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March 1st, 2017

Listening to Bowel Sounds: An Outdated Practice?

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

Medical programs teach us that listening to bowel sounds is an essential part of the physical examination of the abdomen, especially when the differential includes ileus, small bowel obstruction, diarrhea or constipation. Woe betide the student who fails to auscultate the abdomen of patients with these presentations. Yet firstly there’s little supporting evidence for this maneuver, and secondly there’s a lack of consensus about correct technique. Despite these issues, bowel sounds are claimed to help us develop our differential and cinch our diagnosis. The relationship between bowel sounds and pathology is not evidence based. It appears to be more a reflection of tradition and anecdotal evidence.

The Technique 

The noises produced by the movement of gas and fluids during peristalsis are bowel sounds. The technique learned depends on the school, the clinical gut of faculty and staff, and the physical exam text chosen. Some educators teach students that listening in one area is enough whereas others teach them to listen in all four quadrants. Bates’ recommends listening in only one spot, Mosby’s in all four quadrants, and DeGowin’s suggests listening in all four quadrants and the midline. Given that borborygmi may disseminate across the entire abdomen, and what you hear in one quadrant may reflect another part of the abdomen, the precise placement of your stethoscope seems irrelevant.

Also controversial is the duration of auscultation. Educators (and texts) teach students to listen for bowel sounds for anything from 30 seconds to 7 minutes. In reality, a healthy person may have no sounds for several minutes but then later have up to 30 a minute. Bowel sounds may cycle with peak-to-peak periods over 50-60 minutes. This means that any analysis less than that time will be inadequate.1 Additionally, some intestinal contractions are silent, so we cannot presume that a quiet bowel is a motionless bowel.

This complexity is further compounded by order of operations. Schools in the United States teach students to listen prior to palpation whereas schools elsewhere teach students to auscultate after palpation. I was taught to listen in each quadrant for up to 30 seconds or until bowel sounds were heard. This was done prior to palpation. Reversing the procedure was considered unacceptable. The thinking here is that palpation might disturb the intestines, trigger peristalsis, and thus alter the physical exam. My question is — so what?

There’s little evidence to suggest that borborygmi triggered by palpation are any more or less pathological than those that are not. I also suspect that patients might push on their own bellies before a clinician ever enters the room or even in their presence to illustrate their pain: it hurts here! 

In researching this issue lately, as I folded page corners of great medical tomes and drew boxes around pertinent information, I felt that I might do just as well turning those pages into something tangible, relevant and concrete; something akin to the Japanese art of origami – a model of bird’s beak esophagus perhaps.

The Evidence

A friend and colleague of mine who trained as a surgeon in South Africa in the 1970’s described to me his memories of learning the nuances of borborygmi. Back then, this was their art.

“When I trained, and did a lot of intestinal surgery, borborygmi really meant being able to hear loud bowel sounds without a stethoscope. We learned to listen for those differences that depict ileus from mechanical intestinal obstruction, an important distinction since the mechanical obstruction often needed an urgent operation while ileus did not; we learned to distinguish propulsive sounds from ‘tinkling,’ non-propulsive ones. I got quite good at that as a chief registrar in Johannesburg. My teachers and the master clinicians who taught me, translated bowel sounds into action. Propulsion — operate! Tinkling — don’t operate!”

The most common and urgent reason to listen to bowel sounds is small bowel obstruction (SBO). The instruction is that bowel sounds will be hyperactive or absent in the setting of SBO. This is the time when the diligent clinician should wield their scope, placing the diaphragm below the diaphragm. However, in a recent study, 53 doctors used a Littman’s electronic stethoscope to assess the bowel sounds of patients with and without SBO. The median frequency with which doctors classified borborygmi as abnormal did not differ significantly between patients with and without bowel obstruction (26% vs. 23%, P=0.08). The study concluded that auscultation of the abdomen provided little help when making clinical decisions regarding management.2

A study published in The Journal of Surgical Education  in 2010 came to similar conclusions. They found that “listeners frequently arrive at the incorrect diagnosis.” Listeners were unable to accurately characterise bowel sounds as normal, SBO or ileus. They also noted no difference in accuracy between surgical and internal medicine residents. They concluded that listening to bowel sounds is not a clinically useful part of the physical exam.

Another reason to listen to bowel sounds is ileus. A study in 2012 examined the utility of listening to bowel sounds as a method of determining the end of post-operative ileus. This study determined that there was no association between the finding of bowel sounds and the return of bowel activity. This research concludes that routine assessment of bowel sounds for resolution of ileus is according to an outdated and unnecessary procedure.4 Undeniably, patients with ileus and SBO often do have abnormal bowel sounds, but it appears that listening for them has little utility in clinical practice today.

The Conclusion 

I am a keen supporter of the history and physical exam. I advocate for the use of hands, ears and eyes. However, clinicians must be progressive, embracing new modalities and letting go of less reliable methods. For example, teaching bedside ultrasound for the diagnosis of SBO might be a better use of time. A recent systematic review and meta-analysis of the diagnostic modalities used to identify SBO found ultrasound to be superior to all other modalities.5

It is unlikely that medical, nursing and physician assistant programs will stop teaching students to listen for borborygmi any time soon. I hope though that the lack of both evidence and standardisation will at least encourage students, educators and clinicians to question the efficacy and utility of this maneuver. No one should fault the clinicians of earlier times; they lacked the technology and data we have today. Some might consider auscultating for bowel sounds as another part of our arsenal for deployment, rather like Homans’s sign for deep vein thrombosis: something to pull out of our medical tool bag when diagnostic resources are scarce – when our scope is all we have. That said, given the lack of consensus and supporting evidence, I believe patients might benefit more from the ancient art of origami than borborygmi. At least the former might soothe the patient.

