Saturday, February 19, 2011

Family Medicine: A Flu-less, Star-less week in Little Boxes

I'm thinking this will be the start of the flu week, reinforced by the blog post of Dr Fatty Finds Fitness in Texas who said they're full of flu patients this week.  So two or three folks today were close to flu but not miserable enough.  The flu is associated with lots of pain and lots of mucous (which I refer to as "the state bird of Ohio").  One common finding in my  flu patients over the years:  They are so miserable with pain and mucous that they often say, "for a while I felt like I might die, and it would be OK."  THAT is THE FLU.  No, the flu warriors haven't arrived yet.

The strep mongers showed up, though.  Group A, Beta hemolytic Streptococcal pharyngitis is ruining many President's Day Weekends for the local school kids.  Parents seem to be slightly more likely to choose the Penicillin injection for their child this year than most.  In the "Families Only Practice" model that I adhere to, if we get half of the family with strep throat, we offer treatment to  everyone in the family with an appropriate antibiotic (because an old study showed that 75% of family members will get strep pharyngitis once two people have it).

Notice that the parents or patients are choosing which therapy they wish after I apprise them of the risks/benefits of the various treatments.  Since they are conscious adults, I believe they can make their own choices after we clarify their assessment (diagnosis) and therapeutic options.  The medical literature implies that physicians treat patients exactly as the literature says, like dictators, and holds physicians responsible for patients always following clinical guidelines.  Patients are worthy of more personal consideration than that.  The insurance companies also act as if patients should have no choices but should be forced to follow clinical guidelines (that may not apply to to them).

We get bonuses from many of the managed care plans if the patients follow the medical literature guidelines (for eye exams, prescribing generic medications, liberal use of statins, mammograms, colon cancer screening, etc.).  The patients aren't usually aware that we make more money if they agree to follow the guidelines.  I disagree with anything that removes the patient's freedom to decide.  They make decisions after we give our perspective and recommendations (there are writings about how we physicians should be more forceful with our recommendations).  With infections that have risks of spread to others, I strongly recommend appropriate infection control strategies such as staying home, staying away from others, covering coughs, washing hands, etc.  If they are impaired from their usual decision making abilities, I help more in the decision process.  Obviously, if patients are suicidal or homicidal or endangering children, we have ethical obligations to act against their wishes, but that is pretty rare.

I believe that patients can define their own quality goals with input from their personal physician.  This leaves me out of Anthem "quality" bonuses for last year (although I always write for generic medications except Plavix, Januvia and a couple others that don't have generics) and their data said I only did it 79% of the time which surprised me.  I also just lost two "stars" on my United Health Care web site where they changed their criteria for quality and cost effective physicians.  I felt like both companies pushed us to diminish the importance of patient uniqueness and choice.  So I'm feeling a bit boxed in by artificial quality guidelines.  Now I'm also a starless physician and somewhat proud of it and somewhat annoyed by it.  Patients are too interesting to get jammed into little boxes (ala, the old Pete Seeger song,  Little Boxes).  I guess we're in the Little Boxes together for a while longer, then the PCMH and ACO's will offer bigger boxes.  Onward.  Where are you, Flu?



  1. I really like your viewpoints here. It makes me feel like there's hope.

    Here are 5 quality stars from a lousy patient.


  2. Thanks, Steve, I've checked it out. The Bible has the right message. Blog On! Dr S
    Thanks for the feedback and the 5 stars. Hope is one of the treatments of choice for most situations we see in our Family Medicine office. Blog On! Dr S