Initial Medical Evaluation Research Articles

Prevalence Of Symptoms Of Obstructive Sleep Apnea In Patients Attending An Inner City Primary Care Clinic.

Background: Obstructive Sleep Apnea (OSA) is an under diagnosed condition. Patients(pts) are not routinely screened for symptoms (sx) of OSA as a part of their initial medical evaluation. We did a prospective study to determine the prevalence of such symptoms in pts attending a medical clinic in the inner city hospital. Methods: During January to August 2005, adult pts attending one of the hospitals primary care clinics were evaluated. A physician administered the Berlin questionnaire for screening for symptoms of OSA to pts who consented to participate. The questionnaire included history of snoring, morning fatigue, excessive daytime somnolence, and falling asleep while driving. Patients with prior diagnosis of OSA were excluded. Results:108 pts participated in the study and 104 completed the study. 4 were excluded due to insufficient data. There were 42 males and 62 females. The mean age was 54 years .The prevalence of symptoms of (OSA) in this group of pts was 35.58% . Among the pts with sx, 75.7% were Hispanics, 18.9% were Afro-Americans, and 4.6% were of other ethnicity. Conclusions: Significant number of patients attending Primary care clinic in the inner city have undetected symptoms of OSA which need further evaluation with polysomnography and specific treatment. As OSA is a serious condition and can have a significant impact on the control of co morbid conditions such as Hypertension, Diabetes, Asthma and cardiac disease, screening for these symptoms is recommended during initial medical evaluation of adult patients.

Erectile dysfunction and testosterone screening with prostate specific antigen screening at age 40: are these three gender specific determinants additive for overall men’s heath and do they improve traditional non-gender specific determinants to lessen ca

Assess support for a recommendation to add screening for both erectile dysfunction (ED) and hypogonadism to the initial medical evaluation of young-to-middle aged (≥ 40 years of age) men in light of recent guidelines suggesting prostate-specific antigen screening occur at that age. A search of literature published from 1998 to 2009 was performed. Search terms included: ED combined with coronary artery disease (CAD), metabolic syndrome and hypogonadism, hypogonadism and ED, hypogonadism, ED and mortality. Articles were evaluated according to the Center of Evidence-Based Medicine. Both retrospective and prospective evaluations have demonstrated a strong relationship between ED, established cardiovascular risk factors, CAD and the potential occurrence of cardiovascular events. Low testosterone levels are associated with ED. Low serum total testosterone is an independent risk factor for both metabolic syndrome and type 2 diabetes and all-cause mortality. Traditionally, ED and testosterone levels have been considered mainly, if not exclusively, in the context of sexual health. The results briefly summarised herein and other recent reviews suggest that ED and hypogonadism are signals of future all-cause mortality and overall health status and thus move these evaluations into the broader arena of public health. Screening for ED and hypogonadism provide 'gender-specific determinants' to assess general metabolic and cardiovascular health risks in men. It is the opinion of the authors that this screening be performed in addition to the well-established non-gender-specific screening tests of lipids, blood pressure, obesity and serum glucose.

Abdominal Sonography in the Medical Evaluation of Aviation Aspirants

Ultrasonography is increasingly used in elderly individuals for screening of occult malignancy and abdominal aortic aneurysm. Its utility as a screening tool in healthy asymptomatic individuals is not yet established. The current study was undertaken to evaluate the utility of abdominal and pelvic ultrasonographic screening as an adjunct to routine physical examination among young adults undergoing initial medical examination for aviation duties. Abdominal ultrasound findings of 2598 candidates (2339 men, 259 women, mean age 20.3 +/- 1.8 yr) reporting for initial aircrew medical examination between January 2004 and December 2006 at two established medical evaluation centers were analyzed. Of the candidates, 90% (N=2339) screened were for cockpit aircrew duties. Sonographic abnormalities were noted in 6.0% of candidates. These included fatty infiltration of the liver in 2.9%, renal abnormalities in 1.57%, gallstones in 0.34%, and splenomegaly in 0.30%. Of the 259 female candidates, 7 were noted to have pelvic abnormalities which included ovarian cyst in 5, and uterine agenesis and fibroid uterus in 1 each. Of the aircrew who had abnormal findings on the initial ultrasonography, 71% required further testing. Based on the ultrasound findings 10 candidates were declared permanently unfit, 39 candidates were declared temporarily unfit, and the remaining were found fit for aviation duties. Abdominal sonographic screening in young healthy asymptomatic aircrew may be a valuable extension of the initial medical evaluation. It is particularly important in the high-risk subgroup of military aviators for determining long-term career prospects.

