Documenting Malnutrition. Part 1

There are several types of malnutrition. There is protein malnutrition (kwashiorkor), calorie malnutrition (marasmus) and the combined protein calorie malnutrition. In our society, the most common form of malnutrition is the latter and it will be the one most used in the medical records. There are also several degrees of malnutrition, mild, moderate and severe) and they can be associated to an acute or a chronic process. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommends that the diagnosis of malnutrition in the adult patient be supported by the presence of two or more of the following: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized edema, and decreased handgrip strength¹. The degrees of malnutrition can be seen in tables, available online² 

Properly documenting malnutrition requires to have the discipline of always including in the history of present illness (HPI) and review of systems (ROS) a nutritional history. A significant percentage of the disease processes that lead to an admission of a patient to the hospital include a problem with food intake or weight loss. In addition to this, the physical exam can enable us to describe the loss of muscle mass, the loss of subcutaneous fat, the presence of edema and the decreased handgrip strength. The assessment and plan (A/P) should include a nutritional diagnosis (if pertinent) and its chronicity, degree of severity and type.

Lastly, once the diagnosis is established, a plan to deal with it has to be formulated. This plan could be a dietitian consult, a gastroenterology consult for a feeding tube, an interventional radiology consult for TPN vascular access, to cite some examples.

References

1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

2. http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved December 13, 2016

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

What is Obstructive Sleep Apnea? Who is at Risk?

Obstructive Sleep Apnea (OSA) is a very common condition in which the upper airway gets obstructed by relaxed soft structures during sleep. This obstruction leads to inadequate air exchange in the lungs, increased diaphragm and chest wall muscle contractions as efforts to relieve the obstruction occur. In addition, OSA is characterized by poor sleep quality due to multiple brief periods of waking up during the night as the body moves and loud gasps happen. Finally, due the the poor sleep quality, daytime sleepiness is a feature of this condition, with all the problems this entrails.

There are certain groups of people who are at risk of having OSA. Obese or overweight individuals, patients with enlarged tonsils or large tongues, people with a thick or large neck or individuals who have upper airways with small diameters. The formal diagnosis of OSA is made with an overnight sleep study, however it can be strongly suspected if a person has daytime sleepiness, snores loudly and if there are visible episodes of “not breathing” (apnea) during sleep.

OSA can lead to elevated blood pressure, problems with attention and concentration, daytime sleepiness, irritability, and headaches. Treatment includes the avoidance of alcohol, sleeping on a side, use of a continuous positive air pressure (CPAP) device, surgery to remove extra tissue, and the use of an implantable upper airway stimulator. A primary physician will be able to refer someone who may have this condition to a local sleep specialist.

Marco A. Ramos MD

5 Facts Everyone Needs to Know About Factor V Leiden

Here are 5 facts that everyone needs to know regarding a common condition that predisposes to potentially deadly clot formation, either deep vein thrombosis (leg clots) or pulmonary embolism (lung clots).

1. Factor V Leiden (FVL) is a mutated Factor V, one of the factors essential to form a clot. The mutated factor, once activated, is more difficult to clear by the body, being this the reason why people with this mutation may form clots easier than people who do not have it.

2. About 5% of Caucasians have at least one copy of FVL (of 2 possible from mother and father). It is rare in other ethnicities. 0.02% of Caucasians have the two mutated copies.

3. A person with one copy of FVL has a 4 to 8 times increased chanced of developing a clot. A person with 2 copies has up to 80 times increased risk of developing a clot. Someone with a normal Factor V has a chance of developing a clot of 1 in 1000 in 1 year. This means that an individual with one copy of FVL can have a 4-8 in 1000 (0.4-0.8%) chances to develop a clot in a year and an individual with the 2 copies can have a risk of 8% per year to develop a clot.

4. Smoking, estrogen therapy, pregnancy and recent surgery are situations known to increase the chance of blood clots in any person, however the effects can be more pronounced in people with FVL

5. If a person with FVL develops a second clot, he or she is a candidate for lifelong anticoagulation (blood thinning) therapy.

References

1. Learning About Factor V Leiden Thrombophilia. Retrieved on August 28, 2016 from https://www.genome.gov/15015167/

Marco A. Ramos MD

Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

3 Important Things Patients Need to Know About Telemedicine

Technology is improving and advancing fast. What was impossible just a few years ago, is becoming possible now. Nowadays, a physician can see a patient, interview him or her, auscultate, examine the skin, prescribe medications and document in an electronic medical record, without being physically by the patient’s side. 

