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A new year—and new features
Last week at family medicine grand rounds, a resident presented a fascinating case of a 36-year-old policeman who came to the clinic with a 2-day history of pain behind his left ear. The patient had no discharge or hearing loss, and the physical findings were nonspecific. An x-ray was suggestive of mastoiditis, so the patient was started on amoxicillin. But the pain worsened over the next 2 days, and he broke out in a vesicular rash and developed a facial nerve palsy.
I’m sure many of you astute diagnosticians have already identified this as a case of Ramsay Hunt syndrome. But there’s another twist to this case. The patient was hospitalized the next day, with difficulty swallowing due to involvement of cranial nerves IX and X. He also developed hearing loss. Although he was treated promptly with steroids and acyclovir, he left the hospital with a feeding tube. We’re hoping for a full recovery, although the prognosis remains uncertain.
Involvement of 4 cranial nerves is unusual for Ramsay Hunt syndrome. But I’m certain that you, too, see unusual cases. If we define a rare or unusual case as one with an annual incidence of 1000 or less, it is safe to assume that most family physicians see at least 4 rare cases per year—or 140 such cases over a typical (35-year) career.
Each month, I receive several case report submissions to this journal. I find them fascinating, and think you would, too. That’s why we are launching a new department, Case Review (at right), starting with this first issue of the year. Over the course of several years, we expect to accumulate a wealth of case reports that will be valuable both for teaching and diagnosis.
Do you have a case you’d like to share? If you have a case that you think readers would be interested in, send it to us for consideration. The format is straightforward: Start with a pithy case history with pertinent positive and negative findings and the clinical course of illness; follow with a brief literature review, a discussion of the condition and its treatment, and a conclusion or recommendations. (McCarthy and Reilly’s article on writing case reports is an excellent resource.1)
Questions to consider: What is the takeaway for the reader? Was this a difficult diagnosis that hinged on a key finding in the history or physical exam? Was this a common problem that presented in an uncommon way?
Also this month… In addition to Case Review, JFP is launching another new feature: Watch & Learn, a how-to video series. This month’s 4-minute video demonstrates the proper way to do a punch biopsy.
Now that you know what’s new at JFP, I invite you to write and tell us what’s happening in your world—and to submit your most interesting cases.
Wishing you a happy, healthy year!
REFERENCE
1. McCarthy LH, Reilly KE. How to write a case report. Fam Med. 2000;32:190-195.
Last week at family medicine grand rounds, a resident presented a fascinating case of a 36-year-old policeman who came to the clinic with a 2-day history of pain behind his left ear. The patient had no discharge or hearing loss, and the physical findings were nonspecific. An x-ray was suggestive of mastoiditis, so the patient was started on amoxicillin. But the pain worsened over the next 2 days, and he broke out in a vesicular rash and developed a facial nerve palsy.
I’m sure many of you astute diagnosticians have already identified this as a case of Ramsay Hunt syndrome. But there’s another twist to this case. The patient was hospitalized the next day, with difficulty swallowing due to involvement of cranial nerves IX and X. He also developed hearing loss. Although he was treated promptly with steroids and acyclovir, he left the hospital with a feeding tube. We’re hoping for a full recovery, although the prognosis remains uncertain.
Involvement of 4 cranial nerves is unusual for Ramsay Hunt syndrome. But I’m certain that you, too, see unusual cases. If we define a rare or unusual case as one with an annual incidence of 1000 or less, it is safe to assume that most family physicians see at least 4 rare cases per year—or 140 such cases over a typical (35-year) career.
Each month, I receive several case report submissions to this journal. I find them fascinating, and think you would, too. That’s why we are launching a new department, Case Review (at right), starting with this first issue of the year. Over the course of several years, we expect to accumulate a wealth of case reports that will be valuable both for teaching and diagnosis.
Do you have a case you’d like to share? If you have a case that you think readers would be interested in, send it to us for consideration. The format is straightforward: Start with a pithy case history with pertinent positive and negative findings and the clinical course of illness; follow with a brief literature review, a discussion of the condition and its treatment, and a conclusion or recommendations. (McCarthy and Reilly’s article on writing case reports is an excellent resource.1)
Questions to consider: What is the takeaway for the reader? Was this a difficult diagnosis that hinged on a key finding in the history or physical exam? Was this a common problem that presented in an uncommon way?
