Central sensitization, chronic pain, and other symptoms: Better understanding, better management.

Central sensitization, a pathophysiologic process in which the central nervous system undergoes changes that alter its processing of pain and other sensory stimuli, may be the mechanism underlying various conditions in which patients have unexplained pain and fatigue. Patients frequently misunderstand the cause of their symptoms and pursue unnecessary evaluations and treatments. Clinicians have a pivotal role in decreasing this misunderstanding by providing patient education, which can affect perception, management, functional status, and quality of life.

Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review.

In both primary care and consultative practices, patients presenting with fibromyalgia (FM) often have other medically unexplained somatic symptoms and are ultimately diagnosed as having central sensitization (CS). Central sensitization encompasses many disorders where the central nervous system amplifies sensory input across many organ systems and results in myriad symptoms. A pragmatic approach to evaluate FM and related symptoms, including a focused review of medical records, interviewing techniques, and observations, is offered here, giving valuable tools for identifying and addressing the most relevant symptoms. At the time of the clinical evaluation, early consideration of CS may improve the efficiency of the visit, reduce excessive testing, and help in discerning between typical and atypical cases so as to avoid an inaccurate diagnosis. Discussion of pain and neurophysiology and sensitization often proves helpful.

A cultural and economic history of old age in America.

The lives of today's elderly population have deep historical precedents by which we can better understand current social policies, health care, and retirement. The history of old age in America is more complex and varied than most people realize. This history has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, few individuals saved sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family members willing or able to provide for an elderly relative resulted in the relative moving to the dreaded poorhouse. Passage of Medicare and Medicaid legislation resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. However, serious deficiencies in care have continued to occur, prompting additional federal legislation. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons.

Ethical issues in geriatrics: a guide for clinicians.

Because of demographic trends, it is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues, in turn, may lead to daunting ethical dilemmas. Therefore, clinicians should be familiar with ethical dilemmas commonly encountered when caring for elderly patients. We review some of these dilemmas, including ensuring informed consent and confidentiality, determining decision-making capacity, promoting advance care planning and the use of advance directives, surrogate decision making, withdrawing and withholding interventions, using cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for interventions, allocating health care resources, and recommending nursing home care. Ethical dilemmas may arise because of poor patient-clinician communication; therefore, we provide practical tips for effective communication. Nevertheless, even in the best circumstances, ethical dilemmas occur. We describe a case-based approach to ethical dilemmas used by the Mayo Clinic Ethics Consultation Service, which begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.

Caregiver and clinician shortages in an aging nation.

Despite a burgeoning elderly population, the number of nurses and other providers of direct care has declined to critical levels at many health care facilities. There are also insufficient medical clinicians to meet the demand for health services. A shrinking workforce, an aging population, financial pressures, and increased consumer demand will translate into severe personnel deficits in the future. Similarly, family fragmentation and the trend toward bureaucratization of long-term care have reduced the availability of informal caregivers. Younger workers should be considered a scarce resource for health care organization and planning purposes. The ability of the United States to meet its entitlement promises is likely to be compromised by a reduced labor pool and simultaneous budgetary constraints. Because good geriatric care is often labor-intensive, meeting this goal poses an increasing challenge.

Improving efficiency and reducing administrative burden through electronic communication.

BACKGROUND: The InBox messaging system is an internal, electronic program used at Mayo Clinic, Rochester, MN, to facilitate the sending, receiving, and answering of patient-specific messages and alerts. A standardized InBox was implemented in the Division of General Internal Medicine to decrease the time physicians, physician assistants, and nurse practitioners (clinicians) spend on administrative tasks and to increase efficiency. METHODS: Clinicians completed surveys and a preintervention InBox pilot test to determine inefficiencies related to administrative burdens and defects (message entry errors). Results were analyzed using Pareto diagrams, value stream mapping, and root cause analysis to prioritize administrative-burden inefficiencies to develop a new, standardized InBox. Clinicians and allied health staff were the target of this intervention and received standardized InBox training followed by a postintervention pilot test for clinicians. RESULTS: Sixteen of 28 individuals (57%) completed the preintervention survey. Twenty-eight clinicians participated in 2 separate 8-day pilot tests (before and after intervention) for the standardized InBox. The number of InBox defects was substantially reduced from 37 (Pilot 1) to 7 (Pilot 2). Frequent InBox defects decreased from 25% to 10%. More than half of clinicians believed the standardized InBox positively affected their work, and 100% of clinicians reported no negative affect on their work. CONCLUSIONS: This project demonstrated the successful implementation of the standardized InBox messaging system. Initial assessments show substantial reduction of InBox entry defects and administrative tasks completed by clinicians. The findings of this project suggest increased clinician and allied health staff efficiency, satisfaction, improved clinician work-life balance, and decreased clinician burden caused by administrative tasks.