People make poor decisions about when to call their physicians when they are faced with new or worsening symptoms regardless of their level of education.  I came close to making a similar mistake about 8 years ago that could have cost me my life.

It was early in the Fall of 2003 when I started having symptoms of an aching pain in my left shoulder.  It would come and go, and I thought it was due to some sort of musculoskeletal strain of that shoulder or referred pain from a neck problem.  I started noticing it would occur when I was walking or doing other exercise.  My wife & I were on vacation, and during a round of golf I noticed it when I had to walk across the fairway to my ball.  Again, though in the back of my mind I thought it could be my heart, I denied that possibility.  I thought it was due to the fact I hadn’t swung a golf club in years.  What made me face the possibility of something more serious occurred about a week later.  When my wife & I were walking our dog on a Sunday evening it became clear that the pain was brought on by walking.  Adding to my concern and suspicions of something more ominous was an accompanying profound tiredness and shortness of breath relieved by rest.  I called my primary care physician the next morning.  He suggested I call a cardiologist since I would probably need a stress test or possibly a cardiac catheterization.  I immediately called one of the cardiologists I knew, and he scheduled a stress test for me the next day.

The next day I had the stress test with an accompanying echocardiogram.  The echocardiogram shows how the different portions of the heart are functioning under the stress of exercise.  As I was exercising that left shoulder discomfort began and persisted throughout the rest of the test.  My cardiologist was there the whole time and said the EKG (elctrocardiograph) portion of the test looked good, but he had some questions about what the echocardiogram was showing.  He was going to speak with one of his partners about it.  He wanted me to get dressed and would see me in the exam room.  I changed back to street clothes, and went to an exam room.  There the nurse checked my blood pressure and found it to be a bit low, so she had me lay down.  My doctor soon came in and said he wanted to do a cardiac catheterization that day to determine why one of the walls of the heart was not moving normally.  (When your coronary arteries are blocked, certain areas of the heart wall don’t get enough oxygen-carrying blood and will move abnormally.)  Of course I agreed, but wanted him tell my wife, Mary.  She soon joined us, and as he started to tell her, everything went black and I had a cardiac arrest.

They made three attempts at electrical defibrillation before finally bringing me back with the fourth. The first thing I remember is a nurse lifting the oxygen mask from my face and asking, “Are you back with us?”  I guess I still had my sense of humor because I replied, “I didn’t know I had left.”  Everyone was relieved and all the staff involved with my resuscitation laughed.  Mary, who was waiting in the hall, heard the laughter and started to breathe a little easier.

My point in relating my experience was to show how even a doctor who deals with these signs and symptoms every day with his patients can be in denial about his own situation. If not for my finally facing my symptoms objectively and the good fortune of having the cardiac arrest in the absolutely best place, I probably would not be writing these words.  It’s better to be overly cautious about new or worsening symptoms.  Let your doctor assess them, because they can deteriorate in an instant.

In future posts I’ll share more of my experiences with the health care system.   I’ll talk about surviving two hospitalizations and making lifestyle changes to prevent another heart attack.  In the next one I’ll give some pointers about how to handle new and worsening symptoms.

For Your Health – Dr. Bob

One of my responsibilities in my current and past positions is the coaching of nurses to help them better improve the health of the health plan members with whom they speak.  Consequently I have listened to a lot of conversations between them and the members.  (Yes, this is a case of the phrase we’ve all heard hundreds of times, “this conversation may be monitored and recorded for quality purposes” being true.)  I often hear members at a decision point in their lives, a point when they are trying to decide what to do about some new or worsening symptom they are having.  Often they have made a decision, and it is just fate that our nurse is speaking with them.  Very often, their decision is not the best one from a health perspective.  When that happens our nurse can usually guide them in making a better decision. 

Unfortunately, it is only a coincidence that that conversation took place.  There are countless times that a person is making the wrong health care choice because they don’t know how to make a better one.  Many times it’s because they don’t understand all the relevant issues surrounding illnesses or using the health care system.

Let me give you an example of the kind of poor decisions I mean.  This example is a composite from many conversations I’ve either heard personally or heard about over the years.  In this example, a patient was just discharged from the hospital on an antibiotic after being treated for his emphysema complicated by acute bronchitis.  Instead of getting a little better each day, this patient actually was feeling worse wih increasing difficulty breathing.  When the nurse suggested he should call his doctor right away to have his worsening symptoms evaluated, he said he’d just wait until his scheduled appointment with his doctor in 2 weeks.  Fortunately the nurse was able to convince him to see his physician that same day.  The doctor switched his antibiotic, and he started improving after the third dose of the new medication.  The nurse knew that without prompt evaluation and alteration of therapy, he could deteriorate very rapidly with the only recourse being a trip to the emergency room and rehospitalization.

Why did he plan on waiting?  Several thoughts come to mind.  He might have been in a state of denial regarding how serious his symptoms were and how quickly they could deteriorate.  Or perhaps he didn’t know their significance at all.  I find that hard to believe since people with emphysema typically have frequent attacks that start quickly.  Maybe he wanted to avoid going to the doctor since he thought he might be put back into the hospital.  Of course, avoiding the physician while his symptoms grow worse will not prevent hospitalization, if anything, the delay can make it more likely. 

Another rationale I’ve heard is that the patient wants to avoid the copay for the doctor’s visit.  The only problem with that logic is that the copay for the emergency room is usually a lot more than that for the doctor’s office visit. 

Finally, some patients don’t want to bother the doctor for something that they think will go away on its own. The trouble is that patients don’t always know their bodies the way they think they do, and instead of going away, things often worsen.  An important part of a physician’s responsibility is responding to their patients’ needs after office hours.  Most doctors make arrangements with other physicians to provide this service when they are unavailable so that their patients can get help whenever they need it, so it really is no bother.