Also this month… In addition to Case Review, JFP is launching another new feature: Watch & Learn, a how-to video series. This month’s 4-minute video demonstrates the proper way to do a punch biopsy.
Now that you know what’s new at JFP, I invite you to write and tell us what’s happening in your world—and to submit your most interesting cases.
Wishing you a happy, healthy year!
Last week at family medicine grand rounds, a resident presented a fascinating case of a 36-year-old policeman who came to the clinic with a 2-day history of pain behind his left ear. The patient had no discharge or hearing loss, and the physical findings were nonspecific. An x-ray was suggestive of mastoiditis, so the patient was started on amoxicillin. But the pain worsened over the next 2 days, and he broke out in a vesicular rash and developed a facial nerve palsy.
I’m sure many of you astute diagnosticians have already identified this as a case of Ramsay Hunt syndrome. But there’s another twist to this case. The patient was hospitalized the next day, with difficulty swallowing due to involvement of cranial nerves IX and X. He also developed hearing loss. Although he was treated promptly with steroids and acyclovir, he left the hospital with a feeding tube. We’re hoping for a full recovery, although the prognosis remains uncertain.
Involvement of 4 cranial nerves is unusual for Ramsay Hunt syndrome. But I’m certain that you, too, see unusual cases. If we define a rare or unusual case as one with an annual incidence of 1000 or less, it is safe to assume that most family physicians see at least 4 rare cases per year—or 140 such cases over a typical (35-year) career.
Each month, I receive several case report submissions to this journal. I find them fascinating, and think you would, too. That’s why we are launching a new department, Case Review (at right), starting with this first issue of the year. Over the course of several years, we expect to accumulate a wealth of case reports that will be valuable both for teaching and diagnosis.
Do you have a case you’d like to share? If you have a case that you think readers would be interested in, send it to us for consideration. The format is straightforward: Start with a pithy case history with pertinent positive and negative findings and the clinical course of illness; follow with a brief literature review, a discussion of the condition and its treatment, and a conclusion or recommendations. (McCarthy and Reilly’s article on writing case reports is an excellent resource.1)
Questions to consider: What is the takeaway for the reader? Was this a difficult diagnosis that hinged on a key finding in the history or physical exam? Was this a common problem that presented in an uncommon way?
Also this month… In addition to Case Review, JFP is launching another new feature: Watch & Learn, a how-to video series. This month’s 4-minute video demonstrates the proper way to do a punch biopsy.
Now that you know what’s new at JFP, I invite you to write and tell us what’s happening in your world—and to submit your most interesting cases.
Wishing you a happy, healthy year!
REFERENCE
1. McCarthy LH, Reilly KE. How to write a case report. Fam Med. 2000;32:190-195.
REFERENCE
1. McCarthy LH, Reilly KE. How to write a case report. Fam Med. 2000;32:190-195.
How well do you know your patients?
At a recent seminar for first-year medical students, I was struck by a statement made by a presenter—an attorney who advocates for health care for the underserved. “Know your patients,” she advised.
Know them well, she meant—where they live, who’s in their family and whom they live with, whether they have a job, and more. I was reminded that, while we family physicians pride ourselves on knowing our patients, in the bustle of daily practice there’s often no time for even a rudimentary social history.
Yet, recent research highlights just how important knowing our patients really is. Saul Weiner, MD, who has been studying what he calls “patient context” for years, has identified 10 domains that doctors should be aware of: access to care, social support, responsibilities, relationship with other health care providers, skills and abilities, emotional state, financial situation, cultural beliefs, spiritual beliefs, and attitude toward illness. Being truly patient-centered, he contends, means considering all 10 domains when we prescribe tests or treatments.
Weiner added to his body of research recently with a study in which he and his colleagues1 put hidden recorders in physician offices, and recorded doctor-patient conversations—more than 600 in all. In listening to the recordings, the researchers identified 548 red flags (eg, medication nonadherence, frequent ED visits, poor diabetes control) that the treating physician should have, but often failed to, follow up on.