 

1)      McGee, S, Evidence-Based Physical Diagnosis, 3rd Edition. Philadelphia, PA: Elsevier-Saunders; 2012

2)      Breum BM, Rud B, Kirkegaard T, Nordentoft T. Accuracy of abdominal auscultation for bowel obstruction. World Journal of Gastroenterology : WJG. 2015;21(34):10018-10024. doi:10.3748/wjg.v21.i34.10018.

3)       Felder S, Margel D, Murrell Z , Fleshner P. Usefulness of Bowel Sound Auscultation: A Prospective Evaluation. Journal of Surgical Education, 2014-09-01, Volume 71, Issue 5, Pages 768-773.

4)      Massey R. Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition? Medsurg Nursing, 2012-05, Volume 21, Issue 3, Page 146 -150

5)      Taylor N, Lalani M. Adult Small Bowel Obstruction. Journal of the Society of Academic Emergency Medicine,5)  2013-06-12, Volume 20, Issue 6, Pages 527-544

February 24th, 2017

Deep Brain Stimulation Targeting in Neurosurgery, Part I of III

Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.

This three-part series is for providers who lack an intimate level of knowledge and/or experience with deep brain stimulation (DBS) targeting. My goal is to provide a baseline understanding of each target, its indications, contraindications, and adverse side effects that may be observed from imperfect electrode placement and/or imperfect programming.

Specifically, I will discuss the basics regarding the three most frequently used DBS surgical targets for Parkinson’s disease (PD), dystonia, and essential tremor (ET): the ventralis intermedius (Vim) nucleus of the thalamus, globus pallidus internus (GPi), and the subthalamic nucleus (STN).

This first post will focus on the Vim.

Thalamus, bilateral. Vim (green). (Reprinted with the permission of Medtronic, Inc. © 2017)

I’ll start by briefly describing deep brain stimulation. DBS has become a commonly used and well-known surgical intervention for the treatment of medically refractory movement disorders such as PD, dystonia, and ET. The intervention involves the implantation of unilateral or bilateral electrodes that provide chronic stimulation into the deep brain at one of the aforementioned targets. The electrodes receive power from a battery-powered simulator that is typically implanted in the chest just beneath the skin and a couple of inches below the clavicle. The entire DBS system, including connecting wires, resides under the skin. We aren’t exactly sure of how DBS works, but some think that the mechanism of action is consistent with the blocking of neuronal signals transmitted through the stimulated structure and desynchronization of abnormal oscillations [1, 2].

It is important to note that DBS programming is an art form and requires a team effort. It isn’t something you just turn on and off. It requires a good knowledge of anatomy and the equipment’s capabilities. Although programmers (typically neurologists, neurosurgeons, or PAs and NPs who work in those settings) get better with experience, every patient is a little different, thus requiring finesse and good communication within the DBS team to combat programming troubles. High-volume centers generally have good working relationships between the neurology, neurosurgical, and neuropsychiatry teams for the purpose of achieving the best patient outcomes in the face of these challenges. The neurosurgery team handles the electrode placement and then communicates that placement to the programming team to give them an idea of how to start programming. Aside from proper patient selection, it is helpful to set patient expectations prior to surgical intervention. DBS is not a cure for any disease, though for many, it can significantly improve quality of life by treating their symptoms.

Ventralis Intermedius (Vim)

Where is it located? 

Vim (green). Subthalamic nucleus (turquoise, below VIM). (Reprinted with the permission of Medtronic, Inc. © 2017)

The ventralis intermedius is located on the ventral aspect of the lateral thalamus.

Indication:

  • Tremor – Vim stimulation has been shown to be as effective as a thalamotomy but with fewer adverse side effects. Although it has excellent anti-tremor effects, it does not show the same effectiveness on other prominent parkinsonian symptoms such as bradykinesia and rigidity. For this reason, it is most commonly targeted in essential tremor and not Parkinson’s disease.

Contraindication:

  • There is no glaring contraindication to the selection of this target; however, as mentioned before, it isn’t the first choice for patients with PD, and since dystonia does not have a tremor component, Vim is not an appropriate choice for dystonia.

Stimulation adverse side effects based on location of electrode in relation to optimal placement [3]:

  • Too lateral: With stimulation of the internal capsule, effects consist of muscular contractions and dysarthria.
  • Too medial: Potential speech and swallowing issues
  • Too posterior: With stimulation of the ventral caudal nucleus, effects consist of persistent paresthesias
    • Evoking paresthesias during the programming process is not abnormal in itself, but the patient will habituate – they should not be persistent.
  • Too anterior: Suboptimal tremor reduction at typical voltages
    • May need higher voltage to attain good control, which requires more frequent battery changes
  • Too superior: No effect on tremor
  • Too deep: A range of side effects depending on how deep, ranging from no effect on the tremor to ataxia and muscle contractions

In Part II of this series, I will address selection of the globus pallidus internus (GPi) as the DBS target.

