Posts Tagged cough

Telemedicine — the good, the bad and the ugly.

noseviewTHE GOOD:  If your brother is a doctor and you call him for medical advice that is probably good Telemedicine.   The doctor clearly has your interest at heart, you can call again, the doctor will likely look up information and will probably give you some Internet links to check out.  And, the doctor does not want to make you upset or interfere with the relationship you have with your actual doctor.  Good idea, except doctors will not usually prescribe for a relative, or should not.

THE BAD:  The same things wrong with actual provider interactions can still be wrong on video — not being given enough time to state the problem, not enough patient education, not enough of a partnership, and poor follow-up.  Also, prescribing antibiotics for viral infections (the common cold) can be even a greater temptation by video.

THE UGLY:  A low position of the video camera that seems to look up the doctor’s nose — yes, that’s ugly.

The most common reasons for visits to a health care provider are: cough, joint pains and skin conditions.

Evaluation of cough by telemedicine is difficult because it requires looking in the nose, ears and throat and listening to the lungs for wheezing or other sounds.  This is better in person.   Although, a telemedicine follow-up might be just fine.

Evaluation of joint pains is fairly easy with telemedicine.  For example, back pain is usually temporary and x-rays are not advised.  It’s easy to suggest ways to avoid straining the back and be encouraging.  Treatment usually involves over-the-counter medications.

Evaluation of a skin condition also is fairly easy with good quality video.  Diaper rash and acne are no-brainers.  But, trying to separate skin cancer from a benign seborrheic keratosis is a little harder — probably best left to an office visit.

Follow-up visits for lots of things can be done by telemedicine.  A follow-up visit for congestive heart failure can be done by video especially if the patient has a reliable scale at home.

Follow-up visits consume valuable office time that could and should be allotted to new or serious problems.  The phone will often work just as well.  Telemedicine visits can be done when office staff is not working — thus at a much lower overhead cost.

Provider-to-consultant video conferencing is a great idea.  This works particularly well if the two individuals work in the same organization.  If they are not in the same organization financial issues often get in the way.

A fine example of peer-to-peer video conferencing is in the UK where groups of NHS neurosurgeons at one hospital communicate with groups of NHS neurosurgeons at another hospital sharing x-ray images and and clinical details.  Very difficult decisions are often better with input from colleagues — and consistency of care is improved.

Telemedicine does not solve bad-care problems.  Switching bad-care in person to bad-care by video is not helpful.

Telemedicine can reduce the cost of care for simple issues that mainly need better health literacy and for follow-up of known health problems.  The capacity of health care is not adequate in many countries (including the US).   Telemedicine is a provider-extender and needs to be used a lot more.

 

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Say “NO” to antibiotics but then what?

cougherKudos to Consumer Reports for the article on the over-use of antibiotics “How to Stop a Superbug” in the August 2015 issue.  One of the most common reasons people see primary care doctors is cough.  And, as it turns out, most of those coughs should NOT be treated with antibiotics.  Of course, it does not mean they do not need treatment — just not with antibiotics since the cause is usually a recent viral infection.  Antibiotics do nothing for viral infections.

Doctors who inappropriately treat a cough with antibiotics often do so just to get the patient out of the office as quickly as possible.  Statements like “could be early pneumonia” or “I hear some pneumonia” or “you have bronchitis” is the politically correct version of “you will get over it, take this pill and don’t bother me”.

So what is going on?  A virus irritates the lining of the bronchial tubes.  The tubes become inflamed and overly sensitive, causing the symptom of coughing.  Coughing is bothersome, it keeps people awake at night, makes noise at work and after a while it hurts the ribs and chest — it’s super irritating — please get rid of it!

The bottom line is that a virus infection causes a temporary form of asthma.  Doctors have hesitated to make that diagnosis because once you say “asthma” it is like a life-long diagnosis — in fact, it could have been a reason for an insurance company to deny coverage in the past.  So, by avoiding the “a”-word adequate treatment is not offered.  Anti-asthma treatment really works! and it is almost always a temporary treatment (unless the person really does have typical asthma).

Why a researcher would do such an experiment is not clear but they have compared the benefit of antibiotic treatment versus an asthma inhaler for “acute bronchitis” and found the inhaler works better — duh — treating a virus with an antibiotic is a placebo treatment.

Cough after a viral infection, particularly influenza, can last a long time, sometimes months, even though the virus itself is gone.  And, when people have a long-term cough other diseases need to be considered.  A cough that lasts for more than a few weeks usually needs to be evaluated with a chest x-ray as a precaution.

Many times a long term cough is the result of ineffective treatment — the failure to prescribe adequate inhaled medication to begin with.  Sometimes, it is the failure of the patient to have the prescription for the inhaled medication filled (it’s expensive) and sometimes it is a failure to take the inhaled medication correctly.

Very few doctors explain how to take an inhaled medication — it just takes too long, and they expect the pharmacist to do that.  Sadly, the pharmacy tech who hands out prescription has no idea how an inhaler should be used — and the pharmacist is not much better.  Proper technique (click on the link) is critical for the medication to work.

What inhaler is best? — there are several to choose from.  Check your insurance formulary for a combination product containing both a steroid and a bronchodilator.   There are no generics in this class of prescription drugs and that is another story!  Some choices include Dulera, Advair, and Symbacort (there may be others depending on what country you live in).

Again, thanks to Consumer Reports.  But, they did omit the obvious question for a cough:  if you don’t take an antibiotic for a cough, exactly what do you do?  If it’s mild, cough-drops and nasal decongestants are helpful, but if it is a bigger problem an anti-asthma inhaler is often a huge help.  Be proactive, tell you doctor you don’t want an antibiotic for your cough but you do want an asthma medication — bring this article with you.

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