Chart audits, conducted up to 9 months lat- er, highlight the importance of “patient context”: Among patients with red flags, 71% of those whose doctor directly addressed the problem showed improvement, vs 46% of those whose red flags went unacknowledged and unaddressed.
As we discussed these issues at the seminar I attended, a medical student with experience in the health care industry identified another important domain that doctors should be aware of: patients’ health insurance status. While some thought this might stigmatize patients with little or no coverage, others—including me—agreed that when ordering expensive tests and drugs, it is vital to know what the potential financial burden might be.
It’s yet another reminder of what FPs know, but often lose sight of: To be optimal healers, we must go beyond the medical problem at hand and get to know the patient in front of us.
REFERENCE
1. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.
At a recent seminar for first-year medical students, I was struck by a statement made by a presenter—an attorney who advocates for health care for the underserved. “Know your patients,” she advised.
Know them well, she meant—where they live, who’s in their family and whom they live with, whether they have a job, and more. I was reminded that, while we family physicians pride ourselves on knowing our patients, in the bustle of daily practice there’s often no time for even a rudimentary social history.
Yet, recent research highlights just how important knowing our patients really is. Saul Weiner, MD, who has been studying what he calls “patient context” for years, has identified 10 domains that doctors should be aware of: access to care, social support, responsibilities, relationship with other health care providers, skills and abilities, emotional state, financial situation, cultural beliefs, spiritual beliefs, and attitude toward illness. Being truly patient-centered, he contends, means considering all 10 domains when we prescribe tests or treatments.
Weiner added to his body of research recently with a study in which he and his colleagues1 put hidden recorders in physician offices, and recorded doctor-patient conversations—more than 600 in all. In listening to the recordings, the researchers identified 548 red flags (eg, medication nonadherence, frequent ED visits, poor diabetes control) that the treating physician should have, but often failed to, follow up on.
Chart audits, conducted up to 9 months lat- er, highlight the importance of “patient context”: Among patients with red flags, 71% of those whose doctor directly addressed the problem showed improvement, vs 46% of those whose red flags went unacknowledged and unaddressed.
As we discussed these issues at the seminar I attended, a medical student with experience in the health care industry identified another important domain that doctors should be aware of: patients’ health insurance status. While some thought this might stigmatize patients with little or no coverage, others—including me—agreed that when ordering expensive tests and drugs, it is vital to know what the potential financial burden might be.
It’s yet another reminder of what FPs know, but often lose sight of: To be optimal healers, we must go beyond the medical problem at hand and get to know the patient in front of us.
At a recent seminar for first-year medical students, I was struck by a statement made by a presenter—an attorney who advocates for health care for the underserved. “Know your patients,” she advised.
Know them well, she meant—where they live, who’s in their family and whom they live with, whether they have a job, and more. I was reminded that, while we family physicians pride ourselves on knowing our patients, in the bustle of daily practice there’s often no time for even a rudimentary social history.
Yet, recent research highlights just how important knowing our patients really is. Saul Weiner, MD, who has been studying what he calls “patient context” for years, has identified 10 domains that doctors should be aware of: access to care, social support, responsibilities, relationship with other health care providers, skills and abilities, emotional state, financial situation, cultural beliefs, spiritual beliefs, and attitude toward illness. Being truly patient-centered, he contends, means considering all 10 domains when we prescribe tests or treatments.
Weiner added to his body of research recently with a study in which he and his colleagues1 put hidden recorders in physician offices, and recorded doctor-patient conversations—more than 600 in all. In listening to the recordings, the researchers identified 548 red flags (eg, medication nonadherence, frequent ED visits, poor diabetes control) that the treating physician should have, but often failed to, follow up on.
Chart audits, conducted up to 9 months lat- er, highlight the importance of “patient context”: Among patients with red flags, 71% of those whose doctor directly addressed the problem showed improvement, vs 46% of those whose red flags went unacknowledged and unaddressed.
