Docnotes

Informed Consent

For about 10 years - ok maybe more - I've been teaching a session in the summer clerkship for 3rd year medical students. Tonight (like I don't have better things to do - Teresa?) I was cajoled into making a presentation. Something about how a Vulcan Mind Meld wouldn't be sufficient to convey it to the folks who will try to teach it in the Summer while I'm in vacation in Tuscany. Go figure.

More links for today

(from Kevin, MD) - Indian parts too small for prophylactics.

Useful holiday tips for diabeteic patients.

Patients who ask for antibiotcs are actually asking for pain

relief.  Address pain relieft and don't rx abtibiotics:


Antibiotics don't improve outcomes in rhinosinusitis (duh).

MinuteClinics?

Bruce writes about MinuteClinics .. then Richard comments.

They are both right.

Quickie Clinics may threaten family physicians' business.    Sure ..

But is this bad?  Not necessarily.  Today I saw a child with a sore throat.  She lives 40 miles away.  Dad called the office and asked us to refer her to an urgent care clinic near their home.  The insurance rule is that we can refer to urgent care if we can't see her .. or if we are closed.  But not if we are open.  So we said no.  She needs to come in. 

So she comes in and the rapid strep is positive.  As I am writing the rx for her, I ask her if she has any allergies to medication.  She says "yes - Amoxicillin gives me a rash" (she's <10!) .. and dad nods.  The EMR warns me of an allergy to penicillins.  Everyone agrees.

So I write a prescription for something more appropriate (no -- not azithro!) and schmooze a bit with her.  She tells me that "dad wants to get a new doctor -- he is mad we had to drive all the way here."

I nod and say that I understand and that it's a long drive and there are lots of doctors near your new house and I bet that there are some nice doctors there.

Then dad says "yeh - I was frustrated with the drive.  But you held her in your hand when she was tiny and you have been with us all of this time - so I was grumbling during the drive down - but you walk through the door and it all falls away and then I remember why we still come here."

And of course he is talking about the connection between a physician and a family that we can't replace with wal-mart medicine - no matter how good it is.

Would she have gotten BAD care at the quickie medical clinic if there was one (and I was allowed to refer her there)? .. no .. but I bet it's more likely that she would have gotten something like azithromycin rather than something more appropriate.

Why do free-standing urgent care facilities prescribe more gatifloxacin and azithrmoycin (and antibiotics in general) than we do?  Because PLEASING THE CUSTOMER is a primary focus of the visit.   Yet without an established relationship and trust - quick "this will make you better" prescriptions are more likely to be the name of the game.  Refusing an antibiotic for the negative rapid strep will be a challenge for these quickie clinics .. and I am much more concerned about THAT than I am about losing the business.

Another concern is how we would all coordinate care .. and how .. in the case that the kid and the dad forget about the allergy .. the minuteclinic can avoid harmful errors.  Do they call us and ask for an allergy list?  ugh .. this WOULD bug me.  I don't want to pay my staff to be fielding phone calls like this .. while others make money on rendering the care.

Very complicated.

And this is all too new to really understand.

EBM for the busy physician

Chris Cates' website  provides wonderful essays on evidence-based medicine. I love his graphical depictions.  Here's an example:

Kinda makes you think twice about using statins reflexivley in these patients - eh?

Grand Rounds #53 - almost

Grand Rounds #53 is "in press" and will be posted shortly!

"My appointment was 47 minutes and he talked for 45 of them"

I am his fourth primary care physician in as many years. He described his sole encounter with his most recent physician something like this: "Hell of a nice guy and he worked as a volunteer firefighter during medical school. And so in talking with him ... and out of my 47 minute visit, I think he talked about his days in the fire department for 45 of them. Now that's all fine and I'm happy to chat about the good old days but that's for the coffee shop on Sunday morning, not for my visit when paying him 140 bucks." This happened on the same day that another patient called me and told me he was transferring care out of my practice. He told me he wasn't happy - frustrated because sometimes it was hard to reach me. "You're a hell of a nice guy Doc - but I need to be able to reach my physician more easily, you know?" Patient-physician communication. It's at the core of what we do. My new patient was complaining because his previous physician talked too much and listened to little. My old patient was complaining bacuse I wasn't accessible enough to him. Accessibility is very challenging. I do want to be as accessible as possible to all of my patients but it's so hard to call them all right back instantly when I have 35 telephone messages waiting for me every day. How can we possibly give such personal care to so many people? When we started our practice four years ago it seemed impossible that we would become so busy as we have in such a short time. And the nurses today were complaining because "we've lost the personal connection" and we're getting too big. And this may be true. It seems that we always strive for growth, as growth in business and therefore revenue seems to be so important as the pressures of daily practice (rent, salaries, mortgage, looming college education bills for our children) pressure us to maintain revenue and therefore always increase work. But increasing work simply can't be done above a certain level. For the new patient coming in, I try my best to set his expectations at a level where I can deliver. No, I won't always call him back instantly, and sometimes he will get a callback from my nurse instead of for me and this has to be okay with him. At the same time, if something is very serious and he insists on speaking with me were coming in, I will always do my best to accommodate him. The 9-year-old I saw this week asked he was my favorite patient. I hesitated, and told him that all of my patients are main favorites. He seemed disappointed. "Well, of course you're my favorite." A sigh of relief from the boy. So today when a prospective medical student asked me what's the difference between family physicians and other primary care physicians I didn't have much trouble answering her. Yes, internists and pediatricians are compassionate, kind, thoughtful people. But family physicians are explicitly trained to address the psychosocial needs of our patients and those of us who deeply believe that this is an important part of what we do -- do our best to live these values.

