Month: May 2013

Chronic cough

For this topic, I’ll begin with a recent patient encounter:

“11y/o male patient with history of asthma and allergies, seeing me for first time with Mom, has been seen with our providers here for the past 3-4 months for a chronic, persistent cough. In review, he was seen and treated by 2 of our for asthma and likely whooping cough with various inhalers, codeine cough syrup, Tessalon Perles (cough tabs), Singulair, Claritin, Advair, steroids and Azithromycin (antibiotic). His most recent appointment was a week ago, where he was treated a second time with steroids and antibiotics due to the persistent, dry cough occurring in fits. He denies sick contacts, shortness of breath, fever, post nasal drainage, wheezing, or night time cough. He’s been skin tested for allergies, with +horse hair and tree allergies. He notes some mild acid taste in throat occasionally. There is no smoke exposure. He never had a swab to confirm Pertussis (whooping cough infection) and a chest x-ray done in January which was negative”.

His mother and I racked our brains for the cause of his never-ending cough. It was now keeping him, a straight A-student, out of school, due to the disruption of his fits of cough. It was distracting to him and his classmates and was embarrassing. It was concerning to his mother because nothing worked. She wanted him to see a lung specialist. After various trials of cough medicines, antibiotics, asthma inhalers, and allergy medicines, the cough was non-stop.

Causes of chronic cough generally include the following: side effects from medicines, allergies and mucus production, asthma, respiratory infections, and acid reflux. With GERD, or gastro-esophageal reflux disease, there is increased acid production and decreased acid suppression in the stomach. The acid rises and ascends up the esophagus into the pharynx, or back of the throat, and irritates the vocal cords. Sometimes, it can also cause growths, or cysts, on the vocal cords, which can cause hoarseness out of nowhere, or produce a chronic cough.

For this patient, we’d already treated him for allergies, asthma, and infection multiple times. After thinking, I realized his cough probably started out as a whooping cough infection, but after many rounds of antibiotics and chronic irritation, he was likely developing some acid reflux on top of it. We tried Zantac twice a day, and his cough quickly stopped. Success! He was still seen with a lung specialist for follow up, but by then, his cough was gone. I saw his mother later and she was very pleased the cough was gone, and he could return to school without embarrassment. 

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Why the long wait?!

Published Wednesday, April 3, 2013
by C. Nicole Swiner, M.D., Columnist 

Two of the most difficult things to balance as a medical provider are seeing enough patients during the day and staying on time. Patients who schedule us for care check in at the front desk (on time, hopefully) and usually have to wait a while before they are brought back to the exam room.

Once in the exam room, they still have to wait some more before seeing the doctor. This usually leads to frustration and irritation on the patients’ parts, which leads to decreased satisfaction after their visit. Why does all of this happen?

 At risk of confusing this issue even more, I thought I’d put my two cents in and see if I can clarify some things from both sides.

From the doctor’s perspective, many patients don’t realize we only have 10 minutes to 20 minutes total for a patient encounter or visit. That doesn’t mean we have that amount of time to see you; it means your ENTIRE VISIT from start to finish is supposed to be done in that time. 

So stop a minute and think how unrealistic that may be. If a patient has an appointment at 10:30 a.m. and checks in on time, there may be a three minute to five minute process of waiting in the check-in line behind other patients and getting checked in by the front desk. If their information is out of date, this has to be updated at check-in. That takes time.

Once a patient sits in the waiting room, he has to wait for the appointment ahead of him to finish. Now, stop for another minute and imagine what’s going on with the patient ahead of you; he’s waited just as long to see the doctor, if not longer and also has important questions to ask. Even though his appointment was made for “a cold,” he also wanted to squeeze in some questions about his weight, low mood and if he can also get a physical done.

For the provider, this is difficult because we all want to give our patients the best care possible and satisfy them without overwhelming ourselves and the other patients we have waiting. Patients can be forceful and demanding oftentimes or may guilt us into doing more than we should. Now, multiply that situation by 15 to 30 people we see a day.

Or, take this situation for instance, which is what happens to me more often than not: An established patient comes in for a routine “follow-up” visit. We get started, and at the very end of the visit, tears begin to fall. It’s usually in response to my asking “So, how’s the family?” or “How’s work?” or “Are you sleeping well? 

There is almost always an underlying element of stress that leads to these issues. These are also the type of scenarios that we should start with at the beginning and not at the end of the visit. As the doctor, how do I rush that patient away when he clearly needs extra time with me to vent? The answer is I can’t. It’s a very difficult but necessary part of the job of taking care of people. 

This is what I would suggest to patients to help all of us be more efficient and gain more satisfaction:

• Come to your visit 10-15 minutes early to account for standing in line, checking in and editing information at the front desk.

• Schedule the appointment for only what is needed, i.e. medication refills, physical exam/pap, cold, etc. If you have issues that may take additional time, schedule another visit.

• Start with your most important complaint first. This means not waiting until the last minute of the visit to bring up the issue that would take the most time discussing.

• Make sure all of your demographics, addresses and insurance information are up to date at the time you schedule your appointment and don’t wait until check-in.

• Ask to come in two to three days before a scheduled visit for fasting blood work, if needed. This saves time and prevents you from having to come back to discuss results, and saves back and forth phone calls from the nurse or doctor trying to reach you later.

• If your lab has the ability to send your results via Internet or email, sign up for it. This way, you get your results quicker and saves time on the phone.

• Make sure to ask for refills needed at your visit. Most “extra” time that takes away from seeing patients for the staff and providers is spent on the phone or online filling refills that could have been handled at the time of the patient’s visit.