1. Immunization Discussions: Getting longer. Parents (Usually Moms) who had delayed initiating immunizations for a child are signing their child up for vaccines, building into the required immunization schedule starting with one or two combination immunizations, with sensitivity to family history and context issues (who is on chemotherapy, pregnant or otherwise vulnerable?). None ever mentioned any concern about the British publication about MMR. Many don't agree with the varicella vaccine mandate (chicken pox shot) due to their personal and family history of a benign experience with the chicken pox. Well child visits are expanding in time needed for education about vaccine preventable diseases.
2. Increased Numbers of Thyroid Abnormalities: More men with elevated Thyroid Stimulating Hormone (TSH) than usual and increased numbers of women. They were experiencing fatigue, hair loss, dry skin, swollen neck and fluid retention. It seems that they reduced their salt intake leading to decreased iodine ingestion. Recent surveys of salt products found lower levels of iodine than expected. This is a key ingredient in thyroid hormone production. Many patients had shifted to use of sea salt for cooking. Sea salt typically doesn't contain iodine. Sea salt and iodine advised the patients who had decreased iodine intake to take kelp tablets which are loaded with iodine. An excellent article from Life Extension magazine October, 2011 issue just happens to discuss this problem.
The Silent Epidemic of Iodine Deficiency
3. Unusual diseases: About 9% of patients in a family physicians practice have unusual or rare diseases. These are interesting and often challenging. One interesting site to use for reading about rare diseases that have a genetic basis is OMIM, listing over 12,000 single gene disorders. Online Mendelian Inheritance in Man.
More later.
Wednesday, October 12, 2011
Tuesday, October 11, 2011
Family Medicine: Pain
The Family Physician cringed mentally as he wrote the prescription for Percocet 5/325 #240 (two hundred forty). Take one or two every four hours as needed for severe pain. The patient had five years of low back pain, two before the surgery and three after, with numerous therapies and medications initiated and many rejected as inadequate or overly generous with side effects. Long acting opiates yielded unacceptable brain side effects for the patient, not noted with short acting opiates. The patient lost jobs and insurance coverage three or four times during our five year engagement so far. Three trials of physical therapy seemed to be thwarted by the low back pain, loss of insurance and missed appointments.
Allodynia, hyperalgesia, palpable muscle spasms quadratus lumborum and paraspinous muscles. Mid line tenderness is minimal at L4-5 with right sided tenderness of sacroiliac joint. Straight leg raise positive on right at 45 degrees. Deep tendon reflexes - 2 plus and equal knee jerk bilaterally.
The physician reflected on the low back pain in the patient's father, also a patient in the practice, who followed a similar course with low back pain in 1995, including several years of opiate therapy and two years of total disability. How did his father get out of the pain situation? He experienced a sudden priority change when his father died and mom needed a caretaker in his family home of origin. Within two months he was off the Percocets and into fitness, church, vitamins and supplements.
Many Family Physicians are frustrated by patients with chronic pain who become "energy vampires" or get stuck. Many are also tired of doing the "tough love" by confronting the behaviors of patients like the first one above to finally get them into physical therapy or other supportive strategies or even terminating their relationship if appropriate. How will the next era deal with these patients? And these doctors?
What experiences have you had with either side of the patient-physician chronic pain relationship? How can it improve?
Allodynia, hyperalgesia, palpable muscle spasms quadratus lumborum and paraspinous muscles. Mid line tenderness is minimal at L4-5 with right sided tenderness of sacroiliac joint. Straight leg raise positive on right at 45 degrees. Deep tendon reflexes - 2 plus and equal knee jerk bilaterally.
The physician reflected on the low back pain in the patient's father, also a patient in the practice, who followed a similar course with low back pain in 1995, including several years of opiate therapy and two years of total disability. How did his father get out of the pain situation? He experienced a sudden priority change when his father died and mom needed a caretaker in his family home of origin. Within two months he was off the Percocets and into fitness, church, vitamins and supplements.
Many Family Physicians are frustrated by patients with chronic pain who become "energy vampires" or get stuck. Many are also tired of doing the "tough love" by confronting the behaviors of patients like the first one above to finally get them into physical therapy or other supportive strategies or even terminating their relationship if appropriate. How will the next era deal with these patients? And these doctors?
