Going to see your doctor these days can be like sitting an exam. You have to get all your information ready beforehand, and then when you are in the examination you have to try and remember everything that might be important. Effective communication is the key to getting the most out of your doctor – so how do you do that? Here are 5 top tips on how:

1)      Prepare. Before you even leave your home, list all the symptoms you can, whether or not you think they are relevant. If this is a routine check-up, note any changes since last time. List any and all medications being taken and how often, to help the doctor understand your current medication regimen.

2)      Honesty. Be up front about lifestyle choices. If alcohol, tobacco and other drugs feature then be clear about this to help the doctor to see the big picture. Do not avoid raising a subject just because you think it is sensitive or embarrassing. If you hide something from the doctor they may not be able to make the best decision for you.

3)      Pertinence.  If you do not ask questions then the doctor might assume that you understand and nothing else needs explaining. So you should pipe up with any Who / What / When / Why / How questions that you might have. Query any medical terms used that you don’t understand. Ask about treatments and procedures as well as the doctor’s general diagnosis.

4)      Persistence. If you feel that you haven’t understood what the doctor has told you, ask for clarification. Do not be rushed or made to feel stupid or awkward – it is their job to explain it to you. If necessary, schedule another visit or phone call to clarify things. And of course, you are always within your rights to seek a second opinion.

5)      Particulars. Write down everything that you’ll want to remember. Ask for literature (not just books and pamphlets, but also audio and video) that is relevant, and trusted online sources of information.

Above all, remember that for communication to be effective, both sides have to be understood. Your questions need to be heard and answered, and the doctor’s information needs to be clear and understandable.

Taking proper care of a sick person, whether it is yourself or a loved one, needs an understanding of the condition and treatment – so don’t go home without both.

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I attend physician appointments with my patients every day.  I am always surprised at the lack of questions posed from the patient and/or family members.  When did we decide that the doctor knows best and we should simply take his or her advice without questioning the why, how come, and what is my alternative?  A story in Better Health suggested that there are typically five reasons patients fail to ask questions.

1.  Fear-In my practice I do feel that there is a fear of many of my patients that they will look or sound stupid.  I think it is much more stupid to fail to ask!

2.  Doctor Knows Best-Someone had to graduate at the bottom of their class.  Is it your doctor?

3.  Not wanting to interrupt-These days the visits are shorter and shorter and our physicians are rushed to get to the next room, but you are the one paying for this visit.  Be prepared with questions in hand and take the time you need.

4. Not being asked by the doctor if they have questions-Fifty percent of the time or less, physicians fail to ask their patients if they have any questions.  In my experience, very few visits end with a physician requesting questions.  Good thing I am there to help.

5.  Feeling rushed-This goes back to number 3.  It’s your time.  Ask questions now because it is much easier to get an answer when you are face-to-face with the doctor than trying to get an answer from him or the staff at a later date.

As a case manager, I work as an advocate for the patient.  I help them remember what they planned to ask and even ask questions on their behalf.  I educate my patients on the terminology used by the physician and provide alternative treatment options to consider.  Unfortunately, not everyone has a case manager to attend their appointment with them, but there are things you can do to make the most of the time you have with your physician.

• Be prepared-do your homework, research your condition, have your medication bottles with you, complete your health history
• Write down your questions-this way you won’t forget to discuss each item and if you are too fearful to ask, you can always hand the questions to your physician or the staff
• Remember you are a consumer-it is your right to not only ask questions, but to be an active participant in your own health care

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A Massachusetts jury has awarded the family of Antwoine Key more than $2 million in a wrongful death lawsuit filed against a Massachusetts doctor allegedly responsible for his death. In 2001, Dr. Dorina R. Abdulah had deemed Key medically eligible to play collegiate basketball at Eastern Connecticut State University. Key died on the court in 2005 of hypertrophic cardiomyopathy. During his review, Abdulah found a “slight systolic murmur” in Key’s heart, but deemed him healthy enough to play. The lawsuit claimed that Abdulah should not have approved Key to play without further examination.  Stewart Bishop, Boston Globe

As a mother of adult children, I know how difficult it is to “make” them do things they don’t want to.  No matter how much I have their best interests at heart, there is only so much parents can do once their children have become of age, especially if they go away to school.

