Family Medicine Notes

Abstract Appeal -- The Terri Schiavo Information Page is one of the few unbiased resources on the Internet that describes this tragic case.  There are many sad components to this case, but from my perspective, the lesson here is that everyone should fill out a Health Care Proxy and a Living Will.  It seems that she had made her feelings clear to her husband, but she had never done so in writing.  

An example:  you can find the New York Health Care Proxy (pdf) on New York's health department website.  This document on the NYSDOH website actually performs both functions - as it defines who is the proxy - and then it provides a space to guide the proxy:

"Putting things in writing is safer than simply speaking to people, but neither method is as effective as appointing someone to decide for you. It is often hard for people to know in advance what will happen to them or what their medical needs will be in the future. If you choose someone to make decisions for you, that person can talk to your doctor and make decisions that they believe you would have wanted or that are best for you, when needed. If you appoint someone and also leave instructions about treatment in a Living Will, in the space provided on the Health Care Proxy form itself, or in some other manner, the person you select can use these instructions as guidance to make the right decision for you."

Posted by Jacob Reider, MD at 01:04 AM | Permalink | Comments (3)

Dr Bob posts on DB's Medical Rants an interesting reference to his paper in Journal of General Internal Medicine.   Family physicians feel your pain, man ...  and I agree with you that there remains a place for General Internal Medicine ... but ... here's what may be an odd concept:  the General Internist as specialist in complex adult medicine .. just as the pediatrician could be positioned as a specialist in complex pediatric medicine. 

Ever Since Family Medicine displaced "General Practice"  many years ago - the identity of the "other" generalists (peds and IM) has certainly been threatened.  Yes, yes ... this isn't the message of Dr Centor's paper ... he seems to be more concerned with pressure from the right -- the specialists.  But I would argue that there exists some pressure from the left (FP) as well.

It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem.  Why?  Because in some cases, the training of an Internist simply prepares them better for handling such situations.    A good generalist knows the boundaries of his/her skill -- and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women -- there are some situations in which we are better off having the help of someone who specializes.  "You are worth it" I tell my hesitant patients.   They sometimes seem to wish I could do everything for them.  I can't.  This is why we have specialists. 

Yet with their identities as "general adult medicine" physicians -- there is no good method for me to refer a patient to an Internist for consultation.  Since they are  primary care physicians - there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all. 

The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) ... and we may learn not to be so threatened by them. 

Our Mantra seems to be "we provide the same care as they do."  Which is accurate in many ways ... and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician - especially for a family.  

But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine - no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.

Last week, a patient transferred out of my practice.  She had complex problems that I frankly told her I didn't understand.    She asked for the name of another physician who might be helpful, and I suggested an Internist colleague who works across town.  Bottom line:  our Internist pal figured it out.  Something rare and complicated and I hadn't even thought about it.  But she did ... ordered the right tests,  and I'm happy about that ... but now the relationship with my patient is severed .. and .. yes .. my ego is bruised a bit. 

Had I referred the patient to a rheumatologist or cardiologist etc etc ... I wouldn't be severing the relationship with my patient -- nor would my ego be bruised by such a situation.  Indeed, assistance with the diagnosis and/or management of a complex problem is the purpose of such a referral. 

Hmm ... so, Dr. Bob (is that what DB stands for?) ... how would this work?  Referrals to the Internist ...  why not? 

Posted by Jacob Reider, MD at 10:35 PM | Permalink

Craig's notes:  Family docs, pap smears, and cervical cancer risk opens up a compelling thought along the lines of my discussion the other day of prostate cancer screening:

"..The vast majority of the post-hysterectomy patients in my practice who were also seeing gynecologists or had previously seen gynecologists were still under the impression that they needed regular Pap smears."

He's right.  Like the PSA talk -- this one takes a long time, and inherently involves a discussion of risk.  Women who are post-hysterectomy are not without some risk ...but ... the real risk is quite low:

"The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent "

 yet ... like the free prostate screenings so commonly advertised in the local paper ... this may be better business than it is medicine.  ugh.

Posted by Jacob Reider, MD at 11:56 PM | Permalink | Comments (1)

From the Cleveland Clinic: Prostate Cancer: Screening Guidelines

Short, unbiased and to the point. 

I struggle with this subject daily.  When I'm pressed for time, I find that I order the PSA, do the DRE and discuss it far less than I should.  These are generally patients who have had annual PSA tests done int he past - and have been told by someone that she "need to have a PSA."  When I'm not so pressed for time (or in denial) ... I engage my patients and provide true informed consent.  All-in-all, a good discussion of PSA pro & con takes at least 10 minutes, and usually involves a quick review of this paper and its implications.

I'll usually bring in data that most men have some prostate cancer by the time we turn 60 .. and nearly half have some by age 50.