What experiences have you had with either side of the patient-physician chronic pain relationship? How can it improve?
Family Medicine: Do Consumers Need Consumer Coaches?
When I'm with a patient, I'm a human first and a family doctor second. I consider them to be human first and patient second. As they shift their roles, I'm often a consumer coach, a safety advocate and a small business owner. How do we get anything done shifting through several roles during encounters with patients? Does each member of the dyad know which role they are manifesting at each moment? I don't think so.
Should we both have signs that identify our roles as we progress through each office engagement? Will we each understand the other better if we know when roles shift along with expectations of each other?
The identity confusion is one of our problems in Family Medicine these days. We are generalists who care deeply about people. How should we address this issue? Do consumers need consumer coaches (concurrent with family physician role or separate)?
What do you think?
Should we both have signs that identify our roles as we progress through each office engagement? Will we each understand the other better if we know when roles shift along with expectations of each other?
The identity confusion is one of our problems in Family Medicine these days. We are generalists who care deeply about people. How should we address this issue? Do consumers need consumer coaches (concurrent with family physician role or separate)?
What do you think?
Tuesday, October 4, 2011
Family Medicine: Pancreatitis, Gallstones and the Differential Diagnosis
The patient has severe abdominal pain and nausea after supper. It's unbearable so they get the spouse to drive them to the local ER. In the ER, the patients pulse rate is 110, BP is 136/82, Temperature is 99.4, weight 152. The 46 year old patient appears to be uncomfortable, holding the upper abdomen and moaning intermittently. The physician notes a normal physical exam except for some perspiration on the forehead and upper lip, the tachycardia (without gallop or murmurs) and epigastric tenderness without rebound or guarding. Rectal exam is negative for occult blood. Past Medical History is significant for Rheumatoid Arthritis, currently on Sulfasalazine (ssz) orally and Methotrexate but recently tapered off prednisone over a prolonged period of time.
The ED physician orders some lab tests, IV fluids and opiates (as needed for pain), and an abdominal CT scan.
IV morphine relieves the pain from 9/10 to 3/10. Lab results include elevated amylase, lipase, ALT, AST, BUN and WBC (13,500).
The examining physician gets the CT report from the physician in Australia who reads night imaging studies from this hospital. The report notes several normal elements and comments on several gallstones present in a normal appearing gallbladder without thickening of its walls or other evidence of inflammation of the gallbladder. The pancreas appears normal, but the mid-portion is blocked from view by overlying intestine.
The patient is admitted to the hospital and undergoes evaluation by a gastroenterologist, a general surgeon and a hospitalist, who was the admitting physician. The rheumatologist does not come to the hospital, but was called by the hospitalist to discuss the status and treatment of the RA.
Five days later, the patient sees the family physician in the office and relates the story of the hospitalization. "Have you ever had an NG tube in your nose, Doctor?" The patient begins. "And people analyzing everything coming out of your body for exact fluid content? Do you know how inefficient hospitals are? Three different people asked me the same questions on the night of my admission. It was like the clipboards from Hell.
The doctors said I had pancreatitis. I survived and got the tube out of my nose. The surgeon wanted to blame my gallbladder for the pancreatitis, but the gastroenterologist gave it a clean bill of health, at least for now. The surgeon suggested surgery and the gastroenterologist suggested changing one of my RA drugs.
I'm not excited about surgery and I feel horrible if I don't get that drug. The rheumatologist said there was an extremely low likelihood that the drug caused the pancreatitis. What do you think?"
Health System time out: The Family Doctor used to do all their own admitting, but the hospitalist movement and increasing employment of family physicians by hospitals has dramatically decreased the percent of doctors admitting their own patients. So the patient doesn't know the admitting physician or the consultants.
This decreases the patient's trust and belief in the information received. The stress of the situation from abdominal pain, the NG tube in the nose and down the throat, the loss of privacy with the counting of intake and output of fluids, the excessive repetition of the same administrative/billing questions, and the general sense of uncertainty about what's going to happen is overwhelming, increasing the patient's discomfort and fear.