The first issue that needs to be brought up is the location of the medical act. It has been defined that the medical act occurs where the patient is located. This has consequences regarding licensing and regulations. As it is well known, in the United States, licensing goes state by state, so the physician has to be licensed in the state where the patient is located. This means that, so as the doctor is licensed in the state where the patient is located (and the state medical board is OK with it) the physician can be located anywhere in the world and see, listen and treat a patient.

A second issue is the question of insurance reimbursement. As of today, not all insurance plans reimburse for telemedicine services, although this is increasing by the day. The patients have to be aware if a service rendered by telemedicine will be reimbursed by a particular insurance plan if not paying out of pocket.

The third issue is that there are some specialties that are more ready for telemedicine, than others. For example, Neurology and Psychiatry have been using this services for some years. The surgical specialties (due to the nature of their service) have not quite embraced it yet. It is not impossible to think that in the future, a surgeon might operate remotely, using devices similar to joysticks.

Marco A. Ramos MD

MTHFR mutation. One in 6 people have it. What to do if you have it?

MTHFR mutations are one of the commonly found mutations in genetic testing. If someone is homozygous (carrying one mutation from your father and one from your mother) for the C677T mutation, it may be associated with increased cardiovascular events (heart attacks, strokes), malignancies and birth defects (spina bifida). This does not mean that if someone has the homozygous mutation that person will have a problem. It means that there may be an increased risk.

MTHFR stands for methylenetetrahydrofolate reductase, an enzyme in the metabolic of folic acid. It is also the name of the gene that codes for that enzyme. People with the homozygous mutation have a defective enzyme and  may have some difficulty with the metabolism of folic acid. At the same time, there may be increased levels of homocysteine in the blood, an amino acid associated with thrombotic problems. 

What to do if someone is homozygous for the C677T mutation? Many people find this after testing in commercially available genetic testing. If this mutation is found, a physician or genetic counselor should be contacted. The most likely next step would be an evaluation of homocysteine levels in blood. If normal, the person should be reassured that its risk for cardiovascular events and other problems is probably similar as the rest of the population. If the levels of homocysteine are high, it does not hurt to try to reduce it by having folate supplements and increased vegetables with the diet.

Marco A. Ramos MD

3 Reasons Why “Weight Loss Challenges” May Be Unsafe

Weight loss challenges have become a popular way to lose weight. People who consider themselves to be overweight sometimes gather as a group and engage in them in order to lose the extra pounds they consider they have. On some occasions, these activities are promoted by gyms and “fitness” centers. They may consist on exercise routines that may be extreme and in dietary regimens that may be unhealthy. Here are 3 risks that any person participating in these challenges may be exposed to.

1. Risk of muscle injury. Muscle injury (rhabdomyolysis) is a condition that may happen if muscles which have not been subject to exercise regularly are suddenly exposed to it. The main problem with muscle breakdown (besides the pain) is the release of muscle enzymes into the bloodstream. These enzymes are known to be toxic to the kidneys and are known to cause kidney failure.

2. Risk of low sodium concentration. Low sodium in the blood (hyponatremia) can occur in people when they lose body salts through sweat from exercise and drink pure water or low salt-containing fluids. The body, when dehydrated, tries to retain fluid and when a dehydrated person drinks water most of it stays in the body, diluting the remaining sodium concentration. If sodium becomes too low, it can precipitate seizures .

3. Risk of low potassium concentration. Low potassium in the blood (hypokalemia) is known to happen when someone has a prolonged decreased food intake. The main risk of hypokalemia is the development of cardiac arrhythmias that can cause a person to collapse and even to have a cardiac arrest. 

There are other risks of performing unusual physical activity coupled with severe restrictions of food intake. The ones presented in this post are ones that are known to happen and that may pose a risk to a person’s health. Whenever there is a health related issue that needs to be addressed, the primary physician is the best suited professional that can guide a person through the process. He or she should be able to create the best approach for losing weight

Marco A. Ramos MD

Is Moderate Alcohol Drinking Good for your Cardiovascular Health?

