Search for tag: "outpatient"

Interviewer: So you or a loved one have opted to have endoscopic spinal surgery rather than one of the more traditional methods. What can you expect on the day of the procedure and afterwards?

We're here with Dr. Mark Mahan. He's an associate professor of neurosurgery at the University of Utah Health. Now, Dr. Mahan, when it comes to endoscopic spinal surgery, what can someone expect, you know, leading up to the procedure, the day after? Where do they start? And what should they be expecting?

Dr. Mahan: The wonderful thing about endoscopic spine surgery is that in, I would say, 99% of the cases, it's outpatient surgery. So that is a little bit of a reframing of what an individual will be expecting, because it's not a traditional come to the hospital, stay there for several days, eat wonderful hospital food, stay in wonderful hospital beds. This is something that you would anticipate going to one of our outpatient locations. A patient would expect to arrive that day. Typical requirements are for, you know, for any surgery are, you know, no eating from the night before, coming in, unfortunately, you know, sort of extra early because we all like to end our days early, and so we try to get started early.

And then you would expect that you're going to be meeting a whole host of new individuals that are going to come in and take care of you. And meaning that we're going to have nurses and others that will come in and check-in and make sure that you're ready. We'll go through a surgical consent. That's an important part for me personally because I want to make sure that everybody understands, ahead of time, both what the surgery entails, what the risks are, what your expectations will be both in recovery as well as long term. And so that we all can meet in a common understanding about what our goals are and what you'd be facing. And then through also about, you know, how to best optimize your recovery long term.

And then after surgery, obviously, these are generally performed under general anesthesia, which is the type of anesthesia where you would have a breathing tube. And so waking up, coming around is usually a time when most people don't remember, fortunately, and then just recovery, make sure that you've, you know, that you're ready to go, you're steady on your feet, that you're eating, you're feeling well, and then we get you back to your car and you can go home.

Interviewer: So how long are you actually in the operating room for a procedure like this?

Dr. Mahan: Typically, it really depends on what the problem is we're seeking to treat. Some of the disc surgeries go really, really quick, like on the order of about half an hour.

Interviewer: Oh, wow.

Dr. Mahan: Now some of the more complex narrowing can be two hours. It really truly depends on what the work that needs to be done.

Interviewer: Now, after the patient is home, what can they expect? We're dealing with pain control, recovery. How long until they're back on their feet, etc.?

Dr. Mahan: Yeah, now, pain control is a particular focus of mine because I really want every individual to really have that smooth glide path because, you know, even though that the endoscopic technique is meant to minimize tissue trauma, it is still a spine surgery. It is still the goal of removing something from your spine. I don't want to make that sound scary, but I don't want to make other people feel like, oh, it's a magical procedure, right? It's not. There's a reality here that we're removing something that's pressing on the nerves and causing pain and discomfort.

And so that you would expect to have some irritation or some discomfort from having something removed from your spine. And so what I do is I do everything I can to possibly minimize it. Number one, endoscopic techniques, minimal incisions, minimal approaches. Number two, often using a lot of numbing medication can really make the recovery much more straightforward. So we'll use a long-acting anesthetic into the muscles of the spine to make them comfortable and relaxed even before we even start doing surgery.

So the first step, block the muscles. Make it comfortable. It also leads to some numbness of the skin where the skin incision is so that that is not too much discomfort. But the block will wear off. So the things that we do is try to, obviously, avoid a lot of powerful pain medications because powerful pain medications can have their side effects and consequences. So we're using things like ice, heat, anti-inflammatories, and then we talk about milder pain medications so that you don't get into the complications associated with strong pain medications.

Interviewer: Now other than the pain management that happens afterwards, when they go home, are they up for a day or two? Are they on their back for a day or two? On their belly? Like, what are you having a patient do to heal up from a procedure like this?

Dr. Mahan: In the majority of the cases, you're doing exactly what you want to do.

Interviewer: Oh wow.

Dr. Mahan: Yeah, the limitations really come down to if somebody has had a disc herniation, we want to minimize the risk of re-herniation, meaning that another part of the disc fractures out and presses against the nerve roots, which can occur. Other than the disc herniations, I want the individual doing as much as they feel comfortable doing. Oftentimes that sometimes means tempering people. I had one patient the day after surgery he asked if he could go on a snow bike up the mountain. And I was like, it was one of those moments where you have that sort of, you know, common sense questions, like, well, just tell me what would happen if you got halfway up there and you had a back spasm? You had difficulty coming back?

Interviewer: Right?

