Grand Rounds and Polls

Susan at Rickety Contrivances of Doing Good put up this week's Grand Rounds. It is an interesting edition and it's subject is Narrative Medicine.

Pioneered by Rita Charon, an internist and professor at Columbia's College of Physicians and Surgeons, Narrative Medicine trains doctors and other caregivers to use careful listening and reflective writing to forge deeper connections with their
patients, resulting in better care.

Susan included my post on helping people with social anxiety in the first cut. Many thanks, Susan!

Go check the whole story. It sounds very interesting:

http://improbableoptimisms.blogspot.com/2007/08/grand-rounds-volume-3-number-49.html

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Second news is that I put up a new poll with questions on what are you using to help with your social anxiety. I think we are all curious what percentage of us uses medication vs. what else is used. I will leave this poll up through the whole month of September.

How to tell your doctor that you have social anxiety

This is a question that comes up quite often in the search strings on my blog...

So how do you tell your doctor? First thing to try is to just say it, prepare your "speech" in advance, repeat it, and then when at the doctor just take a deep breath and say it: I have social anxiety. For them it's not really as much of a big deal as it is for us. It's just another disease and another diagnostic code.

The thing is, each of us is different, my social anxiety mostly kicks in when I really like someone and want to be closer to them. So for me it worked quite well with a new doctor. I said it when I saw him the second time and it wasn't such a big deal. I had to repeat it again after I've been through a pregnancy with him and respected him much more. That time it was hell for both him and me; it came at the expense of his lunch break. It was very difficult but also very relieving. I felt very light coming out of that room... also emotionally drained.

So, again, try to say it, as difficult as it seems. If this doesn't work, write it down and send a letter and an email a week or so before your appointment. You might be embarrassed that the office staff might read it. I was very embarrassed to see my emails in my medical record. At the end of the day, for the medical office staff, you are just another patient with another diagnostic code, they don't really care that much. If anything, they will be nicer to you. The general idea of what social anxiety is that you're cutely shy and easily teasable. Few people really understand the emotional turmoil we go through.

Another idea is to say that you have anxiety. The doctor should not jump in with medication, they should send you to a therapist, psychiatrist or the like... Then the only person you need to give details to is the therapist. I recommend that you don't start dealing with social anxiety by taking medication. There's always the chance that you can do without and the medicine for SA are not innocent.

So good luck! and feel free to comment (anonymously or not) on how YOU told your doctor about it.

Rebuild your back

The other blog that I recently started reading is Dean Moyer's Rebuild Your Back. I love the way Dean is teaching others to deal with back pain. It seems to me like the right way to resolve it. Doctors and pain medicine can only do that much, chiropractors and other alternative medicine options seem to mainly work on "if you believe it, it will happen".

If you have back pain, visiting the site and the forum is a must. It just happened that about three of my closest friends had back pain since I started reading his blog... so I keep telling them: See, I told you!

The blog has other topics that I found both interesting and controversial, and the links to the Skeptic's Circle opened a different world to me.

Check it out! And thank you Dean for discovering me on the Grand Rounds and commenting on my blog.

I love my kid's pediatrician

I have a good positive post for you guys!

I love the pediatrician office. I am very proud that I found them and stayed with them. It's a small practice with 3 doctors. I think this is the best because it's small enough that you know each doctor , but big enough to cover all the hours, so you don't get to talk to some other doctor on call. It's always one of the three. Less than that and you would end up meeting a complete stranger for on-call. For more than that, it would be difficult to know each doctor and have unfragmented care.

I can ask for one of the doctors or just rotate through them as I wish. They are a bit far away from us, but they work with two of the best hospitals around and I think that is important. They are out of network for my insurance and I am actually happy about that because I know that they get paid a fair amount and don't have to reduce quality to cut costs.

They have evening hours, they get you in the same day for a sick child and they even come on the week-ends if needed. They are usually on time and I never had any issues with them.

At one of my first appointments, I felt attacked when the old doctor asked the usual questions about not leaving the baby alone on the adult bed, baby-proofing the house, fire arms, etc. I then realized they have to always ask these questions and it's not personal, so I relaxed.

Initially I rotated through each doctor to get to know them, but for 9 months or so, I just stayed with the youngest one. He has a kid about the same age as my kid and it's really cool to share the experience. He's fun: "Oh, I worry unnecessary about my kid as well." I love that he takes the time to talk to me and that listens to my concerns and reassures me. It's also cool that if I think he's missing something, I can go to the "old doctor" and ask about it.

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I wonder what is it that makes this relationship so good and why am I so critical towards other doctors. I'm pretty sure it's something internal with me and how I react or come across to other people, but I can't figure out what it is.

I think this is more like a partnership for making sure the kid is fine. I think that doctor-patient relationships that are based on mutual respect are successful. If the doctor feels threatened, or if the patient feels unheard, the relationship just fails.