 

References

  1. Benazzouz A, H.M., Mechanism of action of deep brain stimulation. Neurology, 2000. 55 (12 Supplement 6).
  2. Ashby P, R.J., Neurophysiologic aspects of deep brain stimulation. Neurology, 2000. 55 (12 Supplemental): p. 17-20.
  3. DBS Anatomy & Side Effects. A Presentation by Kirk Finnis, PhD. Medtronic.

February 13th, 2017

What’s Your Sign(out)?

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

My house is a disaster zone. After working a string of 12-hour shifts, there is a mountain of dishes in the sink and a minefield of dirty clothes on the floor. As I navigate that post-apocalyptic landscape, my mind tends to wander back to the hospital I just left. I sometimes pause on the small victories, sure, but more often I find myself focused on all of the potential improvements.

I’ve noticed that the flavor of reflection often depends on my very last interaction of the day. For shift work in the ICU, that means sign-out: the ritual of passing pertinent patient information from one clinician to the next. There’s a reason it feels like that single act can make or break a shift. Because it can.

Sign-out can be a stressful time for medical providers and a dangerous time for patients. Every transition of patient care presents a chance for effective communication or an information fumble. It can be the difference between a missed diagnosis and a brilliant save. It can mean success or failure.

There might not be a single perfect method of sign-out, but there are key concepts to keep in mind and pitfalls to avoid. I offer some here:

Find a system: A little organization goes a long way toward ensuring a safe sign-out process. Variation between clinicians is O.K. as long as everyone provides information in a logical fashion.

Some teams and hospitals, particularly large-volume academic centers that feature many individual hand-offs in a given day, have developed standardized systems to assist in the sign-out process. At least one randomized crossover study suggests that a computerized system can save time and might improve patient care.

Allow Questions: The absent smile, the slow nod. The glazed-over eyes that stare right through you. If you see these signs, chances are you’ve lost your audience. It happens more than we like to admit and is a sure-fire way to miss important information. It’s also the reason sign-out should be a safe place for both parties to ask questions and seek clarification.

Of course, how and when we ask questions is just as important. Avoid confrontational language or tone and try to limit interruptions. A good sign-out should sound more like a dialogue than an interrogation.

Lose the Retrospectoscope: It’s tempting to become a sports analyst during sign-out, to look at information and retrospectively judge the decisions of our predecessors. Of course, that kind of glaring hindsight bias is unfair to our colleagues, especially if we don’t have a complete understanding of the context of those decisions. A harsh critic on the receiving end of sign-out will only hamper communication and may foster an environment of animosity rather than an open and honest exchange of information.

Avoid Anchoring: In an effort to give a complete sign-out, we often include our opinion, theories, and clinical judgment in the information we pass on to our colleagues. It makes sense to summarize our conclusions and attach a diagnosis or prognosis to the patients for whom we cared. Why make our counterparts reinvent the wheel, right?

Unfortunately, this habit anchors our colleagues’ brains to our ideas and negates much of the benefit of having a fresh set of eyes on a problem. We may unintentionally influence them to ignore signs that would otherwise prompt a workup, or to stick to a particular treatment plan despite an evolving clinical situation. Even if we are conscious of these risks, once an idea is planted in a colleague’s mind, it will continue to exert subconscious bias on future decisions. An idea can be as contagious as a virus.

Sign-out is a great time to take a step back and reexamine possibilities that might have been dismissed. It is an opportunity to open up the differential diagnosis, however briefly, and acknowledge alternative possibilities. This doesn’t mean we should start every workup from scratch. But we should maintain the same skepticism that we would apply to a new patient. Besides, if two clinicians still reach the same conclusion, they are much more likely to be on the right track.

Of course, this concept is not restricted to the world of diagnosis. It’s just as dangerous to transmit other judgments about our patients. If we say a patient is mean or rude, we have set up our coworkers to be less empathetic toward that person. If we dismiss someone as “just a little crazy,” the next caregiver could miss important signs of withdrawal or intracranial hemorrhage. The negative effects of cognitive bias are dangerous enough without passing them on to the next shift.

There are many great ways to improve clinical sign-out. Please leave yours in the comment section below.

 

February 8th, 2017

Want to Work Abroad?

Megan Tetlow, PA-C

Megan Tetlow, PA-C, is from Fort Myers, Florida, now working in Sheffield, England, as part of the National Physician Associate Expansion Program. She practices in gynecologic oncology and is a guest blogger for In Practice.

Have you ever thought about working abroad? Maybe like me you’ve always daydreamed about living and working in another country, maybe you’re hungry for a new experience, or perhaps recent political news in the U.S. has you googling the feasibility of moving to Canada. Regardless of your motivations, for those individuals motivated and willing to do the legwork (and paperwork!  I’m not going to lie, there’s quite a bit of paperwork.), it is possible to work outside of the good old U.S. of A. Today, I would like to share some of the potential avenues for American physician assistants interested in working abroad.

While the U.S. has by far the largest PA workforce (over 100,000 proudly certified PAs!), other countries are trialing and adopting the PA role in their own health systems. I currently practice in England as part of the National Physician Associate Exchange Program, a two-year program to expand the role of PAs in the National Health Service in England. A colleague of mine participated in a similar program in Scotland. Australia and New Zealand both have conducted similar trials investigating the PA role and how it could be integrated. Closer to home, Canada has a growing PA workforce, and American PAs that have graduated from an ARC (Accreditation Review Commission)-accredited PA program and are certified by the NCCPA (National Commission on Certification of Physician Assistants) are eligible to take the Canadian PA Certification Exam. Other countries that employ PAs include Northern Ireland, Wales, the Netherlands, South Africa, Ghana, and India (let me know in the comments if I’m missing anyone!).