.. an interesting picture of an Italian perspecitve:

"Screening should be banned from current practice until its efficacy is demonstrated"

.. and here's the most recent news tidbit:  Inuit are protected against prostate cancer.

Posted by Jacob Reider, MD at 02:26 AM | Permalink

From American Medical News: Doctor redefines visits with phone, e-mail ... American Medical News

It's an interesting story about a physician who has set up a practice based largely on cash payments (he accepts no insurance) for visits, phone calls, and e-mail communication.

Dr. Dappen charges $20 for a five-minute block spent on the phone and $25 if that time is spent in the office. However, he reduces his fees -- $15 for a five-minute phone visit, $22 in person -- if the patient sets up a prepaid account that allows Dr. Dappen to withdraw funds as services are provided. He said he doesn't charge for time spent doing the "back-end work," like faxing information or ordering a test after the conversation is completed.

It's an interesting concept.  I would agree that the current method of reimbursment isn't working very well.  Capitation didn't work so well either.  Most days, I would say that I spend 60 - 70 minutes talking with patients by e-mail or on the phone.  E-mail certainly speeds this up a bit, and it does provide a useful method of communicating quickly.    The fees for office visits seem inflated -- until one considers the "free" care that goes on between office visits.  Perhaps it all comes out in the wash.  Hmmm.

Posted by Jacob Reider, MD at 01:30 AM | Permalink | Comments (2)

Posted by Jacob Reider, MD at 01:22 AM | Permalink | Comments (1)

PDA versions of many practice guidelines are available from Guidelines.gov

Posted by Jacob Reider, MD at 12:32 AM | Permalink

Today was Psychiatry day in the office. Very challenging. Some short (ugh -- too short) breaks in the action for some well-child visits and a few upper-respiratory infections, but the majority of my visits today involved depression, anxiety or personality disorders. I find personality disorders especially challenging, since their diagnosis is so difficult, and intervention is equally difficult.

Our colleagues in psychiatry seem equally challenged - I had one patient referred back to me for management of this disorder. Uh ... "tag - you're it" he seemed to say to me. We have a paucity of psychiatrists here in Albany - so it is especially challenging to find services sometimes. Yesterday (ok .. so maybe yesterday was psychiatry day too) .. I saw a man with type 2 diabetes, obesity and depression with some psychotic features. His depression has been very well managed on Risperidal - and he's not seen a psychiatrist in many years. I'd love to get him on to something that would not cause weight gain. Aripiprazole has recently been introduced, and it does not cause weight gain like risperidal. Hmm ... should I change him? I've never used Aripiprazole ... but ... nor have most psychiatrists yet. Hmmm ... what to do? ... I referred him to a psychiatrist today. We'll see what happens. A nice review of the new antipsychotics appears in this month's Archives of General Psychiatry.

Posted by Jacob Reider, MD at 12:17 AM | Permalink | Comments (1)

Red Sox fans everywhere - I'm sorry about tonight's game - it was my fault.  I'm not one of those crazy sports fans who think that my actions would control the outcome of a game .. but this series has been different.  I can't watch the games.  If I do - the Sox lose.  Last weekend, they won both of those games in Oakland as I was driving to/from Boston on the Mass Pike.   This weekend, Sam and I were at the game on Saturday - and we lost.  Sunday I was banned from the room by my wife - so that I wouldn't watch (and therefore ruin the game).  The won.  Tonight - (I am sooo sorry) I watched one inning with Sam before I sent to the office at about 5:00.  The Yankees got 3 runs in that inning and you know the rest.  I apologize to Red Sox fans everywhere.  I promise not to watch any more Red Sox games!

Posted by Jacob Reider, MD at 09:50 PM | Permalink | Comments (3)

The New York Times article: New Doctor, New Diet, but Still No Cookies covers a topic that remains compelling and controversial.  It's a great overview of the South Beach Diet and the book that promotes it.

Bottom line:  South Beach seems to be more reasonable than Atkins .. and it may very well fit the bill as an ideal plan for those interested in avoiding diabetes and/or reducing their risk of cardiovascular disease.  I'll read the book .. um .. when I have free time ..  after the kids finish college.

Posted by Jacob Reider, MD at 01:14 AM | Permalink

Posted by Jacob Reider, MD at 12:18 AM | Permalink | Comments (1)

While I squawk about medical weblogs providing trancparency into the practice of medicine, most people at last week's conference agreed that there is such a thing as too much transparency.    Where is the line between too much transparency and just enough?  I'm not sure.  Today's entry may tread the line .... hmmm ..