Health advance directives, policy and clinical practice: a perspective on the synergy of an effective advance care planning framework

The delivery of quality care at the end of life should be seamless across all health care settings and independent from variables such as institutional largeness, charismatic leadership, funding sources and blind luck ... People have come to fear the prospect of a technologically protracted death or abandonment with untreated emotional and physical stress.

The Back Disability Risk Questionnaire for Work-Related, Acute Back Pain: Prediction of Unresolved Problems at 3-Month Follow-Up

To assess the validity of the Back Disability Risk Questionnaire (BDRQ) to predict developing chronic back disability. Five hundred nineteen working adults (67% male) seeking outpatient care for acute, work-related back pain (<or=14 days) completed the BDRQ. After the initial medical evaluation, clinicians provided prognostic impressions in a 10-item questionnaire. Pain, functional limitation, and work status were assessed at 3-month follow-up. In multivariate analyses, the presence of persistent pain, functional limitation, or impaired work status (31.4%) was predicted by six BDRQ questions: injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about re-injury, expectation for early return-to-work, and stress. Classification accuracy at 3 months was 76.3%. Initial clinician impressions showed no multivariate associations with outcomes. The BDRQ may provide prognostic information not observed in a routine medical evaluation for acute BP.

Histologic dating of bruises in moribund infants and young children

It is generally held that leukocytes are found within bruised subcutaneous tissues within 4-12 h of injury as part of a standard cellular response to trauma. As a corollary, the absence of leukocytes is often cited as evidence of more recent injury. To investigate how long after injury it may be before a leukocyte response occurs selected bruises from three children aged 27, 11, and 3 months, respectively, were examined microscopically. All of the children had sustained lethal head trauma, with survival on life-support equipment for some time in hospital, and with bruises of at least 24-h duration confirmed by medical evaluation (at 30, 44, and 79 h from the time of initial medical evaluation to death). Histologic examination of selected lesions in all three cases revealed extravasation of red blood cells within subcutaneous tissues, but no leukocyte infiltration or other cellular reaction. Other bruises in these children exhibited a standard inflammatory response. This study has shown that selected bruises in three children were present for at least 30 h without a leukocyte infiltrate. Caution should, therefore, be exercised in assigning too rigid a time course to bruising in infants and young children based on a lack of a vital reaction, as the absence of leukocytes within soft tissues of bruised skin in these cases may not necessarily indicate that the injuries are recent. Variability in tissue response may also occur in different bruises in the same individual. Whether severe craniocerebral trauma played a role in delaying the cellular response in these particular injuries is unclear.

Patient Clusters in Acute, Work-Related Back Pain Based on Patterns of Disability Risk Factors

To identify subgroups of patients with work-related back pain based on disability risk factors. Patients with work-related back pain (N = 528) completed a 16-item questionnaire of potential disability risk factors before their initial medical evaluation. Outcomes of pain, functional limitation, and work disability were assessed 1 and 3 months later. A K-Means cluster analysis of 5 disability risk factors (pain, depressed mood, fear avoidant beliefs, work inflexibility, and poor expectations for recovery) resulted in 4 sub-groups: low risk (n = 182); emotional distress (n = 103); severe pain/fear avoidant (n = 102); and concerns about job accommodation (n = 141). Pain and disability outcomes at follow-up were superior in the low-risk group and poorest in the severe pain/fear avoidant group. Patients with acute back pain can be discriminated into subgroups depending on whether disability is related to pain beliefs, emotional distress, or workplace concerns.