In this case, this young man could still be alive if he had followed up on getting the electrocardiogram.  Just guessing here, but I would bet his parents urged him to go and like most young adults, he didn’t see the importance of it.  I am not trying to place blame on the victim, the physician had responsibility to follow up with him and to make it clear to him the potential danger that could be involved if he didn’t get fully checked out.  She also signed off on him to play college basketball without the test, which could have been leverage to force him to go—i.e. refuse to clear him for sports without the test, which in my opinion is exactly what should have happened.

Bottom line, if you aren’t clear about something your doctor recommends, ask for details, and find out what the ramifications are if you elect not to take his/her advice.  If you aren’t satisfied with the answers, get a second opinion.

I contacted an attorney client this week to let him know that a potential care management client might be calling to speak with him about my work.  I asked that he be brutally honest and not embellish.  He shot back an email that stated he would just tell her that I was too busy, stressed out, and always takes on too much.  (Now, I must explain that this was said with tongue in cheek and he later stated he would never hesitate to recommend my work and never worried about his reputation being on the line for said recommendation.)  The problem; he was pretty spot on.

Ellen Fink-Samnick, a case manager and Commissioner for Case Manager Certification, recently published an article in Care Manager entitled Being in a Caring Profession Doesn’t Mean We Can’t-and Shouldn’t-Care for Ourselves.  She explained that this syndrome of fatigue, stress, and burn out is an occupational hazard that comes with being a health care services professional.  I couldn’t agree more.   We must advocate for ourselves just as we advocate for others.

Ms. Samnick feels that if we cannot give our own needs priority or at least equal attention that we give to our clients and patients we threaten the quality of case management.  A good friend once told me that if I don’t set my priorities someone would set them for me.  Oh so true!  But also a tough concept as a small business owner.

Avoiding burnout requires a different prescription for different people.  During one such period of burnout, my father became critically ill with renal cell carcinoma.  I began to provide case management services for him just as I would one of my other patients.  After seeing the tremendous relief of my family secondary to what I was doing, it renewed my love for what I do. Some nurses facing stress and fatigue may need to spend some time doing other things they wish to accomplish such as writing or speaking or taking a class.  Others may need to take a yoga class or get a pedicure or massage.

Some of us (me included) need to be reminded of this often.  Being a small business owner makes setting priorities (especially for self-care) extremely difficult.  I often feel that if I were to turn down a job when overwhelmed, I will not receive another.  As I get older, and the business has a proven track record, I see some progress in caring for myself.  Having new grandbabies on the way may help push me to take advantage of more downtime as well.  I can’t think of a more relaxing time away from work than rocking an infant.

Are you battling stress and burnout.  What do you do to care for yourself?

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This year marks the centennial year of Florence Nightingale‘s death.  Florence Nightingale (1820-1910) is the founder of modern nursing.  Her contributions to nursing theory, education, practice, research, statistics, public health, and healthcare reform are foundational and inspirational and allow me to do what I do today.  She was a health care advocate to influenced leaders of her time.  She impacted public awareness and changed how people understood and valued health.

Not only was Florence Nightingale a patient advocate, she was also an advocate for nurses and nursing.  She asked that we continually be renewed to sustain our effective, compassionate, and caring practices (something I need to do more of).

This year a grassroots organization has come to honor nurses, our values and wisdom, and to act as catalysts for achieving a healthy world.  There are estimated to be more than 15 million of us.

International Year of the Nurse, has set out 8 goals.

1.  Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empower women

4. Reduce child mortality

5. Improve maternal health

6. Combat HIV, AIDS, malaria, and all communicable/noncommunicable diseases

7. Ensure environmental sustainability

8. Develop a global partnership for development

To learn more go to 2010iynurse.net

As fall prevention programming becomes embedded in more community sites, as well as health care settings, it is useful to find a statistical analysis of the evidence regarding the most effective types of exercise programming.  A meta-analysis was conducted to establish the effect of exercise on falls rates and to determine the particular features of effective fall prevention exercise programs.  After identifying 1,107 relevant studies, the authors applied strict inclusion standards resulting in a final sample of 44 randomized clinical trials where it was possible to discern the specific exercise intervention and falls were measured as the outcome.  Combined, these trials involved a total of 9,603 older adults, the majority of which were community dwelling.  However, 6 studies involved older adult nursing home patients.  Estimates of the effects of exercise were statistically extracted from each study.  

