Why you should avoid afternoon surgery – CNN.com
By Dr. Anthony Youn , Special to CNN
Surgery team fatigue and shift changes might spell problems for afternoon surgeries, Dr. Anthony Youn observes. Editor’s note: Dr. Anthony Youn is an assistant professor of surgery at the Oakland University/William Beaumont School of Medicine in Michigan. He is the author of “In Stitches,” a memoir about growing up Asian-American and becoming a doctor.
(CNN) — It’s 3 p.m. You’re checked into the hospital for a routine surgery, scheduled to begin in 15 minutes. This is the first operation you’ve had.
Lying on a small gurney, covered only by a thin patient gown, you begin to shiver. Your heart pounds. Four words race through your head: “Am I gonna die?”
Then you meet the operating room team. The anesthesiologist, nurse anesthetist and operating room nurse all exude a combination of compassion and confidence. This is just what you need.
Your pulse slows, and the shakes disappear. The surgeon and OR nurse hold each of your hands. The anesthesiologist then injects a powerful sedative. The last thing you hear prior to drifting off is, “We’ll take good care of you.”
Why doctors fall asleep while treating you
Suddenly, you’re jolted awake. Intense, blinding lights glare into your face. You find yourself gagging on a thick plastic tube stuck down your throat. The lights turn away. Your eyes begin to adjust, and you see four faces you’ve never seen before.
The time of day you have surgery can affect your outcome.
That was the finding of a 2006 Duke University study published in the journal Quality and Safety in Healthcare. Researchers found operations starting between 3 and 4 p.m. had a higher rate of nausea, vomiting and postoperative pain.
Why is this? I suspect there are two major factors.
Our bodies follow natural circadian rhythms, which regulate our sleep/wake cycle, brain wave activity and certain bodily functions. These circadian rhythms dip between 3 and 5 p.m. each day, causing many of us to feel sleepy.
The Spaniards apparently discovered this long ago when they instituted the afternoon siesta. And George Costanza of “Seinfeld” fame isn’t the only one who naps on the job. Nike and Google have reportedly instituted official sleeping rooms so their employees can deal with the afternoon circadian dip. It’s also the reason why I put a couch in my office.
Unfortunately, there is no napping in the operating room. So it’s definitely possible that getting a case of the sleepies plays a role in the higher rate of adverse events in midafternoon surgeries.
But there’s another factor that’s probably more important.
Most members of surgical teams arrive for work between 6:30 and 7 a.m. That means, when accounting for a 30-minute lunch break, the eight-hour shifts of most anesthesiologists, OR nurses and surgical technologists end at 3 p.m. This is when a new team takes over, sometimes right in the middle of surgery.
So who puts you to sleep won’t necessarily be who wakes you up.
I see this routinely. Although the team members being replaced are typically very complete in the information transfer during handoff, key details about the patient may not be conveyed to the next provider. These details usually aren’t life threatening, but can still have an impact on a patient’s outcome.
For example, the original anesthetist might forget to inform her replacement that the patient doesn’t respond well to a certain nausea medication. The replacement anesthetist (and the patient) then learns this the hard way.
So is there anything that can be done to prevent shift changes in the operating room? Not really.
We’re all human. Health care providers can’t work endless hours or be expected to be completely mistake-free. And there are no signs that workplace regulations are going to be lightened.
But one fact typically remains that should give patients comfort. Anesthesiologists and nurses may come and go, but when you have surgery, whatever time of day, there is one constant. Your surgeon should be with you the whole time.
But if he or she gives you a choice between having surgery at 7:30 a.m. or 3 p.m., think long and hard.
Then choose 7:30 a.m.
Please thank your nurse this Christmas
Feisty patients live longer. Feisty and Educated patients THRIVE!
Letting Patients Read the Doctor’s Notes
By Pauline W. Chen, M.D.New York Times
October 4, 2012
The patient, a wiry businessman in his 50s, needed a
copy of his medical records to bring to a specialist for
a second opinion. He assumed that getting the copies
would be straightforward; the records were, after all,
But after multiple trips to his doctor’s office and the
hospital and several days of missed work, he learned
otherwise. At the hospital, after spending the good part
of a morning hunting down the right person to process
his request, he learned that signing the requisite
permission forms was not enough. He would have to pay
for the copies that would take several days to put
together. Those copies turned out to be incomplete, so
he had to wait another few days, and pay more, for
copies of the missing pages.
