint fluid;
4. Gout can progress to destruction of joints and kidneys, so it needs proper treatment.
It was 1972 and I was a green sophomore med student spending my summer shadowing a doctor in Watertown. As soon as we walked into the patients room, my hero-teacher told me the patient was suffering from an acute attack of gout.
The crusty old German doctor explained we were seeing the classic signs of inflammation. He said that the great Celsius, a physician living in the first century, described inflammation with four cardinal signs and the definition still applies.
"In Latin it's rubor, calor, tumor, dolor," is what he said. "Commonly inflammation means infection, but in this case there is no infection. Rubor is redness, calor is heat, tumor is swelling, dolor is pain, and add to that loss of function." There it was, a red, hot, swollen, painful toe. And the patient said, "It hurts so bad I can't stand for my wife to look at it."
The patient was a 45 year-old man with a tendency to drink too much, a prior experience of similar bouts of severe single joint inflammation, and he came from a family many of whom also experienced this same condition. He was moderately over-weight, quite sedentary, and was taking a water-pill for high blood pressure.
"This is the classic picture of gout," my teacher told me. "His body suffers from too much uric acid, partly because of dehydration from the water pill, partly because of his weight and lack of exercise, maybe a little from eating too much protein, but mostly because he inherited the tendency. Too much uric acid causes the formation of needle shaped crystals in the joint fluid, and then comes inflammation."
"We need to treat the inflammation first, and then later get at reducing the uric acid level, or he may destroy his joints, develop kidney stones and destroy his kidneys," he instructed.
The complex treatment of gout made our patient better. It was the perfect lesson from a great teacher.
Take home lesson:
1. Inflammation is characterized by redness, heat, swelling, pain, loss of function, and can be due to reasons other than infection.
2. Gout most often presents as recurrent episodes of a severely inflamed single joint, most often involving the big toe but it can effect other joints as well;
3. This condition results from the formation of uric acid crystals in joint fluid;
4. Gout can progress to destruction of joints and kidneys, so it needs proper treatment.
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