 The New York's department of Professional Misconduct and Physician Discipline is New York's attempt to insure that physicians practicing in this state are well trained and well behaved.  Sometimes I help review the cases of physicians who are - for some reason - being scrutinized by this department.  While I sometime know why the physician is being reviewed, I usually make an effort to be blind to this - I think that it makes my review more objective.

It's always awkward.  I feel uncomfortable challenging another physician's judgement, decksionmaking skill, or personality.  The process usually involves reviewing a videotape of the physician interacting with one of the "standardized patients" we have in the medical school.  (A "standardized patient" is an actor - someone employed and trained by our faculty to act out a particular problem.  We use these "patients" in the training of our students, and it gives us insight into the students' ability to interact with patients, and their physical exam skills.)

After I review the videotape, I usually review a few real charts from the physician's practice, and then there is an interview during which I ask questions about the progress notes and the videotape.  This often the most awkward part, but of course reveals the most about their thought processes.  Here's the sad news:  some physicians simply should not be practicing medicine.  They're humans too - so physicians are sometimes in a position that makes them unable to properly do their jobs.  The trouble is that their livelihood depends on their practice - and most physicians have enormous debt that remains from medical school and residency - even as many as ten or fifteen years later.

LIke the bus driver who can't see very well - it's a sad situation, but it's clearly unsafe.  The tricky ones are where it's not so obvious as the vision impaired bus driver. 

Hence the need for reviews such as that described above.  In the end - I make no decision, thankfully.  Rather - I provide feedback to the State, and they are empowere to take corrective action based on my assessment and several others. 

I find the process to be remarkably appropriate.  The situations are alwayds delicate, but I think that the process is thorough enough to identify problems if they exist - yet with enough "due process" to provide respect and some presumption of "innocence."

Want to see if a physician in New York has been disciplined in any way?  New York has made that easy too ... just go to the New York State Physician Finder and look up the physician.  Once you've found the physician, click on "Legal Actions" and you can see any current or previous actions against that physician.  Now there's transparency, eh?

Posted by Jacob Reider, MD at 10:44 AM | Permalink | Comments (1)

The Jim Mullen Foundation is giving away free computers to people with disabilities.  I can think of a few patients who would benefit from this .. can you?

(update: please don't ask me to help get computers for someone.  Follw the link and apply)

Posted by Jacob Reider, MD at 11:46 PM | Permalink | Comments (7)

Posted by Jacob Reider, MD at 11:08 PM | Permalink

From Pediatrics:

Breastfeeding was inversely associated with reduced risk of neonatal respiratory tract infections in girls but not in boys. Breastfeeding may confer protection against some community-acquired infections as early as the first month of life.

The authors can't come up with a mechanism for why there is this difference - but they suggest that these results be interpreted with some caution.  The bottom line is that breasfeeding is good:

Currently, exclusive breastfeeding is recommended for approximately the first 6 months of life and breastfeeding with complementary solid foods for at least the first year of life.²⁸ However, in the United States, most mothers do not breastfeed for this duration.²⁹ In counseling mothers of newborns about their infant feeding choices, our data suggest that the protective effects of breastfeeding start during the first month of life and that even a short period of exclusive breastfeeding may benefit young children.

Posted by Jacob Reider, MD at 08:41 AM | Permalink | Comments (1)

An excellent review article on Serum Tumor Markers is in this month's issue of American Family Physician.

 "Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumor markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumor markers do not have sufficient sensitivity or specificity for use in screening. Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer. Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses. CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy."

Posted by Jacob Reider, MD at 08:34 AM | Permalink

Johnny Damon was badly hurt in Monday night's game in Oakland. Fortunately, he's OK .. but it made me think that there must be a way for the players to communicate with each other in the outfield even if the fans are too loud.   ?Little ear-bud radios?  Proximity alarms?  Hmmm...

We've got tickets to  both games in Boston this weekend.  I've not been to a playoff game since Game 6 of the World Series, 1975. 

Posted by Jacob Reider, MD at 02:49 AM | Permalink

It's the time of year that we need to write Dean's letters for the medical students.  These letters serve as a summary of the students' medical school careers -- and (we hope) help them get in to the residency of their choice. 

It's hard work to write these things .. carefully walking a line of being the student's advocate - while also being honest about students who have not performed so well as they could.  Three more to go.  I was hoping to finish tonight .. but it's not going to happen.

--

I enjoyed meeting everyone at Bloggercon - and I think that the "medlical weblogs" session was productive.  I've been thinking about a "work product" that we could creat that might summarize some of our discussion - perhaps a "guide to medical weblogging" that might help frame some of the issues that we discussed, and could help claify some of the common "do's and don'ts" of medical weblogging. 

Then again ... maybe not.  Should there be rules?  No .. but guidelines?  Perhaps.  HIPAA looms large, as do medical ethics.  In our enthusiasm to share OUR experiences, we're also share the experiences of our patients and colleagues.  Hmm ..