At his doctor’s office, the staff and then his own
physician had responded to his request by asking him why
he even needed his records. “I told them the truth, that
I wanted a second opinion, but it was more than a little
awkward,” he recalled. “I’m not sure if my doctor will
treat me differently from now on.”
“It’s like they and the hospital were doing everything
they could to make it harder for me,” he said.
Two weeks later, dossier in hand, he swore he would
never let it out of his sight. But, he added, “I can’t
say that this whole experience has given me a lot of
confidence in my doctor or my hospital.”
This patient’s experience, like those of so many others
who have tried to obtain their medical records, came to
mind this week when I read about the long-awaited
results of a study in which patients were given complete
access to their doctors’ notes. The findings, published
in the Annals of Internal Medicine, do more than shed
light on what patients want. They make our current ideas
about transparency in the patient-doctor relationship a
quaint artifact of the past.
Since 1996, when Congress passed the Health Insurance
Portability and Accountability Act, or Hipaa, patients
have had the right to read and even amend their own
In fact, few patients have ever consulted their own
records. Most do not fully grasp the extent of their
legal rights; and the few who have attempted to exercise
them have often found themselves mired in a parallel
universe filled with administrative regulations, small-
print permission forms, added costs and repeated delays.
Many physicians also remained hesitant to share their
notes, part of the patient’s records, because of
concerns that such openness might have harmful effects
on both their patients’ well-being and their own
practices. Some worried that mention of minor
abnormalities in laboratory values – for example, a
slightly elevated prostate specific antigen or white
blood cell count – could cause patients to worry unduly
about some dread disease.
Other doctors feared that common medical abbreviations
like “SOB” (shortness of breath) or “anorexic” (lack of
appetite) could be misinterpreted. Still others imagined
that writing notes with patient readers in mind would
only complicate the process, adding to the already
Sisyphean administrative demands of practice and
inviting an onslaught of patient e-mails and calls for
Those fears, it now turns out, were largely unfounded.
For one year, the study, aptly called OpenNotes, allowed
over 13,000 patients from three medical centers – the
Beth Israel Deaconess Medical Center in Boston, the
Geisinger Health System in Danville, Pa., and the
Harborview Medical Center in Seattle – to have complete
access to one part of their medical records, the notes
that doctors wrote about them. Within days of seeing
their doctors, patients received an e-mail inviting them
to read the doctor’s signed note on a secure patient Web
site. Two weeks before their return visit, patients
received a second e-mail inviting them again to review
their doctor’s note from the previous encounter.
After a year, almost all the patients were enthusiastic
about the OpenNotes initiative.
Surprisingly, so were the majority of doctors.
Approximately three-quarters of all the doctors said
that such transparency had none of the dreaded impacts
on their practice. Many felt there was more trust,
better communication, more shared decision-making and
increased patient satisfaction. While a portion of the
doctors were hesitant at the beginning of the study, not
a single one opted to stop sharing notes with patients
after the study ended.
“Their fears simply never materialized,” said Jan
Walker, one of the two lead authors and a registered
nurse and health services researcher at Beth Israel
There were several surprising results for patients, as
well. While many said they felt more in control of their
own care, up to almost 80 percent of the patients said
that reading their doctors’ notes helped them to take
their medications more regularly and better follow their
doctors’ treatment recommendations. Furthermore, having
access to their doctors’ notes became so important that
nearly all of the patients said any future decisions
regarding doctors or hospitals would be predicated on
being able to access their records easily.
All three hospitals in the study are working to allow
those patients who participated to continue to have
access to their doctors’ notes. Beth Israel Deaconess,
which already allows all patients to view their test
results on a secure patient Web site, plans to expand
the program even further over the coming year, becoming
one of the first hospitals in the country to allow all
patients open access to notes from not only their
doctors but also their nurses and all other health care
And in what may signal even wider adoption of this new
vision of transparency, representatives from several
national health care groups, including the American
Medical Association and the American Hospital
Association, will be meeting in Washington next week to
discuss the study results and ways of implementing
similar programs in other institutions.
“On the one hand, we call this the `new medicine,'” said
Dr. Tom Delbanco, the other lead author and a primary
care physician who is a professor of medicine at Harvard
Medical School. “But we’re also just giving patients
what is already their right.”
He added: “It’s as we say: Nothing about me without me.”
Good relationships are an important to a positive experience.
Surgery, cancer, bad diagnosis, or simply going to a doctor can be a very emotional experience and you need to be able to communicate with your medical team. Do not take for granted that they know what is important to you and your family.