The answer, of course, is more complicated that everyone thinks. For many years, we have been told, (and as a physician I have told people) that drinking alcohol in moderate amounts is good for the cardiovascular health. This is based on  studies that indeed show a decrease in cardiovascular events (heart attacks, strokes and death) in people who drink alcohol moderately compared to non-drinkers or to heavy drinkers. The basis seemed to be an increase in the HDL “good” cholesterol.

Today, with the availability of genetic testing, scientists have been able to identify a subset of people (15-20% of the population) that may get a huge cardiovascular benefit from drinking alcohol moderately. According to one study, they can reduce the risk up to 80%. What this means is that if someone does not belong to this group, drinking alcohol in moderate amounts probably does nothing to the cardiovascular risk.

What are the potential lessons from this information? The first lesson is that Medicine is an evolving science. As knowledge increases, we physicians will be able to practice better and serve patients better. The second lesson is that individualized care is extremely important. Nowadays we tend to look for “fit-for-all” solutions. The reality is that we are all built differently. 

Marco A. Ramos MD

3 Reasons to Obtain a Second Medical Opinion

Healthcare is complicated. Specially if we are talking about complex situations like chemotherapy, dialysis, surgery or advanced procedures. The decisions made between the doctors and the patient will always involve the body of the patient. 

First, a second medical opinion is a way to reassure the patient regarding the course of action its healthcare is taking. There might be many doubts concerning a proposed surgery, for example. A second medical opinion would provide the patient the peace of mind necessary to minimize anxiety associated to the procedure.

Second, a new opinion rendered by a specialized physician would complement and supplement the information that the patient already has. A problem with the current healthcare system is the lack of time physicians have to provide the necessary data that patients need to make informed decisions

Third, a second medical opinion may broaden the options a patient can have. Specialized physicians looking specifically into the patient’s case can provide new insights withe respect to the case and when doing this, alternative therapies can emerge as possibilities when they were not considered initially.

A second medical opinion is a tool that all patients should consider, specially when the the proposed treatment strategies are complex and involve a certain level of risk for the life or wellbeing of the patient.

Marco A. Ramos MD

3 Pieces of Advise if You or Your Relative are Hospitalized

Hospitalization is a reality. It will happen to most of us, for one reason or another. It gets more common as age increases. The hospitalization process can be risky. There are specialized medications being given and invasive procedures performed. Regardless of the training and capabilities of the physicians and the watchful eyes and caring hands of nurses there will be side effects that might threaten the life or well being of a patient.

The first piece of advise is never to be confrontational with the hospital staff. In many occasions healthcare workers are working at the limit of their capabilities. Adding more stress to an already stressful situation by nature (which the hospitalization is) will only create negative feelings towards the patients and families. Healthcare workers are human beings and although they have been trained to be non-judgmental and to treat everyone equally, they are also human beings and have emotions of their own.

A second piece of advise is to make sure that all information about the hospitalization process is understood and that decisions are made together with the doctor. Patients and families sometimes fail to answer the questions because “the doctor already rounded and we missed him or her”.  It is the physician’s duty as the one ordering the treatments to inform the progress to the patient’s and/or families. Nurses know how to locate physicians and they will do it upon patient’s or family’s request.

Last, but not least, what do you do in case, in spite of multiple efforts to comprehend what is going on in the hospitalization process, things are not understood? At this point, what is needed is the intervention of the primary care provider (or even a third party physician patient advocate). Nowadays, there are more and more hospitalist services and the primary providers are staying away from the hospital scene. The primary provider or a private physician patient advocate would be able to interact with the hospital personnel and explain the issues to the patient and family afterwards.

The hospitalization process is complicated, but communication is key to a successful outcome. Barriers to effective communication can convert an already difficult situation into a worse one.

Marco A. Ramos MD

3 Reasons to be Careful with Genetic Testing

Nowadays, it is possible to obtain access to one’s genome data easily and relatively cheap. There are several companies offering this information and together with interesting information regarding ancestry they provide medically relevant data.

The first reason to be careful with is the meaning of the data by itself. The majority of diseases are multifactorial in origin, meaning that not one, but many genes could be involved in their genesis. In addition, the environment is also important, meaning that if even if the “defective genes” are present, a healthy diet and physical fitness can ameliorate the effects. An adequate interpretation of the data has to be performed by a physician and if further questions arise this should be followed by a second medical opinion of a physician with training in genetic counseling.

