08 | May | 2012

The Medical Field Gets its Act Together: Part Two

In my last post, I praise the Choosing Wisely® list, which is aimed at cutting down on unnecessary testing by docs.

I got into medicine because it is FUN, and, of course, to help people. I think most of my colleagues did so as well. I get up every day and I get to go to work and figure out puzzles all day. How cool is that? Sure, it may not always be unwarranted or a bad thing, but testing and more testing can definitely take the fun out of taking care of patients… I want to figure out your problem the old-fashioned way with a good old history and physical! Then and only then, get a test if it is warranted. This is the correct way, and the safe way, to help improve your quality of life.

So why else am I in favor of the Choosing Wisely® (and the mentality behind it)?

Our over-testing can place the patient in harms way, especially if your doctor is not vigilant. There are only three results that can come from any medical study or test. You might find what you are looking for, find nothing (negative/normal result), or a result that is unexpected. A test that shows what you are highly suspecting should be the most common result. Testing that shows nothing or is “normal” should be far and few between. Warranted screening testing or similar testing is not what I am talking about here – I am talking about a patient who has a problem for which an active diagnosis is being sought. On the other hand, we would all hope the any and all screening testing would come up normal.

Tests that show something unintended are where it can get scary folks. And this is something few ever really think about. It is sort of “beware of what you ask for.” Of course, an unintended result such as serendipitous finding an early case of early leukemia or similar is a good thing. Nobody can deny what that discovery can mean to that person and their family.

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01 | May | 2012

The Medical Field Gets its Act Together: Part One

Finally, the medical field, in general, is getting its act together. Simply put, Choosing Wisely®, the brainchild of the American Board of Internal Medicine (ABIM), is an initiative to help cut down on unnecessary medical testing. The goal behind the campaign: improve medical care by “cutting waste.” Although I suggest both doctors and patients read up on it themselves, Christine Cassel, MD – president and CEO of the American Board of Internal Medicine and the ABIM Foundation – describes Choosing Wisely® well:

“For every one of these items [on the Choosing Wisely® list of 45 overused tests and procedures], there are times when it is indicated,” she said. “We aren’t saying you should never do it — these are times you ought to have a conversation about whether you need it or not.”

At this point, this looks to be the best thing to happen in the medical field in my lifetime. Everybody benefits!

Say what you want about me: angry, arrogant, controversial, but who I really am, at my core, is a patient advocate, period. In fact, if you want to really know why I am “angry,” I fundamentally do not care for a lot of things that go on in medicine today. I have been doing this long enough to know the difference.

The four reasons why medicine is at the point it’s at today with over-testing:

• Patients ask for it!
• Testing and screening are so widely available and accessible now.
• The current insurance reimbursement structure in America lends docs, over time, to settle with the path of least resistance in dealing with patients.
• Defensive medicine

I was taught in medical school that I could come up with an accurate diagnosis greater than 90% of the time with an accurate history (as in, your story about your problem with a little of my guidance) and a physical exam. I distinctly remember hearing that and thinking to myself, “what a crock.” But today, I know this as truth. These docs today, considering the fact they can readily get that test (the one patients are ASKING for), will often bypass the effort to really learn and too quickly default to the test. As a result, one’s deeper understanding goes untapped.

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20 | Apr | 2012

DMSO, And My Question for the FDA

While DMSO is controversial, and you know I like that, this blog is really an FYI for something you have likely never heard of and you might want to know about…

DMSO — Dimethyl sulfoxide — is a byproduct of the wood pulp industry discovered in the early 1950′s. To be frank, it sounds dreadful. Have you ever smelled wood pulp at a paper mill……yuck! Yet, DMSO has been used in medicine for more than 50 years. It’s prescribed to relieve pain, to treat head injuries and strokes, for inflammation and arthritis, as an antioxidant…the list goes on and on. I am going on record to say I like this stuff and it works, in many ways. I urge you to read more about it.

Docs from Canada, Great Britain, Germany, and Japan (to name just a few), all prescribe DMSO to patients…but for those of you who don’t know, here in the US, it hasn’t been approved by the FDA.

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28 | Mar | 2012

On Trusting Medical Research Studies – WITH UPDATE

At least twice per month I see a patient whose first words after a greeting are “I took Ciproand I ruptured my Achilles tendon” or implicating some other tendon problem. Hey, if you say so, it must be true? How about the fact you ruptured it playing pickup basketball for the first time in 10 years and you are 52 years old?

