Controlled Medication Agreements

Controlled Medication Agreements for controlled substances are an important part of pain management. For the patient, they offer informed consent on the dangers of longterm opioid therapy and clearly explain the expectations and monitoring requirements of the practice. For the physician, they can offer significant legal protection. This document is offered for educational purposes only and is provided "as is". It is not intended to provide any legal advice or supplement legal counsel. Before initiating any agreement within your practice, I would run your your agreement by a pain medicine specialist and a lawyer. Click here to download a PDF version of this document. Best wishes!

What to say to a patient after a miscarriage?

What do we say to a patient after a miscarriage?

1. You didn't do anything to cause this miscarriage...
2. You didn't do anything to cause this miscarriage...
3. You didn't do anything to cause this miscarriage...

Then...

Listen and weep with the patient.

(Or something like that)

Diagnosing Diabetes

The ADA guidelines for diagnosing diabetes are not always straight forward—there is a barrage of random numbers to memorize. See if this handout which has an easy pneumonic that I made up for the residents helps to ease some of the pain. Also I have included a handout explaining how to use the Homeostatis Model Assessment (HOMA) to determine whether a diabetic patient has an insulin production problem, a peripheral resistance problem, or both. (NOTE: Don't click on the image below since it will only give you a low quality image; click instead on the "this handout" link above).

Finally, I want to give Dr. George Guthrie profuse thanks for his help in putting together these handouts, and for lending his expertise at the 2012 AAFP Scientific Assembly. Thanks George, you are a blessing. He also added feet and toes and eyes to the pneumonic (to help us remember to do our diabetic feet exams and eye exams). Cool!

COOL MEDICAL APPS

It's almost impossible to practice medicine now without using technology. CLICK HERE for a small PDF file with some cool links for some iPhone and Android Apps that you might find useful. This file is a compendium to a lecture that I gave on Technology and Medicine at Florida Hospital. Enjoy! (DISCLOSURE: I have no financial relationship with and of these companies, and I have personally bought every single one of these iOS apps myself—unless, of course, they offer it FREE!)

Tips on Neonatal Jaundice

(SOURCE: Wikipedia)

Neonatal jaundice! Should I start bili lights or not? AHHHHHHH! Nomograms! Charts! Calculating lab draw times! Assessing risk factors! There has to be an easier way to do this. We are in a technological age aren't we? For goodness sake, we have computers that can calculate the prime derivative of thirty billion electrons playing hop scotch in Andromeda! All I want is for the computer to do some pretty basic math and plot it on a simple nomogram! Ok...

Check this website out: www.bilitool.org. Makes all the calculations MUCH easier... And... You're welcome!

Lice! Lice! Lice!

What do you do when the Nix (1% permethrin) does not get rid of the patient's lice? Well... Assuming that you are doing all the other stuff (using the lice comb, treating family members, etc.), consider using Elimite cream. "But Dave, the patient doesn't have scabies!" you say. Well Elimite cream is 5% permethrin which is 5 times more concentrated than the permethrin in Nix. And, for me, this tip usually does the trick.

Of course there are many other Lice tips and tricks and medications (and some are quite flammable!). This is just what works for me.

Vagisil Cream and Manliness?

Ok... I admit it. Vagisil cream is not the most manly thing a guy can pick up at the neighborhood Walgreens. Heck, I'd rather pick up a box of tampons! But, the stuff does relieve minor topical pain. The main ingredient is benzocaine, a local anesthetic. I've used it on patient's with shingles, minor first degree burns, etc. It's much cheaper than the Lidoderm Patches. And I don't have to fill out a prior auth form only to have the Lidoderm Patch denied because I'm using it off-label!

BUT I do recommend that the wives purchase the Vagisil for their man. Real men do NOT purchase Vagisil... NOT EVER!

Making Your Own Jeopardy Game

Have you every wanted to make your own custom Jeopardy Game for a lecture or class or your daughter's 10th birthday party? Why of course you do! Why doesn't? "But it's too hard!" you say. Well fear not! Here's an online tutorial that I did for the STFM Spring Conference on just this topic. It's really easy (and quite fun) with some FREE online tools!

Make Custom Game Shows for Education from David Koo on Vimeo.