A second reason to be cautious is the abundance of information in the internet about certain conditions and the recommendations provided by well intentioned, non-medically trained people. We always have to keep in mind that we are unique and that the combinations in our genetic material probably do not repeat in another person. Therefore, the recommendations have to personalized. Again, as in the previous paragraph, your physician has to be in charge of starting a necessary treatment or reassuring the patient if necessary.

Finally, what would happen if an insurance company obtains someone’s personal information? Would they use to raise premiums if they know that you are at risk for a certain condition? Would a person become uninsurable? Privacy of course has to be a key factor here. Even if you disclose information to your personal doctor and he or he makes it part of the medical record, the insurance company might have access to it.

Genetic testing, now widely available and cheap can provide medically relevant information. However, there are risks associated with obtaining it. The primary physician should be in charge of guiding the interpretation and possible therapies associated with it and also has to be instrumental helping you keep the privacy of the information. Also, we cannot underestimate the importance of a second medical opinion.

Marco A. Ramos MD

3 Situations to be Careful if Taking Diuretics

Taking diuretics has become one of the cornerstones of the treatment of hypertension and heart failure. Although it has benefits, it has risks too. Here are 3 situations that any person taking diuretics has to be watchful for.

People usually follow the doctor’s recommendations and take the diuretics faithfully once, twice or thrice a day. However, if the person taking the diuretics develops, diarrhea, vomiting or loses its appetite, he or she runs the risk of developing low blood pressure for volume loss in the vascular system. This can cause dizziness, syncope (passing out) or kidney failure.

Diuretics always carry the side effect of losing potassium and/or magnesium though the increased urine production. The best way to avoid this is to have a balanced diet or to take supplements. Low potassium or magnesium can cause dangerous cardiac arrhythmias or muscle weakness.

A low sodium concentration in the blood is also a potential consequence of the use of diuretics. This can happen if the person taking this type of medication drinks too much water while replacing the losses through the urine. Low sodium concentration in the blood can cause headaches, loss of balance, and if severe, lethargy, seizures and death. All diuretics can be associated with low sodium concentrations, however, the thiazide type of  diuretics are more commonly  related to this problem.

All medications cause side effects. Always talk with your doctor regarding these when starting a new one.

Marco A. Ramos MD

The Three Most Common Causes of Kidney Failure

The kidneys are very important organs in the human body. They perform many functions other than just make urine (see my blog post published on October 23, 2014). The kidneys can lose 80-90% of their total function and there could not be any symptom, however, if more than that is lost, dialysis or kidney transplantation are needed in order to survive. So, what causes kidney failure? The list is long, however, the three most important causes are as follows:

The number one reason for people requiring dialysis is diabetes mellitus. 38-45% of all cases of kidney failure are caused by this condition.

The second cause for kidney failure is hypertension (elevated blood pressure). 25-28% of the people who require renal replacement therapy have hypertension as its main mechanism. We have to keep in mind that many diabetics are hypertensives too.

The third cause for kidney failure is glomerular diseases in general. Many of these conditions are autoimmune and have long and complicated names and can only be diagnosed accurately by a kidney biopsy. 10-15% of dialysis cases are from these conditions.

These three causes account for about 85% of all reasons for going into dialysis. There are other situations like genetic conditions,
medication reactions or toxicity from herbal “remedies” that can also cause the kidneys to fail. Since kidney dysfunction rarely produces symptoms until it is too late, it is important to undergo yearly physical examinations that include basic laboratory workup that would detect that the kidney is failing. 

Marco A. Ramos MD

How to Correctly Rehydrate a Person

How to Correctly Rehydrate a Person

Dehydration can occur due to many reasons. The most common reasons to become dehydrated are vomiting, diarrhea and lack of oral intake. Doctors prefer to use the term “intravascular volume depletion”, however, it sounds too long and complicated. For the sake of simplicity I will consider “dehydration” and “intravascular volume depletion” equivalent terms.

Many people believe that drinking water or beverages like juices or tea are good to rehydrate a dehydrated person. The problem is that when someone becomes dehydrated he or she loses salts together with water. The content of salts in the above mentioned solutions is minimal. As a consequence of that, the body loses salts and water and gets back water. The sodium (the main electrolyte in the extracellular fluid) becomes diluted. Too much sodium dilution can cause problems like headaches and lack of balance. Severe sodium dilution can cause seizures and death.

In addition to what I have just mentioned, when the body is dehydrated, there is a hormone called anti-diuretic hormone (ADH) which is secreted. This hormone does not allow water to leave the body. This can have the effect of diluting further the sodium in the body. This is why, we need the right amount of salts when rehydrating.

