Saturday, February 18, 2012
Family Medicine: Radiation Safety Miracle- Informed Consent
Radiation Safety: Another first on Emergency Department visit report, "Discussed with____(patient) criteria for CT head and facial bones giving exposure radiation versus benefit of imaging study. After considering that ___(patient) has decided against CT scans."
Could we ACTUALLY be discussing benefits and harms of CT scans and documenting informed consent for them in emergency departments? I have NEVER seen such a statement in a report from an adult emergency department in the Dayton, Ohio area before today. I have many patients in ED's for episodes of trauma, dizziness, confusion, etc who get CT scans. This has NEVER happened in a report about any of my patients in Emergency Departments before today.
I don't have enough children going to Dayton Children's Hospital to know what is happening there, so my comments only apply to adult emergency departments.
It's like a miracle has happened. I'm encouraged. What do you think?
Wednesday, February 15, 2012
Family Medicine: Odds and Ends
Caretaker stress. We see so many people who are caring for an aging parent and get trapped with a variety of symptoms and sicknesses. Once the aging parent gets relief, the caretaker starts to recover- usually.
A physician calls looking for a job. Was working in campus health center, but cut-backs eliminated his position. He'll do part time or full time. Oops, he's not board certified, didn't finish his Family Medicine residency program. Sorry, we aren't able to help him since we have to be board certified to get hospital privileges. We're only admitting newborns at present, but may occasionally provide medical management on our patients when the new hospital opens next door to our office. We'll see what happens. Sorry, Doctor, we're unable to help you with your job needs. We're committed to remaining board certified in Family Medicine. It's still part of our identity.
Marcus Welby, MD season 1 on DVD. Makes me very thankful that the GP's invented Family Medicine education via residency training, including behavioral skills. We had a 3 year training program instead of their internship plus, in many cases, some time in the military. Each training program must include a behavioral science faculty. Stress, family issues, end of life issues, cultural issues, time management, career planning, interpersonal skills, mental health problems, etc. were all part of our training. Poor Marcus Welby, MD and Steve Kiley, MD, his young associate- trial and error was their teacher. America watched as they learned together, or from Dr. Welby's vast experience and fatherly countenance.
A new hospital opens in one week next door to my office. My office staff and I went to the open house tonight. We got tours and munchies and brochures, not to mention coffee cups and thermos bottles with the hospital name and system logo. They say they're having a safer strategy for medical radiation exposure. A new approach to patient radiation safety should make them popular.
New pain law. We have to look up patient controlled substance history on our state network. It takes 30 days or so to get approved for access to the network. Lots of physicians are discouraged by the pain law mandates that impact patients via physicians bailing out.
A physician calls looking for a job. Was working in campus health center, but cut-backs eliminated his position. He'll do part time or full time. Oops, he's not board certified, didn't finish his Family Medicine residency program. Sorry, we aren't able to help him since we have to be board certified to get hospital privileges. We're only admitting newborns at present, but may occasionally provide medical management on our patients when the new hospital opens next door to our office. We'll see what happens. Sorry, Doctor, we're unable to help you with your job needs. We're committed to remaining board certified in Family Medicine. It's still part of our identity.
Marcus Welby, MD season 1 on DVD. Makes me very thankful that the GP's invented Family Medicine education via residency training, including behavioral skills. We had a 3 year training program instead of their internship plus, in many cases, some time in the military. Each training program must include a behavioral science faculty. Stress, family issues, end of life issues, cultural issues, time management, career planning, interpersonal skills, mental health problems, etc. were all part of our training. Poor Marcus Welby, MD and Steve Kiley, MD, his young associate- trial and error was their teacher. America watched as they learned together, or from Dr. Welby's vast experience and fatherly countenance.
A new hospital opens in one week next door to my office. My office staff and I went to the open house tonight. We got tours and munchies and brochures, not to mention coffee cups and thermos bottles with the hospital name and system logo. They say they're having a safer strategy for medical radiation exposure. A new approach to patient radiation safety should make them popular.
New pain law. We have to look up patient controlled substance history on our state network. It takes 30 days or so to get approved for access to the network. Lots of physicians are discouraged by the pain law mandates that impact patients via physicians bailing out.
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?
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?
Wednesday, February 8, 2012
Family Medicine: What is Our Essence?
Is Family Medicine losing its identity? Is the specialty, its leaders and its members selling out? Is Family Medicine only "Primary Care"? Do Family Physicians still exist? Or are they Family Practitioners? Or Family Medicine Practitioners? Or Primary Care Practitioners? Or Primary Care Physicians?
As we seek to serve our patients, our communities and our nation during this time of health care crisis and confusion, is our identity as a specialist in a particular specialty important? Is any medical specialty important? Should ANY physician have a specialty? Do specialties matter? Should we just have physicians and no specialties?
Should we just have Primary Care Practitioners and Secondary Care Practitioners and Tertiary Care Practitioners?
I see Family Medicine as too willing to sell out our unique identity for short term financial or political success with governments or potential funders. We're getting too comfortable using generic terms for who we are and what we do. I'm proud to be a Family Physician! I'm ecstatic about my Family Medicine specialty with it's history and traditions of service to individuals, families and communities.
I worry that the essence of Family Medicine and Family Physicians is being watered down and sold out. What do you think?
Definition of Family Medicine
Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. (1986) (2010 COD) from the American Academy of Family Physicians.
Family Medicine Scope and Philosophical Statement
In summary, the family physician of today is rooted in the historical generalist tradition. The specialty is three dimensional, combining knowledge and skill with a unique process. The patient-physician relationship in the context of the family is central to this process and distinguishes family medicine from other specialties. Above all, the scope of family medicine is dynamic, expanding, and evolutionary.
(1992) (2011 COD)
Saturday, February 4, 2012
The Postphysician Era
"Is it true? Are we actually entering the "postphysician era" in which the ancient, archetypal function of a doctor will now be parceled out among medical technicians and paramedical professionals? I do not think so. But to rediscover the meaning of being a physician within the constraints of today's society will require that we know with certainty the essence of the practice of medicine, the essence of what it means to be a physician. The role of physician is fundamental to human society and culture. In one mode or another, this role has always existed. It represents the blending within the human psyche of knowledge and love, the mysterious but necessary balance between mind and heart, scientific detachment and compassionate engagement in the suffering of our fellow human beings." ...from "The Essence of Being a Physician" by Jacob Needleman, PhD
(Needleman J: The essence of being a physician-In The aim of American
medicine within the constraints of today's society-A forum. West J Med
1986Aug; 145:185-186)
These comments are over 25 years old. Maybe we come to this point at regular intervals. It feels like we're there again. Will it pass?
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