Emotional stress can precipitate severe, reversible left ventricular dysfunction

NEJM -- Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress So the title of the paper is a but clumsy - but this is an interesting paper that makes us think twice about "noncardiac" chest pain. The authors studied patients who were quite ill, and subjected them to rather invasive testing (angiography, myocardial biopsy) and determined that there was significant myocardial injury assosicated with increasted catecholamine levels. Of course this is no surprise .. but it is an objective measure that emotional stress (and other stress) can injure the heart. A caveat is that the patients in the study were over 60. So the 25 year old who complains of chest pain when they go to the supermarket is much more likely to be having a panic attack than a heart attack. Hmm .. But maybe they're not "just fine" ... according to this paper in circulation, women who have anxiety disorder are much more likely to die of sudden cardiac events.

referrals again

This comment from Sparkler on my post a few months ago about referrals just appeared. 

...  A visit to the doctors office takes approximately 90 minutes - I see the doctor for maybe 2 minutes. That means that means nearly all of my care in that office is with staff who are great at common issues, but iffy on uncommon ones. I adore my doctor; he is excellent. This is not a criticism of him, but if I have anything uncommon I skip the gatekeeper visit and see the specialist. If you want to understand why patients demand referrals take a look at the entire experience of visiting a specialist versus a family doctor

It's interesting and disheartening that the physician is adored, yet the time with the physician is only 2 minutes. 

I would suggest that the patient needs a new physician who can spend more than 2 minutes with the patient -- since if 2 minutes really is the am't of time spent - the care is certainly substandard.  No physician can provide adequate care in 2 minutes. 

Red Sox Fever

So the series is finally over, and we can get back to our lives.  I was only 4 in 1967 so I don't remember that one .. but I remember 1975 quite well:

October 22, 1975: In game seven, Boston held a 3-0 lead going into the sixth. Pete Rose hit a lead off single; Joe Morgan flew out to right. Johnny Bench grounded to short, but the Red Sox missed a double play opportunity when 2B Denny Doyle threw the ball into the dugout. Bench advanced to second on the mistake. Tony Perez jacked a Bill Lee curve over the Green Monster for his third home run of the Series; Boston's lead was cut to 3-2. 

My favorite player at the time was Doug Griffin - who was always in competition with Doyle for the spot at second base.  So when Doyle blew a double-play that led to a 2 run homer (the Sox eventually lost the game 4-3) .. my dislike for Doyle was enhanced.  The series in 1975 was my first big experience with being a Red Sox fan.  Doyle was my "Bill Buckner."  Nearly 30 years later, I'm happy to have witnessed this historic series .. to wash all of that away.  Congratulations Red Sox Nation. 

When to make a referral?

Referrals are a tough topic in primary care.

Two phone calls today reflect some of these issues:

"JMR .. patient on phone .. wants referral to a back doctor .. ok to make the referral?"

"uhh .. put her through please"

I want to talk with the patient so that I can understand why she wants the referral and why she thinks this is something that requires a specialist.  Clearly I am not a back doctor or a front doctor or a foot doctor ... but I may be able to help people with problems of these parts.  Turns out that the chiropractor hasn't helped much despite thrice-weekly treatments for 3 months.  She has low back pain.  No symptoms of anything bad.

What to do? 

• I can require that she come in to the office .. but then I am being the "gatekeeper."
• I can just refer her to the orthopoaedist .. but then I am making an inappropriate referral.
• I can refer her to physical therapy (which is what would most likely occur as a result of a visit with me or the orthopoaedist).
  
  Hmm ... which is the right answer?

Ok .. number two is harder.

I care for many physicians in my practice.   Caring for other physicians is tough.   Our office got a phone call a few weeks ago from a specialist about a referral that they needed from us so that they could see a patient who was there for an office visit that day.  The patient never called me .. never asked if I thought that a referral was necessary .. and never asked our office for a referral.  By making the appointment directly with the specialist - a message is sent to the primary care physician that our training and opinion is inferior to the patient's own ability to triage the situation.  For this scenario (I won't go into the details) I am certain that I would have been able to provide the service that the patient was looking for myself.    grrr...