A Medical Navigator Or Curbside Medical Consult For Patients – Rational and Example

I have always felt that every family needs a doctor to help its members navigate what is becoming an increasingly complex and challenging medical landscape. There are so many choices that patients need to make with very limited knowledge and understanding. In addition, there are economic and other forces acting that do not always work in a patient’s favor. For example, the overhead involved in providing state of the art medical care has become so expensive that much pressure is placed on health care providers to see more patients and do more tests and procedures. If a physician has a very expensive hammer, then there are great pressures to make a patient a nail that can be treated. There are also so many layers between patients and physicians such as the people who take the initial call and schedule appointments, nursing assistants, nurse practitioners and physician assistants, interns, residents, and fellows to mention a few. These two conditions, high overhead and many layers, conspire to reduce the quality of care while increasing its costs; not a good combination.

There is hope though. As a physician, I am often asked for advice by family, friends, and colleagues in an informal manner that is called a “curbside consult.” In a few minutes, I can often get a pretty good idea of what the problem is most likely to be and can give advice that at the very least will set the patient on a good course. And if I do not know what is going on, I can usually refer them to another physician specialist or other type of health care provider who can help. This curbside vindictive can save the patient a lot of time, effort, and expense as well as provide emotional support and reduce stress. It is also very satisfying and rewarding for me.

All of these conditions and circumstances lead me to believe that one of the few ways we can provide better care at reduced cost is to provide patients with what I call a Medical Navigator using the internet. It is a GPS like system that allows patients to diagnose certain common conditions easily and rapidly, in some cases, initiate treatment that involves safe and readily available remedies; provides patients with useful information that at the very least will allow them to interact with their family doctor, general practitioner, or internist in a more effective and proactive manner by alerting patients to what potential diagnostic and treatment options are available so that they can take greater agency over their care; potentially reduce the number of clinical visits needed and thereby initiate care sooner and possibly more appropriately, effectively, and SR reduced cost. Another way to look at it – it is taking an Amazon approach, by making greater use of the internet, combined with a Khan Academy approach in disseminating knowledge widely, concisely, and in as simple and understandable a manner as possible. Seems to good to be true? We’ll see the following clinical example applied to a very common medical condition called Carpal Tunnel Symptom (CTS) that often produces unpleasant and debilitating hand symptoms (pain and numbness) and findings (weakness and reduced dexterity).

CTS: what if…

Current treatment pathway:
For months you have been waking up at night with increasing dominant right hand numbness and pain. You also have begun to notice difficulty opening jars. You search the internet and think you may have Carpal Tunnel Syndrome. You call your family doctor and get his nurse practitioner (NP). She says you may have CTS and need to come in for a clinic visit. She fits you into a cancellation spot in 2 weeks. You arrive sleepy and are seen by both your physician and his NP who diagnose you with CTS and recommend you try using a right wrist-hand splint at night fir several weeks. After 3 weeks of persistent right hand discomfort, you call your doctor’s office. They recommend you see a neurologist to undergo an EMG/NCV diagnostic study. They tell you to use the wrist-hand splint during the day when possible. An appointment is made and you see the neurologist 3 weeks later. She agrees that your history and exam indicate a diagnosis of CTS. Your EMG/NCV study is borderline abnormal with mild slowing of right median nerve sensory conduction and a normal EMG. You are told that your options are to continue with medical therapy with the addition of hand therapy on a weekly basis by a hand therapist or undergo a surgical release of the carpal tunnel. Your symptoms have stabilized and you decide to undergo a trial of hand therapy for 4 weeks. After 4 weeks of hand therapy on a weekly basis by a trained therapist and daily on your own, you decide to explore the surgical option. You are referred to a hand surgeon whom you see in 4 weeks who recommends you undergo an endoscopic carpal tunnel release which you undergo 4 weeks later. Your right hand symptoms improve significantly after the surgery. Summary: 3 clinic visits followed by surgery if indicated over 17 weeks (4 months and 1 week).

Possible treatment pathway:
For months you have been waking up at night with increasing dominant right hand numbness and pain. You also have begun to notice difficulty opening jars. You search the internet and find the curbsidemedical site. You are informed that based on your clinical symptoms you most likely have CTS. You are informed that if your symptoms are not severe, meaning that the muscle mass in your hand at the base of your right thumb is not smaller than on your left normal side, you can start with hand therapy for 3, weeks which consists of the following: 1) either at a drugstore or online, purchase a wrist-hand splint to wear at night and during the day if possible; 2) perform Namaste Carpal Tunnel hand stretch exercises three times a day (see video). If your hand symptoms persist, then call your doctor and request a referral to a neurologist for an EMG/NCV study and, if the study is positive, see if you could also see a hand surgeon on the same day or soon after to discuss surgical options which include the following types of procedures: 1) a traditional open carpal tunnel release (CTR); 2) an endoscopic CTR; and 3) a minimally invasive thread CTR. Each has advantages and disadvantages which you should ask about but keep in mind that every surgeon has a preference based on their training and experience. All CTR procedures gave a high success rate when performed properly. Ask your surgeon how many he has done snd what his/her results are. Summary; 1 or 2 clinic visits followed by surgery if indicated over 3 weeks.

This example illustrates the power of using a Curbside Consult approach combined with a Medical Navigator internet based platform to help patients diagnose, initiate treatment early in some cases on their own, and navigate a very complex medical landscape in a more efficient and effective manner in terms of time, outcome, and cost.