There are over the counter solutions available can can help with the rehydration process. A good salty broth can also do the trick. However, if the dehydration is severe and vomiting does not allow proper oral rehydration, you might need to go to the closest emergency department before there is kidney failure or before you collapse

Marco A. Ramos MD

How to Obtain a Second Medical Opinion?

Obtaining a second medical opinion is very important, specially when the medical problem that a person is dealing with is complicated, chronic or needs aggressive and expensive medical care. The primary care provider and the specialist who sees you or your relative may be very good, but ultimately, the body belongs to you and not only you must be seeking  care, but also making sure it is good care.

Here are some steps that may be followed:

1. If you are thinking about obtaining a second medical opinion, you must make up your mind first. If the last medical visit was left with more questions than answers, or you need reassurance, it is always a good habit to give the physician who saw you a call in order to clarify things. Keep in mind that time is not a luxury of doctors these days, so they might just need more time to talk to you. If after talking to the doctor again, questions remain unanswered, then, there is a good case to look for a second opinion.

2. Once the decision is made, you should contact your insurance company in order to see if second medical opinions are covered by your plan and in case they are, to see what physicians can provide it. 

3. When the options are provided, the physicians’ credentials must be verified. You can look into the specific Specialty Board’s website to check the physician’s background and experience.

4. If the choices do not satisfy you, there can be other physicians available. Look into medical schools, hospitals and friends and family recommendations. Do a thorough internet search and verify credentials. Be prepared to pay out of pocket money in these cases.

5. Once the second opinion is obtained, request a written report. This is important because it will give you a document to refer to and will help you when going back to your original physicians. It can contain valuable information and it can help you and your doctor in the developing of the plan of care.

Although requesting a second medical opinion is a right, some physicians may be offended by the fact that you are doing it. Reassure your physician by saying that this is meant for you to be further educated about your condition and its treatment options.

Marco A. Ramos MD

Take a look at www.smopinions.com

The Importance of Organ Donation

Organ donation is extremely important. Many people are currently in waiting lists for kidney, liver, heart, lung, pancreas and intestine transplants. A significant percentage of these patients, pass away before receiving the transplant.

The situation for every organ is different. While people in need for a kidney transplant or a liver transplant can receive an organ (or part of it) from a living donor (provided that the donor is immunologically compatible with the recipient), the other organs need the donor to be a deceased person. Also, while people with kidney insufficiency can undergo dialysis treatments while waiting for a kidney transplant, the situation is different for the other organs because besides medical treatment, there is no effective way of replacing the organ functions. 

How to become an organ donor? There are a couple of ways. Any person, at the time of registering for an state ID or (renewing it) can register as an organ donor. In addition, there are state organ donation registries, accessible through the internet. It is important to carry a card that can provide consent for a donation of organs in the event of sudden death. Living donation is also possible in the event of a friend or relative needing an organ. There are also “paired donation programs” by which, in the event the donor is not compatible with the intended recipient, there could be a “cross donation” by which an organ will be given to a compatible recipient provided that this recipient has a donor compatible with the first recipient.

There are medical conditions that a living donor must not have in order to qualify to donate an organ . These are HIV disease, diabetes mellitus, malignancies or any chronic infectious problem. Also, the donor must not have any condition that may be worsened by organ donation like, for example, chronic kidney disease.

Finally, it is important to say that for the transplant recipient, the problems are not over after receiving the donated organ. They have to continue with lifelong immunosuppressive therapy which has risks of their own. However, overall, it is a second chance for enjoying life.

For further information visit: www.organdonor.gov

Marco A. Ramos MD

The Importance of Individualized Medical Care

In our days, due to the pressures of the health insurance companies (private and public), the legal system, the physician shortage and academia there is a push towards standardizing the medical care at all levels. This would work well if everyone of us were genetically and culturally equal, with the same responses to infectious agents, dietary habits  and the stresses of life in general. However, as you probably already concluded, this is not the case.

Health insurance companies base their profit models in statistics. They use averages, standard deviations and trends in order to make decisions. An individual with a unique problem, who does not fit in the pattern usually creates some degree of stress in the system that needs time to be solved. In many occasions, neither the physician nor the bureaucrats have the time to actually solve the issues.