Refills on Albuterol Inhalers

Each albuterol inhaler has 200 puffs. And since we advised patient to give themselves TWO puffs per treatments. There are about 100 "treatments" in one inhaler. Knowing this, I rarely give out more than 1 inhaler at a time (and I rarely give refills). The reason is that I can use the patient's refill history to give me a rough estimate of the patient's asthma control. If the patient is requesting a refill of their albuterol inhaler every three months, that means they are using their inhaler on the average 1 to 2 times a day (definitely not in control). And if they are requesting their refill only after one month, that means that they are using their inhaler at least three times a day! Yikes!

Typical STABLE (and unstable) Follow-up Intervals

Here are some typical follow-up intervals we use at our residency. Note that these intervals are obviously not set in stone (and the clinical context will dictate the right thing to do):

Classic Anticholinergic Side Effects

• Blind as a bat (blurred vision, mydriasis)
• Mad as a hatter (hallucinations, psychosis, delirium, memory loss, coma)
• Red as a beet (flushing)
• Hot as heat (fever, hyperthermia)
• Dry as a bone (dry mouth, dry eyes)
• The bowel and bladder lose their tone (constipation, urinary retention, ilius) 
• And the heart runs alone (tachycardia, hypertension)

To remember this pneumonic, the first two rhyme with "bat", the next two rhyme with "beet", and the last three rhyme with "bone." Some of this pneumonic doesn't really make any sense since "bowel and bladder lose their tone" suggests diarrhea and urinary incontinence when, in fact, the opposite is the case.

Teenage Shot Schedules

Here is how I manage my teenage shots to cut down on the number of visits to the doctor:

Visit 1:
   HPV #1
   tDaP
   Follow-up in 2 months

Visit 2:
   HPV #2
   Hep A #1 (if not already given)
   Follow-up in 6 months

Visit 3:
   HPV #3
   Hep A #2

Urine Drug Screens

BEFORE ordering a urine drug screen, make sure to ask when your patient last took EVERY controlled medication that you prescribe. And document that conversation in the chart. It is impossible to interpret the drug screen if we don't know what to expect.

Treating Scabies

FIVE simple tips for treating SCABIES... 
#1.  SCABIES CAN LOOK LIKE ALMOST ANYTHING. 

And the classic presentation of furrow lines between the fingers is rare (especially for norwegian scabies). In fact, scabies can accurately be described as "the great imitator". Here are some examples of the "non-classic" presentation of scabies:

#2.  SCABIES REALLY ITCHES. 

When you see a really itchy rash, scabies needs to be high in the differential. Other things in the differential include rhus dermatitis (i.e. from poison ivy), dyshidrotic eczema, and insect bites. I'm sure that are other itchy rashes in the differential but my mind is dull today.

#3.  THE ENTIRE HOUSEHOLD NEEDS TO BE TREATED. 

If one person has it, then it is likely that other people in the household have it. Dogs and cats in the home may need to be treated also.

#4.  THE RASH TAKES UP TO 1-2 WEEKS TO RESOLVE

Although the mite is dead, it's poop "lives on" under the skin! So unless you want an angry phone call the next day from the patient wondering why the rash did not spontaneously resolve after an overnight application of Elimite Cream, make sure you inform the patient that the rash takes a while to resolve. Also, it's not a bad idea to retreat the household in 1-2 weeks.

#5.  OTHER HOUSEHOLD MEMBERS DO NOT HAVE TO HAVE SCABIES FOR YOU TO MAKE THE DIAGNOSIS

Although the likelihood of scabies increases if other members have an itchy rash, that negative historical finding does not rule out your patient having scabies. It's all in the timing. Your patient may be the first in the household to demonstrate symptoms. Also some people also seem to develop a more rigorous allergic reaction to scabies than others. For example, five kids playing in a field of poison ivy will not all develop rhus with the same intensity—some who have never been exposed to poison ivy will likely not develop a rash at all.

RED FLAG FRIDAY: A NORMAL Urine Culture

Let's say that you treat a patient for a urinary tract infection and the initial UA which showed the following:

1+ protein, 1+ blood, 3+ LE, and POS nitrite

Then, several days later, the urine culture comes back normal:

NO GROWTH FOUND.

That result should not provoke rejoicing! It should cause some stress and worrying! Why? Because if the patient did not have a urinary tract infection, then what caused the 1+ blood in the initial UA? Could it be bladder cancer? Could it be renal cell carcinoma?

Whenever, I get a normal urine culture, the first thing that I do is to check the initial UA. If there is blood on the initial UA, I have the patient see me again to repeat another UA with a urine microscopy. If there are more than 3 RBC per high powered field, then I do a urology referral to work-up hematurea.

