Wednesday, March 23, 2005

The Attending Sign

As both a former medical student and a current clinical preceptor, I have experienced the Attending Sign from both sides. All medical students, and hopefully all attending physicians, have experienced it, too. I never knew it by that name, but I've observed it even by myself. That is, I'll ask a patient a question and get an answer. Then I'll ask the same question later in the same interview and get a different answer. Why? I think it's mostly because patients forget details and events, and remember them better after someone jogs their memories. Sometimes it's because they didn't quite trust you enough the first time you asked it. And rarely it's an intentional attempt to deceive.

This article discusses the Attending Sign (AKA Why do patients need to be asked things five times?)
"The patient is having an adverse drug reaction," I announced as I walked out of Mrs. J's E.R. room holding a bottle of antibiotics that had recently been prescribed to her. The medical student assigned to the patient looked sheepish and the senior resident looked surprised. Along with the emergency-department registration staff, the triage nurse, and the nursing student, they had already asked Mrs. J. if she was taking any new medications. Yet the patient waited to tell me--the attending E.R. doc and the final and most senior questioner--about her new antibiotics.

Tuesday, March 22, 2005

More on Dr. Hsu

For a follow up to the story about family physician Dr. George Hsu, I found another news article from June 2004 which gives more insight into his conflict with the North Dakota Board of Medical Examiners:
In another case, Hsu is faulted for not following standard medical procedure, such as administering the drug heparin to a 73-year-old stroke patient without first calling for a CAT scan.

Hsu says there is no published medical authority that requires the scan prior to administering heparin. Besides his experience with such cases, the medical likelihood that the patient had an ischemic, not hemorrhagic stroke, for which heparin is appropriate, was already at 80 percent, he said.

Hoberg noted that there is no documentation that Hsu told the patient about the potential fatal risk of heparin without a CAT diagnosis. Hsu said he talked about it both with the patient and the patient's daughter, who decided to proceed.

Besides, he said, Elgin has no CAT scan and it didn't make sense to transfer the patient to Bismarck and risk a second, possibly fatal stroke in the meantime.

He said practice in a rural setting forces him to rely on his own competency and experience, where doctors like those who reviewed his cases have more sophisticated equipment at their disposal.

This would be a tough decision for me to make. Either call for an ambulance to transport a possible stroke victim 87 miles to Bismarck, knowing that there is only a 3 hour window of opportunity for thrombolytic therapy. Or start heparin in hopes of preventing a progression or recurrence. I wonder if there is only one correct answer? Is the answer different depending if you are the treating physician with a ticking clock, or a reviewing physician with hours to peruse the chart and a CT scanner down the hall? And what is it that they say about hindsight?
The three most compelling cases in the dispute involve what Hsu calls "right to die" cases.

In each, he is criticized for improper medical procedure and documentation.

Hsu says all three cases are instances of the patient and in one case both the patient and her daughters resisting either more tests, treatments or transfers to a Bismarck hospital.

Both the wife of a 78-year-old man, who died of heart failure, and a daughter of a 94-year-old woman, say Hsu followed his patients' wishes.

Neither would be identified for this story and adamantly insisted their names not be used. In both instances, they say the patient made the decision to refuse treatment and testing.

In the case of the 78-year-old, Hsu said the man refused treatment and a transfer to Bismarck.

The chief complaint in the case by the reviewing physician, Dr. Craig Lambrecht of Medcenter One, was that "care went half way and not all that could have been done was done," Hoberg said.

He also wrote, "There was no indication in the medical records other than a nurse's note that the risks of refusing treatment were explained ... and that he voluntarily refused treatment."

However, the man's wife, who insisted on privacy for herself and her husband, said her husband was clear about not wanting treatment or life support.

"According to what he (my husband) wanted, yes, I'm satisfied," she said.

Hsu said in the case of the 94-year-old woman, she told him, "Please don't do anything. Let me die. I'm miserable and I'm glad to die."

That patient's daughter confirms that communication occurred between Hsu and her mother.

"She stated she did not want those tests. Otherwise, he did everything he could for her," she said. "It wouldn't have mattered what the doctor said, her mind was made up."

So according to the family members, Dr. Hsu carried out their relative's wishes. According to the medical board, he didn't document that this was the case. What is the purpose of documentation? To demonstrate that he obtained informed consent from the patient and/or family. It would be a different matter if the family members didn't back up Dr. Hsu's story. This way it's like being arrested for shoplifting because you forgot to keep the receipt when you walked out of the store carrying the groceries you bought, even though you paid your money and the shopkeeper even vouches for you.
"They say I don't document well enough, but I don't keep my records for them. Since this started, I'm spending a lot of time dictating to cover myself, but that's not what I wanted to do in my practice, protect myself from the Board of Medical Examiners," Hsu said.

If all doctors were judged on the quality of their documentation, there'd be a LOT of suspended doctors. Notes that are illegible, incomplete, inadequate are rampant. Even with the coming of the electronic medical record, bad handwritten progress notes are being replaced by bad templated progress notes, which are often applied indiscriminantly, regardless of their correlation to actual physical findings or history.

