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br This high-yield, user-friendly manual is a practical road map for all physicians who diagnose and treat patients with musculoskeletal symptoms, including physiatrists, orthopedists, internists, family practitioners, rheumatologists, and neurologists. Organized by anatomic region, the book provides a step-by-step approach to the diagnosis and aggressive nonsurgical management of common musculoskeletal symptoms. Each chapter opens with diagnosis and treatment algorithms for common chief complaints. Numerous high-yield points give a clear picture of each complaint and a logical, stepwise approach to management. The authors also indicate when a symptom is an emergency or requires surgical evaluation.

h2Comments/h2

pThanks for the guidelines, they are helpful in maintaining my power as a patient./p
p class=postedPosted by: Dean | May 24, 2010 9:54:10 AM/p

pGood stuff. I would want you to be my doctor. /p
p class=postedPosted by: Tim | May 24, 2010 10:51:52 AM/p

pWow! Great post! Clearly you have done a lot of introspection here, which is, in my opinion, the best part about interactive blog-type communication. Group learning. Collective wisdom. Whatever./p

p I think patients should print this and bring it to their docs!/p
p class=postedPosted by: bev M.D. | May 24, 2010 10:58:23 AM/p

pI loved this post – it#39;s what is good in health care today. I hope other physicians and providers strive to live by these guidelines too./p
p class=postedPosted by: Claire Dorrier | May 24, 2010 12:46:46 PM/p

pGreat comments!I believe in primary care as well. The patient is still the most important person in this industry!/p
p class=postedPosted by: Health Insurance Kansas | May 24, 2010 1:51:21 PM/p

pgreat post. /p

pon point #3. I agree that social visits are important to develop trust and are important for the doctor/patient relationship. But…does anyone want to pay for them? The reason we#39;ve been able to get away with those sort of visits is the 3rd payor system we have. Insurance companies don#39;t get to decide how often the patient comes in, but they still have to pay for the visit. The patient often has no cost, or a small copay. /p

p How many people with high deductibles or out of pocket expenses want to pay to socially interact with you if there isn#39;t any pressing medical need? And how many payors want to keep paying for it? /p

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p class=postedPosted by: pcb | May 24, 2010 2:31:03 PM/p

pI think pcb has a good question about people wanting to pay for social visits./p

pDoes a physician really build a meaningful relationship seeing someone for 15 minutes once a year to renew a bcp prescription?/p
p class=postedPosted by: Anon | May 24, 2010 4:14:33 PM/p

pYes! People with chronic problems often ask me quot;do I have to wait that long to see you?quot; It is something you have to read from the patients – I don#39;t want to make even a perception that I am doing this for quot;just social reasons,quot; but the longer a person is a patient, the less they resist this. It does take sensitivity. /p
p class=postedPosted by: Rob | May 24, 2010 5:23:52 PM/p

pWhat#39;s wrong with quot;social visitsquot;? I#39;ve seen older folks on Medicare come in with some vague complaint just so they can talk to somebody. Kids are far away, friends are dead and folks are lonely. Is having someone to talk to, someone who cares, less therapeutic than a bunch of colorful pills for depression? I#39;ll gladly pay a little more taxes for this simple comfort for the elderly./p
p class=postedPosted by: Margalit Gur-Arie | May 24, 2010 6:36:20 PM/p

pHey Rob,/p

pGood rules, in general, but a little weak on the psychological issues of patients./p

pMost importantly, abiding by the rules is incompatible with face buried in computer terminal with hand on the clicker. The person is the patient. In contrast, the patient, according to Blumenthal and Halamka, is the computer./p
p class=postedPosted by: propensity | May 24, 2010 6:39:40 PM/p

pPropensity: My opinion (as someone who has been on EMR for 12 years) is that it is a case of PICNIC (Problem In Chair Not In Computer) – that is, the doctor with his/her nose in the computer would#39;ve had their nose in the paper chart as well. We have computers in every exam room, but it is a tool and is used in a way that I can face the patient during the encounter. Since I type while not looking at my hands, I can take very good notes and keep eye contact. Doctors can hide behind computers if they are intent on hiding, but in my view a computer is a great tool to engage the patient IF USED PROPERLY./p
p class=postedPosted by: Rob | May 24, 2010 7:21:47 PM/p

pIf you do say so yourself./p
p class=postedPosted by: propensity | May 24, 2010 8:02:26 PM/p

pGreat rules. I would have to question rule 1.2 though as a little to simplistic. Patients request things that are harmful all the time, and as doctors we prescribe them. It can be as simple as a statin or more complex, like coumadin for a patient who has had GI bleeds. All interventions, no matter how insignificant we perceive them to be, will have some risk of harm associated with it. The question is will it provide the patient with a greater amount of benefit. Take quot;addictive drugsquot; as an example. I would agree that use of these drugs should not be prescribed for patients without pain. However, for patients living with advanced illnesses, use of opioids may be able to give them the ability to regain function.br /
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p class=postedPosted by: Eric Widera | May 24, 2010 8:13:17 PM/p