Another path for American PAs to work abroad is via a post through the U.S. government. Several federal organizations employ PAs and other healthcare practitioners to provide medical care while their employees are abroad. The U.S. Armed Forces employs civilian PAs to provide care to members of the military and their families on bases both in the U.S. and overseas. Continuing in the vein of government employment, the U.S. State Department hires PAs as Foreign Service medical providers to provide primary care and preventive health services to state department employees and their families. These posts are usually carried out on two-year overseas tours in a wide variety of locations across the globe.

The possibility of working for NGOs and other aid organizations also should not be overlooked. Organizations such as the Peace Corps employ PAs as medical officers. In this role you would be providing medical care to Peace Corps volunteers both within the U.S. and abroad. Additionally, various private companies, research groups, and contract firms employ PAs to support their employees all over the world, from Nepal to Antarctica (bring your mittens!).

Also, while not technically abroad, another option for American PAs is working in a U.S. territory. For example, PAs can work in both Guam in the Western Pacific and in the U.S. Virgin Islands in the Caribbean. Family practice on Friday, snorkeling and piña coladas in St John’s on Saturday? Yes, please.

Finally, there are many avenues for volunteerism abroad as a PA, in both secular and religiously affiliated roles, with both short-term and long-term options. The Peace Corps welcomes PAs and other healthcare provider volunteers in a number of opportunities in community and public health on two-year tours. There are dozens of groups and charities that coordinate shorter-term volunteer work abroad as well (mention any you are aware of or happen to work for in the comments!). PAs for Global Health, a nonprofit organization for PAs interested in volunteering in medically underserved areas around the world, has numerous resources for PAs interested in medical volunteerism abroad.

The road to working abroad is not always easy. There are frustrations and crossed wires, cultural differences, and paperwork — always paperwork. But for those with a will to work abroad and an open mind, it is also an incredibly rewarding experience that I am so grateful to be having. If you have an interest, I encourage you to seek out a similar opportunity. Please see the resources below for more information. Until next time, cheers!

Resources:

1. National Physician Associate Exchange Programme

2. The Faculty of Physician Associates (UK)

3. Canadian Association of Physician Assistants

4. Openings for civilians within the U.S. Military

5. U.S. State Department Foreign Service Medical Providers

6. Peace Corps

7. PAs for Global Health

February 2nd, 2017

From Leogane to Longwood: How Different Are Our Patients?

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

When I worked in family medicine, I considered my practice to have two very distinct patient populations — the pediatric population I served from their birth to adolescence and the adult population — each with a very different set of needs. Now that my practice has changed and I care exclusively for patients over age 18, I am focused on a more limited set of diagnoses and issues. Returning from volunteer work doing patient care in Haiti a few weeks ago, I thought about the Haitians and my U.S. patients: Are these now the dual populations that I serve? Are these two different worlds to be straddled? Or are they more similar than they seem?

I believe that the differences appeared starker to me when I first arrived at Toussaint L’Overture Airport in March 2011. The landscape and population needs —one year after the massive earthquake that is still a defining point of Haitian history — were like nothing I had ever seen.

The view from a clinic site

I was raised in a small New England town and have lived my entire adult life in Boston. However, as I spend more time in Haiti, the edges continue to soften, the lines to blur. And during this year’s trip, it seemed clear to me that there are more commonalities than disparities between my Haitian patients and those who visit me in the Longwood Medical Area of Boston.

One clear example is a clinical visit involving a mother and child. Working in Brockton, I saw many patients for their first newborn visits and then for subsequent well-child checks or urgent concerns. In Haiti, due to the sporadic nature of our clinics, I cannot provide the continuity of care that American children receive. However, mothers there have the same urgent care questions, expressing their concerns over an earache, a loss of appetite, or a fever that leaves a child sweating through their pajamas. They want to know: Are their kids getting what they need? Are they as mothers providing the right interventions? What is “normal”? The American mother and the Haitian mother care equally about their children, regardless of differences in health care and other resources. They share a core desire to understand and help their children. And they both need and respond to the reassurance that a healthcare provider can give, the reassurance that is, 99% of the time, the most important part of an interaction with a patient.

Nurses, interpreters, and patients in clinic

Discussions with adult patients also share common themes, like work-related health effects; outdoor laborers have dry eyes, those who do physical work are more apt to complain about musculoskeletal pain, etc. Age and involvement of family can affect a patient’s ability to obtain care, in both Haiti and Boston. A patient with no one nearby to offer care sometimes presents when a concerned neighbor or friend finally brings them to a visit. Often, these patients are more likely to have mental health issues as a result of their isolation. Although social barriers to health may be present on a wider scale in one place versus another, they are present in both places.

Finally, the truth remains that the anatomy and pathophysiology of disease in one human are largely the same as in every other human. Even as we advance our understanding of the effects of ancestry and genetics on health, by and large, our assessments and interventions are the same because one patient does not vary so significantly from another. Each blood pressure we measure in Leogane is done the same way as one measured in Boston. A diabetic person is more prone to heal slowly from an infection in either city. A severe stroke has the same debilitating consequences in either place.