Direct Patient-Care Face Time (DPCFT)

Most doctors see one patient every 15 minutes. The economics of our medical system dictate this. In order to pay salaries, malpractice, benefits, rent, electricity, and general supplies, we needs to see patients at this pace. But what does that mean to us practically in terms of time management? Let's think about it... Because we all have responsibilities outside of our direct patient-care face time (DPCFT)—typing up a SOAP note, filling out prior authorization forms, reviewing home nursing orders, answering telephone messages from patients, refilling medications from pharmacies, reviewing notes from specialists, reviewing labs from the prior day, calling patients, doing referrals, and so on—those 15 minutes of DPCFT really get cut down to about 10 minutes. TEN MINUTES! That's all we get folks! No jibber-jabber here! No shooting the breeze about Mrs. Johnson's grandson. Although we want to spend more time talking about family, fishing, and fun with our patients, the truth is that we don't have much luxury to do so. And this can be stressful!

So here are three imperfect solutions that I have come up with:

1. Just run late—Honestly, I'm not good at this one. My patients expect to see their doctor on time (since I'm usually on time). But every once in a while, it good to throw efficiency into the wind, take a deep breath, and truly enjoy looking at Mrs. Jone's photo album of her pet pig (true story). 
2. Schedule 30 minute appointments—I judiciously set up 30 minute appointments. They offer a breather for me with complicated followup visits. But obviously, if I set up too many 30 minute appointments, I will not be able to pay for the overhead of our office. 
3. Split up the visit—I do this especially if the patient has multiple complicated medical problems. I often feel like a heel for doing it. But patients are generally understanding. 

Other than those three tips, I can honestly say that I don't know how to increase my DPCFT. People are constantly complaining about how the U.S. medical system is broken. And from my perspective, the most broken aspect of medicine is that I have so little time with my patients. In a traditional practice, doctor who only see 2 patients an hour get themselves fired for being unproductive or bankrupt for not meeting their overhead. It's a strange predicament that we are in.

Fungus Loves Baby Bottoms

Fungus love moist environments (i.e. a baby's bottom). Most diaper rashes will go away simply by leaving the diaper off (which is my recommendation for really bad diaper rashes). I still use anti-fungal creams (like Lotrimin), but keeping the bottom dry work wonders.

The "Think About It" Technique

Sometimes patients need some time to "mull" over things. And the idea of getting certain tests (i.e. colonoscopy) or starting certain medications (which they will have to take for the rest of their lives) is stressful to them. I have learned that for some patients, it is best simply to "bring up the idea" before prescribing an intervention. Here are some of the things that I might say:

Mr. Jones, at your next visit, we should schedule your screening colonoscopy. You've been putting it off for a while now.

Mr. Williams, the treatment of diabetes requires as least 4 different medications: your diabetic medication, something called an ACE inhibitor, aspirin, and a cholesterol medication called a statin. I'm telling you this now because I don't want you to be shock in the future. Today, we'll just start the metformin. As you come back, I'll talk to you more about the benefits of the other medications. 

Mrs. Stevens, your cholesterol is still really high. We should consider starting a cholesterol medication at our next visit in 3 months if it is still elevated.

Treating blood pressure frequently requires 3 or more medications. Most blood pressure medications at their maximum dose will only bring down your blood pressure by 15 points. So don't be alarmed if we have to add more medications in the future.

Guess what Mr. Reed, we need to do your rectal exam at our next visit!

Preparing patients mentally like this, especially for those who are typically against medical intervention, seems to "soften the blow" when the time comes. 

Just a fever, doc, nut'in else!

For folks who present with only fevers or malaise, check for a urinary tract infection. In the elderly, UTIs commonly present as just malaise. For children, fever is frequently the only symptom.

"For The Rest of Your Life!"

This conversation occurs frequently:

"Mr. Jones, your cholesterol has gone back up. Are you taking your simvastatin everyday?"

"No... Was I suppose to?"

This is usually followed by an awkward silence.

"Ummmmm... Yeah.."

"Well, my last cholesterol was good and so I thought that I could just stop the medication."

For medications that need to be taken chronically, I have made it a habit to say something like, "You will likely need to take this medication for the rest of your life. If you make some dramatic changes to your lifestyle or you lose a lot of weight, we can talk about stopping the medicaiton. But don't stop the medication unless we talk about it or you are having a side effect."