Exercise Improves Daily Fatigue Scores for Advanced (StageIV) Cancer Patients

Exercise can help to ameliorate the profound fatigue that often accompanies cancer. Previous studies have demonstrated the impact of supervised exercise programs on fatigue in early stage cancers. The role of exercise in the palliative management of late stage cancers has not been well denned. PURPOSE: To determine the efficacy of a supervised exercise intervention on the daily fatigue scores of advanced (stage IV) cancer survivors still receiving treatment. METHODS: 9 stage IV cancer survivors 2 men and 7 women, (mean age 52+13 years and mean VO2max 22.37 ±14.73mlkg−1·min−1) participated in an individualized cancer exercise program. All participants were involved in treatment for late stage cancer. Diagnoses included breast, cervical, lung, ovarian, testicular, and peritoneal cancer. Initial medical evaluations included a thorough medical history, Karnofsky Score, Berg Balance Score, VO2max, muscle endurance, Beck depression Score, Piper Fatigue Scale, weight, and BMI. Each patient had an individualized exercise prescription for each session. These were one hour in length and included aerobic conditioning, resistance training, core strengthening, flexibility and balance activities. Fatigue scores were recorded pre and post exercise using a standard 10 point fatigue scale. RESULTS: Pre and Post Fatigue scores were recorded for 188 exercise sessions. Pre Exercise Fatigue Scores were 3.91 ±5.6. Post Exercise Fatigue Scores were 1.53±4.47. Significant decreases (P <0.05) were seen in the fatigue scores following the exercise intervention. CONCLUSION: A medically supervised exercise program is an effective way to manage cancer related fatigue in Stage IV cancer survivors undergoing cancer treatment.

Delays in Diagnosis of Deep Vein Thrombosis and Pulmonary Embolism

To investigate delays in the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). We prospectively identified 1,152 patients in whom DVT or PE had been diagnosed at 70 North American medical centers. We recorded demographic characteristics and dates of symptom onset, initial medical evaluation, and confirmatory diagnostic tests. We identified substantial numbers of patients for whom there were delays in the diagnosis of DVT, PE, or both. For acute DVT, 170 of 808 patients (21%) received diagnoses > 1 week after symptom onset, and 40 of 808 patients (5%) received diagnoses > 3 weeks after symptom onset. On average, 80% of the delay in diagnosis of DVT occurred between symptom onset and medical evaluation. Acute PE was diagnosed in 59 of 344 patients (17%) > 1 week after symptom onset, and in 17 of 344 patients (5%) > 3 weeks after the onset of symptoms. Delays in the diagnosis of PE represented both delays in seeking medical attention (mean, 3 days; upper limit of 95% confidence interval [CI], 12 days); and delays from the first medical evaluation to diagnosis (mean, 2 days; upper limit of 95% CI, 9 days). Although the majority of patients with DVT and PE seek medical attention and receive diagnoses promptly after symptom onset, substantial delays exist in the diagnosis of DVT and PE for many patients. There is a need to develop and test strategies that reduce delays in diagnosis.

Childhood dermatofibrosarcoma protuberans: Role of preoperative imaging

Dermatofibrosarcoma protuberans (DFSP) is especially challenging to recognize and diagnose in children. Prompt and definitive treatment is essential based on the tumor's high rate of recurrence. Our purpose is to increase physician awareness and recognition of DFSP in the pediatric population with the largest case series of childhood DFSP to our knowledge thus reported in the literature. We also propose that magnetic resonance imaging (MRI) may be useful in the preoperative assessment. The records of 10 patients with primary DFSP between the ages of 8 months and 16 years were reviewed. Only 1 of 10 patients was given the correct diagnosis at the initial medical evaluation. Of the 10 cases, 5 were congenital. The average delay in diagnosis was 5 years. Of the patients, 5 had preoperative MRI to delineate the size and extent of the tumor. In the two cases with the largest tumors preoperative MRI significantly altered surgical planning and execution. Thus, preoperative MRI may be helpful in planning for successful surgical clearance of large tumors and preventing local recurrence. All 10 cases were treated with Mohs micrographic surgery and no recurrences were noted with a follow-up range of 6 weeks to 17 years.

Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: A prospective study

Background & Aims: Unlike in upper tract bleeding, prognostic factors for ongoing or recurrent bleeding from the lower gastrointestinal tract have not been well-defined. The aim of this study was to identify risk factors for severe lower gastrointestinal bleeding and for significant adverse outcomes. Methods: All patients seeking attention at a university emergency department for gastrointestinal bleeding were prospectively identified during a 3-year period. Ninety-four of 448 (21%) admitted patients had lower gastrointestinal bleeding. Clinical predictors available in the first hour of evaluation were recorded. The primary outcome, severe lower gastrointestinal bleeding, was defined as gross blood per rectum after leaving the emergency department associated with either abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) or more than a 2-unit blood transfusion during the hospitalization. Significant adverse outcomes, including death, were tabulated. Results: Thirty-seven patients (39%) had severe lower gastrointestinal bleeding. Independent risk factors for severe lower gastrointestinal bleeding were initial hematocrit ≤35% (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.2–16.7); presence of abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) 1 hour after initial medical evaluation (OR, 4.3; 95% CI, 1.4–12.5); and gross blood on initial rectal examination (OR, 3.9; 95% CI, 1.2–13.2). Nineteen patients (20%) experienced a significant adverse outcome, including 3 deaths. The main independent predictor of adverse outcomes was severe lower gastrointestinal bleeding (OR, 5.3; 95% CI, 1.7–16.5). Conclusions: Risk factors are available in the first hour of evaluation in the emergency department to identify patients at risk for severe lower gastrointestinal bleeding. Severe lower gastrointestinal bleeding is a significant risk factor for global adverse outcomes.

Pharmacoeconomic aspects of adjuvant early breast cancer treatment in postmenopausal women with anastrozole or tamoxifen: a Slovenian perspective

The frequency of urinary tract infections (UTIs) and mounting pressure for cost containment in medical care emphasize the need to consider costs of evaluating and treating UTIs. Many clinicians base antibiotic choice on drug cost, probably because this information is objective and readily available. However, the cost of treating UTI patients involves other factors, such as pathogenic susceptibility and consequences of inadequately treated infection. These factors and their associated costs can be difficult to assess and weigh against issues such as drug cost. The direct cost of treating a UTI patient includes not only initial medical evaluation and treatment, but what occurs subsequently. If initial treatment is provided with a drug for which a pathogen is not sensitive, patients will be likely to continue to experience symptoms and return for re-evaluation, resulting in a more thorough evaluation and a second antibiotic, generally a more expensive fluoroquinolone. The most important predictor of high cost-effectiveness is high efficacy against the most common urinary pathogen, Escherichia coli. The lower the effectiveness of antibiotics against this pathogen, the greater the number of revisits and cases of progression to pyelonephritis. Increased follow-up care results in diminished cost-effectiveness. Antibiotic cost is a poor predictor of cost-effectiveness, illustrated by the finding that the most and least expensive drugs, ofloxacin and trimethoprim–sulfamethasoxazole, are approximately equally cost-effective. Both of these are more cost-effective than other drugs, nitrofurantoin and amoxicillin, considered in this analysis.

Concordância no diagnóstico radiológico das infecções respiratórias agudas baixas em crianças