As we discussed these issues at the seminar I attended, a medical student with experience in the health care industry identified another important domain that doctors should be aware of: patients’ health insurance status. While some thought this might stigmatize patients with little or no coverage, others—including me—agreed that when ordering expensive tests and drugs, it is vital to know what the potential financial burden might be.
It’s yet another reminder of what FPs know, but often lose sight of: To be optimal healers, we must go beyond the medical problem at hand and get to know the patient in front of us.
REFERENCE
1. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.
REFERENCE
1. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.
When pain persists, so shold investigation
When pain persists, so should investigation
TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.
The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.
Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.
PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.
THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.
VERDICT $950,000 New York settlement.
COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.
Failure to reconsider the initial evaluation
A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.
The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.
Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.
PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.
THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.
VERDICT $934,779 Illinois bench verdict.
COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.
When pain persists, so should investigation
TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.
The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.
Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.
PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.
THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.
VERDICT $950,000 New York settlement.
COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.
Failure to reconsider the initial evaluation
A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.
The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.
Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.
PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.
THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.
VERDICT $934,779 Illinois bench verdict.
COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.
When pain persists, so should investigation
TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.
The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.
Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.
PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.
THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.
VERDICT $950,000 New York settlement.
COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.
Failure to reconsider the initial evaluation
A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.
The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.
Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.
PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.
THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.
VERDICT $934,779 Illinois bench verdict.
COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.
Delayed Dx leads to blindness
Delayed Dx leads to blindness
A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.
The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.
Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.
Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.
The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.
On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.
PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.
THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.
VERDICT $1.4 million Washington settlement.
COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.
Lack of vigilance ends badly
SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.
Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.
PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey settlement.
COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.
Delayed Dx leads to blindness
A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.
The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.
Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.
Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.
The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.
On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.
PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.
THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.
VERDICT $1.4 million Washington settlement.
COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.
Lack of vigilance ends badly
SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.
Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.
PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey settlement.
COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.
Delayed Dx leads to blindness
A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.
The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.
Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.
Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.
The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.
On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.
PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.
THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.
VERDICT $1.4 million Washington settlement.
COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.
Lack of vigilance ends badly
SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.
Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.
PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey settlement.
COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.
Don't mind the noise-- they're just trying to sleep
Two years ago, a house guest apologized to my wife and me as he prepared to turn in for the evening. He was sorry to subject us to his noisy CPAP machine, he said. Last year at a family reunion, my sleepy brother-in-law blamed his lethargy on sleep apnea, and another in-law chimed in to say that CPAP worked great for her.
If my family and friends are any indication, we seem to be surrounded by people with obstructive sleep apnea (OSA), due almost entirely to the steep rise in obesity over the past 30 years.
It is alarming to know that OSA is associated with traffic accidents, worsening of diabetes and hypertension, atrial fibrillation, and a higher risk of death. What we don’t yet know is whether these major health problems are caused by sleep apnea or whether they’re fellow travelers. (In “Obstructive sleep apnea: A diagnostic and treatment guide” on page 565, Gutierrez and Brady present an evidence-based summary of symptoms, diagnostic criteria, and treatment modalities. And in “Peripheral neuropathy linked to obstructive sleep apnea?” on page 577, Schmidt et al highlight a lesser known association with OSA.)
There is excellent evidence that CPAP and, in some cases, dental devices, can alleviate daytime sleepiness in patients with OSA. But more randomized trials are needed to determine whether treatment of OSA can improve hypertension, diabetes control, and atrial fibrillation, as well as prevent excess mortality.
Recent trials offer a glimmer of hope. One found that CPAP therapy led to small but significant blood pressure reductions in patients with treatment-resistant hypertension.1 Another demonstrated that CPAP led to improvement in lipid profiles and hemoglobin A1c in obese patients with diabetes.2 But many more studies are needed to know how effective sleep apnea treatments are in reducing the significant morbidity and mortality associated with OSA.
