Posted by Jacob on April 01, 2008 at 07:23 AM in Medicine | Permalink | Comments (0)
Useful holiday tips for diabeteic patients.
Patients who ask for antibiotcs are actually asking for pain
Posted by Jacob on December 11, 2006 at 03:21 AM in Medicine | Permalink | Comments (0)
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.
Posted by Jacob on January 12, 2006 at 05:37 AM in Medicine | Permalink | Comments (1)
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?
Posted by Jacob on October 16, 2005 at 05:12 PM in Medicine | Permalink | Comments (0)

Posted by Jacob on September 28, 2005 at 04:28 PM in Medicine | Permalink | Comments (0)
Posted by Jacob on August 27, 2005 at 01:01 AM in Medicine | Permalink | Comments (0)
Posted by Jacob on February 22, 2005 at 10:00 AM in Medicine | Permalink | Comments (0) | TrackBack (0)
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.
Posted by Jacob on December 13, 2004 at 08:29 AM in Medicine | Permalink | TrackBack (0)
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.
Posted by Jacob on October 31, 2004 at 09:08 PM in Family Medicine, Medicine | Permalink | TrackBack (0)
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?
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...
Posted by Jacob on October 20, 2004 at 07:52 AM in Medicine | Permalink | TrackBack (0)
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