Dr. Mahan: And, you know, he's like, well, maybe that's not the greatest thing to do today. And you're, like, yeah, the day after surgery may not be the greatest day to go nuts. But people will be walking more. People will be doing more activities. And we want that. We want them to go back to the way that they will choose to live their life.

Interviewer: Now, it's impressive that they are kind of up the next day, or a day or two after their procedure. Maybe a little bit tempered from what they were normally doing. But, you know, not going back up and doing crazy mountain biking, or that snowmobile trip, like you mentioned. But how long until a patient is, you know, all the way healed and sees the most benefit from the procedure, and they're back to normal?

Dr. Mahan: That is an excellent question. And it really is patient-specific. So if somebody had a more profound nerve pressure or nerve injury, and it's been there for a long period of time, meaning that it's going to take longer for their recovery, right? So if you've had a problem that is minor in nature, and it's a short duration, your recovery is going to be quick. If you have a very profound problem that is of long duration, you know, there may be a new normal, even with spine surgery. We can't always erase everything that occurs in time, but you know, we're going to try.

Interviewer: Are you feeling overwhelmed, distressed, depressed, or just simply need to talk, but not sure how to proceed? Dr. Benjamin Chan is a psychiatrist at University of Utah Health. And what do you recommend for someone who feels a need to seek mental health care in today's world? Has that changed, or is it pretty much the same path?

Dr. Chan: It's still pretty much the same path. I mean, we have our outpatient providers, counselors. So we have therapists, psychologists, psychiatrists, not only here at the U, but throughout Utah, throughout the nation.

There has been a large uptick of activity. People are calling in, scheduling appointments, talking through their feelings. There's so much negative emotion, so much uncertainty that it feels good just to connect with someone and share those feelings.

Now, my mental hat that I put on says, "Oh, this has to be with a mental health professional. They're trained. They can do cognitive behavioral therapy. There could be a medication management aspect to this." But when I take off my mental health hat and just put on my human hat, that connection can be with someone in your family or a long lost friend from college or high school. And it's incredibly powerful and beautiful to connect with someone and share those emotions.

So yes, the University of Utah Health, everyone who are mental health providers are here and ready, and we are very, very busy and that pathway is still open. But I also feel that connecting with someone is also a part of that ability to take care of yourself during these times.

Interviewer: Children with autism are more likely to end up in the hospital unnecessarily than children without autism. We'll examine a research study that gives parents and physicians some valuable information and lessons about this topic next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to the Scope.

Interviewer: Dr. Paul Carbone is an associate professor of pediatrics that specializes in autism and related developmental disabilities. You were involved in a recent study called Ambulatory Care Sensitive Hospitalizations Among Children with Autism Spectrum Disorder, and what I'm essentially getting out of this is that children with autism are more likely than children without to end up in the hospital unnecessarily. Is that really what you found?

Dr. Carbone: I think that's true, we looked at a cohort, or group, of children with autism who were hospitalized and we compared them to children in two other groups who did not have autism. We looked at 14 conditions for which they might be hospitalized, we call them ambulatory care sensitive conditions. That's a fancy way of saying that, for this particular condition, if you got good care in your outpatient setting in your doctor's office, you would be less likely to be hospitalized for that condition. So what we found is that children with autism, over half of all of their admissions were for ambulatory care sensitive conditions. Over half were potentially preventable.

Interviewer: So for a parent, this is really concerning because their child's ending up in the hospital where it could have been prevented at an earlier stage. Am I gathering that correctly?

Dr. Carbone: That is correct.

Interviewer: And for physicians that should be concerning because we're missing a lot of opportunities to keep children out of the hospital.

Dr. Carbone: That's what we hope that the findings of these studies indicate that there is an opportunity here to better address these groups of conditions in children with autism in the outpatient setting.

Interviewer: All right, so for parents and physicians, what are some of these conditions that if my child has it or if a child is in my office with it that maybe I should be paying a little closer attention to keep them out of the hospital.

Dr. Carbone: The group of conditions that we studied were derived from various organizations who have defined these conditions because tracking them turns out to be pretty important. Just to give you an idea, ambulatory care sensitive conditions comprise about a third of all hospitalizations in the United States. They cost about four billion dollars.

Interviewer: That's significant.

Dr. Carbone: They count for a million hospital days. So if we're trying to do better care and are trying to do it in a cost efficient way, these conditions are the money. So the conditions that we looked at were things like asthma, pneumonia, constipation, dehydration, epilepsy or seizure disorder, underweight, and mental health conditions which comprise a number of them like anxiety and mood disorder.

Interviewer: So what's happening here? Why are they going out of the office to the hospital with these particular conditions?