Results:  This review suggests that among older adults, exercise programs can reduce fall rates by as much as 17%.  Sub-analysis excluding nursing home residents did not change the results.  The greatest effects of exercise on falls were obtained from programs that:                          

• Challenge balance to a high extent—starting at an appropriate level and individualizing the program to gradually increase the challenge to standing balance.  The authors suggest that Tai Chi is effective for fall prevention because it meets these criteria.
•  Include a higher total dose of exercise—the minimum effective dose equates to a twice-weekly program lasting 25 weeks.  It is suggested that supervised sessions that gradually increase intensity, should be interspersed with instructions to practice between classes at home.  The typical 10 week courses are too short.

(Having both of the above was particularly effective.)

• Did not include a walking program—The authors speculate that this unexpected finding may be due to:    

a) time spent walking may reduce the amount of time spent practicing balance, for example in a timed center-based class, or

b) an increase in activity, such as walking, could precipitate more falls among frail people. 

They observed that walking programs were often offered to more high risk populations.  *The authors note that walking offers many health benefits and that it is to be encouraged.  But if the goal is fall prevention, time is better spent practicing balance. 

Strength training was not shown to be effective in reducing falls.  The authors speculate that increasing strength in the absence of improving balance may account for this finding.  Strength training increases strength, whereas standing balance exercises improve balance and because they include maneuvers that involve maintaining control of body weight-against-gravity, to some extent they simultaneously improve strength.

Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close CT.  (2008). Effective exercise for the prevention of falls: A systematic review and meta-analysis.  JAGS 56: 2234.   

Source: CT Collaboration for Fall Prevention

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Traditionally vitamin D has been recommended with respect to preventing osteoporosis, reasoning that improving the absorption of calcium improves bone strength making them less likely to fracture, should there be a fall.  Thereafter it was discovered that vitamin D has direct effects on muscle strength.  Severe vitamin D deficiency (as one might see in those nursing home residents who do not eat well and are virtually never in the sun) can present as muscle weakness and pain which resolves with vitamin D supplementation.  

Several early trials examining the extent to which vitamin D could prevent falls were unsuccessful.  These studies may have failed to produce the hypothesized result due to methodological issues:  low doses of vitamin D were used; vitamin D is available over-the-counter and may have been in use by those in the control group creating bias toward the null; and finally an issue we can all identify with — the difficulties associated with ascertaining the prevalence of falls due to using an unstandardized definition or incomplete ascertainment.  

A meta-analysis (“study of studies”) conducted by an international team of researchers, was recently published in the British Medical Journal1 to further address this issue.  The meta-analysis included 8 double blind randomized controlled trials of individuals 65 years or older receiving a defined oral dose of supplemental vitamin D3,  vitamin D2  or an active form of vitamin D and with sufficiently robust fall ascertainment.  The aim was to assess the efficacy of vitamin D supplementation for the prevention of falls among older persons by dose and serum concentration of vitamin D [25(OH)D].  The primary outcome measure was the relative risk of having at least one fall among persons receiving vitamin D (with or without calcium) compared to those receiving placebo or calcium supplementation alone.  Note that the current recommended adult daily dose of vitamin D is 400 international units. 

Results:

No fall reduction was observed for a daily dose of less than 700 IU vitamin D or achieved serum 25(OH)D concentrations below 60 nmol/l. 

Daily vitamin D doses in the range of 700 IU to 1000 IU or achieved serum concentrations between 60 nmol/l and 95 nmol/l reduced the risk of falling by 19%.   It is possible that higher doses of vitamin D or higher 25(OH)D concentrations would further reduce falls.  Results were attained with treatment for less than a year (2-5 months) and the benefit was sustained for 12-36 months.

 Preventing falls using this higher dose of vitamin D may not depend on taking additional calcium.

The authors note: “Binding of vitamin D to its nuclear receptor in muscle tissue may lead to de novo protein synthesis, a benefit that appears to precede the effect of vitamin D on bone.”  

