Medical Evaluations

People don't plan well for medical evaluations.  They don't ask questions.  They don't understand what's required.  They therefore come away from the evaluation less than satisfied with what was communicated and often less understanding of what they went through and why.

I perform several types of evaluations in conjunction with a couple of multispecialty groups.  I've also gone through a number of medical evaluations personally. 

It's important to understand what you are wanting to get out of the evaluation.  Are you expecting a diagnosis, a treatment plan, a test result, a letter documenting a specific finding, a condition, a cure, reassurance, money in a legal settlement, a rating for a benefit?  Why are you going through the evaluation procedure?  Did you request the evaluation or did someone else require it?  Those things matter.  Regardless of whether you were required to go, it's still important to know what you want from the evaluation. 

I'm called on to do anywhere between 1 and 9 evaluations in a day.  On the days where I do a single evaluation there is an extensive history process.  The person completes lots of paperwork.  They perform tests that I administer, that are done on computer and complete questionnaires that are taken home and brought back later.  They are told to bring food, wear comfortable clothing, bring something to drink.  Depending on the nature of the evaluation, I may be attempting to exhaust them so I can document performance with fatigue.  I may repeat tests in different conditions.  I may have fluorescent lights on, distracting sounds, frequent interruptions, to see how people cope with visual and auditory distractions in the environment.  In other cases I may have a virtually soundless office with incandescent lighting, done in a very comfortable setting. I may see the same person in both settings.

On days where I perform up to 9 evaluations in a day the questions I am answering are simple.  Usually what is this test result?  The test is specified.  What is this person's full scale IQ score?  Easy.  Give me anywhere between 30 and 90 minutes and I can answer that within a range.  Some agency will ask that.  People might ask that but they really want to know more.  What am I good at?  How do I compare with other people?  How come I'm good in this area but perform poorly in this area?  What can I do to be better at this?  Why can't I pass tests even if I'm smart and know the material?  Those are more complicated questions requiring more time in an evaluation.

If I want to know if someone suffered a traumatic brain injury I can ask them about incidents of concussion, loss of consciousness, or findings on a CT or MRI scan of the brain.  If I want to know what happened to their thinking as a result of a traumatic brain injury I have to evaluate them using a battery of tests, measurements and questionnaires as part of a neuropsychological evaluation that will take several hours.  The more complicated the question the more complicated the evaluation.

It's important to know what question is going to be answered by a medical evaluation or a psychological evaluation to understand and plan for the evaluation adequately.

Clouds and computers

I've been buying books like crazy lately.  These aren't like little paperbacks you consume in an hour.  These are professional text books.  Some are updates to books I already have older editions of like Lezak's Neuropsychological Assessment and Strauss' A Compendium of Neuropsychological Tests.  Others are more fun like The Mind and the Brain.

I've also been updating forms.  That's where computers and clouds come in.  I have a Mac.  I have the basic idea of cloud computing from my iTouch and my Kindle.  Somewhere out in the universe are servers that hold information.  I can link up to those servers and get things from them like applications, files, books and music.  I can send things to them and pick them up somewhere else.

So my main office is in Los Angeles.  My home in California is in Santa Clarita.  I'm currently at my home in Las Vegas.  The office manager is in Reno.  A former student of mine is in West Los Angeles.  So I want to share a file with all of them.  It's a basic questionnaire I created.  It's created on my laptop.  I upload it to a file sharing program.  I then send an email to everyone and tell them how they can link into the file.  They can then all pick up an original file.  If I go to the Los Angeles office without my laptop, I can log into the program and pull up the file.  If I wanted to I could put it on an iPad or my Kindle since it's a pdf file.  Ultimately, it will be on some portable computing device given to someone to complete and save rather than fill out with paper and pen and filed or scanned.

There are some medical groups that are already doing this with history and intake forms and routine office procedures.  A tablet PC links to a desktop which links to a server.  It's all wireless.  The information is all stored in "clouds."  If anything needs to be printed at all it's printed only when it's needed.  No more bulky storage.  Since it's all digital, it's easier to move text and use in reports.

Cloud computing has been used by the government for years.  http://cloudcomputing.sys-con.com/  Now business and industry as well as individuals are starting to use cloud computing.  With Apple computers and the iPhone, cloud computing went to the home computer several years ago and mushroomed out within the past couple of years.  You can sync your phone, computer, laptop, and netbook, depending on technology. 

Head Injury

I met a person yesterday that reported they hurt their back and neck.  They had no idea why they were being referred to a neuropsychologist.  So I started going through a symptom checklist for brain injury.

Do you have headaches?
Do you have memory problems?
Do you have problems with thinking and processing information?
Do you have difficulty with balance and coordination?
Do you have problems with controling your modds?
Do you feel anxious or depressed?
Have others said that you seem changed since your accident?
Do you get lost?
Do you forget words?
Has your vision or hearing changed?
Do you have difficulty feeling "stuck" and having problems starting something, stopping something or changing from one thing to something else when what you are doing isn't working?
Do you have difficulty doing something you used to be able to do?

After he answered yes to most of those questions, we discussed his brain injury.  He had actually lost consciousness briefly when he hurt his neck.  Further he had a prior neck and brain injury which made his most recent injury more complex than it would have been if it was his first injury.  Although he's been seen, evaluated and treated by three different medical specialists he had no idea he'd had a likely brain injury at the time of his accident.