Sleep medicine is a young specialty, so it is not surprising that high-quality randomized trials of sleep apnea are in their infancy. (The American Academy of Sleep Medicine was founded in 1975 and the American Board of Sleep Medicine was established in 1991.) Because the science is evolving, I encourage you to stay abreast of new developments in the field. In the meantime, nothing works better for improving sleep apnea, hypertension, and diabetes than good old-fashioned weight loss!
1. Lozano L, Tovar JL, Sampo G, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28:2161-2168.
2. Weinstock TG, Wang X, Rueschman M, et al. A controlled trial of CPAP therapy on metabolic control in individuals with impaired glucose tolerance and sleep apnea. Sleep. 2012;35:617B-625B.
Two years ago, a house guest apologized to my wife and me as he prepared to turn in for the evening. He was sorry to subject us to his noisy CPAP machine, he said. Last year at a family reunion, my sleepy brother-in-law blamed his lethargy on sleep apnea, and another in-law chimed in to say that CPAP worked great for her.
If my family and friends are any indication, we seem to be surrounded by people with obstructive sleep apnea (OSA), due almost entirely to the steep rise in obesity over the past 30 years.
It is alarming to know that OSA is associated with traffic accidents, worsening of diabetes and hypertension, atrial fibrillation, and a higher risk of death. What we don’t yet know is whether these major health problems are caused by sleep apnea or whether they’re fellow travelers. (In “Obstructive sleep apnea: A diagnostic and treatment guide” on page 565, Gutierrez and Brady present an evidence-based summary of symptoms, diagnostic criteria, and treatment modalities. And in “Peripheral neuropathy linked to obstructive sleep apnea?” on page 577, Schmidt et al highlight a lesser known association with OSA.)
There is excellent evidence that CPAP and, in some cases, dental devices, can alleviate daytime sleepiness in patients with OSA. But more randomized trials are needed to determine whether treatment of OSA can improve hypertension, diabetes control, and atrial fibrillation, as well as prevent excess mortality.
Recent trials offer a glimmer of hope. One found that CPAP therapy led to small but significant blood pressure reductions in patients with treatment-resistant hypertension.1 Another demonstrated that CPAP led to improvement in lipid profiles and hemoglobin A1c in obese patients with diabetes.2 But many more studies are needed to know how effective sleep apnea treatments are in reducing the significant morbidity and mortality associated with OSA.
Sleep medicine is a young specialty, so it is not surprising that high-quality randomized trials of sleep apnea are in their infancy. (The American Academy of Sleep Medicine was founded in 1975 and the American Board of Sleep Medicine was established in 1991.) Because the science is evolving, I encourage you to stay abreast of new developments in the field. In the meantime, nothing works better for improving sleep apnea, hypertension, and diabetes than good old-fashioned weight loss!
Two years ago, a house guest apologized to my wife and me as he prepared to turn in for the evening. He was sorry to subject us to his noisy CPAP machine, he said. Last year at a family reunion, my sleepy brother-in-law blamed his lethargy on sleep apnea, and another in-law chimed in to say that CPAP worked great for her.
If my family and friends are any indication, we seem to be surrounded by people with obstructive sleep apnea (OSA), due almost entirely to the steep rise in obesity over the past 30 years.
It is alarming to know that OSA is associated with traffic accidents, worsening of diabetes and hypertension, atrial fibrillation, and a higher risk of death. What we don’t yet know is whether these major health problems are caused by sleep apnea or whether they’re fellow travelers. (In “Obstructive sleep apnea: A diagnostic and treatment guide” on page 565, Gutierrez and Brady present an evidence-based summary of symptoms, diagnostic criteria, and treatment modalities. And in “Peripheral neuropathy linked to obstructive sleep apnea?” on page 577, Schmidt et al highlight a lesser known association with OSA.)
There is excellent evidence that CPAP and, in some cases, dental devices, can alleviate daytime sleepiness in patients with OSA. But more randomized trials are needed to determine whether treatment of OSA can improve hypertension, diabetes control, and atrial fibrillation, as well as prevent excess mortality.