*Since vitamin D is fat soluble and stored in the body it can accumulate to toxic levels over time and therefore periodic blood levels should be assessed.

1.  Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP and Henschkowski J.  Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials.  BMJ 2009; 339:b3692.

Source: CT Collaboration for Fall Prevention

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Did you know that today has been designated as World Alzheimer’s Day?  Alzheimer’s is a degenerative neurological disease affecting millions worldwide.  The theme for this year’s World Alzheimer’s Day is: Diagnosing Dementia: See It Sooner. The ultimate goal of World Alzheimer’s Day is to gain the attention of the media and to ensure legislative bodies and political entities across the world are reminded of the impact that Alzheimer’s and dementia will have on our growing elderly population.  Every 70 seconds someone is diagnosed with dementia.  We need to raise awareness so healthcare practitioners recognize the importance of early diagnosis and treatment as a way to slow the progression of the disease.

The Alzheimer’s Association provides us with the following facts:
• There are as many as 5.3 million people in the United States living with Alzheimer’s.

• Alzheimer’s and dementia triple healthcare costs for Americans age 65 and older.

• Alzheimer’s is the seventh-leading cause of death.

• The direct and indirect costs of Alzheimer’s and other dementias to Medicare, Medicaid and businesses amount to more than $148 billion each year.
These are just a few of the facts in the new report, 2009 Alzheimer’s Disease Facts and Figures. The report is a comprehensive statistical abstract of data from the United States on Alzheimer’s disease that includes:

• prevalence
• mortality
• the costs of Alzheimer care
• caregiving
• a special report on Mild Cognitive Impairment and early-stage Alzheimer’s

There is still no cure for Alzheimer’s, however, there are many medications on the market that have the proven ability to slow the progression of the disease. Common drugs approved to slow the progression of the disease include Namenda, Reminyl, Aricept, and Exelon. Although research has afforded us the ability to slow the progression of the disease, we still need a cure. Worldwide, there will be memory walks, lectures, and other activities to help raise funds for the research to find a cure for Alzheimer’s. The following is a list of some of the sights where you can get involved, and maybe, be a part of the Memory Walk for a Cure.

In the United States
http://www.alz.org/memorywalk/overview.asp
Alzheimer’s Association
http://www.alz.org/index.asp

In the United Kingdom
Alzheimer’s Disease International
64 Great Suffolk Street
London, SE I OBL
United Kingdom
info@alz.co.uk
http://www.alz.co.uk/adi/wad

ABLEDATA: Provides information on assistive technology and rehabilitation equipment, including how to find and purchase it.  Also offers an online forum for consumers, caregivers and others to submit and read reviews of products and classified ads of equipment for sale. (800) 227-0216

http:/ / www.abledata.com

Able Project.org: A nonprofit organization with an online directory that allows people to research, compare, locate and obtain mobility and assistive products, such as wheelchairs, canes, walkers, bars and rails. (408) 263-8000

http:/ / www.ableproject.org

Alzheimer’s Association: Provides reliable information, care consultation and supportive services for dementia caregivers through state and local chapters. The website also includes an interactive tool, CareFinder, which helps families to:
• Recognize dementia care
• Plan and pay for care
• Communicate with care providers
• Find local support and resources

(800) 272-3900
http:/ / www.alz.org

AssistiveTech.net: Government-sponsored website with a directory of assistive devices and other products, which includes information about cost and vendors. (800) 726-9119

http:/ / www.assistivetech.net

Association of Jewish Family & Children’s Services (AJFCS): An online directory of AJFCS  member agencies throughout the country. Services include:
• Care management
• Chore services
• Adult day services
• Kosher meals on wheels
• Respite care

(800) 634-7346

http:/ / www.ajfca.org

CancerCare: Provides support services for anyone affected by cancer including limited financial assistance grants for:
• Transportation
• Child care
• Home care

Patient must currently be receiving treatment for cancer (800) 813-4673

http:/ / www.cancercare.org

Catholic Charities: Provides social services to individuals in need, including family support, respite care and home care services.