In recent days, we have heard much on the news about the differences between people both within and outside the borders of our country. From my unique and privileged position as a healthcare provider, it seems to me that now is a good time to be reminded of the basic human commonalities we all share; we really are more the same than we are different, from Leogane to Longwood and around the world.

Elizabeth, a colleague, and a returning patient

January 26th, 2017

Can Medical Professionals Ask Patients About Guns?

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

A student recently asked me if clinicians can talk to patients about gun ownership and safety. Her question triggered my month-long search for data to provide a solid evidence-based response.

Alas, my research did not unearth such an answer. But I did find endless writing that discussed this increasingly contentious question in terms of rights, ideology, law, politics, ethics, and medicine.

I realized that if we are to have an honest discussion about the relevance of gun safety to medical practice, it is essential to study the major conundrums that have caused polarization among patients, providers, state legislatures, and medical organizations. The American Medical Association (AMA), the American Academy of Pediatrics, and the Society of Adolescent Medicine are examples of organizations that encourage clinicians to counsel patients about gun safety; they oppose legislative action that limits or obstructs such discussions. Florida and Montana are examples of states that have passed legislation that limits questions by physicians about gun ownership, a stance supported by gun lobby groups.

The Issues                        

Can we legitimately call gun violence an epidemic like polio, measles, and HIV? 

According to gun lobby groups, gun violence is not an epidemic. Epidemics refer to diseases; more specifically, to surges in infectious disease. The use of the word epidemic is a misnomer aimed at creating an emotional response. Some dismiss such language as rhetoric and hyperbole, lacking in caliber and sincerity.

Undeniably, epidemic in the past was limited to infectious diseases. Today, the scope is much broader: an epidemic refers to a condition, disease, or undesirable phenomenon that affects a disproportionately large number of the population. Such new definitions can be seen in dictionaries like Merriam-Webster and the Oxford English dictionary: “the practice had reached epidemic proportions” or “an epidemic of crime.” Given this change, it is reasonable to refer to gun violence as an epidemic.

If we look at an epidemic as “a surge” or disproportionate increase, such terminology becomes questionable. Firearm mortality rates have generally remained stable over the past 30 years. The agency defines an epidemic as “a recent increase in amount or virulence of [an] agent.” I am not sure we can say gun violence is virulent, although it may feel so at times. If we consider gun violence in terms of type, then we can see America has had a stark increase in mass shootings — namely an epidemic. Precision in the language of medicine matters.

 What about the data? 

According to the CDC, the total number of firearm-related deaths in 2015 was 36,252; of these, 2824 affected individuals aged 0-19 years. Mortality data can be subdivided into suicide, homicide, legal, and unintentional. Whether or not you consider these numbers to be disproportionately large is somewhat subjective: how many deaths from firearms are too many? Gun lobby groups cite that few of these deaths are accidental; some are related to gang violence or are suicides, but this surely leaves us making value judgments according to intent, mechanism, or ideology. Are deaths from suicide any less preventable or tragic?

How do we define a “public health issue,” and are guns a threat to public health?

Gun groups contend gun violence is not a public health issue, as most injuries and deaths occur from the negligent or malicious use of a firearm. It is neither a disease nor a medical problem. Thus, questions regarding gun control and measures to ensure public safety should be under the jurisdiction of the legal system. The National Rifle Association sees the public health approach as an attempt by medical organizations at gun control.

Public health is defined by the CDC Foundation as “the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention.” Given the number of injuries caused by firearms, it is legitimate to consider gun violence a public health issue. Merriam-Webster also includes “preventive medicine” as part of its definition of public health. Talking to patients about gun ownership and safety is preventive medicine.

Are questions about gun ownership an invasion of privacy or violation of the Second Amendment?

Gun lobby groups and gun owners see questions about ownership of firearms as a value judgment. Some worry that documentation of gun ownership in medical records might be accessed by the federal government to create databases. Others consider clinician questions about guns as a challenge to their Second Amendment rights. They cite fears that the information will be used to discriminate against gun owners or discourage gun ownership. They consider these discussions to be an underhanded means of promoting an anti-gun political agenda.

Medical organizations argue that personal questions are an essential part of medical practice inherent to the clinician-patient relationship. Pediatricians ask about guns just as they would car seats, swimming pool fences, and safe storage of noxious chemicals. Patients have the right to decline to answer such questions. Additionally, the AMA suggests that “physician gag laws” violate the First Amendment rights of clinicians.

Reconciling rights and ideology with the Hippocratic Oath (duty to protect) is difficult. In response to my student’s question: yes, medical professionals can ask about gun ownership and safety, but they need to be attentive to state legislation that sets parameters for such questions and cognizant of the patient’s right not to answer. A reasonable approach is to ask such questions in situations where gun ownership and gun safety are relevant to the context of the encounter: a well-child check, gun-related injuries, or when patients are at risk of suicide or homicide.

January 19th, 2017

Interview with Jon Harris, PA-C — Health Care for the Homeless

Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.

Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.

I met Jon Harris, PA-C, during his days as a PA student at Northeastern University and was immediately impressed. He excelled in my course, and I knew that he was destined to be an impactful clinician. He previously had graduated from Columbia University with a degree in environmental sciences and spent several years working in the nonprofit, nonmedical community. On a friend’s advice, he started volunteering as an EMT in rural Vermont and quickly found a love for medicine. Jon now works for Boston Health Care for the Homeless Program (BHCHP) and makes a difference everyday in a medically challenging population.