Recent trials offer a glimmer of hope. One found that CPAP therapy led to small but significant blood pressure reductions in patients with treatment-resistant hypertension.1 Another demonstrated that CPAP led to improvement in lipid profiles and hemoglobin A1c in obese patients with diabetes.2 But many more studies are needed to know how effective sleep apnea treatments are in reducing the significant morbidity and mortality associated with OSA.
Sleep medicine is a young specialty, so it is not surprising that high-quality randomized trials of sleep apnea are in their infancy. (The American Academy of Sleep Medicine was founded in 1975 and the American Board of Sleep Medicine was established in 1991.) Because the science is evolving, I encourage you to stay abreast of new developments in the field. In the meantime, nothing works better for improving sleep apnea, hypertension, and diabetes than good old-fashioned weight loss!
1. Lozano L, Tovar JL, Sampo G, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28:2161-2168.
2. Weinstock TG, Wang X, Rueschman M, et al. A controlled trial of CPAP therapy on metabolic control in individuals with impaired glucose tolerance and sleep apnea. Sleep. 2012;35:617B-625B.
1. Lozano L, Tovar JL, Sampo G, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28:2161-2168.
2. Weinstock TG, Wang X, Rueschman M, et al. A controlled trial of CPAP therapy on metabolic control in individuals with impaired glucose tolerance and sleep apnea. Sleep. 2012;35:617B-625B.
Will screening open Pandora’s box?
"If it ain’t broke, don’t fix it" or "A stitch in time saves nine"—which do you prefer?
When I taught epidemiology at the University of Chicago, I asked first-year medical students that question before discussing the science of screening for early detection of disease. Each year, the class was about evenly divided. Their split response reinforced to me the need for shared decision making when we offer screening tests to our patients.
Shared decision making is especially important in light of new evidence about the effectiveness (or lack thereof) of some screening tests. Several bread-and-butter screening procedures and tests promoted for years have been debunked as having no value (routine testicular exam and monthly self-breast exam), having harms that might outweigh the benefits (PSA for prostate cancer), or having marginal benefit for those in certain age groups (mammography in women younger than 50). And, as treatments for cancer get better and better, screening will have less and less value. What would a 30-year-old do if he found out he has a gene that makes him susceptible to Alzheimer's disease?
The biggest screening test challenge, however— genome screening—is still to come. Genomic sequencing analysis is already useful for the diagnosis of certain genetic disorders and for treatment decisions in certain cancers. Genomic sequencing to screen for disease, however, is fraught with ethical challenges and the absolute need for shared decision making.
What if gene analysis uncovers "incidental findings" about risk faced by asymptomatic patients, like the "incidentalomas" described in "When to worry about incidental renal and adrenal masses"? The debate about what to do with incidental findings from genetic analysis is heating up because of the American College of Medical Genetics and Genomics' recent recommendations1 to automatically screen for 56 genes that may contain "potentially important" findings when genome sequencing is done for any reason.
Talk about Pandora’s box! Suppose a 30-year-old finds he carries a gene that makes him susceptible to Alzheimer’s disease. What would he do with that information, other than get depressed when he realizes there are not yet any effective early interventions?
Family physicians are likely to be asked more and more questions about genome analysis.* Be prepared. You can start by asking patients whether they adhere to an "If it ain’t broke…" " or "A stitch in time…" approach.
Reference
1. Green RC, Berg JS, Grody WW, et al. ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med. 2013;15:565-574. Available at: https://www.acmg.net/docs/IF_Statement_Final_7.24.13.pdf. Accessed August 20, 2013.
"If it ain’t broke, don’t fix it" or "A stitch in time saves nine"—which do you prefer?
When I taught epidemiology at the University of Chicago, I asked first-year medical students that question before discussing the science of screening for early detection of disease. Each year, the class was about evenly divided. Their split response reinforced to me the need for shared decision making when we offer screening tests to our patients.
Shared decision making is especially important in light of new evidence about the effectiveness (or lack thereof) of some screening tests. Several bread-and-butter screening procedures and tests promoted for years have been debunked as having no value (routine testicular exam and monthly self-breast exam), having harms that might outweigh the benefits (PSA for prostate cancer), or having marginal benefit for those in certain age groups (mammography in women younger than 50). And, as treatments for cancer get better and better, screening will have less and less value. What would a 30-year-old do if he found out he has a gene that makes him susceptible to Alzheimer's disease?