pWhat#39;s wrong with social visits is that for people who work, we have to take a half day off, spend a load of money (and we pay, if it#39;s through insurance or directly, we pay). I don#39;t want to pay to socialize. And I don#39;t want to use sick leave, which I need in case I get sick. So that#39;s a half day of my meager vacation time. (I may get to choose if I#39;m lucky.) To pay to socialize? no thanks./p
p class=postedPosted by: Anon | May 24, 2010 8:55:40 PM/p

pAs a like-minded family doctor, I really enjoyed this post, and I do wish that more doctors shared this same view. Some specific comments on your Top 10:/p

pRule 1 – It#39;s the Patient#39;s Visit. Totally agree. Patients shouldn#39;t be made to come in to the office if they don#39;t really need it. But our current system really pays for visits. So guess what the system gets? Visits! This is one reason I am so excited about the PCMH concept./p

pRule 2 – Minimize. I have been burned again and again when ordering a test to quot;reassurequot; myself or the patient. PS – this is why I hate the full body CT. What do you do with all those incidentalomas./p

pRule 3 – Relationships. One of my core beliefs is that life is all about relationships. I agree that better relationships lead to better care. This is my biggest worry about PCMH, will the team-based model dilute the doctor-patient relationship? I think it will to some degree, but the benefits will outweigh the negatives, particularly if we are mindful of the issue./p

pRule 5 – ALWAYS a Reason. I think this can be one of the most fun parts of our job. Why did you come in TODAY? What is really going on? And I have found that when someone says, quot;I don#39;t knowquot;, they usually know, but may not be aware that they know./p

pRule 7 – Compliance follows communication. I am not a huge fan of quot;compliancequot;, feels too laden with negative judgment. I like to tell my students to think that rather than the patient has a compliance problem, think that you and the patient have an alliance problem. And then work on the only thing you have any control over, your actions, explanations, etc./p

pRule 10 – Enjoy. Absolutely! We have the best job in the world, and it seems that the more I focus on the good stuff, the more good stuff that comes. That seems to be true for my patients as well. /p

pAnd I love your PICNIC acronym in the comments. You are right on about docs who bury their noses in computers are the ones who buried them in paper charts. This was shown in a nice study (Frankel R, et al. Effects of exam-room computing on clinicianndash;patient communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20:677ndash;82.) Computers can really be used to improve care, but, like with most things, the devil is in the details. /p

pbr /
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p class=postedPosted by: Michael Coffey, MD | May 24, 2010 9:21:48 PM/p

pPropensity: I willbr /
Eric: Yes, these are simplistic. They are rules, not laws. There will always be exceptions, but in the context of a post they need to be kept general.br /
Michael: Thanks for your comments. I wrote the compliance bit because docs tend to blame-shift things on patients. They don#39;t see that they have a role in the issue. We can achieve better compliance if we take the time and explain (and listen, of course)./p
p class=postedPosted by: Rob | May 25, 2010 5:56:27 AM/p

pquot;The person is the patient. In contrast, the patient, according to Blumenthal and Halamka, is the computer.quot;/p

pquot;that is, the doctor with his/her nose in the computer would#39;ve had their nose in the paper chart as well.quot;/p

pThe problem isn#39;t the computer in the exam room: it#39;s the overwhelming bureaucratic and administrative load of Meaningful Use and the PCMH that will inevitably require that doctors, nurses, and staff spend more time in front of the computer and less time in direct patient care.br /
/p
p class=postedPosted by: pcp | May 25, 2010 6:59:45 AM/p

pIn concert with Propensity. Rob is grandstanding on the virtues of his typing skills. The patient has a chief complaint. The computer has a lack of usability disease. The patient gets shortchanged. The computer gets the attnetion. Sad./p

pRob#39;s list is too long for me to remember. Put it on the computer as an app to enable me to go through the list./p
p class=postedPosted by: tsuris | May 25, 2010 7:32:53 AM/p

pHe he. Grandstanding? I didn#39;t realize I was doing that! Our practice has been on EMR for 12 years and it is used well by more than just me. None of our staff or docs would ever practice without it. I#39;ll post on this, but I refer back to the PICNIC acronym and Dr. Coffee#39;s reference. Computers certainly CAN be in the way, but it#39;s more a case of dumb docs than it is misplaced tech. The tech needs improvement, but it is an improvement over paper charts./p
p class=postedPosted by: Rob | May 25, 2010 8:03:16 AM/p

pThese are good rules guidelines. There is one section where I may differ; the section on using the least expensive medication. /p

