Docnotes

Living Wills and Health Care Proxies

Abstract Appeal -- The Terri Schiavo Information Page is one of the few unbiased resources on the Internet that describes this tragic case.  There are many sad components to this case, but from my perspective, the lesson here is that everyone should fill out a Health Care Proxy and a Living Will.  It seems that she had made her feelings clear to her husband, but she had never done so in writing.  

An example:  you can find the New York Health Care Proxy (pdf) on New York's health department website.  This document on the NYSDOH website actually performs both functions - as it defines who is the proxy - and then it provides a space to guide the proxy:

"Putting things in writing is safer than simply speaking to people, but neither method is as effective as appointing someone to decide for you. It is often hard for people to know in advance what will happen to them or what their medical needs will be in the future. If you choose someone to make decisions for you, that person can talk to your doctor and make decisions that they believe you would have wanted or that are best for you, when needed. If you appoint someone and also leave instructions about treatment in a Living Will, in the space provided on the Health Care Proxy form itself, or in some other manner, the person you select can use these instructions as guidance to make the right decision for you."

"In some other manner" suggests to this non-lawyer (but I know one pretty well!) that any written communication would be helpful.  An e-mail, a letter .. anything.  For the record .. if I end up like Terry for some horrible reason ... let me go. 

Another version of a Living Will and a Health Care Proxy for New York.

Internal Medicine

Dr Bob posts on DB's Medical Rants an interesting reference to his paper in Journal of General Internal Medicine.   Family physicians feel your pain, man ...  and I agree with you that there remains a place for General Internal Medicine ... but ... here's what may be an odd concept:  the General Internist as specialist in complex adult medicine .. just as the pediatrician could be positioned as a specialist in complex pediatric medicine. 

Ever Since Family Medicine displaced "General Practice"  many years ago - the identity of the "other" generalists (peds and IM) has certainly been threatened.  Yes, yes ... this isn't the message of Dr Centor's paper ... he seems to be more concerned with pressure from the right -- the specialists.  But I would argue that there exists some pressure from the left (FP) as well.

It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem.  Why?  Because in some cases, the training of an Internist simply prepares them better for handling such situations.    A good generalist knows the boundaries of his/her skill -- and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women -- there are some situations in which we are better off having the help of someone who specializes.  "You are worth it" I tell my hesitant patients.   They sometimes seem to wish I could do everything for them.  I can't.  This is why we have specialists. 

Yet with their identities as "general adult medicine" physicians -- there is no good method for me to refer a patient to an Internist for consultation.  Since they are  primary care physicians - there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all. 

The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) ... and we may learn not to be so threatened by them. 

Our Mantra seems to be "we provide the same care as they do."  Which is accurate in many ways ... and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician - especially for a family.  

But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine - no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.

Last week, a patient transferred out of my practice.  She had complex problems that I frankly told her I didn't understand.    She asked for the name of another physician who might be helpful, and I suggested an Internist colleague who works across town.  Bottom line:  our Internist pal figured it out.  Something rare and complicated and I hadn't even thought about it.  But she did ... ordered the right tests,  and I'm happy about that ... but now the relationship with my patient is severed .. and .. yes .. my ego is bruised a bit. 

Had I referred the patient to a rheumatologist or cardiologist etc etc ... I wouldn't be severing the relationship with my patient -- nor would my ego be bruised by such a situation.  Indeed, assistance with the diagnosis and/or management of a complex problem is the purpose of such a referral. 

Hmm ... so, Dr. Bob (is that what DB stands for?) ... how would this work?  Referrals to the Internist ...  why not? 

Pap Smears

Craig's notes:  Family docs, pap smears, and cervical cancer risk opens up a compelling thought along the lines of my discussion the other day of prostate cancer screening:

"..The vast majority of the post-hysterectomy patients in my practice who were also seeing gynecologists or had previously seen gynecologists were still under the impression that they needed regular Pap smears."

He's right.  Like the PSA talk -- this one takes a long time, and inherently involves a discussion of risk.  Women who are post-hysterectomy are not without some risk ...but ... the real risk is quite low:

"The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent "

 yet ... like the free prostate screenings so commonly advertised in the local paper ... this may be better business than it is medicine.  ugh.

Prostate Screening

From the Cleveland Clinic: Prostate Cancer: Screening Guidelines

Short, unbiased and to the point. 