My view on Electronic Medical Records - EMR

I have read a lot about EMR systems, but I never really saw one. I imagine they handle appointments and allows staff to maintain a patient database. Maybe the more advanced ones electronically transmit data to insurance agencies and pharmacies and get lab results.

But I wonder if they actually help the doctors at all. I suspect they are just electronic notebooks for doctors having them enter notes electronically instead of dictating them.

I wonder if the lab results and other documents are stored in the database as searcheable numbers or they are simply pictures of the other documents.

I imagine that a good EMR should allow the doctor to select options from lists of values and then generate codes and reports. I looked at my doctor's notes once. He started by dividing the sheet in 3 areas and labeled each with the subject he needed to cover. It could have been Chronic hypertension, right upper quadrant pain and heart (I'm making it up, I don't remember the details). Anyway, it would be nice to have a program where you just enter a few letters and it fills out the rest. If you have a category that is not in the list, you can enter it in a separate field and the program should be smart enough to "learn" it and use it next time.

Then, because hypertension was selected, it would open up a history of that and give the doctor options. The computer should suggest a billing code, but allow the doctor to modify it. It should give medication options and allow the doctor to pick one.

When done, it should generate any report that is needed: referrals, letters to other doctors, insurance papers, etc. and allow the doctor or staff to review it one more time before sending it electronically.

Is this what EMRs are about? I doubt it. I am building database software systems and I am very aware how difficult it is to build something with such high level of artificial intelligence, but if they don't do all that, why would we be surprised that doctors are slow to adopt them? What do they bring the doctors? I think that the existing systems are more about keeping the office lean (less staff) than actually helping the doctor.

Why am I writing all this? What a good question... I guess because I am dreaming to build such a system, but I see few chances to get there.

Another doctor story

My dear and beloved readers, I promise, I tried my best to not be critical, I wanted this to be my happy post and everything to be good. It is not. I am not unhappy, just sad with the way the world is. So here goes another doctor story.

I have this mild but annoying foot pain since I was pregnant - 20 months ago. It is only annoying when I walk for a long time (like our 10 miles hike from a month ago). It's not that bad, but I figured if I can make it go away why not try.

My doctor very warmly recommends this podiatrist and tells me that all the doctors he recommends are his friends, but his patients actually like this guy. This is big for my doctor.

I call and get a 7PM appointment - hey, appointment at a convenient time, amazing! They send me directions, they call me twice to confirm my appointment with an automatic message. This guy obviously has an EMR system... I am grounded. I loved him even before I met him.

When I get there, it turns out that he doesn't take my insurance, but the first appointment is free. I quit caring about my insurance a while back. The doctors I have the best relationship with are out of network anyway. So this doesn't put me off.

The doctor comes in with a laptop, examines my foot, asks the questions, etc. He finds a spot that hurts and explains what he thinks is wrong. I listen and then tell him: oh, so if I just wear wide shoes it should go away. He says that's not enough and sets me up for a X-ray and U/S. I am presented with a U/S paper where I promise that I pay $50 if my insurance doesn't. Hey $50 is not the end of the world.

The X-ray is perfect, On the U/S he shows me a black area that is supposed to be my infection. Before I know, I get a hydrocortizone injection, a pad on my foot and I am armed with a cream and pads ($24.5). I shyly ask if it might not just go away just by wearing wider shoes. Doctor becomes uncomfortable and hurries out the room. I am set up to have another appointment in a week.

Will my pain go away? Likely. Would it just go away if I wore wider shoes anyway? Probably. Would I go back to the doctor if he just told me that? Likely not, but just because I would feel better.

Why are we so hungry for intervention? Why is this doctor basically a vendor? A very good and courteous one, but at the end of the day just a vendor. That EMR system that he has needs to be paid for...

And BTW, I had to peek at the EMR system and saw his notes: they started with "This 37 yo female patient..." He typed that in... shouldn't that be automatic, generated by the system?

I lost any hope that I am not the most critical freak that ever existed.... Everybody likes this guy, even my doctor, and I don't? What's wrong with me? Can I just be happy?

ETA: Check out the development of this story.

Poll results

OK, so my poll results are:

11 - have social anxiety (SA)

3 - don't have social anxiety but want to find out more about it

1 - is here for other reasons than social anxiety

This result was very surprising to me. I did not expect the SA people to come out and participate. Many many thanks for participating and for reading. I realize that for some of you even taking this anonymous poll might have been difficult. I also realize that you are coming here again and again because you find yourselves in what I am writing, realizing that you are not alone or finding hope that your issues have chances to be resolved or at least become acceptable. I now feel responsible to keep writing and letting the world know about us.

I was hoping that more people don't have SA, but are interested in it. I was secretly dreaming that there are SA researchers out there that would try to learn more about SA and find ways to help us... I guess research money is not much and it's mainly given by drug companies, so research in this area will have something to do with medication.