Eligibility varies by program (see website)

http:/ / www.catholiccharitiesinfo.org

Easter Seals: Assists children and adults with disabilities and their families by providing adult day services, including medical and social services. Children and adults with disabilities. (800) 221-6827

http:/ / www.easterseals.com

Faith in Action: Network of interfaith volunteer caregiving programs across the country. Volunteers shop, cook, drive or just check in on those with long-term health needs.

Eligibility varies by program (see website) (866) 839-8865

http:/ / www.fianationalnetwork.org/

Hospice Foundation of America: Provides information about end-of-life care. Its website includes a “Locate a Hospice” search which allows the user to search for hospice and palliative care programs, and a “Caregiver‘s Corner” that offers publications and tips on caregiving for persons near the end-of-life. See website for local contact information.

http:/ / www.hospicefoundation.org

Lutheran Services: Provides services ranging from health care to disaster response, as well as services for children and families and care for older adults. Eligibility varies by program (see website)

http:/ / www.lutheranservices.org

Meals on Wheels Association of America (MOWAA): Offers online directory of local meal programs across the country for adults who are elderly, homebound, disabled, frail, or at risk.

http:/ / www.mowaa.org

National Adult Day Services Association (NADSA): Online directory of NADSA member agencies throughout the country (including adult day services and adult day health programs).

(800) 558-5301

http:/ / www.nadsa.org

National Association for Home Care and Hospice (NAHC): Online “Agency Locator”  helps consumers to find and choose a home care provider in their state and local area to match their specific needs. Database consists of NAHC members, more than 20,000 home care and hospice agencies.

http:/ / www.nahc.org

National Association of Professional Geriatric Care Managers: Online directory of its members, who provide services throughout the country at varying fees. These professionals (nurses, social workers, etc.)  specialize in aging and elder care and can help families assess needs and plan suitable care.

http:/ / www.caremanager.org

National Center on Senior Transportation: Provides online directory of transit agencies and community transportation providers for older adults. A toll-free line is available to answer questions regarding transportation services for older adults. (866) 528-6278
http:/ / www.seniortransportation.net

National Hospice and Palliative Care Organization: Provides information about end-of-life care. Its online “Find a Provider” search allows the user to search for member hospice and palliative care programs for individuals who have advanced illness or have been considered terminally ill by a physician. (800) 658-8898
http:/ / www.nhpco.org

National Private Duty Association (NPDA): Online directory of home care agencies, both medical and non-medical, in 44 states.  Database consists of NPDA members.

See website for local contact information

http:/ / www.privatedutyhomecare.org

National Resource Center on Supportive Housing and Home Modification: Sponsored by the University of Southern California, the website features a section entitled “Home Modification for Caregivers” and an online national directory of home modification resources geared to help older persons remain independent.

http:/ / www.homemods.org

Senior Corps- Senior Companion Program: Provides assistance to frail older persons and adults with disabilities so they can live independently in their own homes or communities. Volunteers offer:
• Respite for caregivers
• Companionship to care recipients
• Help with various tasks and chores

Frail older adults and adults with disabilities

http:/ / www.seniorcorps.org

Shepard’s Centers of America: Some centers hold monthly meetings of education and support for those who care for older adults. Centers also provide:
• Respite care
• In-home visitors
• Home health aides
• Support groups
• Adult day care
• Information and referral

(800) 547-7073

http:/ / www.shepherdcenters.org/ memberCenters.aspx

United Way: Over 1,350 programs operating throughout the country to promote increased access to health care for disease prevention and treatment, and medical rehabilitations for people with disabilities. Services focus on under- and uninsured populations.

http:/ / national.unitedway.org

Visiting Nurse Associations of America (VNAA): Online resource helps consumers locate a VNA in their area. VNAs offer comprehensive home health care or personal care to individuals in their respective communities for a fee. The website includes tips on choosing a home health agency and information about insurance coverage. Services vary by agency but may include:
• Skilled nursing
• Home health aide services
• Rehabilitation therapies: physical, occupational and speech-language
• Medical social services
• Hospice and palliative care services

• Anyone requiring care – medical orders from a physician are usually required for care
* Individuals must pay privately. Medicare, Medicaid or private insurance may pay for the service if the care is medically necessary, depending on each payer’s eligibility requirements http:/ / www.vnaa.org