So how does the personal family physician of this patient respond? First is to show respect for the human who is also the patient and to reaffirm the patient-physician relationship which already includes an element of trust because of past interactions. Next is to listen to the patient's story, honoring their humanity and recognizing their suffering. Responding to the feelings expressed during the story helps to protect the patient from flashbacks to loneliness and fears experienced initially in the hospital and validates their view of their experience.
The family physician has already seen the hospital reports and the discharge medication list in the fax or EMR via the hospital relationship. They now think of the natural history of all the pathologic processes and phenomena noted in the hospital as well as the RA. They seek to detect where the patient is on those natural history time lines, determining further information needed by way of further history, physical exam, laboratory testing and imaging if indicated. They know that it's not over for this episode of sickness.
While the pancreas has calmed down, the gallstones aren't going to disappear, so the physician will inquire about the patients impression of the surgeon's comments about the cholelithiasis (gallstones) and gallbladder, later comparing that information with the final discharge summary dictated by the hospitalist. "Cholelithiasis" is added to the patients problem list by the family physician for future reference.
All of this information is filtered through the patients personal values, goals and dreams in their living, learning and working worlds. Yes, it is complex, challenging and even fun. The patient gets to make the decisions, so the family doctor has to do this medical mental work (including the development of an ongoing differential diagnosis for both the pancreatitis and the cholelithiasis- maybe using SPIT) in the overall context of the patient via the biopsychosocial model, explained in a post last year. Using the Biopsychosocial model to detect.
The family physician has seen thousands of patients and filters the patient situation through many similar experiences and their understanding of the medical literature to offer their best insights about what may happen with each of the patient's options relative to this illness. Their knowledge and experience becomes a resource for the patient, whose interaction with the physician in the context of a trusting relationship enables a refreshed perspective on their options.
Human to human, patient to physician communication enables the dyad to move ahead to develop a follow-up plan. What do you think?
The ED physician orders some lab tests, IV fluids and opiates (as needed for pain), and an abdominal CT scan.
IV morphine relieves the pain from 9/10 to 3/10. Lab results include elevated amylase, lipase, ALT, AST, BUN and WBC (13,500).
The examining physician gets the CT report from the physician in Australia who reads night imaging studies from this hospital. The report notes several normal elements and comments on several gallstones present in a normal appearing gallbladder without thickening of its walls or other evidence of inflammation of the gallbladder. The pancreas appears normal, but the mid-portion is blocked from view by overlying intestine.
The patient is admitted to the hospital and undergoes evaluation by a gastroenterologist, a general surgeon and a hospitalist, who was the admitting physician. The rheumatologist does not come to the hospital, but was called by the hospitalist to discuss the status and treatment of the RA.
Five days later, the patient sees the family physician in the office and relates the story of the hospitalization. "Have you ever had an NG tube in your nose, Doctor?" The patient begins. "And people analyzing everything coming out of your body for exact fluid content? Do you know how inefficient hospitals are? Three different people asked me the same questions on the night of my admission. It was like the clipboards from Hell.
The doctors said I had pancreatitis. I survived and got the tube out of my nose. The surgeon wanted to blame my gallbladder for the pancreatitis, but the gastroenterologist gave it a clean bill of health, at least for now. The surgeon suggested surgery and the gastroenterologist suggested changing one of my RA drugs.
I'm not excited about surgery and I feel horrible if I don't get that drug. The rheumatologist said there was an extremely low likelihood that the drug caused the pancreatitis. What do you think?"
Health System time out: The Family Doctor used to do all their own admitting, but the hospitalist movement and increasing employment of family physicians by hospitals has dramatically decreased the percent of doctors admitting their own patients. So the patient doesn't know the admitting physician or the consultants.
This decreases the patient's trust and belief in the information received. The stress of the situation from abdominal pain, the NG tube in the nose and down the throat, the loss of privacy with the counting of intake and output of fluids, the excessive repetition of the same administrative/billing questions, and the general sense of uncertainty about what's going to happen is overwhelming, increasing the patient's discomfort and fear.