To evaluate the inter-observer agreement of radiological diagnosis of lower respiratory tract infections in children. Chest X-rays from 60 children younger than 5 years of age were evaluated by three physicians: a pediatric radiologist (PR), a pediatric pulmonologist (PP) and an experienced emergency pediatrician (EP). All children had sought an emergency room due to acute respiratory infections with apparent lower respiratory tract involvement. Observers were blinded to the original diagnostic conclusions, but clinical and laboratory data from the initial medical evaluation were provided with each film. Variables were grouped into five categories: a) film quality; b) site of abnormality; c) radiological patterns; d) other radiographic images; e) diagnosis. Inter-observer agreement was assessed using Kappa statistics, accepting prevalence-bias-adjusted values (PABAK). compare the prevalence of breastfeeding and exclusive breastfeeding during the first six months of life among pacifier and non-pacifier users. Kappa values for each of the three observer pairs (RP vs. PP, RP vs. EP, and PP vs. PE) were 0.41, 0.43, and 0.39, respectively. The overall inter-observer agreement was moderate (0.41). Agreement on other variables was as follows: regular for "film quality" (0.30); moderate for "site of abnormality" (0.48); fair for "radiological patterns" (0.29); moderate for "other radiographic images" (0,43); and moderate for "diagnosis" (0.33). The overall intra-observer agreement was "moderate" (0.54), which is below the agreement values reported by other studies on chest X-ray variability. Inter-observer variability is an intrinsic characteristic of the interpretation of chest X-rays, and the diagnosis of lower respiratory tract infections in children remains a challenge. Most of our results were similar to those previously reported.

Organization and function of academic psychiatric emergency services

Psychiatric emergency services (PES) are evolving as freestanding, parallel components of emergency departments at many tertiary care medical centers in the U.S. While PES facilities provide an increasing percentage of first-line care for patients with psychiatric crises, the services they provide and their interactions with medical emergency services have not been systematically assessed. The purpose of this study was to examine PES structure, care processes, patient characteristics and relationship with medical emergency services by surveying PES directors with a 70-item questionnaire about PES facilities in 1998. This report presents information about staffing adequacy, medical evaluation and other procedures, length of stay, and aftercare. The response rate was 91% ( n=51), and most sites (>90%) were academic training sites. A large percentage (92%) of PES sites were open 24 h a day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h daily. PES psychiatrists performed initial medical evaluation at 55% of sites and were often responsible for medical clearance. Pharmacologic therapy was routinely initiated for patients being admitted in 92% of facilities and for patients being released in 70% of facilities. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES facilities were effective at referring patients to aftercare, and 51% of PES sites provided follow-up care. However, 69% of respondents reported inadequate referral options for patients with substance abuse. The mean recidivism rate was 18%, primarily attributed to substance abuse and medication noncompliance. The results of this survey show that PES facilities are organizationally complex units in which staff routinely perform medical clearance, initiate treatment, and coordinate aftercare. Our findings highlight the importance of adequate medical training for PES psychiatrists, the need for improved aftercare programming, and better access to substance abuse treatment for discharged patients.

Physiological Responses of Men and Women to Barley and Oat Extracts (Nu‐trimX). II. Comparison of Glucose and Insulin Responses

ABSTRACTThis study was designed to compare the glucose, insulin, and glucagon responses to consumption of high‐soluble β‐glucan compounds from oats and barley. After an initial medical evaluation that included blood and urine testing, 11 men and 11 women, nondiabetics, 35–57 years, were selected. Subjects consumed a controlled diet for three days. On the third day of five successive periods, subjects consumed 1 g/kg of body weight of carbohydrate as glucose or 0.66 g/kg of body weight pudding (predominantly sucrose) and 0.33 g/kg of body weight as oat bran, barley flour, oat or barley extract (Nu‐trimX) in a Latin square design. Order of treatment was randomly assigned. Glycemic responses were calculated using the trapezoid method. Data were analyzed using mixed procedure analysis of variance program. Glucose responses to oats, barley, and both extracts, and areas under the curve were significantly lower than responses to the glucose solution (P &lt; 0.0001). Insulin responses for the barley extract were lowest and were significantly lower than for glucose solution. Oat and barley extracts retain the beneficial effects of the grains from which they are extracted. High‐soluble fiber barley is more effective than standard oats. Oat and barley carbohydrate‐based fat substitutes can provide a useful addition to menus to control plasma glucose responses.

Using lymphoscintigraphy to evaluate suspected lymphedema of the extremities.