Dr. Carbone: Well that's a great question, and these data that we looked at, remember, we're just looking at a group of patients who are already hospitalized. So we can't follow these patients from the outpatient setting into the inpatient setting to look at what are the factors involved that got them into the hospital. All we can say here is that these conditions are more commonly seen in children with autism as a cause of their hospitalization compared with children without autism. But, we can always speculate because that's what we do when we come up with data.

About a quarter of all admissions in children with autism in the United States are for mental health conditions. That is an amazing statistic because the data set that we used called the Kids in Patient Database, or the KID, looks at hospitals across the country. We looked at over two million admissions. A quarter of all admissions for children with autism are for mental health conditions which is amazing because these hospitals aren't psychiatric hospitals, they're medical hospitals. So it really represents almost a failure of the system that somebody would be admitted to the hospital for a mental health condition.

Interviewer: Okay.

Dr. Carbone: So what I think one of the most important implications is we need to address these issues in a proactive way in the office, before they come to a head and the child eventually becomes, what I think probably happened with most of these admissions for mental health conditions, is the child becomes aggressive. Can't be managed at home, is then admitted and then stays in the hospital for that.

Interviewer: What about some of these other conditions?

Dr. Carbone: The other conditions, one that was very prevalent that drove a lot of the differences that we saw between the groups was epilepsy. And that's not entirely surprising because children with autism have a higher rate of epilepsy compared to children without autism. So we know that it's there. The challenge, I think, in the outpatient setting is how do we manage it so that we can reduce some of these admissions, and I think in children with autism if you think about them they're delightful people but they have deficits in social communication and they do a lot of repetitive behaviors. They need sameness all the time.

So how that manifests in the management of epilepsy is that I have a drug that I would use for this patient because of the type of seizure that he has, but he won't take that medicine because he doesn't take pills. So then I have to think of something else. Or, the child is simply not adherent with the medicine thereby necessitating a hospitalization because it gets out of control. So that's just one aspect of treating children with autism. They're not worse, they're not better, they're just different. So you have to have a plan B, a plan C, and a plan D for how to manage their conditions because sometimes they don't want to do plan A.

Interviewer: Sure, or plan B or C for that matter.

Dr. Carbone: Correct

Interviewer: So I think you gave us a couple of good takeaways for physicians, have those extra plans. What about parents. What should parents take away from this conversation?

Dr. Carbone: Well, I think that again, because of the very nature of these conditions, because they are ambulatory care sensitive, we want parents to focus on that relationship that they have with their pediatrician or primary care doctor in the office. And to me, I think it's really about a partnership. I've been taking care of kids in an ambulatory care setting in a clinic here at the university called the Neurobehavior Home Program for quite a while and we really focus on developing a relationship with families so they feel comfortable in telling us everything.

We give them a little bit more time. Our system of care is a bit different and I think that that's one of the problems in the system that we have. Most physicians see patients for five minutes and we really need that to be longer for patients with autism because it may take them 10 or 15 minutes just to get into the exam room.

Interviewer: And at the end of it all, that extra time could result in a child not needing to go to the hospital at some point.

Dr. Carbone: I can address many conditions in a visit, whereas my other colleagues in pediatric medicine can only address one per visit. So it allows me to sort of address some of these ambulatory care sensitive conditions and make sure we're managing them so that they don't escalate to where we're stuck and we have to go the hospital.

Interviewer: So what's next?

Dr. Carbone: These data are the first time that anything like this has been published about ambulatory care sensitive conditions in people with autism. I think they'll be helpful because since they were published in 2009, these data, now a newer version of the KID is coming out, so it presents an opportunity to follow this over time.

We've done a lot of things to help pediatricians take better care of children in the office setting since 2009. There's something called the Autism Treatment Network. The American Academy of Pediatrics has given a lot of guidance to pediatricians on how to manage these conditions in the office. So it will be fun to see over time if we're able to move the needle on the percentage of potentially preventable conditions.

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Interviewer: Three things patients should ask and three things all doctors should be sure their patients understand. That's coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Sometimes as a patient when you're in clinic with a physician, you leave and you're like, "I don't know what's wrong with me and I don't know what to do about it," and you're just confused. But if you ask these three questions, and if you're a provider you make sure patients understand the answers to these three questions you could solve all the problems. We're going to find out more about the Ask 3 Program. Darren Doman, he's the Patient Education Specialist here at University of Utah Health Care. What is the Ask 3 Program and it sounds magical?