So how does the personal family physician of this patient respond? First is to show respect for the human who is also the patient and to reaffirm the patient-physician relationship which already includes an element of trust because of past interactions. Next is to listen to the patient's story, honoring their humanity and recognizing their suffering. Responding to the feelings expressed during the story helps to protect the patient from flashbacks to loneliness and fears experienced initially in the hospital and validates their view of their experience.
The family physician has already seen the hospital reports and the discharge medication list in the fax or EMR via the hospital relationship. They now think of the natural history of all the pathologic processes and phenomena noted in the hospital as well as the RA. They seek to detect where the patient is on those natural history time lines, determining further information needed by way of further history, physical exam, laboratory testing and imaging if indicated. They know that it's not over for this episode of sickness.
While the pancreas has calmed down, the gallstones aren't going to disappear, so the physician will inquire about the patients impression of the surgeon's comments about the cholelithiasis (gallstones) and gallbladder, later comparing that information with the final discharge summary dictated by the hospitalist. "Cholelithiasis" is added to the patients problem list by the family physician for future reference.
All of this information is filtered through the patients personal values, goals and dreams in their living, learning and working worlds. Yes, it is complex, challenging and even fun. The patient gets to make the decisions, so the family doctor has to do this medical mental work (including the development of an ongoing differential diagnosis for both the pancreatitis and the cholelithiasis- maybe using SPIT) in the overall context of the patient via the biopsychosocial model, explained in a post last year. Using the Biopsychosocial model to detect.
The family physician has seen thousands of patients and filters the patient situation through many similar experiences and their understanding of the medical literature to offer their best insights about what may happen with each of the patient's options relative to this illness. Their knowledge and experience becomes a resource for the patient, whose interaction with the physician in the context of a trusting relationship enables a refreshed perspective on their options.
Human to human, patient to physician communication enables the dyad to move ahead to develop a follow-up plan. What do you think?
Sunday, October 2, 2011
Family Medicine: The Differential Diagnosis
How do Family Physicians analyze patient complaints? Traditionally, the Chief Complaint (CC) is the driving force in the patient's and doctors minds. The physician will listen to and expand the patient's story to develop a differential diagnosis, a list of possible causes of the CC.
I like to start with a four component acronym to cover four types of possible causes for the CC: SPIT, which stands for Serious, Probable, Interesting and Treatable.
What is Serious (potentially causing loss of life, limb or a significant life function) that could cause the CC?
What is Probable (given the patient's life situation, age, gender, work, exposures, etc.) that could cause the CC?
What is Interesting (unique or novel from the physician perspective or the patients theory of causation- very important if they have a theory about the cause) that might cause the CC?
What is Treatable (responsive to a known therapy) that might cause the CC?
How does this fit into the Human Centered Health Home (HCHH) that I've promoted in this blog? Here's an expanded explanation from a post in November of 2010: Using SPIT in the HCHH
From the simple SPIT Acronym, the thinking may get more focused before expanding again as the physical exam is performed to further clarify possible causes of the patient's CC and lead to revision of the SPIT list. Many other mental models and decision aids are used by Family Physicians from time to time as they engage a wide variety of patients.
How do you like to think about causes of symptoms, illness and disease?
I like to start with a four component acronym to cover four types of possible causes for the CC: SPIT, which stands for Serious, Probable, Interesting and Treatable.
What is Serious (potentially causing loss of life, limb or a significant life function) that could cause the CC?
What is Probable (given the patient's life situation, age, gender, work, exposures, etc.) that could cause the CC?
What is Interesting (unique or novel from the physician perspective or the patients theory of causation- very important if they have a theory about the cause) that might cause the CC?
What is Treatable (responsive to a known therapy) that might cause the CC?
How does this fit into the Human Centered Health Home (HCHH) that I've promoted in this blog? Here's an expanded explanation from a post in November of 2010: Using SPIT in the HCHH
From the simple SPIT Acronym, the thinking may get more focused before expanding again as the physical exam is performed to further clarify possible causes of the patient's CC and lead to revision of the SPIT list. Many other mental models and decision aids are used by Family Physicians from time to time as they engage a wide variety of patients.
How do you like to think about causes of symptoms, illness and disease?
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