BB: So, how did you become interested in BHCHP?

Jon Harris, PA-C

Jon Harris, PA-C

JH: Actually, I originally thought I wanted to go into oncology, and then I did a rotation during PA school at a state hospital for low-income patients and I loved it. I found the same type of challenging medicine that I sought with oncology, but in a unique population. I found that I connected well with the patients and felt like this was the work I wanted to do. I didn’t even know BHCHP existed but was introduced to the organization by a generous PA who helped me during my job search. It’s fascinating medicine, but more importantly, it is a venue where close relationships with patients make a difference. I find it satisfying to tune into the person in front of me and recognize if they need something like humor, time for silence, or just brutal honesty.

BB: Sounds like you really love the work, what’s your favorite part of the job?

JH: I really do. I love this job because it connects me to the beauty of another human being. Homeless people may appear disheveled on the street or arrive intoxicated for multiple visits to the emergency room, and these sorts of things unfortunately create distance between them and their medical providers. I have found, however, that when we speak to each other in the exam room and let pretenses and guardedness dissolve, patients communicate to me that they want the same things I do: loving relationships and a fulfilling life. Not only do we share similar dreams, but we also have the same shortcomings.

BB: You clearly have a passion for working with this population, but I’m sure — like with most jobs — there are challenges. What’s the most challenging aspect of working with the homeless population?

JH: Yes, I have definitely explored and discovered the boundaries of my compassion doing this work. For example, I took care of a young pregnant woman who was also addicted to multiple substances. She would repeatedly arrive at our clinic high, requiring us to send her to the OB/GYN clinic that specializes in pregnant women with addiction. Thinking of the injury she was repeatedly causing her unborn child made me furious. I forced myself to remember her awful childhood filled with its own abuse and addiction. This works sometimes, but not often. In the end, I recognize that with some patients I need to accept the sinking feeling of not knowing where to find empathy and do my best to treat the human being in front of me.

BB: That must be tough. Do you see illnesses on a regular basis in this population that most other clinicians don’t see that often?

JH: The team sees chronic illness at a greater severity than many other clinicians in other health care settings. For example, many of my diabetic primary care patients have a terribly high hemoglobin A1c with multiple complications: peripheral neuropathy, chronic kidney disease, limb amputations, etc. Because our patients often have an extensive problem list, we also face the challenge of managing heavy polypharmacy.

In addition to what I’ve already mentioned, we also see a lot of HIV, hepatitis C, cirrhosis, and addiction. These are usually related to alcoholism and IV drug use.

BB: Do you only see these patients in the clinic or urgent care?

I frequently am asked if we only provide urgent care to the homeless population. We actually provide primary care in quite unique settings. PAs work in shelters. Our workspace is literally a clinic embedded within a shelter. We have a Street Team that does rounds throughout the streets of Boston providing care to patients who prefer to stay on the street instead of the shelter, as well as a Family Team that works with homeless families.

Photograph by Christian Kozowyk. Reprinted with permission BHCHP.

Photograph by Christian Kozowyk. Reprinted with permission from BHCHP.

BHCHP also has a 104-bed inpatient respite facility, the Barbara McInnis House, which is staffed mostly by PAs and NPs. We admit patients who are too sick to be on the street but not sick enough to be admitted to a hospital, such as someone with pneumonia or requiring perioperative care. I spend one day a week working at the Pine Street Inn, a shelter in Boston’s South End, and the remaining three days at the Barbara McInnis House.

BB: Wow! You have a lot of diversity in your job. What is one piece of advice that you’d give to someone looking to transition into working with the homeless population?

JH: I once asked a patient to give his advice on working with homeless people to a new provider I was orienting at BHCHP. His eloquent response best answers this question:

“I’ve been an alcoholic since my father gave me liquor when I was a kid. Please don’t think you’re going to cure my alcoholism. You’re not. Instead, I would really appreciate you taking the time to listen to me.”

BB: That’s incredible advice. Thank you for taking the time to chat with me and sharing what you do. I bet you have inspired some people to look into health care for the homeless.

January 11th, 2017

On the Front Lines of Regional Medicine

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

Being of Alaska Native decent, my desire to practice medicine in Alaska was only natural. However, once I started venturing out into the large geographical region my institution serves, I realized there is nothing scarier than sending a fragile patient home to some of these isolated areas.

A large part of my job is to collaborate with regional providers. With my limited knowledge on the subject, I decided to ask exactly what it’s like to provide regional specialty care to children across a vast area of land.

In speaking with Dr. Jim Christiansen, pediatric cardiologist in Anchorage, I learned a great deal. With only 4857 miles of paved roads in Alaska, access to clinics is typically a combination of many modes of transportation. Think planes, bush planes, boats, and snow machines. His practice, which he shares with one other cardiologist, travels to 11 different practice sites throughout the state. Most of these visits rely on air travel.

Dr. Christiansen says a fair number of his patients rely exclusively on mail-order pharmacies to get their medications, which makes for some creative thinking when weather or other natural phenomena interrupt mail delivery. In fact, there was a time a patient ran out of Coumadin only to be rescued by his school principal who was also taking the medication.