The legal system uses the “standard of care” as the standard to compare the practicing behaviors of physicians with at the time of malpractice litigation. Because of this, the practicing patterns of physicians tend to be similar regardless of the patients’ uniqueness. This is one of the characteristics of “defensive” medical practice, which increases the cost of care without necessarily increasing its effectiveness.

The physician shortage has created a situation by which physicians do not have enough time to analyze the situation of a particular patient, specially if the problem is complex. This is one of the reasons, why diagnoses of rare conditions can take longer than they would if the physicians had the necessary time to study the rare and complex cases.

Academia has pushed for the practice of “evidence-based medicine”. While this is a great concept specially at the time of gathering knowledge, it can become a problem if the practitioner applies the conclusions of research to patients who do not fit the inclusion criteria of the same research.

There is no simple fix for the healthcare system as a whole. Individuals have to take responsibility of their own healthcare and use the available resources in order to solve their problems, specially if they are complex. for example,there are the private-pay “concierge” practices. These physicians can offer more time to patients and they would definitely make the patient understand his or her own issues. There are also several second medical opinion services, which can provide access to specialists who can dedicate their time to analyze the patient’s case in detail. These services, I believe, understand better the need for individualized medical care.

Marco A. Ramos MD

The 15 Minute Visit to the Doctor's Office

Medical problems can be complex. They have the potential of altering our lives completely and for good and even the power of terminating life. Physicians have devoted a huge proportion of their lives to understand medical issues and to learn the art of palliate if not cure disease. 

Ideally, we should visit a doctor for prevention, advise end general education regarding health problems. The duration of the visit should be determined by the nature of the problem and by the complexity of the tools needed to solve it. Nowadays, in most settings, it is almost impossible to do that. Physicians watch the clock, not because they want to leave and go home, but because there is another patient waiting. And after that patient, there is another and another. All of them can carry problems of similar complexity. Is it fair to squeeze the 13 years of training that a specialist has (not counting the many years of experience after that) into 15 minutes of patient talk? 

An office visit, has the following elements: conversation with the doctor, physical exam, analysis of laboratory values, another conversation to report the physician’s ideas, prescription of medications, ordering further tests, documentation of the encounter and in many occasions, an interaction with the insurance companies to seek approval for certain medications or tests. Is it possible that a good job could be accomplished in 15 minutes?, in 30 minutes? 

This is one of the reasons why the doctor’s office has become a revolving door of patients who come for a prescription refill from a doctor who struggles to keep the practice afloat due to low insurance reimbursements. This is the reason why many complex problems remain unanswered, this is the reason why diagnosis can take longer to be achieved and the reason why so many unnecessary  tests are ordered. This is one of the reason of polypharmacy, medication side effects and medication errors.

What can be done? Nothings substitutes good professional advice. This is why, in order to have a question properly answered, the internet should not be used. It should only serve to seek for a good physician. Second medical opinions provided by doctors that devote the proper amount of time to the medical problems are an invaluable tool that will help not only the person looking for the answer, but also the primary care physician who initially did not have the right amount of time to deal with the issue.

Marco A. Ramos MD

Why a Second Medical Opinion?

The doctor-patient encounter has traditionally been a strict relationship between a physician and the patient requesting the services. However, there were always concerns regarding the cost of the services and how accessible the services were. Starting some decades ago, insurance companies (private and government owned) started to participate in the relationship in an effort to make it more efficient. This had the consequence of spreading the risk and making healthcare more available to people. 

As time passed, healthcare became more dependent on the wellbeing of the insurance programs or companies. In order to be able to provide for all enrollees, the reimbursements to the providers started to decrease and, as a consequence of that, the time that the providers give to the patients also started to decrease (because they had to see more patients in less time so as to pay for overheads and remain profitable.) 

The natural result of this is that people remain with more unanswered questions and more doubts regarding their conditions or diseases. In this current world of gigantic leaps in the development of pharmaceuticals, surgical techniques, gene therapy, amongst others, the explanations that professionals (primary care providers and specialists) need to give their patients are complex. Many patients try to enhance their knowledge by using the internet. This is risky. The internet is filled with unreviewed information posted by un-credentialed people who might confuse or even misguide the patient who needs more answers.

A second medical opinion is a tool that will enable patients to be better informed, to be more reassured regarding their conditions and to bring up the possibility of more educated and effective communication with their doctors. For complex problems, two minds are better than one.

Marco A. Ramos MD