Client and partner should set aside time and talk over each other’s needs and expectations.
Client and advocate should sit and talk with doctor face to face.
Explain what things are important to you and why.
Your medical team is concerned about your safety and emotional needs. You must let them know what your needs are and how they can help.
Creative positive feelings at the hospital:
Always introduce yourself to people who you meet or come into your room. Ask if you can use first names (if you want to).
Take the initiative in setting the atmosphere YOU want (chatty and relaxed or more calm and quiet).
Ask questions in a direct, positive way. Make requests pleasantly. Try not to demand. Don’t hesitate to request more information when you want it.
Information to obtain for informed consent if a problem arises:
Every situation is unique. Education in advance gives you background information, but information about specific problems can only be obtained at that time. Relax and ask for help understanding the situation. Speak up if you need more information or disagree.
The following questions should help obtain information you need in order to make a wise decisions:
- Tell me more about this drug or procedure. Explain the reasons this is the best drug or procedure for me.
- 2. What are the expected results? Will I be better off for taking it or having it done? Or is it a routine procedure?
- Are there other options?
- Tell me more about the known side effects and liabilities?
- Will its benefits outweigh the side effects?
- What is the risk if I don’t take it or have it done? How long can I wait before deciding?
Don’t let important medical information slip through the cracks. Check out the most comprehensive Personal Health Record & Patient Management System available today at http://www.savvypatienttoolkit.com .
Learn how to collect & use your personal health record to communicate more effectively & receive better care. Best time to do this is right after you have received a medical diagnosis. Do not wait.
Create a free of charge, private, web-based community to organize family, friends, neighbors, and colleagues – a family’s ‘circles of community’ — during times of need. Easily coordinate activities and manage volunteers with our intuitive group calendar. Communicate and share information using announcements, messages boards, and photos.
Top Empowered Patient tips for 2010
Find this article at: http://www.cnn.com/2009/HEALTH/12/31/top.empowered.patient.lessons/index.html
By Sabriya Rice, CNN Medical Producer
- To be an empowered patient, do more than the minimum — take charge of your health care
- Get a second opinion; at the very least, it educates you
- Ask questions, but also be prepared for the answers
- There are resources available If you need discounted or free health care
(CNN) — Being an empowered patient means doing more than the bare minimum. It means taking an active part in your own health care.
Over the past year, we’ve brought you the extraordinary stories of ordinary people who took health problems into their own hands — from a young girl who diagnosed her own condition in science class, to a wife whose memory of a disco tune saved her husband’s life.
Your actions, however, don’t have to be extraordinary: It’s often the little, everyday things that mean the difference between a good health care experience and a bad one. Several common themes run through the stories of the people we’ve profiled. Here are the top lessons that emerged that can help you to become a more empowered patient in 2010.
1. Don’t believe everything you hear (get a second opinion)
“Getting a second or even third opinion is critical, says Dr. Angelo Cuzalina, president-elect of the American Academy of Cosmetic Surgery (AACS). “The extra effort and additional consultations will undoubtedly educate you further… which is always self-empowering.”
2. Ask a ton of questions
You’ve heard the phrase “there’s no such thing as a stupid question,” and experts couldn’t agree more.
To make sure you get all of your questions answered:
• Take a list with you. Let’s face it, doctors are often rushed these days, so it’s up to the patient to be as prepared as possible. One good rule of thumb is to write down your questions beforehand, and take them with you. This can save both you and the doctor time.
• Schedule time for questions. When possible, try to schedule an appointment that gives you enough time to get all of your questions in. “Tell the receptionist you’d like an extended session,” recommends Dr. Linda Reid Chassiakos of the David Geffen School of Medicine at the University of California, Los Angeles, adding that “many providers set up longer visits at day’s end where you can have their uninterrupted attention.” Once you’re there, get the stuff that’s really troubling you out of the way first. “If you save the questions about the burning pain in your groin for a ‘by the way’ at the end of the visit, there won’t likely be time to address your real issue fully.”
• Be prepared for answers. Asking the right questions is great, but it’s equally important to be prepared for the response.”When the visit concerns a potentially serious problem, anxiety, fear, disbelief and denial are omnipresent … the chance of you hearing exactly what the doctor says and remembering what you are supposed to do about it are slim,” bioethicist Art Caplan says. He suggests bringing along someone you trust to be a second set of ears; if no one is available, bring a tape recorder and ask the doctor for permission to record what you are being told.