Often times, the choice of surgical procedure (e.g., mechanical vs. bioprosthetic valve) will depend on geographical location and accessibility to appropriate INR monitoring. This proves to be especially challenging when a patient requires Lovenox, as there are only two labs within the state that manage low-molecular-weight heparin levels. In the Bethel census area, there is only one pharmacy serving an area the size of Oregon

planeRoughly 70% of Alaska’s physicians reside in only two cities (Anchorage and Fairbanks). In general, subspecialty care is restricted to these locations. Sometimes villages are staffed by a health aide for care. Pediatric specialties are especially limiting — for example, Dr. Matthew Hirschfeld, director of maternal-child medicine at Alaska Native Medical Center, travels to Nome approximately once every other month. Up until about 4 months ago, he was the only pediatrician who traveled to the region. Nome serves as the central hub for 19 surrounding villages. The total population for Nome and these villages is about 10,000, with about 40% being younger than 19 years old.

Being one of the only pediatricians who travels to Nome, Dr. Hirschfeld and his case manager follow roughly 300-350 kids who either have chronic medical conditions or who have been referred for consultation.

Alaska is not the only state with limited resources. I have worked with areas in central Washington and Montana, informing local hospitals and fire departments of fragile patients. I have gone as far as providing education for each specific patient. As one can imagine, with HIPPA laws being what they are, this gets to be tricky.

sledDr. Jeremy Archer, pediatric cardiologist in Billings, Montana, has similar concerns. Not only is he a cardiologist, he has a master’s degree in health outcomes and policy. So he is quite passionate regarding the topic of Regional Medicine. Dr. Archer has found a calling in creating quality-improvement pathways for fragile patients. He believes the same level of care should be given regardless of patient location. He has created risk-stratification guidelines for his patients and is very open-ended with families when discussing outcomes and location to care. He occasionally advises patients that it would be in their best interest to relocate to bigger cities, despite the financial and social challenges for their families. He feels honesty regarding outcomes is best.

In addition to providing cardiology care to his patients, Dr. Archer assumes the care of gastrostomy tubes and other noncardiac needs. It is often too difficult to find specialty care specific to his patients needs in such areas.

Knowing these limitations, my job is to help patients prepare for discharge with the goal being home disposition. However, some of our patients are so fragile, and live in such distant villages, that we have started to collaborate with local hospitals to transport patients back to the institution they came from. For example, in Anchorage, before sending patients home, we transport them to the Alaska Native Medical Center, which then arranges travel back to their medical hub, where a pediatrician sees them before transport all the way home. Best case scenario: at each phase in these transfers, provider-to-provider communication occurs to formally hand off each patient. The hope of this interaction is to decrease the number of fragile patients discharged without adequate resources, thereby lessening the subsequent bouncebacks to the hospital or even subsequent deaths.

I ask myself, in our ever-changing healthcare system, is it irresponsible to leave these patients in such need? Or is what we are doing — bringing more and more awareness to regional medicine — enough?

January 8th, 2017

7 Medical Terms to Ditch in 2017

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

Your new diet plan might fail. That daily planner might collect dust on the corner of your desk. The gym membership gifted by a well-intentioned (but not-so-subtle) cousin might go unused. But fear not. You can still resolve to make 2017 just a little bit better than last year. And it starts by cleaning out the clutter of some terminology that must retire.

The following list includes terms that in some way hamper, impede, degrade, misinform, or otherwise gunk-up communication in the healthcare setting. If you’re rolling your eyes and thinking to yourself, “oh great, a grammar snob is going to spend an entire blog picking over the semantics of my charts,” you’re right. But you already clicked on the link so you might as well keep reading.

Besides, you might like it.

“Liver Function Tests” or “LFTs”- People often use the phrase “liver function tests” (or “LFTs”) to refer collectively to aspartate transaminase (AST) and alanine transaminases (ALT). Although this shortcut is ubiquitous in healthcare, we have inexplicably agreed to accept a complete misnomer. Generally speaking, the AST/ALT values do not describe liver function as much as they represent enzymes released in the setting of hepatocellular destruction or death. It’s like calling your favorite cocktail “liver function sauce.”

In fact, there is a longer list of labs that better represent the metabolic and synthetic function of the liver that often seem to escape the traditional umbrella of “LFTs.” While I’m sure most clinicians understand this concept, many still enjoy the convenience of the erroneous term. The fix is simple: use “transaminases.”

toothpaste“Regular Rate and Rhythm” or “RRR”- Another common shortcut that places convenience over accuracy, you’ll find this abbreviation in the physical exam section of many progress notes. Even some large, commercial electronic medical record services place the “triple Rs” as a one-click option. You’ve probably already guessed my beef: while a rhythm can be regular, a rate cannot. Use “regular” to describe your rhythms and your toothpaste. Call your rate “normal.”

“Nauseous” vs. “Nauseated”– I’m the first one to admit my own guilt here, but it’s important to know this distinction when you’re confronted by a real grammar geek. The primary definition of “nauseous” is actually “causing nausea.” So during morning sign-out when you say your patient “became nauseous overnight,” someone might think he made his nurse puke. But I bet you really meant the patient experienced nausea or was nauseated.

By now, you might think this blog is pretty nauseous, too.

“AAM”/ “AAF”- When I read this abbreviation in the first line of a note, I assume it means “African-American male” or “African-American female.” The truth is, I don’t really know. There should be a separate debate about whether or not race/ethnicity/skin tone should be included in the first line of a note. But this term has plenty of other reasons to get the boot. There’s the confusion factor: it could just as easily mean Asian-American male, Armenian-American female, or any other combination of words based on your geographic perspective. And then there’s the respect factor: my patients are “ladies” and “gentlemen” (or something else, if they prefer). Leave the gonadal descriptors to the biologists.