Thank you again for participating. I will keep writing about SA and I will try to attract people that don't know much about it so we can increase awareness. The first step will be to edit my post on helping SA people and submitting it to the Grand Rounds this week. Wish me luck! Feel free to offer suggestions, anonymous comments are allowed!

Dr. Rob

I have a few blogs I started to read recently. One of them is Dr. Rob. He is on the list of the best 100 medblogs and pretty much everyone on the medical blogs world has a link to his blog. I am so happy that so many people like him. This alone makes the world a better place. He has a lot of common sense, is smart (hey a doctor building his own EMR... - I am in IT after all, this has to impress me) and very very sweet.

He surprised me this morning with a post on children's fears... as you'll see it's not just children's fears and it matches very well the subject of this blog. Make sure to read it.

Thank you Dr. Rob for writing... and if you ever get stuck in Newark, let me know. I'll be happy to offer a place to lay down, a dinner and an ear eager to learn about your IT achievements and not only...

Edited to add: Two more Dr. Rob posts that you should not miss

Read To My Patients and give it to your doctor to share with their patients.
http://distractiblemind.ambulatorycomputing.com/2007/07/23/to-my-patients/
It's wonderful. I especially like this part:

You are not crazy. I have a lot of people who are really anxious about
things in their life and they are worried that they are “going crazy.”
There is a huge difference between being “crazy” (psychosis) and struggling
in life. Everyone is struggling in life (no matter how “together” they
appear on the outside). One of the best parts of sitting in my seat is
that I have a whole bunch of people opening up to me with their insecurities
and anxiety. I have realized that everyone is just as insecure as I am
- and this really makes me feel better in my own struggles. If you
can’t share your anxieties with me, then who can you share them with?
I promise not to make you feel that you are feeling the wrong emotions.

Also check Perfect words ... how nice is that? http://distractiblemind.ambulatorycomputing.com/2007/07/25/perfect-words/

Please take my poll

Please fill in my poll on the righthand side of the main screen. I am so curious what attracts people to my blog, and especially what brings them back... I'm looking forward to seeing your answers.

Many thanks!

Helping socially anxious people

I love to check the search strings on my blog. A quite common thread is people that ask how can they help a socially anxious person. Of course there's the conventional path that they need to be encouraged to take and that I recommend: tell their doctor, find a therapist, read tons of books on the subject, read blogs and try to hook up with people that have the same issue, read blogs and try to hook up with people that don't have this issue, write a blog or keep a journal for their feelings, symptoms, etc.

In this post though, I'd like to talk about how to interact with them on a daily basis. The simple answer is just be there for them and let them know you are there for them. When I was pregnant I had a cyber-friend that emailed me each time I posted an update on the Preeclampsia Forum. Each and every time, I would get an email saying she's thinking about me, she's glad I'm doing well or sorry that I'm not doing so well. There were months when I didn't even get myself to answer those emails, but they kept coming. Thank you so much for those emails, N! They really helped.

So the long term solution is to reach out to them occasionally even if they don't answer back. But I think an even more interesting question is how to react to the emotional roller coaster they go through and they sometimes drag the other ones around into.

I stand by my previous posts ( see Dealing with Emotional People and Dealing with Emotional People - Part II) that when upset, you need to listen to their vent and empathise. Don't try to rationalize (it will just demonstrate to them they are irrational) and don't tell them it's all in their head. After they relax, make sure to reassure them that you still love them, you think they are fine, that this kind of meltdowns happen to everyone (an example of when this happened to you is great).

What about when they are overcome with shyness, obviously not being able to get over it: blushing, nervous, trying to say something, but can't, wringing hands, looking down, etc. I think you need to do the same: break the silence with a question, ask what are they thinking, say it's OK, they are fine, that you have time to listen. Don't go away trying to relieve them of their obvious discomfort, just help them go through it.

Sometimes the silence becomes so awkward for the socially anxious that they wouldn't start talking because the issue is too small and they made too big of a deal of it. This will extend the silence even more and make it even more awkward. All they want is to run away and hide. Don't let them run away. It will make them feel good for a short time, but will hate themselves later. Again, after the episode, make sure to let them know they are fine and you still love them. Don't laugh at how small their issues are.

The question that comes up in our heads time and time again after these episodes is: what is he/she going to think about me? He/she will run away and never want to see me again.

Happy Anniversary to Paul Levy's blog

Paul Levy's blog is 1 year old today. Happy anniversary!

Paul's blog was my inspiration to start my own blog. I read his for about a month and then decided I need to talk to Paul. As it seemed practically impossible, I decided to write a blog instead and invite him over.

Paul was more open than I ever expected. He emailed me back, welcomed me on the blogosphere, read and commented on my posts and generally encouraged me on my road. He created the Personal stories group on his blog roll and I am always proud to see my link the first one there.

More than anything, his posts are like an vacation island to me and a window on a part of the world that I never had access to before. I learned the power of openness, and the freedom that comes with it.

Thank you so much Paul for opening up to us and for helping me grow. Here's to many more years of great blogging.