Posted by Jacob Reider, MD at 02:42 AM | Permalink | Comments (1)

Steve sent me a link today on the Forbes.com: Best Medical Blogs article. 

The Author called me yesterday and we talked for a few minutes.  He quotes me as saying that .. "one of the problems that I perceive to be a persistent one about how medicine has been practiced in this country is this theme of paternalism." 

Yep .. I said that ... more or less ... but I was referring to the old ways of practicing medicine... not what I think/hope usually occurs now.  The old  "Physician Knows Best" kind of medicine.  The sort of medicine that exalted physicians .. and no one challenged them or their confidence.

Things are different now.  We do our best to share decision-making with patients -- to be transparent and expose what we know and what we don't know.  I think that weblogs are a way to enhance this transparency. 

--

I've noticed this before ... but I think it's noticeable from the notes in Forbes ... 3 of the 5 medical weblog authors featured are 40 years old.  And I know that Steve turned 40 just a month or so before I did ... I wonder what's up with all of these 1963 babies and weblogs ...

I was talking with Dave a bit this morning and he reflected that his girlfriend thinks of physicians as uncaring ferrari-driving rich jerks.  Man .. I wonder how commonplace this sentiment is.  So far from reality. 

The day in the office was hectic again .. and ... like the previous few days ... many problems revolved about psychiatric issues.    Very challenging stuff.  While I do my best to use all of my "15 minute hour" skills ... I often envy the psychiatrists who really do have an hour to spend with their patients.  

One bright spot ...  I got an e-mail today from a patient I saw on Monday.  It's  a very long story, but the bottom line is that she's being appropriately withdrawn from steroids, after having been on them for many years - following a misdiagnosis of Addison's disease.  Of course, she's on a sloooow taper, but she feels terrible.  Her baseline depression is much worse, and she's got so little energy that she can barely function.  Taking a suggestion form a colleague, I tried modafinil, and she reports that she's feeling much better in general.

Posted by Jacob Reider, MD at 12:20 AM | Permalink | Comments (4)

In JAMA  this week there is an article on the introduction of cereal into a child's diet.

There's quite a bit of controverys about when is the best time to introducce solids.  This paper is interesting in that it demonstrates that a window may exist:  kids who are exposed to cereal before 4 months or AFTER 7 months have a higher risk of developing type 1 diabetes later in life.

Wow.  While the concept of "too early" introduction being related to problems is nothing new .. this is the 1st discussion of how waiting too long to introduce solids may also be harmful.

Posted by Jacob Reider, MD at 11:50 PM | Permalink

It was a hectic day in the office.  Moday was dermatology day ... scabies, pinworms, and roseola.  Today was psychiatry day.  Conversion Disorder was, I believe,  the diagnosis of my most troubled patient.  Oddly - my second patient with this diagnosis in as many months.  Is it me? 

Posted by Jacob Reider, MD at 12:27 AM | Permalink | Comments (2)

Posted by Jacob Reider, MD at 11:59 PM | Permalink

In July's Family practice news (OK .. so I'm just now catching up on the reading next to the toilet) is an interesting article about how physicians still do annual physical exams:

Most primary care physicians don't accept current national guidelines that recommend abandoning routine annual physical examinations in favor of a more selective approach to prevention, Dr. Allan V. Prochazka said at the annual meeting of the Society of General Internal Medicine. ...

Dr. Prochazka surveyed 890 randomly selected primary care internists, family physicians, and ob.gyns. in the Denver, Boston, and San Diego areas. The physician survey was a follow-up to his earlier patient survey conducted in the same metropolitan areas, which showed that 66% of the general public want and expect an annual physical examination that includes many tests (Ann. Intern. Med. 136[9]:652-59, 2002).

Many of the surveyed physicians clearly had some of their facts wrong. For example, 56% believed that national organizations recommend a routine annual physical examination, which is no longer the case, and 63% felt that the annual physical examination is of proven value, a notion debunked in national guidelines, the internist continued.

.. and some interesting statistics:

The percentage of surveyed primary care physicians who believe that routine annual physical exams are:

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A valuable opportunity to provide counseling about preventive health services	94%
Helpful in improving the doctor-patient relationship	93%
Expected by most patients	78%
Useful in detecting subclinical disease	74%
Of proven value	63%
Covered by most health insurance plans	60%

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The percentage of primary care physicians who think that the following lab tests should be part of an annual physical exam in all patients:

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Serum glucose	46%
Urinalysis	44%
CBC	39%
Kidney function	32%
Liver function	28%
Source: Dr. Allan V. Prochazka.

Posted by Jacob Reider, MD at 08:18 AM | Permalink | Comments (1)