I struggle with this subject daily.  When I'm pressed for time, I find that I order the PSA, do the DRE and discuss it far less than I should.  These are generally patients who have had annual PSA tests done int he past - and have been told by someone that she "need to have a PSA."  When I'm not so pressed for time (or in denial) ... I engage my patients and provide true informed consent.  All-in-all, a good discussion of PSA pro & con takes at least 10 minutes, and usually involves a quick review of this paper and its implications.

I'll usually bring in data that most men have some prostate cancer by the time we turn 60 .. and nearly half have some by age 50.

.. an interesting picture of an Italian perspecitve:

"Screening should be banned from current practice until its efficacy is demonstrated"

.. and here's the most recent news tidbit:  Inuit are protected against prostate cancer.

Doctor redefines visits with phone, e-mail

From American Medical News: Doctor redefines visits with phone, e-mail ... American Medical News

It's an interesting story about a physician who has set up a practice based largely on cash payments (he accepts no insurance) for visits, phone calls, and e-mail communication.

Dr. Dappen charges $20 for a five-minute block spent on the phone and $25 if that time is spent in the office. However, he reduces his fees -- $15 for a five-minute phone visit, $22 in person -- if the patient sets up a prepaid account that allows Dr. Dappen to withdraw funds as services are provided. He said he doesn't charge for time spent doing the "back-end work," like faxing information or ordering a test after the conversation is completed.

It's an interesting concept.  I would agree that the current method of reimbursment isn't working very well.  Capitation didn't work so well either.  Most days, I would say that I spend 60 - 70 minutes talking with patients by e-mail or on the phone.  E-mail certainly speeds this up a bit, and it does provide a useful method of communicating quickly.    The fees for office visits seem inflated -- until one considers the "free" care that goes on between office visits.  Perhaps it all comes out in the wash.  Hmmm.

Developmental Pediatrics

Here's a nice chart with Developmental Milestones.

Guidelines

PDA versions of many practice guidelines are available from Guidelines.gov

Antipsychotics

Today was Psychiatry day in the office. Very challenging. Some short (ugh -- too short) breaks in the action for some well-child visits and a few upper-respiratory infections, but the majority of my visits today involved depression, anxiety or personality disorders. I find personality disorders especially challenging, since their diagnosis is so difficult, and intervention is equally difficult.

Our colleagues in psychiatry seem equally challenged - I had one patient referred back to me for management of this disorder. Uh ... "tag - you're it" he seemed to say to me. We have a paucity of psychiatrists here in Albany - so it is especially challenging to find services sometimes. Yesterday (ok .. so maybe yesterday was psychiatry day too) .. I saw a man with type 2 diabetes, obesity and depression with some psychotic features. His depression has been very well managed on Risperidal - and he's not seen a psychiatrist in many years. I'd love to get him on to something that would not cause weight gain. Aripiprazole has recently been introduced, and it does not cause weight gain like risperidal. Hmm ... should I change him? I've never used Aripiprazole ... but ... nor have most psychiatrists yet. Hmmm ... what to do? ... I referred him to a psychiatrist today. We'll see what happens. A nice review of the new antipsychotics appears in this month's Archives of General Psychiatry.

Magical Thinking

Red Sox fans everywhere - I'm sorry about tonight's game - it was my fault.  I'm not one of those crazy sports fans who think that my actions would control the outcome of a game .. but this series has been different.  I can't watch the games.  If I do - the Sox lose.  Last weekend, they won both of those games in Oakland as I was driving to/from Boston on the Mass Pike.   This weekend, Sam and I were at the game on Saturday - and we lost.  Sunday I was banned from the room by my wife - so that I wouldn't watch (and therefore ruin the game).  The won.  Tonight - (I am sooo sorry) I watched one inning with Sam before I sent to the office at about 5:00.  The Yankees got 3 runs in that inning and you know the rest.  I apologize to Red Sox fans everywhere.  I promise not to watch any more Red Sox games!

South Beach Diet

The New York Times article: New Doctor, New Diet, but Still No Cookies covers a topic that remains compelling and controversial.  It's a great overview of the South Beach Diet and the book that promotes it.

Bottom line:  South Beach seems to be more reasonable than Atkins .. and it may very well fit the bill as an ideal plan for those interested in avoiding diabetes and/or reducing their risk of cardiovascular disease.  I'll read the book .. um .. when I have free time ..  after the kids finish college.