For clarification, I do not know Dr. Hsu, and have never met him. But I could see myself in a similar situation someday, through no fault of my own, but because people don't realize how difficult it is to be a family doctor.

Lastly, I wanted to post Dr. Hsu's comments that he left in response to my entry about him (since I figure most people don't read the comments).
I appreciate your comments and insight; I also applaud your efforts to move from the "norm" of what I call "institutional medicine". I graduated from medical school at age 41 and from a FP residency at 44. After one year as an employee of a tertiary care hospital I took the chart of an uninsured rural patient who needed a cholecystectomy, but got in addition every conceivable consult (including a pyschiatric consult because he had expressed concern about the cost of his hospitilization) to the CEO with my resignation and the comment "this is not medicine, this is rape."

I started an independent rural clinic fifteen years ago and have had the kind of rewarding practice I believe most of us aspire for-- one based on trust and compassion rather than compensation.

I do not resist change nor distrust technology. But I feel strongly that investigative procedures are no substitue for clinical judgment, and when a choice has to be made, I have trusted my clinical judgment. And although I was correct in every case before the board of medical examiners, their comment was that I was "lucky". I was criticized for not ordering an EKG on a patient who "might have" had an MI, and for not ordering a CXR on another patient who "might have" been in heart failure, though neither patient in fact had either entity and both DX's had been ruled out on clinical exam.

Well, good luck to both of us.

Ditto.

Maybe Dr. Hsu should give these guys a call.

What's Old is New Again

When I embarked on my journey towards a solo practice, I thought I was trying something revolutionary. Since then, I've found some articles on the internet about the revival of solo or old-fashioned medicine. When I read them, I realized that others have shared the same goal of what medical practice should be like, to a time when people mattered more than money, and doctors weren't too busy to care. Several of these articles credit the dropping of the middleman -- insurance companies -- to make their practices a success.

Here's a recent article about a physician's success at going solo.
The popular perception is that solo practitioners are stuck in the past-carrying black bags and wearing mirrors on their foreheads. In fact, says Joseph Heyman, M.D., physicians who practice solo have to be on top of the latest technology to make it work. Heyman, a gynecologist, runs his own practice in Amesbury, Mass., where patients can ask for appointments and medications at his Web site. Since April 2001, he's maintained an electronic medical record and prescribed electronically. He runs a paperless office and batches his own billing at the end of the day. The advantages? "I soon realized that no one else would be as unrelenting as I am in keeping insurance companies honest," says Heyman, who left group practice. With only one employee, Heyman can keeps costs down while making a decent living. He also has more time to spend with patients. The maverick practitioner chats about the merits of going solo.

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From Businesweek: Doctors Who Make House Calls
DECEMBER 10, 2004

Tired of conveyor-belt medicine, a growing number of physicians are finding a viable market -- and better results -- in old-fashioned home visits

Doctors aren't afraid to say it: Practicing medicine has never been more difficult. General practitioners are under intense pressure to see dozens of patients daily. Because of an overburdened health-care system, many say a once-personal business has shifted to a hand-on-the-doorknob, quantity-over-quality model.

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The doctor is out: Local physicians shun HMOs for new -- or some would say old -- ways to practice
March 05, 2003

In the 1990s, California was heralded as a leader in the charge into managed healthcare. Today, California physicians are sounding a retreat.

Or so concludes Dr. Kevin Grumbach, a UCSF professor and director of the Center for California Health Workforce Studies. In December, he and a team of researchers polled California doctors that found that only 58 percent of them physicians interviewed would take a new patient who carried private HMO insurance, even though more than 90 percent were accepting new patients.

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From Minnesota Public Radio: A new "old-fashioned" doctor
In an age when many patients complain about paying too much money for too little time with their doctors, a central Minnesota physician is trying something different. Dr. Susan Rutten considers herself an old-fashioned country doctor. Rutten makes house calls, and her patients pay in cash. And even though she doesn't take insurance, she provides affordable healthcare by keeping her costs low. Dr. Rutten hopes her work inspires other doctors to consider a more patient focused approach.

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From CBS News: Old Fashioned Doctoring

Jan. 22, 2001

Some doctors say they're sick of insurance companies. So, in an effort to provide better patient care, they're turning back the clock, CBS Health Contributor Dr. Emily Senay reports.

It's no secret that many patients have had it with their HMOs. But so have a lot of doctors. In Denver, Dr. Senay visited a couple of renegade doctors who call their practice HMNo. Husband-and-wife medical partners Dr. Jonathan Sheldon and Dr. Heather Sowell make house calls, spend plenty of time with their patients, and answer their own phones.

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And finally, a story about a practice that didn't survive, but should have.

Is there room for the old-fashioned medicine?
Early this month, a young pediatrician got the surprise of his life. He walked into a Bay Area meeting hall and was greeted by several hundred patients and their parents. "Yay, yay, yay!" The cheers echoed from voices young and old for several minutes. The doctor ducked his head and laughed in delight.

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Will my practice end up like the doctor's in the first article or the last? We shall see.