Opinion Perspective
more with less—see more patients through shorter visits, coordinate complicated care with fractional reimbursement, and click more required boxes while holding fewer hands. But let us also do Published Online: January 5, 2015. doi:10.1001/jamainternmed.2014.7124. Conflict of Interest Disclosures: None reported. Additional Contributions: Thanks to Robin Canada, MD, and David Grande, MD, MPA, for their inspiration and guidance.
PERSPECTIVE
Sandra Zimmerman, RN Intersocietal Accreditation Commission, Ellicott City, Maryland.
Corresponding Author: Sandra Zimmerman, RN, Intersocietal Accreditation Commission, 6021 University Blvd, Ste 500, Ellicott City, MD 21043 (katanick @intersocietal.org).
more for those with less, and be a voice for those who cannot even make it through our clinic doors—to alleviate the pain and eliminate the pus.
1. Philadelphia Department of Public Health. Community health assessment (CHA): Philadelphia, PA. http://www.phila.gov/health/pdfs/CHAslides _11513.pdf. Accessed November 11, 2014.
do not expand Medicaid. http://kff.org/health -reform/issue-brief/the-coverage-gap-uninsured -poor-adults-in-states-that-do-not-expand -medicaid/. Accessed November 11, 2014.
2. The Henry J. Kaiser Family Foundation. The coverage gap: uninsured poor adults in states that
All My Husband Needed Was a Good Physical Examination My husband had been experiencing tremor in his hands for approximately 2 years. He is 69 years old, had worked for many years for a telecommunications company, and is now retired. The tremors come and go unexpectedly. One night they flared up when he was carving a ham. Sometimes he needed 2 hands to hold a cup of coffee in the morning, and the tremors show up when he writes. We were afraid that he had Parkinson disease. We went to our primary care physician whom we have known for a long time. He ordered a dopamine transporter (DAT) scan at a local hospital. This required injecting a radiopharmaceutical agent in the veins in a procedure called SPECT (single-photon emission computed tomographic) imaging. The results of the test created more uncertainty. Our primary care physician said that they were normal. I work in the health care field and asked 2 nuclear medicine physicians who are experts to read the scan. One concluded that it was normal, and the other thought that it showed early signs of Parkinson disease. We were worried about what a Parkinson diagnosis would mean for our quality of life in years to come. I contacted a nuclear medicine colleague who graciously agreed to reconstruct the raw data from the camera at the hospital, and he, along with 2 colleagues, reviewed and discussed the study. They said that my husband had not been properly positioned during the examination. His head was slightly tilted and rotated during the test, which made the images difficult to interpret. With this limitation, they did not agree that the study showed Parkinson disease, and they concluded that the results were probably normal. They also said that the 2
Published Online: January 5, 2015. doi:10.1001/jamainternmed.2014.7183.
physicians whom I had asked to review the results may have seen only the screen captures and not the raw projection data and therefore would not have caught the asymmetry in positioning. My husband and I needed answers about why he was experiencing tremors. I asked physician colleagues for a reference for a neurologist. We made an appointment, and the physician performed a thorough examination. My husband has had head injuries over the years but never lost consciousness. He is able to walk normally and does not have any voice tremors. When the physician asked whether any family members have tremors, my husband said that 1 family member has a tremor. Much to our relief, my husband does not have Parkinson disease. He received a diagnosis of familial essential tremor of the upper limbs. We learned about essential tremors and medications that can alleviate the symptoms. We realize that the treatment goal is not to eliminate the tremors but to reduce them to a point where they are less of a hassle doing day-to-day things. We also learned that the DAT scan was not necessary. My husband prefers to avoid medical tests, especially if they are not necessary. According to evidencebased guidelines, in general, a clinical examination is sufficient to differentiate essential tremor from Parkinson disease in almost all cases and a DAT scan is only rarely needed.1 We also learned that these scans are not infrequently misread. The cost of the DAT scan was $5700. In the end, all my husband needed was a good physical examination by a primary care physician.
1. Elias WJ, Shah BB. Tremor. JAMA. 2014;311(9): 948-954.
Conflict of Interest Disclosures: None reported.