405 ymphedema is the painless progressive accumulation of proteinrich fluid in the interstitial spaces of the skin, resulting from an anatomic or functional obstruction of the lymphatic system [1]. Lymphedema of the lower or upper extremities is typically a chronic condition that has several possible causes and that presents considerable physical as well as psychological difficulties for patients [2]. Patients with lymphedema experience extremity swelling, decreased coordination and mobility, and secondary infections [2]. The disorder typically affects the dermis and spares the deeper compartments [3]. At the initial medical evaluation of patients with suspected extremity lymphedema, it is highly desirable for physicians to define the abnormality; to determine whether the suspected abnormality is, in fact, a lymphatic one (Figs. 1 and 2) before instituting a therapeutic plan; and to establish an objective baseline [3]. The differential diagnosis of suspected extremity lymphedema includes obesity, venous disease, and systemic disease (e.g., hypoalUsing Lymphoscintigraphy to Evaluate Suspected Lymphedema of the Extremities Mariam Moshiri 1 , Douglas S. Katz 1 , Marvin Boris 2 , Elizabeth Yung 1

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

THE NEUROENDOCRINOLOGY OF OBESITY

The regulation of energy balance is enormously complex, with numerous genetic, hormonal, neural/behavioral, and societal influences. Although the current epidemic of obesity has its underpinnings in the changes in culture during the last half century, the role of the neuroendocrine system in the genesis of obesity is physiologically and therapeutically unavoidable. Increased understanding of this system has suggested organic etiologies (and therapies) for some rare and not-so-rare forms of obesity. With so many inputs, it is not implausible that dysfunction of other parts of this feedback system will be found to explain other forms of obesity in the future. Fortunately or unfortunately, diet and exercise remain the mainstays of obesity therapy. Most diet-exercise programs result in an acute 11-kg weight loss in adults; the question is whether it can be sustained without significant long-term behavior modification. In the European Sibutramine Trial of Obesity Reduction and Maintenance (STORM), 42% of treated patients dropped out; of those remaining, 77% of subjects lost more than 5% of initial body weight, but only 43% of these individuals maintained greater than 80% of this loss over 2 years. Could there be an organic component in persons who do not respond? Obesity pharmacotherapies sometimes have beneficial acute effects, but these effects are impermanent; discontinuation tends to result in a rebound weight gain, suggesting that the etiology of the obesity is still present. A useful guiding principle is that patients who do not respond to diet and exercise should undergo an initial medical evaluation, including assessments of birth weight, past medical history, weight history, family history, diet, exercise, and fasting insulin and thyroid levels. As the nosology of obesity improves, diagnostic efficiency and therapeutic success should increase, leading to a decrease in associated morbidity, mortality, and socioeconomic ramifications.

THE NEUROENDOCRINOLOGY OF CHILDHOOD OBESITY

The regulation of energy balance is enormously complex, with numerous genetic, hormonal, neural and behavioral, and societal influences. Although the current epidemic of obesity clearly has its underpinnings in the changes in culture during the past half-century (see other articles in this issue), the role of the neuroendocrine system in the genesis of obesity, as described in this article, is physiologically and therapeutically unavoidable. An understanding of this system has suggested organic causes (and therapies) for some rare and not-so-rare forms of obesity. With so many inputs, it is not far-fetched to assume that dysfunction of other parts of this feedback system will be found to explain other forms of obesity in the future. What does this mean for obese children entering the pediatrician's office? Fortunately or unfortunately, diet and exercise are the mainstays of obesity therapy for children and adults. Most diet-exercise programs result in an acute 11-kg weight loss in adults; the question is whether it can be sustained without significant long-term behavioral modification. For instance, the European Sibutramine Trial of Obesity Reduction and Maintenance trial showed that 42% of treated subjects drop out; of those remaining, 77% of subjects lost more than 5% of initial body weight, but only 43% of those maintained more than 80% of this over 2 years. Could there be an organic component in those who do not respond? Of course, obesity pharmacotherapies sometimes have beneficial acute effects, but these drugs work for only as long as they are consumed; discontinuation tends to result in a "rebound" weight gain, suggesting that the cause of the obesity is still present. Furthermore, in 2001, there are no obesity drugs approved for children. A useful guiding principle is that children deserve at the minimum an initial medical evaluation, including birth weight, medical history, family history, dietary evaluation, and exercise assessment. Perhaps the most important feature that can distinguish "organic" from "behavioral" weight gain in childhood is the age of the "adiposity rebound." The Centers for Disease Control and Prevention now supplies BMI charts for boys and girls at www.cdc.gov/growthcharts. Plotting of the BMI versus age allows pediatricians to determine the age at which the BMI starts to increase (mean, 5.5 years). The earlier the adiposity rebound, the more likely the child will be obese as an adult, and the more likely that an organic cause can be determined. In such patients, thyroid levels and fasting insulin and leptin levels should be measured. An initial attempt at diet and exercise is essential; patients who do not respond with BMI stabilization should be investigated for a more ominous cause of their obesity. As the nosology of obesity improves, pediatricians will be able to increase the diagnostic efficiency and therapeutic success of this unfortunate, debilitating, and expensive epidemic.