3. If you are going to use the Web, search smart
According to research from the Pew Internet and American Life Project. eight out of 10 Internet users have searched the Web specifically for health information.
The Web is a wonderful resource for any empowered patient, but it can also be a pit of misinformation. “Remember that anyone can create a Web site about ‘health’ or ‘medical treatments,’ ” says Dr. Rhonda Medows, commissioner of the Georgia Department of Community Health.
On the other hand, a proper search can render information that is useful, even cutting-edge. “Read medical literature to learn the documented facts about your procedure of interest,” advises Cuzalina of the AACS. “It’s worth it when you get facts that are supported by empirical evidence.”
Here are some tips for surfing for health information on the Web:
• Check your URL. Dr. Jennifer Shu, a pediatrician and Living Well expert for CNNHealth.com, says it’s best to narrow your search to specific URLs. “Look for sites that end in .gov, .org or .edu, which generally provide credible information.” But don’t just stop there. Shu says that if your Internet research turns up something interesting or useful, share it with your doctor. “When patients do this in my office, I can confirm the information they have is medically sound, or suggest other sites that may be either more accurate or easier to understand.”
• Protect your privacy. “Health insurance is a very personal transaction, so don’t give out personal information,” says Sande Drew, a patient advocate and consultant for Ehealthinsurance. She says to look for sites that allow you to initially search anonymously, prompting you to enter only your ZIP code, date of birth and gender.
• Compare and contrast. In many instances, you can check prices, hospital ratings and what services are offered online before your visit. “When a serious medical condition or emergency occurs, customers typically rush to the closest hospital, which may not be the best hospital,” says Dr. Archelle Georgiou, president of a health care strategy firm in Minneapolis, Minnesota. Web sites such as Hospital Compare, My Health Compare, Health Grades and Ucompare Health Care allow you to compare hospital quality and patient satisfaction. Knowing your preferences in advance can help you decide quickly how to proceed if you ever need to rush to the emergency room.
4. Free and discounted care is out there
“In today’s tough economic times, everybody is bargain hunting, trying to save pennies here and there,” says UCLA’s Chassiakos. But beware of scams, she warns. “If a bargain is too good to pass up, be prepared that there may be a catch.”
Here are some ways to find dependable help:
• Pay what you can. The Department of Health and Human Services provides assistance through federally funded health centers. You pay what you can afford based on your income level. The services include everything from preventive care to dental work. http://www.findahealthcenter.hrsa.gov/
• Find an advocate. When you get laid off and lose your health insurance, you may need someone in your corner. Several groups specialize in helping people find affordable insurance and free care, including: Coverage for ALL Ehealthinsurance Healthcare Advocacy, Patient, Patient Advocate Foundation and Patient Services Incorporated.
• Get prescription drug help. If you can’t afford health insurance, or if your insurance doesn’t include good prescription drug benefits, look for $4 generic drugs at many major supermarkets and drug store chains. Also, your state may offer a discount drug program. You can also check these private groups that offer prescription assistance:Chronic Disease Fund, Family Wize discount drug card, Health Well Foundation, Needy Meds, Partnership for Prescription Assistance, Rx Assist and Rx Hope.
. If you’re voluntarily or involuntarily laid off from your job, or if you experience a large reduction in work hours, you may be eligible for COBRA, a program that allows you to keep your employer’s insurance. But there’s one big catch: You have to pay the premium in its entirety, which can sometimes be upwards of $1,000 per month. As part of the congressional stimulus package passed earlier this year, people who involuntarily lost their jobs can have the government pay 65 percent of their COBRA premiums. Several rules apply. For more information, go the Department of Labor’s Web site: http://www.dol.gov/ebsa/cobra.html
5. Paying attention can save your life
You know your body better than anyone else. If your gut tells you something just isn’t right, then listen to it.
Read more on how important it is to listen to your instincts: http://www.cnn.com/2009/HEALTH/04/16/ep.emergency.room.kids/index.html
Here are some other ways paying attention can make a difference:
• Know your medications. Keeping track of what medications you’re taking is crucial. Medows, from the Georgia Department of Community Health, recommends writing a word or two on the bottle to remind you of what the medication is for. “Life can get too complicated to depend on memory alone to keep track of everything,” Medows says.
• Track your progress. If your treatment involves a prescription, change of diet or physical therapy, make sure you understand what you have to do each step of the way before you leave the doctor’s office. “Clear communication is always a challenge. It’s even harder when the stakes are your health,” says Caplan, the ethicist. Write down the steps and keep track of how long before you should see improvement and when you should schedule a follow-up appointment.
