Informed Consent

For about 10 years – ok maybe more – I've been teaching a session in the summer clerkship for 3rd year medical students. Tonight (like I don't have better things to do – Teresa?) I was cajoled into making a presentation. Something about how a Vulcan Mind Meld wouldn't be sufficient to convey it to the folks who will try to teach it in the Summer while I'm in vacation in Tuscany. Go figure.


Bruce writes about MinuteClinics .. then Richard comments.

They are both right.

Quickie Clinics may threaten family physicians' business.    Sure ..

But is this bad?  Not necessarily.  Today I saw a child with a sore throat.  She lives 40 miles away.  Dad called the office and asked us to refer her to an urgent care clinic near their home.  The insurance rule is that we can refer to urgent care if we can't see her .. or if we are closed.  But not if we are open.  So we said no.  She needs to come in. 

So she comes in and the rapid strep is positive.  As I am writing the rx for her, I ask her if she has any allergies to medication.  She says "yes – Amoxicillin gives me a rash" (she's <10!) .. and dad nods.  The EMR warns me of an allergy to penicillins.  Everyone agrees.

So I write a prescription for something more appropriate (no — not azithro!) and schmooze a bit with her.  She tells me that "dad wants to get a new doctor — he is mad we had to drive all the way here."

I nod and say that I understand and that it's a long drive and there are lots of doctors near your new house and I bet that there are some nice doctors there.

Then dad says "yeh – I was frustrated with the drive.  But you held her in your hand when she was tiny and you have been with us all of this time – so I was grumbling during the drive down – but you walk through the door and it all falls away and then I remember why we still come here."

And of course he is talking about the connection between a physician and a family that we can't replace with wal-mart medicine – no matter how good it is.

Would she have gotten BAD care at the quickie medical clinic if there was one (and I was allowed to refer her there)? .. no .. but I bet it's more likely that she would have gotten something like azithromycin rather than something more appropriate.

Why do free-standing urgent care facilities prescribe more gatifloxacin and azithrmoycin (and antibiotics in general) than we do?  Because PLEASING THE CUSTOMER is a primary focus of the visit.   Yet without an established relationship and trust – quick "this will make you better" prescriptions are more likely to be the name of the game.  Refusing an antibiotic for the negative rapid strep will be a challenge for these quickie clinics .. and I am much more concerned about THAT than I am about losing the business.

Another concern is how we would all coordinate care .. and how .. in the case that the kid and the dad forget about the allergy .. the minuteclinic can avoid harmful errors.  Do they call us and ask for an allergy list?  ugh .. this WOULD bug me.  I don't want to pay my staff to be fielding phone calls like this .. while others make money on rendering the care.

Very complicated.

And this is all too new to really understand.

“My appointment was 47 minutes and he talked for 45 of them”

I am his fourth primary care physician in as many years. He described his sole encounter with his most recent physician something like this: "Hell of a nice guy and he worked as a volunteer firefighter during medical school. And so in talking with him … and out of my 47 minute visit, I think he talked about his days in the fire department for 45 of them. Now that's all fine and I'm happy to chat about the good old days but that's for the coffee shop on Sunday morning, not for my visit when paying him 140 bucks."

This happened on the same day that another patient called me and told me he was transferring care out of my practice. He told me he wasn't happy – frustrated because sometimes it was hard to reach me. "You're a hell of a nice guy Doc – but I need to be able to reach my physician more easily, you know?"

Patient-physician communication. It's at the core of what we do. My new patient was complaining because his previous physician talked too much and listened to little. My old patient was complaining bacuse I wasn't accessible enough to him.

Accessibility is very challenging. I do want to be as accessible as possible to all of my patients but it's so hard to call them all right back instantly when I have 35 telephone messages waiting for me every day. How can we possibly give such personal care to so many people?

When we started our practice four years ago it seemed impossible that we would become so busy as we have in such a short time. And the nurses today were complaining because "we've lost the personal connection" and we're getting too big.

And this may be true. It seems that we always strive for growth, as growth in business and therefore revenue seems to be so important as the pressures of daily practice (rent, salaries, mortgage, looming college education bills for our children) pressure us to maintain revenue and therefore always increase work.

But increasing work simply can't be done above a certain level. For the new patient coming in, I try my best to set his expectations at a level where I can deliver. No, I won't always call him back instantly, and sometimes he will get a callback from my nurse instead of for me and this has to be okay with him. At the same time, if something is very serious and he insists on speaking with me were coming in, I will always do my best to accommodate him.

The 9-year-old I saw this week asked he was my favorite patient. I hesitated, and told him that all of my patients are main favorites. He seemed disappointed. "Well, of course you're my favorite." A sigh of relief from the boy.

So today when a prospective medical student asked me what's the difference between family physicians and other primary care physicians I didn't have much trouble answering her. Yes, internists and pediatricians are compassionate, kind, thoughtful people. But family physicians are explicitly trained to address the psychosocial needs of our patients and those of us who deeply believe that this is an important part of what we do — do our best to live these values.

Emotional stress can precipitate severe, reversible left ventricular dysfunction

NEJM — Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress

So the title of the paper is a but clumsy – but this is an interesting paper that makes us think twice about "noncardiac" chest pain. The authors studied patients who were quite ill, and subjected them to rather invasive testing (angiography, myocardial biopsy) and determined that there was significant myocardial injury assosicated with increasted catecholamine levels.

Of course this is no surprise .. but it is an objective measure that emotional stress (and other stress) can injure the heart.

A caveat is that the patients in the study were over 60.

So the 25 year old who complains of chest pain when they go to the supermarket is much more likely to be having a panic attack than a heart attack.

Hmm ..

But maybe they're not "just fine" … according to this paper in circulation, women who have anxiety disorder are much more likely to die of sudden cardiac events.