Again and again I hear Cipro, Levoquin, et al., the flouroquinolones, being held responsible for tendinitis and tendon ruptures. After careful review of the literature, here’s my stance: as of now, I’m not convinced. But hey, I challenge you to prove me wrong…so I’m opening up the discussion to you — both those who are qualified and unqualified.

For those who don’t know much about the topic, this class of antibiotics, the flouroquinolones, has been implicated in tendon issues in the past few years. Somewhere some smart doctor, or attorney, made a very loose association and urban myth became a fact that many simply aren’t even questioning! The literature is loaded with case report after case report of flouroquinone use and ruptures or tendinitis. But that is where science ends! Hey, I took Tylenol once and I broke my arm skiing two days later. Could I sue J&J? I also took Viagra once, OK, twice and…never mind!

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25 | Jan | 2012

Morton’s Neuroma: Controversial to Say the Least

What really pushed me over the edge when it came to Morton’s Neuroma (MN) was watching Steven Tyler on OWN. During his interview with Oprah (okay, I saw it with my wife – her idea!), I realized one, that he’s an awesome dude, but two, he is mislead in thinking his problem is just a MN… he showed one of his “dogs” right there on TV, and a MN, even if he has one, is the least of his worries!

First of all, a MN is not a neuroma at all… and, Morton did not describe Morton’s neuroma! What tha…? Technically speaking, it is perineural fibrosis, sort of a misplaced overgrown protective “scar” tissue surrounding and compressing an otherwise normal nerve. And this choking effect of the common digital nerve is what produces the pain. Durlacher described “Morton’s” neuroma, but I guess Morton’s neuroma sounded better. I’m certain it is easier to spell.

So, what does MN feel like? It is bottom-of-the-foot, or plantar, pain that usually comes on very slowly — months to years — and never is a result of injury or trauma. At first the pain is vague, and difficult to describe or localize, but in time, over a period of months to years, it will localize and the ability to describe the pain sharpens. You may or may not have numbness or shooting pains out into the associated toes.

Common and characteristic complaints are increased pain with tighter shoes, the urge to take ones shoe off and rub the foot, and/or the feeling that there is a fold in the sock, when there isn’t. It’s a nerve thing. The exam is defined by re-creation of the pain with palpation in the web space and possibly eliciting a pain reproducing Mulder’s click.

When I see a patient and I suspect a MN, it becomes a diagnosis of exclusion, especially if it is in the second web space. This means that all other prospects/suspects are ruled out first, usually by history and exam. BTW, a Morton’s neuroma may “feel” like swelling on the bottom of your foot, but that’s a sense that many get from numbness anywhere. However, actual, real swelling never accompanies MN. Never. The only other diagnostic test available is a diagnostic injection with or without cortisone.

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19 | Dec | 2011

Your Foot’s Asleep While Exercising? Then STRETCH!

Ever had numbness in your toes when exercising?

Patients of mine who use the Stairmaster (probably the worst offender), elliptical, bicycle (including spinning), and even those involved in outdoor sports come to me concerned about their “sleepy foot.”

Before I get to what you can do to help it, let’s look at why it happens. The cause is the stretching of the tibial nerve as it comes down out of the leg, wraps around and behind the medial malleolus, and changes direction as it enters the foot heading out to the toes.

Tension on this tibial nerve is increased dramatically as a result of the increased arch depression forces when someone’s calf is too tight. Typically, I see that flatfooted people are generally more susceptible, only because the stretch of the nerve is even more pronounced.

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11 | Nov | 2011

Shooting Yourself in the Foot – When WebMD Becomes “Dangerous”

I just hate it when patients shoot themselves in the foot. In my particular case, being a foot and ankle orthopedic surgeon, this might be closer to fact than fiction. What I am talking about here are the more low-key diagnostic and treatment decisions in general, but this concept rings true throughout medical decision-making as you will see.

Each and every one of us must be our own patient advocate, but too much of a good thing can be bad. There is no doubt that patients and/or their family will all too often unwittingly try very hard to force/dictate a poor outcome. This unhealthy influence can be wielded anywhere from a small medical problem all the way to a life threatening issue. You know these people, they are the controllers, micro managers, type A’s, etc., and they make up about 15% of my personal patients. Ask them and they usually have no clue that they are even doing this.