A BUSINESS PLAN FOR A PAIN CLINIC

Millions of people suffer from chronic or intractable pain. Persistent pain varies in etiology and presentation. In some cases, symptoms and signs may be evident within a few weeks to a few months after the occurrence of an injury or the onset of disease. The cause of pain is not always known or apparent. For many patients, initial medical evaluation and treatments effectively relieve pain that might otherwise become chronic. Like many illnesses that at one time were not well understood, pain and its many manifestations may be poorly treated and seriously underestimated. Inappropriately treated pain seriously compromises the patient's quality of life, causing emotional suffering and increasing the risk of lost livelihood and social integration. Severe chronic pain affects both the pediatric and adult population, and often leads to mood disorders, including depression and in rare cases, suicide … Each physician bears the responsibility to evaluate and treat persistent pain as a serious medical condition. Principal treatment physicians must approach each patient with respect and urgency and provide appropriate and timely referrals to a pain medicine specialist when primary medical care has not been effective. Such referrals are appropriate because pain medicine specialists can provide a more advanced level of treatment to patients suffering from chronic or intractable pain … As physicians, we are trained to preserve patients' quality of life and relieve their pain and suffering. We must use all available resources to achieve these goals for our patients. (Adapted from the American Academy of Pain Medicine. Position Statement. February, 1997.) Pain management is an emerging discipline emphasizing an interdisciplinary approach with a goal of functional restoration, and reduction of pain and suffering. In 1976, the United States Social Security Administration officially recognized chronic pain as a significant form of morbidity in the aging American population. This decision extended benefits to cover chronic pain and rehabilitative treatment, and produced an explosion of providers and centers dedicated to its mission. More than 300 centers opened their doors that first year. Since that time, a diverse group of pain treatment centers have emerged in communities throughout the United States. In 1998, the American Pain Society reports there are more than 3000 clinical entities with the focus of treating chronic pain in the United States, up from an estimated 1500 centers reported in 1987. 1 Only a fraction of these entities are truly multidisciplinary in orientation. Pain centers are specialized entities set up to evaluate and treat patients with complex, intractable, and disabling problems. In designing a pain practice, it is important to keep the following in mind. A pain center has three customers: the patient, the referring physician, and the payer. Many patients are referred to these specialized entities as the “court of last resort.” Patients with chronic pain are often bitter, having failed under the care of primary medical providers. They are also cynical about spending large amounts of time in doctors' offices. A successful pain center will be designed to put such patients at ease. The facility will be approachable, provide telephone access between patients and care providers around the clock, communicate frequently with other treating physicians, provide comfortable waiting areas, be accessible to transport teams (including ambulances), and generally make patients feel welcome. Referring physicians want to know that their patients are being cared for effectively. Close communication with other treating doctors is also essential. General questions are asked of the pain physician by first-time referring doctors. It is important for the new pain practitioner to be respectful and accurate when responding to these queries. Additionally, payers are interested in cost-effective care. Patients with pain use a great percentage of health care dollars. 2 Payers are concerned about providing quality care in a cost-effective manner. Strategies for demonstrating to the payer outcomes and benefits of pain therapies will need to be rapidly developed. In summary, a successful pain practice will keep all users satisfied (referring physician, patient, and payer).