Brain injuries generally improve over time.  They continue to improve for at least 10 to 15 years and maybe longer.  People will often just start recognizing their symptoms over the first 18 to 24 months so it may appear to them that they are getting worse.  If there are orthopedic problems then those difficulties often get the first attention leaving the brain difficulties to take a back seat.  Complaints of brain related problems get referred to primary care or orthopedic doctors who may not be familiar with symptoms of post-concussive disorder and do not perform an adequate screening for loss of consciousness.

The individual I spoke with said he had flown about 10 feet at the time he was hit by a car.  So I asked him about his trip through the air and his landing.  He didn't recall them.  He recalled seeing the car approach him.  He recalled getting up from the ground and feeling disoriented.  It wasn't until I asked him about what happened that he came to the realization he had had a brief loss of consciousness.  Because he came to prior to emergency personnel being on scene he had not had an adequate evaluation for head injury. 

We discussed how he could communicate better with his health care providers and make use of support groups, technology, and rehabilitation systems as well as help with support for his family to better understand what had happened to him. 

The screening evaluation I provided him was just the first step in an overall evaluation that will point him in the direction of greater understanding of what happened to him and how he can best profit from rehabilitation efforts.

Health and Medical Psychology

Health and medical psychology is a field which works at the intersection between medicine and psychology.  It answers questions and provides resources to patients involved in health care and wellness, and to physicians regarding providing health care in an effective manner.  It provides information to patients on how to reduce stress, lose weight, increase exercise, stop smoking, decrease health risks and comply with medications, treatment plans, and follow-up.  It helps physicians with diagnostic formulations by documenting an adequate patient history, patient selection for at-risk surgical procedures, reduction of malpractice, and provides a contact point in complex and problematic cases.

When you take your child for a vaccination health psychologists have determined that distraction is one of the better ways to get your child through the shot.  Telling the child that the shot won't hurt is not effective and undermines confidence in information being provided by the health care provider.

Having patients keep a diary of symptoms to bring into the doctor helps the patient focus on the target symptom and helps the physician look for patterns of symptoms.  It is a frequent treatment plan for chronic pain conditions such as headaches, fluctuations in blood pressure and blood sugar, peak flow values in asthma, and symptoms which are intermittent in nature to collect data to help with medical management.

For people on complex medication "cocktails" having a system of alarms, pill containers for daily medications, and an understanding of the medication, it's use, when it's to be taken and how it's to be taken is essential.  Health psychologists provide the systems and work with the person to put the systems in place that will help with compliance.  They can explain how pharmaceutical medications, herbs, supplements and foods all work together and help the person understand any interactions between them.  They can explain side effects and allergic reactions, and help patients understand risk-benefit issues of medications.

For people with medical symptoms that are unexplained after a few visits to the physician, the health psychologist can provide ways to collect data for symptom reporting to the physician, medical research into a diagnostic decision tree, and psychological support until a diagnosis is reached. They can help the person find support systems including online support groups, local groups and caregiver support groups.  They can help them understand the lab tests, and the medical research involved in their illness or symptoms.

Health and medical psychologists and rehabilitation psychologists work with stroke, heart attack, and head injured individuals to determine best practices in recovery, improving functioning, and explaining what has occurred in non-technical ways.  They help with things like phantom limb pain.  They help clarify what is psychological from what is physical.

Cognitive Science

Cognitive Science is the field of psychology that combines a number of fields (psychology, anatomy, medicine, neurology, and technology) to determine how people think.  Psychological assessment has used computers for years.  More and more types of psychological tests are being created for computer use.  As professionals become concerned about the way individual people function following discovery of disease, brain injuries or the determination of problems with learning, it becomes important to determine how a specific person thinks and interacts in their environment.  That allows for the best applications of structured rehabilitation plans, assessment protocols, and strategic interventions within the environment to help the individual gain the most optimal functional abilities and to maintain those gains in every day life. 

I've had a couple of head injuries.  Both were considered mild.  One was in 1985 the other was in 1997.  I was a psychologist at the time of both injuries.  I became a neuropsychologist after the first injury.  Following the second injury, I realized that some of the research in the field of neuropsychology was lacking some information.  In the past 12 years the field of neuropsychology has expanded exponentially.  As neuropsychologists we now recognize that there are hundreds of thousands of people impacted by head injury on an annual basis.  The impact of multiple concussive injuries is starting to be understood and the data base is moving from male professional athletes to the general population as a whole.  Data on the elderly and head injury including people considered old-old (over age 80) is substantially increasing.  The impact of medical conditions and head injury is starting to be understood.  As medical conditions, medications, and brain function becomes better understood we gain greater insight into how medications interact with neural functioning, and the field of psycho-neuro-immunology (the impact of thinking) on immunology is expanding.  The body is an integrated machine.  The heart, brain, and kidneys all function as a system to circulate blood and nutrients to keep the body able to function and the brain able to think.  Changes in blood flow and kidney function change how the brain works.  That system is being increasingly understood.  Our returning veterans having sustained multiple concussive injuries from rocket-propelled grenade blasts and improvised explosive devices will provide even greater information on the impact of multiple mild head injuries.  The numbers of people impacted by head injury will prompt greater advances in rehabilitation, protections for further injury and rehabilitation efforts.

Computers have the ability to speak to people, read for them, and provide information on visual tracking and perception.  As we integrate computers more and more into our daily lives we can harness their ability to make sense of the information we process to assist with diagnosis, treatment efficacy, and functional ways to interact with people.  

http://www.echalk.co.uk/amusements/OpticalIllusions/illusions.aspx  We have a better understanding of how the brain perceives things.  As our use of technology improves we will be able to have more psychological services available remotely, more automated and self-serve delivery systems, and greater ability to provide services both just-in-time and on-demand.

It's an exciting time in the field.