340
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 05/18/2015
jamainternalmedicine.com
more with less—see more patients through shorter visits, coordinate complicated care with fractional reimbursement, and click more required boxes while holding fewer hands. But let us also do Published Online: January 5, 2015. doi:10.1001/jamainternmed.2014.7124. Conflict of Interest Disclosures: None reported. Additional Contributions: Thanks to Robin Canada, MD, and David Grande, MD, MPA, for their inspiration and guidance.
PERSPECTIVE
Sandra Zimmerman, RN Intersocietal Accreditation Commission, Ellicott City, Maryland.
Corresponding Author: Sandra Zimmerman, RN, Intersocietal Accreditation Commission, 6021 University Blvd, Ste 500, Ellicott City, MD 21043 (katanick @intersocietal.org).
more for those with less, and be a voice for those who cannot even make it through our clinic doors—to alleviate the pain and eliminate the pus.
1. Philadelphia Department of Public Health. Community health assessment (CHA): Philadelphia, PA. http://www.phila.gov/health/pdfs/CHAslides _11513.pdf. Accessed November 11, 2014.
do not expand Medicaid. http://kff.org/health -reform/issue-brief/the-coverage-gap-uninsured -poor-adults-in-states-that-do-not-expand -medicaid/. Accessed November 11, 2014.
2. The Henry J. Kaiser Family Foundation. The coverage gap: uninsured poor adults in states that
All My Husband Needed Was a Good Physical Examination My husband had been experiencing tremor in his hands for approximately 2 years. He is 69 years old, had worked for many years for a telecommunications company, and is now retired. The tremors come and go unexpectedly. One night they flared up when he was carving a ham. Sometimes he needed 2 hands to hold a cup of coffee in the morning, and the tremors show up when he writes. We were afraid that he had Parkinson disease. We went to our primary care physician whom we have known for a long time. He ordered a dopamine transporter (DAT) scan at a local hospital. This required injecting a radiopharmaceutical agent in the veins in a procedure called SPECT (single-photon emission computed tomographic) imaging. The results of the test created more uncertainty. Our primary care physician said that they were normal. I work in the health care field and asked 2 nuclear medicine physicians who are experts to read the scan. One concluded that it was normal, and the other thought that it showed early signs of Parkinson disease. We were worried about what a Parkinson diagnosis would mean for our quality of life in years to come. I contacted a nuclear medicine colleague who graciously agreed to reconstruct the raw data from the camera at the hospital, and he, along with 2 colleagues, reviewed and discussed the study. They said that my husband had not been properly positioned during the examination. His head was slightly tilted and rotated during the test, which made the images difficult to interpret. With this limitation, they did not agree that the study showed Parkinson disease, and they concluded that the results were probably normal. They also said that the 2
Published Online: January 5, 2015. doi:10.1001/jamainternmed.2014.7183.
physicians whom I had asked to review the results may have seen only the screen captures and not the raw projection data and therefore would not have caught the asymmetry in positioning. My husband and I needed answers about why he was experiencing tremors. I asked physician colleagues for a reference for a neurologist. We made an appointment, and the physician performed a thorough examination. My husband has had head injuries over the years but never lost consciousness. He is able to walk normally and does not have any voice tremors. When the physician asked whether any family members have tremors, my husband said that 1 family member has a tremor. Much to our relief, my husband does not have Parkinson disease. He received a diagnosis of familial essential tremor of the upper limbs. We learned about essential tremors and medications that can alleviate the symptoms. We realize that the treatment goal is not to eliminate the tremors but to reduce them to a point where they are less of a hassle doing day-to-day things. We also learned that the DAT scan was not necessary. My husband prefers to avoid medical tests, especially if they are not necessary. According to evidencebased guidelines, in general, a clinical examination is sufficient to differentiate essential tremor from Parkinson disease in almost all cases and a DAT scan is only rarely needed.1 We also learned that these scans are not infrequently misread. The cost of the DAT scan was $5700. In the end, all my husband needed was a good physical examination by a primary care physician.
1. Elias WJ, Shah BB. Tremor. JAMA. 2014;311(9): 948-954.
Conflict of Interest Disclosures: None reported.
340
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Manchester Library User on 05/18/2015
jamainternalmedicine.com