“Little Old Lady” or “LOL”- I assume this is a relic of the pre-texting era. But since I have read this in a real present-day chart, I feel obligated to include it. There’s an image this phrase conjures: your own grandmother set down her knitting needles and her tea and drove herself to the hospital. It attaches the kind of bias that makes even the best clinicians miss the diagnosis of alcohol withdrawal or a sexually transmitted infection. Plus, in the abbreviated form, it sounds like you had a good laugh in the middle of writing your note. This vernacular belongs in its own retirement home.

The entire Glasgow Coma Scale (“GCS”) – Like the VCR, the floppy disc, and most technology from the 1970s, the Glasgow Coma Scale (GCS) has outlived its utility. The GCS was designed to communicate neurologic status in trauma patients and has since crept into the lives of nearly every other specialty.

And what’s not to love? In a single number you can communicate a wealth of information about your patient’s mental status.

Except it doesn’t work. A GCS of 10, for instance, tells you that something is wrong but nothing more. It could be a confused patient with quadriplegia. Or it could be a patient who followed your every motor command but refused to open his eyes or speak until you knuckled his sternum. Besides, were those “motor responses” bilateral and equal or was there something focal to report? And did his eyes open spontaneously because he was seizing?

The fact is, any score other than a perfect 15 or a rock bottom 3 requires a longer explanation. And that’s a conversation you could have without attaching a silly, confusing number.

Midlevel”- The letters behind my name mean I am contractually obligated to mention this once per year. The collective term for PAs and NPs (and CRNAs and nurse-midwives) is not “midlevel.” Pick your favorite reason as discussed by every blog on the Internet: an outdated hierarchy of medicine, the false idea that PAs somehow bridge the nursing and medical worlds, the implication of substandard care.

But I offer an appeal to your pragmatic side. “PA/NP” is only five characters when typed. “Midlevel” is eight. So if you won’t ditch the term for your colleagues, do it to save space on Twitter.

Scour these terms from your vocabulary and leave a comment with your own medical term to ditch in 2017.

December 22nd, 2016

A Lesson in Hospitality

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

A couple of weeks ago I was wandering through the centuries-old walled city of Assisi in the central region of Italy. I was lost in the quaintness of the cobblestone streets, the piazzas, the fountains … and then curiously interested in the oldest thing I had ever seen up until that point (having not yet reached our destination of Rome, the Eternal City) — the Temple of Minerva erected in the 1st century BC. I started thinking to myself — looking at all the beautiful white stone, the view of the city in the valley from our perch atop a hill — if nursing doesn’t work out for me, I could definitely move to Assisi. And then I heard our tour guide, Giuseppe, start chatting about the town hospital. So much for my vacation mentality.

He told the story of a building that was located in close proximity to a monastery, a convent, walled-city-of-assisiand a cathedral. My friend Giuseppe — a farmer who tended to olive trees and goats most days of the week but on others was a secret historical expert tending to groups of tourists tromping through his father’s hometown — began to explain the hospital of the 15th century. He told us of the hospital as a resting place for those who were suffering, a refuge for those with few resources — the poor, the hungry, the sick.  They came to this place to be cared for, to rest, to receive what the monks and nuns all those centuries ago had to give — they came to receive hospitality.

Where this blogger has decided she will live if she retires to Italy

Where this blogger has decided she will live if she retires to Italy (photo by Mary Donahue)

I think I had an existential revelation in that moment (one of many to be fair): Who could go to Venice and not be mesmerized? Who could gaze at the ceiling of the Sistine Chapel and not be moved to feel something bigger than themselves? But also this one, a revelation standing in front of a hospital built in the 1400s, on a tiny street in the small town of Assisi, thousands of miles from home: I could stand in that place finally appreciating the meaning behind the place where I spend 40 (or let’s be honest, more like 60) hours of my week. A hospital, the place where one sought hospitality.

Seven hundred years later, I don’t think it’s just the etymology of the word hospital that gives it the same meaning as that small white stone building in Italy. The same spirit lives inside the doors of Brigham and Women’s Hospital — and I have the privilege to see it every day. We may not be wearing habits or robes (scrubs are more practical and comfortable), and life is generally much more secular here, but we are providing the same basic services for people from all walks of life that the clergy of the 15th century set out to offer. Staff from all disciplines (registrars, nurses, florists, providers, valets) are essentially hosts for our patients. We listen to them when they tell us what type of aid they are seeking, we help determine what they need, and we do our best to provide it. So while over the course of many years, our specialties, education, titles, technology, and so much else has changed, it still comes down to this place of hospitality, a place for those in need to seek care and others being present to provide it. It is certainly a reminder for this provider to be the best host I can be.

Hospitality — the friendly and generous reception and entertainment of guests, visitors, or strangers 

Hospital — a charitable institution for the needy, aged, infirm, or young

The Donahues pause for a family photo during their trip.

The Donahues pause for a family photo during their trip.

NP/PA Bloggers

NP/PA Bloggers

Bianca Belcher, MPH, PA‑C
Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Harrison Reed, PA‑C

Advanced practice clinicians treating patients in a variety of settings and specialties

Learn more about In Practice.