Friday, March 25, 2011

Family Medicine: End of Lice to End of Life, We're There. What do You Think?

On top of my pile at the start of the day before seeing my first patient:  Someone calling this morning about their child, sick from school but they can't come in and mom wants a note from a physician faxed to the school saying the child can't go to school.  What would you do?

Next on the pile, a mom calls about two kids with head lice.  Please call in a prescription, is the message.  What would you do?

Next is someone calling to say they forgot to get their chronic disease prescription for their depression when they were here recently- acutely ill. What would you do?

I take a call from a hospice nurse who is concerned about a family not yet seeming to be understanding that the patient is going to die.  The patient is one day out of an extended care facility after a long hospitalization for severe heart and brain diseases with a terminal situation.  There are several medicines ordered for heart and brain diseases.  The patient told the family he wanted to be with Jesus. What would you say?

The first patient is here for chronic disease management:  hypertension, insulin resistance, hypertriglyceridemia, weight management.  We relate about the 3 months of winter being extremely cold.  The patient asks how the blood test results look.  I give him one copy of the results and point at a few elements on the file copy that look good.  "What do you think?" I ask.

"This doesn't look too good," he comments, pointing to the triglycerides of 187.  "What is this test?" he adds pointing to the Hemoglobin A1C of 6 which is in dark black ink usually indicating an abnormal lab value.  "It's like the cousin of the triglycerides, leaning in the direction of diabetes.  Notice that at 6.4 or above, the A1C is consistent with the diagnosis of diabetes.  Look at your last test, though and notice your triglycerides of 265 and A1C of 6.2.  You are doing something that's pushing back your diabetes potential.  What do you think that is?"

"Could it be the mall walking that my wife and I started two months ago? I guess the diet changes are helping, too.  And it's been easy to do since we met with the dietitian." "Those are important factors in what we're seeing. How are you doing it?" I ask.  He looks up and to his left, "We looked at our life and our health and our weight after the push from the last lab results and decided to act.  Now, I'm seeing a smaller me and both my wife and I are looking 5 years younger." What would you say?

I find Family Medicine to be  interesting, challenging and personally rewarding.  We deal with people and families in all stages of life and all contexts. What do you think?


  1. The note for the school - I'm not sure that you can ethically claim someone is sick if you don't know that to be true. Years ago we had neighbors who often kept their elementary-age daughter home from school to take care of their baby because they (parents) were too hungover or stoned to take care of anyone. The child had so many absences that, legally, a doctor's note was required whenever she wasn't in school. I'm not sure how they managed to get the notes because the kid was rarely sick; she just had crummy parents who wouldn't let her go to school. It would have been better if CPS had intervened and made sure the kid got an education. Anyway, that's a long-winded way of saying I don't think doctors should ever write an excuse note documenting illness unless they know that to be true.

    Lice - that mom might have thought it's better not to take the kids anywhere to prevent the chance of spreading lice to others. Can you have treatment options listed on your office website so that people don't phone and request scripts for things that are available otc?

    I'm so glad you included the visit with your first patient of the day. It must be nice to work with someone and see positive results.

  2. WarmSocks, Thanks for your comments. The blog post accurately depicts situations in daily family medicine offices. It's fun to ask the readers what they would do in these types of situations. Many would not be sensitive to the ethical boundaries of physicians. (Note the responses to stories from Wisconsin about off work notes given in the crowd outside the state capitol to protesting teachers by family physicians from the U of Wisconsin.) You are Correct: We can't write notes for people who we don't engage in a medical way (covered by license boundaries and professional/ethical boundaries). Often, we tend to re-frame the question from a person that expects more of us than we can legally/morally/ethically deliver. The context of relationship exists so we're wanting to help each other. Hopefully, respect also exists so we honor our mutual limitations. We usually express to the patient/family our concerns for their circumstances and make a statement of our limitations. Then, "We'd be happy to see____ this morning or this afternoon if that would be of help." etc., etc. Sometimes the parent doesn't really need MEDICAL help for their child, but they need ADMINISTRATIVE help to validate their claim of child illness. We see those people, too, and honor their administrative situation with our medical expertise and off school note, if they qualify. They don't automatically qualify just because they come to our office, either. Previous posts by Dr S reflect on these relationship and boundary discussions with patients also.
    The lice comment is helpful and timely in light of increasing internet and social media use. New tax laws about medical deductions drive many creative or financially distressed people to ask for prescriptions for otc drugs. Several otc pharmaceuticals that used to be prescription drugs are also authorized as covered drugs for our patients on Medicaid if physicians write a prescription. As a result, Doctors and pharmacists are being deluged with requests to "medicalize" otc products.
    Yes, we enjoy celebrating with our patients, which happens frequently in family medicine.
    Thanks again for your comments and your wonderful blog at:

  3. Thank you for your kind words.

    Administrative help... I recall going back to work when my firstborn was six months old. I found a daycare just a couple blocks from my office; my employer was very flexible, allowing me to leave a couple times a day to go nurse my baby (the alternative being that I wouldn't return to work at all). The daycare was supposed to phone if the baby got hungry early. They never phoned, but one day when I arrived he'd been screaming for 30 minutes and they told me that I must leave a bottle for him or have a doctor's note that it was okay for him to be exclusively breastfed. I tears, I phoned the doctor's office. The nurse asked my baby's age, and sounded hesitant - as if he might need more to eat than I could provide him. Then she asked his length/weight and realized at the 96th percentile length and 99th percentile weight, he was obviously growing just fine. The doctor's office was happy to write a note for me.

    That was 17 years ago. Knowing what I know now, I'd probably make an appointment to request the note.