From my experience, these are some of the most common explanations for why people make these poor health care decisions.  Next time, I’ll discuss some things to consider when you are faced with this kind of decision.

For Your Health – Dr. Bob

Changing any behavior, especially ones associated with our daily lifestyle habits, will take a lot of energy and work.  Everyone has great intentions when they first start a weight loss program or stop smoking.  As they get into the program and realize the difficulty, they often rethink whether it will be worth it.  This is where they need to draw from the strength of their motivation for starting to make these changes in the first place.

In my opinion, it is best to identify your motivations while you are in the planning stage, before you start making your changes.  You need to clearly identify why you are committing yourself to the work involved in changing your target behaviors.  You should write this and all components of your change plan down in a notebook or keep it on your computer so you can refer to it later.

Motivations come in all shapes and sizes.  They can be related to improving one’s health, looking better, being more attractive to one’s partner or wanting to see one’s daughter get married.  They can be somewhat abstract, such as, “I want to feel better” or much more concrete, such as, “I want to stop smoking so I can avoid hospitalizations for my lung disease.”  Motivations can be relatively trivial or much more serious, such as, “My husband thinks I’m too fat, and the spark is gone from our marriage.”  These are common reasons for people to want to change their behaviors.

Again, as you begin to make your behavior change plan, you should identify and write down your motivations. Over the following months as you make the necessary changes you will be faced with barriers to your success.  The strength of your motivations will help you conquer those barriers.  The more meaningful the motivation is for you, the greater its power.

Goals are often related to motivations.  For smoking, it is to completely stop smoking by a specified date.  For the woman who wants to be able to wear a certain bathing suit when she and her husband go to the Bahamas in July, her goal is to lose a specific number of pounds by a specific date, the date her trip begins.

A lot has been written about the characteristics a goal should have.  The concept of SMART goals identifies the key characteristics.  There are some differing thoughts as to what each of the 5 letters stand for, but here is one that makes sense for what we are discussing:

• Specific – What needs to happen by the goal date for the goal to be met?  For smoking, it is usually complete smoking cessation.  For weight loss, it is losing a certain number of pounds or weighing a certain amount.
• Measurable – It needs to be something that you will clearly know that it has been attained or not.
• Attainable – The goal can be reached taking into account the goal date.  Losing 50 pounds in one month is just not safely attainable.
• Relevant – It is relevant to you and your condition and circumstance.  This often ties in with motivation.
• Timebound – There is a specific target date when the goal is to be attained.

As you prepare your plan be sure to use these characteristics in writing your goal. 

Please add your comments on these topics or share some of the motivations you’ve used to reach your own goals.

For Your Health – Dr. Bob

Over the upcoming weeks and months I’ll give you my thoughts about the behavior change planning process.  I have added a page to this blog, the Weight Loss Plan Components page,  that gives an overview of the components of most behavior change planning.  Even though it’s focused on weight loss, it’s useful for whatever behavior you are trying to change.  Weight loss is a little more complicated than most others since it usually includes behavior changes in eating and exercise. 

By the way, think of behavior change as habit change.  Most of the healthier lifestyle activities that we want to add to our lives require changing or stopping our current not-so-healthy habits or behaviors.  Usually the best way to stop one behavior is to substitute another healthier one for the unhealthy one. 

Since you are reading this, you are at the very least considering making some behavior change.  Starting to build your plan will require you to consider why you want to make your change and how will you know you’ve succeeded.  It’s best to spend the time writing your own behavior change plan before you take action.  On the next post, we’ll talk a bit more about goals and motivation.

Regards,

Dr. Bob

I truly believe that a lot of smart people don’t understand and don’t apply some basic concepts about wellness, illness, treatments, the roles of the members of the health care team and how to interact with these pieces.  Throw into the mix the varying levels of coverage health insurers provide and the rules they have in place, and it’s no wonder many people are confused about what to do when they face a medical situation in their lives.

This gap in health care literacy is costly in terms of people’s health and additional cost to the system when they make choices that are ill-informed from the viewpoint of basic health principles.  Some may make a distinction between health literacy and health care literacy.  Health Literacy would be defined as the knowledge of wellness, illness, managing one’s acute and chronic conditions and responding medically appropriately when things change with one’s health.  Health Care Literacy might be defined as the knowledge of how to use the health care system, including where to get care when necessary and efficiently and effectively using your health care insurance benefits.  For simplicity, I’ll use Health Care Literacy in this blog to include both of these concepts since they are closely related.

So what are we talking about here?  In a recent (March 1, 2011) Washington Post article, Sandra G. Boodman from Kaiser Health News, cited several examples of low levels of health literacy, such as, misunderstandings of discharge instructions leading to the development of life-threatening infections, or individuals not using prescribed medications properly because they don’t understand the directions.  I would add to this list instances where people misjudge the severity of their symptoms and wait too long to contact their physician.  The delay often allows their condition to deteriorate further so that when they do seek care, the physician is forced to send them to the emergency room or admit them to the hospital.  Antibiotics that could have been taken by mouth if begun earlier must now be taken intravenously, often in the hospital with added risk of complications, poorer outcomes and higher cost.  I have personally heard about examples of this happening many times.  And these incidents add up.  Boodman references a 2007 study that estimated the cost of this problem to the US economy could be as much as $238 billion annually.   This problem is widespread as demonstrated by a 2006 survey published by the U.S. Department of Education which found that only 1 in 8 adults has the skills to deal with complex health material.

I plan to publish posts to help improve a person’s health care literacy.  They’ll talk about some basic approaches a savvy health care consumer can take to optimize their health, minimize the impact of illness and save money.  I welcome comments about this post as well as suggestions about related topics of interest to help guide the discussion.

Regards,

Dr. Bob