By Dr. Keith Block on September 30, 2011. http://blockmd.com/
Benefits of Yoga and Mindfulness for People with Cancer
Many people facing a diagnosis of cancer are looking for ways to release stress and tension. Yoga and mindfulness training that is, practices intended to cultivate present-moment awareness and relaxation are two of the best-studied options in this regard. But can such practices really help people with cancer?To answer this question, in this blog, I examine some of the most recent research findings concerning the potential benefits of yoga and mindfulness after a cancer diagnosis.
First off, there is little doubt that yoga can play a key role in helping you relax and enjoy a better quality of life, as indicated by a meta-analysis published online ahead-of-print in the March 9, 2011 issue of “Evidence-Based Complementary & Alternative Medicine.” This analysis included a total of 10 studies in which cancer patients practicing yoga were compared to those not practicing yoga or receiving nothing more than “supportive therapy.” Based on comprehensive psychological assessments and pooling the findings from all ten studies, the yoga groups showed statistically significant lower levels of anxiety, emotional distress, depression and overall stress, when compared to the cancer patients in the control group.
Yoga incorporates a blend of elements: relaxation, meditation, imagery, controlled breathing, stretching and movement. Of my patients who practice yoga and/or mindfulness training on a regular basis, most report a greater sense of calm and improved sleep. Also, yoga can help with recovery from cancer treatments. For example, breast cancer patients may experience limited arm motion due to scarring from surgery and radiotherapy; yoga can increase flexibility as well as range of motion in the affected arm.
I mentioned above that better sleep is among the frequently reported benefits of practicing yoga. Exercise and sleep do seem to go hand in hand. Over the years, I have met many people who swear by this interrelationship: the better their exercise habits, the deeper and more satisfying their sleep tends to be. And because cancer patients frequently have problems with sleep, there is good reason to consider sleep as one of the worthwhile benefits of an integrative physical care program that includes yoga and possibly mindfulness training as well.
Researchers at the M. D. Anderson Cancer Center in Houston, Texas, recently conducted a randomized trial of cancer patients practicing Tibetan yoga, which involves a combination of movement and meditation. Reporting in a 2004 issue of the journal “Cancer,” Lorenzo Cohen, Ph.D., and his M.D. Anderson colleagues found that those patients who practiced Tibetan yoga for seven weeks had better overall sleep quality compared with lymphoma patients who did not practice yoga. The yoga-practicing patients went to sleep faster, slept longer and used less sleep medication than their non-practicing counterparts.
All of the patients in the yoga group reported that they found the program was beneficial, and more than half the group said they practiced at least twice a week during the follow-up period. While there was a trend toward improvement in such factors as fatigue, depression and anxiety, the only statistically significant difference between the two groups was sleep quality. As might be expected, patients practicing Tibetan yoga also had better energy levels and less daytime sleepiness.
Developed over thousands of years, the movements of Tibetan yoga are gentle and subtle. The two forms used in the intervention group, called Tsa lung and Trul khor, involve controlled breathing, visual imagery, and maintaining awareness of the present moment. Dr. Cohen hypothesized that Tibetan yoga might serve as a stress-reduction practice for people with cancer ? much like going to the gym is for many people who sit behind a desk all day. Based on the study’s outcome, he concluded that Tibetan yoga is particularly useful for people receiving and recovering from chemotherapy. In addition, one of the key findings in studying cancer patients who practice Tibetan yoga is that they also have more favorable cortisol profiles. This is very important, as cortisol is a stress hormone associated with chronic anxiety, depression, poor immune function and a worsening prognosis for breast cancer patients.
A recent study of the effects of Mindfulness-Based Stress Reduction (MBSR) found that these practices led to statistically significant reductions in blood pressure, heart rate and respiratory rate, along with a more relaxed, present-moment awareness. The MBSR training also led to a statistically significant effect on the morning cortisol level, as reported online ahead-of-print in the October 2010 issue of “Western Journal of Nursing Research.”
More research is needed to determine whether the favorable effects of yoga and mindfulness training on cortisol levels hold true. However, if other studies find such an effect, it could very well be that such practices would help extend survival in people with cancer. My belief is that any practice that improves the quality of life and overall functioning of a person is worth pursuing, not only because quality of life itself is a worthwhile goal, but it has, in fact, been associated with improved survival.
For more information on how to optimize your health, visit lifeovercancer.com
Photo credit: MyNeChimKi