In fact, what they do think is that they are trying to facilitate their own care and safety. In most cases this couldn’t be further from the truth. With the Internet poring out massive amounts of medical knowledge, good and bad, we all feel more knowledgeable and EMPOWERED these days. OK, I know what your thinking, “Here is another doctor who does not like being told what to do.” You’re damn right I don’t like being told what to do when it is not in your best interest and you are asking me to place you directly in harms way.

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04 | Nov | 2011

The Big Day

Over the past few years I have become increasingly aware that when a patient visits the doctor it is a BIG DEAL. Even the simple visits. I should not have realized this, but I did and I am glad I did. If you have had an illness of any note you will surely identify with my words. My personal experiences aided in my awareness and they have confirmed this notion time and time again.

Many of my colleagues wouldn’t have a clue as to what I am talking about. In today’s medical world time is money. You get your number and you are rushed through with less and less personal attention or explanation. However, this culture, I contend, is much less about money and more about your doctor not looking through your eyes.

You see, what we doctors do seems so special to the layperson, but in reality it is generally everyday ho-drum repetition to us. We really don’t get that exited. I just saw 31 other patients just like you with your same problem just last month. Been there, done that, boring. However, we too often forget you have an experience of exactly ONE, and even with the almighty internet you may feel isolated. Your problem IS big and you are depending on us!

I have walked that mile in your shoes.

I was diagnosed with cancer 11 years ago, had surgery and I am now “cancer free.” But I still have to go in for testing in the form of blood work. I am just fine until just after they draw my blood. It generally takes about 8 hours for the test to come back. Let me assure you that for a guy who is “cancer free” those are not a comfortable 8 hours. My test results always get completed about 7 p.m. that evening. Thank God I can call the lab (I really am a doctor) and get my own results that very night. Otherwise I would have to rely on my doctor to get back to me with the results the next day if I am lucky.

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10 | Oct | 2011

Shockwave? For Foot Pain?!

Many of you have asked me about potential treatments you’ve heard about about for chronic plantar fasciitis and other foot ailments. Two that continue to come up in conversation: GS surgery and ESWT.

In short, here is what my experience shows:

Gastrocnemius Slide (GS) surgery, also known as the Strayer Procedure

What It Is: Lengthening the triceps surae or Achilles tendon.

Pros: Potentially, you arrive quicker at your desired result and it requires less effort and diligence on your part. This surgery indeed does address the underlying cause.

Cons: First and foremost, money! Also, the risk involved – which is inherent to any surgery – should be considered (infection, nerve damage, scaring, etc.). But, there are also risks specific to GS, including over-lengthening of the muscle – potentially a real problem; permanent calf weakness; DVT, to name a few. All of these are low incidence, but as they say: you can’t win the lottery unless you play (lose in this case), or when you fall under that 2-3% chance of complication!

Recovery is not easy with the procedure, and 6 weeks immobilization and 2-6 weeks of no weight bearing is what you can expect.

Conclusion: I don’t support the surgery as a primary way of treating plantar fasciitis. For those who fail a bona fide six month course of stretching, and their problem remains recalcitrant, then I would consider this surgery.

Again, it comes down to the fact that stretching fixes the real problem in almost all cases. But it requires patience!

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16 | Sep | 2011

My Pet Peeve: NOT Sticking To Stretching

(…Or just about anything else we tell ‘em.)

Patients are predictable I’m sorry to say. Non-compliance is a very large problem with patients.

I give approximately 85% of my patients explicit, written directions to do calf stretching and – even with the most compelling reasons – they leave the office sold on the concept and the exercise and then… more than 50% of them won’t do it. Did I say my directions even have pictures?

I don’t know, maybe they go home saying, “What? I paid for an office visit, and this guy just told me to stretch? He must be crazy.”

Then, they come in for their follow-up and some version of this conversation occurs:

“Doc, your stretching is not working.”
“What’s wrong with it? ?”
“Are you DOING the stretching?”
“No. Should I? Did you really mean it?”
“Yes I meant it! What about, ‘the calf stretching is the ONLY thing that will FIX your problem,’ did you not get?”

C’mon, people. I’m telling you what, 95% of the time, is effective! However, the stretching is effective 0% of the time if they are not done.

I’m asked why I focus so much on calf stretching. It’s simple. It works. Stretching is prevention and cure rolled up into one. If you have pain now, this stretching will make it go away. If you don’t want pain later, KEEP STRETCHING.

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