Stay tuned for more…

Michel Kliot MD

 

A Medical Navigator Or Curbside Medical Consult For Patients: Tips On The – Evaluation & Treatment Of Benign (Schwannomas and Neurofibromas) And Malignant Nerve Tumors

The most common types of peripheral nerve tumors are benign.  The two most common types are Schwannomas, which usually occur spontaneously and sporadically but may occur as part of the Schwanommatosis Genetic Syndrome (mutation on chromosome 17) when several are present, and Neurofibromas which usually present as part of the NF1 genetic syndrome (mutation also on chromostome 17 – one of most common genetic mutations with prevalence of 1 in 3,500). Many of these tumors stop growing for very long periods of time and therefore are asymptomatic and may be observed with serial imaging studies (MRN and/or ultrasound).  The symptomatic tumors usually present with pain, numbness, and/or weakness.  Symptomatic and/or growing tumors should be considered for biopsy and surgical resection. Many of these tumors are can be surgically removed with minimal damage to functioning nerve fibers resulting in minimal or no loss of function.  Sometimes, especially in the case of plexiform neurofibromas, resection is limited due to the intimate association of functioning nerve fibers and tumor tissue. Particularly in the setting of partially resected tumors, a postoperative MRN study with contrast should be performed which can serve as a baseline going forward.  If malignancy is suspected a specialized team dealing with such challenging tumors should be consulted:  further diagnostic studies often include a CT of the chest and abdomen as well as a bone scan looking for evidence of metastatic spread, a PET CT study and/or MRN with diffusion study to look for evidence of malignancy, and an open or percutaneous biopsy is often performed to confirm the diagnosis.  A surgical resection combined with additional treatment such as radiotherapy is usually recommended if the tumor proves to be malignant.  Again, malignant peripheral nerve tumors should be managed by a team of specialists who frequently deal with such challenging cancer problems.

 

 

References:

 

  1. Kliot, Y. Ince, T. Tihan. M. Wilson, and M. Kliot. To grow or not to grow, that is the question. Thinking Outside The Box Section of New Developments On The Horizon Supplement. Surg Neurol Int; 4:S407-10.  2013.

 

  1. Kwok, J. Slimp, D. Born, R. Goodkin, and M. Kliot. The evaluation and management of benign peripheral nerve tumors and masses. M.S. Berger and M.D. Prados (ed.s).  In:  Textbook of Neuro-Oncology.  Philadelphia, W.B. Saunders.  2004. pp 535-563 (Chapter 73).

 

E.L. Yuh, S.K. Jain, G.M Lagemann, M. Kliot, P.R. Weinstein, N.M Barbaro, and C.T. Chin.  Diffusivity measurements from MR neurography differentiate benign from malignant lesions in patients presenting with peripheral neuropathy.  AJNR 36:  203-209.  2015.

A Medical Navigator or Curbside Medical Consult For Patients: Clinical Grading Of Entrapment Neuropathies Helps One Diagnose And Formulate An Appropriate Treatment Plan

The diagnosisandtreatmentof peripheral nerve entrapment syndromes (eg
Carpal Tunnel Syndrome, Ulnar Nerve Compression Across the Elbow, to mention only a few)  depends on an understanding of their different clinical grades that reflect severity of nerve damage and the resulting symptoms.

Diagnosis:

A mildclinical grade occurs with intermittent symptoms but no evidence of axonal loss as shown on clinical exam by muscle atrophy (loss or wasting) on motor examination and/or increased 2 point discrimination (the ability to detect two small points applied to the skin, usually on the finger tips, several millimeters apart) on sensory examination and no evidence of muscle denervation on EMG (electromyographic) testing.  A moderateclinical grade occurs with constant symptoms but no clinical or EMG evidence of axonal loss.  A severeclinical grade occurs with clinical and EMG evidence of axonal loss.

Treatment Possibilities:

A mild clinical grade entrapment syndrome is initially treated with non-surgical measures (eg splinting, ergonomic modifications, and physical/hand therapy) while in the case of a severe clinical grade entrapment syndrome surgical decompression is usually recommended.  A moderate clinical grade entrapment syndrome can be treated either surgically or non-surgically:  if non-surgical therapy fails then surgery is recommended.

Reference: 

G.A. Grant, R. Goodkin, and M. Kliot.  Evaluation and surgical management of peripheral nerve problems.  Neurosurgery 44:  825-840.  1999.

A Medical Navigator Or Curbside Consult For Patients: Regression To The Mean

“Regression to the mean” is a very important concept with significant clinical implications. Most chronic diseases have a fluctuating clinical course. For example, patients with chronic back pain will have pain that varies from day to day and can be exacerbated by certain postures and/or activities. Patients will usually contact a physician when their symptoms are most severe. Therefore if nothing were to be done, it is likely but not certain,that the symptoms would improve over time as the severity reduces or regresses to its mean (average) level. It is therefore not uncommon for patients’ symptoms to improve by the time they see their physician. This does not mean that no intervention should be done. However it does make it difficult to determine what if any effect an intervention is actually having on a clinical outcome. Regression to the mean, as well as the powerful placebo effect (the topic of another future blog), are factors that can exert significant effects that are difficult to control for. One way to do so is to design rigorous clinical double blind randomized controlled trials that subject groups of patients that are statistically similar to protocols that differ in a specific manner without the patients or evaluators being aware of this treatment difference. By doing so, any difference in outcome can be attributed to the treatment given since the effect of other factors should average out. Regression to the mean is a very important concept to keep in mind when evaluating and treating patients with chronic diseases whose clinical manifestations fluctuate significantly over time.

 

A.G. Barnett, J.C. van der Pols, and A.J. Dobson. Regression to the mean: what it is and how to deal with it. The International Journal of Epidemiology: 34: 215-220. 2004.

 

  1. Ariely. Predictably Irrational, Revised and Expanded Version: The Hidden Froces That Shape Our Decisions. Harper Collins. 2009.