pMy guideline is:/p

pI will prescribe what I consider the best medication for a particular scenario without regard to cost. I will become completely knowledgeable about a medication including benefits and side effects but not formulary. I will allow a generic substitution, but I will rarely write specifically for a generic unless it makes Wal-Martrsquo;s printed list. Costs are beyond the control of the prescribing doctor that it does not make sense for a physician to make decisions based on it. A general ball park figure for a medication might be helpful, but I have had patientrsquo;s bring the same medication from two different pharmacies and the final price could vary by more than 150%. Medications are cheaper at a pharmacy when there is a competitor on the same corner. A pharmacist might change a medication because it costs less (and he receives a higher dispensing fee) and tell the patient that a particular medication is cheaper. Though this may be true, the reality for the patient is that both medications have the same copayment. Sometimes the difference in price might be miniscule. This is just the tip of the iceberg. In a similar fashion, I may recommend a consulting physician, but I donrsquo;t base it on cost. I may recommend a particular facility, but unless it is a cash paying patient where I can negotiate a lower cost for the patient, I donrsquo;t recommend a facility based on cost./p

pThere is no possible rule on cost. br /
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p class=postedPosted by: Contrarian | May 25, 2010 9:01:12 AM/p

pThanks Doc. Just curious, if you would be able to advise your HSA/HD patients on where to get good and affordable treatments from?/p

pThis apart, I would really love to see a patient#39;s dossier. One understated aspect of a patient#39;s lives is that they make decision regarding doctors and treatments to choose. Now doctors are very well trained in their profession so they can make sound decisions, most of the time. We the patients have zilch education but have ultimate authority to take our decisions on our behalf. It#39;s a tough job, if someone is trying to do it responsibly./p

pAny suggestions, from anyone if any book to educate patients exists?/p
p class=postedPosted by: Vikram C | May 25, 2010 10:21:28 AM/p

pVikram: My advice is quite biased, of course, but I honestly think that an educated patient along with a TRUSTED PCP is the most cost-effective approach. There is no way a non-medical person will be able to know if the decisions they make are the best, having not had the cross-section of experience. That does NOT mean that the patient should be passive; the patient#39;s job is to take the advice of the PCP along with what they can read from trusted Websites (I like UpToDate and the Mayo Clinic sites). It#39;s not bad to read several sources, then go to the doc with your questions. In the end, the decision belongs to the patient and the job of the PCP is to give the best information they can give. A trustworthy PCP will understand and encourage the patient#39;s final say in the process./p

pWhy a PCP? Seeing patients every day gives a wealth of experience that goes beyond the formal education/training. Plus, PCP#39;s are not financially rewarded for sending you for more tests and spending more money (as opposed to many specialists). You pay your doctor for something you can#39;t get anywhere else: experience and training, but the decision in the end is yours./p
p class=postedPosted by: Rob | May 25, 2010 2:37:33 PM/p

pContrarian;/p

pI agree with what you say up to a point. Example: I once took my daughter to a dermatologist for acne. He prescribed, among other things, 75 mg tetracycline (or it could have been doxy, that#39;s not the point) bid. So when I go to fill the prescription, 75 mg is, like $80, but 50 mg or 100 mg is an order of magnitude lower – like $8. (I am inventing the exact $#39;s b/c I don#39;t remember, but it#39;s the huge difference that matters.)br /
Since I have an HSA and no drug benefit, this matters to me./p

pSo I call the office, ask to speak to him, and explain the problem. He is SHOCKED, just SHOCKED, at the price difference and says yes of course she can take 50 mg in the am and 100 mg in the pm for the same total daily dose./p

pThis was totally avoidable if he had educated himself on what must be a very frequent prescription for him. Most patients, also, would just fill it since they are not paying./p

pI#39;m sure it is easy to find other examples. I believe docs should educate themselves on the costs of their frequently prescribed drugs in this manner and avoid a lot of waste./p
p class=postedPosted by: bev M.D. | May 25, 2010 5:21:58 PM/p

pRob,br /
Thanks for your reply. I am generally in agreement with what you say. Probably the stakes aren#39;t too high when visiting a PCP. But let#39;s say it#39;s one of those case, say, as happened in St John#39;s Hospital, MD. Hundreds of patients got letter from hospital that they were possibly unnecessarily stented. One doctor in question has been stripped of his position./p

pNow if I were to be the unfortunate one to get such advice and based on my extensive research I find that it#39;s not necessary, what should I do- trust doctor or myself?/p

pI am not looking to debate and harangue the doctors, but I am not willing to abdicate my responsibility towards my well being either./p
p class=postedPosted by: Vikram C | May 25, 2010 8:59:07 PM/p

pI earlier alluded to patient decision making. Here are some of patient decision areas that I could think of./p

p1. Branded vs genericbr /
2. Choosing Doctor amp; Hospital , first timebr /
3. Changing doctorbr /
4. When treatment is not workingbr /
5. Supplementary and alternatives therapy alongside prescribed medicine.br /
6. When to visit and not to visit doctor.br /
7. Handling second and possibly conflicting opinion.br /
8. Side effects and limitations of medicine.br /
9. Overmedication, concern or actual experience.br /
10. When you think you know more than doctor about your condition/p
p class=postedPosted by: Vikram C | May 25, 2010 9:28:30 PM/p

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