Thursday, February 9, 2012

Family Medicine: Boundaries and Relationships

The patient with several chronic diseases was in for a quarterly visit relating to three of the diseases and medications related thereto.  A new musculoskeletal problem slipped into the conversation, warranting a temporary detour from the chronic disease focus.  As we were wrapping up the visit, the patient added, "I am scheduled to get an osteoporosis scan next week.  My gynecologist ordered it."

I knew that I had ordered and interpreted her last two DEXA scans for osteoporosis, so I quickly looked at them, noting that the patient had osteopenia (a category invented to push people-mostly women- into earlier use of pharmaceuticals .  She had increased her focus on her bone health, including dietary, exercise and supplement use (Calcium, Vitamin D3, magnesium and soy isoflavones).  She did not wish to take bisphosphonates such as Actonel, Fosamax or hormone replacement therapy, such as estrogen.

I then commented that I was concerned that another physician was going to get involved in her bone health and possibly generate confusion..  It was also possible that the test, ordered at a hospital where they charged a "facility fee", not covered by insurance, would cost the patient more.  I expressed my concerns about the confusion that can happen when extra physicians get involved in ordering tests for patients, but this was her year to get the next test anyway and we could clarify how the test results related to her bone health if there was a problem with multiple perspectives.  She may wish to go ahead with the test and please make sure that I am copied on the results.  She decided to go ahead with the test.

Two weeks later, she made an urgent appointment with me to review the test results from the test I hadn't ordered, since she disagreed with the treatment strategy recommended by her gynecologist and received in the mail by the patient one day before the urgent visit with me.  The newest intravenous bisphosphonate (Reclast) and another injectable medication (Forteo) were offered my patient, who was to read about the drugs and select one that the gyn office would arrange for my patient to take.  The patient read the materials respectfully and became quite anxious.

I responded to her fears about the medication and commented about our long term concern about bone health due to the increasing life expectancy of women (81.1 years is the average in the US) and,  therefore,the increasing risks for fractures of the hip and spine.  I commented about how physicians are prone to action, but that patients get to decide what they really want to do.  I sought clarification from her about how she wished to relate to me and her gynecologist about this issue.  "The gynecologist and I seem to  have different perspectives about bone health," but would both want good health for our patients.  I apologized for my profession adding to the confusion by overlapping perspectives about her bone health.

I was annoyed that the gyn had not clarified with our mutual patient how she wanted her bone health attended to and who had ordered and acted on her last two DEXA scans.  We each have a relationship with the patient.  We each have a scope of practice that includes overlap with each other's specialties.  How do we work through the boundary issues?  How do we define our respective roles as medical specialists (Family Medicine for me and Gynecologist for her)?

In the "old days" the physicians knew each other through relationships at the hospital where all admitted or consulted on patients.  We had face to face clarifications about who would do what and why.  We could professionally disagree, but continue in a professional relationship as we gradually defined how we went about our physicianly tasks and responsibilities.  We had a continuing sense of relationship with medical ethics which we shared through committee work, positions on the hospital medical staff and interactions in the county medical society.  Those interactions are now few and far between.  We don't all go to the hospital any more.  We barely have any meetings.  What is going to happen?

How are we going to relate for the good of our patients and our profession?


  1. You raise an important point that I haven't seen addressed.

    As a patient, I find having multiple physicians with differing viewpoints can be extremely frustrating and confusing.

    For example, my primary care physician was hesitant to treat hypothyroid unless the TSH was 'out of range'. My psychiatrist feels that hypothyroid needs to be treated aggressively in patients with depression. They both had different strategies and different reasoning, and neither communicated with the other. It put me into a double-bind of choosing the advice of one over the other.

    My feeling is that the increase in specialization has caused fragmentation so that their are 'too many cooks in the kitchen' and not nearly enough support for the patient to navigate the options.

    Thank you for raising this important issue.

  2. I love your perspective here on the patient's role in their care. You sound like an amazing physician.

    I have no idea how to solve the conundrum. Mostly I was shocked an OB/GYN would care about bones?!? Have not seen that myself...


  3. Thanks for your comments, Penelope and MM. Part of the problem is deciding what constitutes "Primary Care" since many OB/Gyns may be the primary care physician for many women. A much larger group of women do have a family physician, but sometimes there are financial incentives for the physicians to apply "guidelines" for early diagnosis or prevention during a specified timeframe. I get bonus money if the percentage of women in a particular age group who get mammograms exceeds a defined "quality" percentage. Many of those women never see me for their annual woman's exam, so my "quality" is dependent on the actions of the ob/gyn, who doesn't get credit for the bonus (1% on two insurance contracts).
    To make things more confusing, physician extenders such as physician assistants may perform screening physicals for many physicians, not as likely to clarify details about the patient-physician relationship.
    Penelope, your overlapping physicians should reveal their probabilistic thinking involving the risks and harms of your thyroid health/therapy and let you decide (my subtle bias).
    Thanks again for your comments. apj