Doman: It is pretty magical. It's an initiative put together by the National Patient Safety Foundation and it's meant to just help improve communication between health care providers and their patients in efforts to improve health outcomes. So basically they synthesize every visit into three main questions.

Interviewer: Okay.

Doman: First, "What is my main problem?"

Interviewer: Yeah okay.

Doman: That's a good question.

Interviewer: That's a great question. That's why you're there.

Doman: Exactly.

Interviewer: Yeah.

Doman: Put a label on it, give it a name. The second question is, "What do I need to do about it?" And then the third question is, "Why is it important for me to do that?"

Interviewer: I love that because I think it synthesizes in very, three very quick little questions. Like when you're a patient you leave and you don't understand what just happened and you're trying to figure out, "What could I have done to change it?" I think this is perfect.

Doman: Absolutely and there's some research out of Great Britain that shows that when it comes to an outpatient doctor patient interaction, 80% of people leave that visit without accurately recalling any information that the doctor told them.

Interviewer: So it would be hard for them to tell their husband, their wife, their kids, anybody.

Doman: Exactly, but when they probed the 20% that remembered something a little bit closer, only half of them actually got it right.

Interviewer: Really?

Doman: So it's really 9 out of 10 people leave the doctor's office not able to remember accurately what the doctor told them.

Interviewer: That's pretty incredible and that's based on research.

Doman: Based on research out of the UK.

Interviewer: All right so the Ask 3 Program, "What's my main problem?" "What do I need to do?" "Why is it important for me to do this?" Is there any research on showing if people ask these questions what retention rates are?

Doman: Well the most current research that I read was showing that patients aren't actually asking these three questions.

Interviewer: Okay.

Doman: So we need to take a step back, revamp the program, and maybe think about it a little bit differently. Which I think is a perfect opportunity for us to talk to providers and say, "You know, here's three great questions. If your patients aren't asking these questions, why don't you just help them out and give them this information?"

Interviewer: Yeah just make sure that they understand these three things.

Doman: Exactly and that speaks to the need for open communication between patients and doctors to really get the message home. Patients need to be asking the questions, doctors need to be telling the patients the right things, and they need to be checking to make sure that the message was received.

Interviewer: So it sounds like a good idea as a patient if I go in that maybe when it starts getting a little confusing I just need to fall back on those three, you know? Because sometimes the issues get a little muddled right?

Doman: Absolutely, and just bring it back to, "Okay what's the main problem?"

Interviewer: "What do I need to do?"

Doman: And, "Why is it important to do it?"

Interviewer: And as a provider it might be a good idea after you tell them these three things to ask them, "Okay do you understand what your problem is? Tell me what it is." When I was in my communication classes that's all part of listening, it's all part of checking to make sure the person understand what you just said to them is to ask them to tell you what you just said to them.

Doman: Absolutely and providers who are really keyed into this can do it very artfully. They can say, "I think your main problem is this," and then, "Later when you get home what are you going to tell your spouse that your main problem is?" Just to check and see.

Interviewer: Yeah, because a lot of times we assume that the person understood us and we don't want to insult their intelligence by insinuating on some level that they didn't, but a lot of times people don't. I mean there's a lot of a thing that can go wrong with communication, it's not either individuals fault.

Doman: It's true, and double checking message received is never a bad idea.

Interviewer: What's keeping patients from asking these three questions do you think?

Doman: When it comes to patients asking questions in doctors' visits I always think its fear based. They don't want to look stupid in front of their care provider. Maybe they kind of know the answer but they're a little bit afraid of actually hearing somebody else say it. So there are reasons why they might not pipe up and actually ask.

Interviewer: But at that point it's important beyond your ego, beyond anything else, to clearly understand what's going on, what you need to do, and how important it is.

Doman: Sure, yeah.

Interviewer: And how about physicians, is there a barrier to them adopting kind of just these three questions making sure patients identify it? Is it something they ever thought about before?

Doman: I think it takes that moment of just engaging your brain and checking in rather than getting into too much of a routine. Everybody kind of gets their routine going, they kind of do it the same way they've always done it, in and out, keep the flow going. But if we can actually engage with the patients say, "Here's my new routine, here are these three important things that I need every patient to understand," I think we're going to have a better go of patient interaction, better communication, and ultimately better health outcomes.

Interviewer: Any final thoughts on the Ask 3 Program? I think it's brilliant.

Doman: I think its brilliant too, and just getting the word out to patients and providers alike that it's a conversation. It shouldn't be one-sided doctor talking all the time. The patient should have some input as well and if the patient doesn't know quite what to ask here's three good questions. Anybody who asks these isn't going to look stupid in front of their doctor.

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