The biggest screening test challenge, however— genome screening—is still to come. Genomic sequencing analysis is already useful for the diagnosis of certain genetic disorders and for treatment decisions in certain cancers. Genomic sequencing to screen for disease, however, is fraught with ethical challenges and the absolute need for shared decision making.
What if gene analysis uncovers "incidental findings" about risk faced by asymptomatic patients, like the "incidentalomas" described in "When to worry about incidental renal and adrenal masses"? The debate about what to do with incidental findings from genetic analysis is heating up because of the American College of Medical Genetics and Genomics' recent recommendations1 to automatically screen for 56 genes that may contain "potentially important" findings when genome sequencing is done for any reason.
Talk about Pandora’s box! Suppose a 30-year-old finds he carries a gene that makes him susceptible to Alzheimer’s disease. What would he do with that information, other than get depressed when he realizes there are not yet any effective early interventions?
Family physicians are likely to be asked more and more questions about genome analysis.* Be prepared. You can start by asking patients whether they adhere to an "If it ain’t broke…" " or "A stitch in time…" approach.
"If it ain’t broke, don’t fix it" or "A stitch in time saves nine"—which do you prefer?
When I taught epidemiology at the University of Chicago, I asked first-year medical students that question before discussing the science of screening for early detection of disease. Each year, the class was about evenly divided. Their split response reinforced to me the need for shared decision making when we offer screening tests to our patients.
Shared decision making is especially important in light of new evidence about the effectiveness (or lack thereof) of some screening tests. Several bread-and-butter screening procedures and tests promoted for years have been debunked as having no value (routine testicular exam and monthly self-breast exam), having harms that might outweigh the benefits (PSA for prostate cancer), or having marginal benefit for those in certain age groups (mammography in women younger than 50). And, as treatments for cancer get better and better, screening will have less and less value. What would a 30-year-old do if he found out he has a gene that makes him susceptible to Alzheimer's disease?
The biggest screening test challenge, however— genome screening—is still to come. Genomic sequencing analysis is already useful for the diagnosis of certain genetic disorders and for treatment decisions in certain cancers. Genomic sequencing to screen for disease, however, is fraught with ethical challenges and the absolute need for shared decision making.
What if gene analysis uncovers "incidental findings" about risk faced by asymptomatic patients, like the "incidentalomas" described in "When to worry about incidental renal and adrenal masses"? The debate about what to do with incidental findings from genetic analysis is heating up because of the American College of Medical Genetics and Genomics' recent recommendations1 to automatically screen for 56 genes that may contain "potentially important" findings when genome sequencing is done for any reason.
Talk about Pandora’s box! Suppose a 30-year-old finds he carries a gene that makes him susceptible to Alzheimer’s disease. What would he do with that information, other than get depressed when he realizes there are not yet any effective early interventions?
Family physicians are likely to be asked more and more questions about genome analysis.* Be prepared. You can start by asking patients whether they adhere to an "If it ain’t broke…" " or "A stitch in time…" approach.
Reference
1. Green RC, Berg JS, Grody WW, et al. ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med. 2013;15:565-574. Available at: https://www.acmg.net/docs/IF_Statement_Final_7.24.13.pdf. Accessed August 20, 2013.
Reference
1. Green RC, Berg JS, Grody WW, et al. ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med. 2013;15:565-574. Available at: https://www.acmg.net/docs/IF_Statement_Final_7.24.13.pdf. Accessed August 20, 2013.
How I manage difficult encounters
In ”Challenging cases: How can we better manage difficult patient encounters?” (which begins on page 414), Dr. Teo and his colleagues offer excellent advice. Based on my 38 years in family practice, their 3-principle approach to difficult patient encounters (focus on the relationship between doctor and patient, incorporate the patient’s emotional experience, and let the patient’s perspective be your guide) rings true.
The practical strategies Teo et al recommend should be standard tools in every pri- mary care physician’s medical bag. I especially like the BATHE mnemonic, a reminder to engage patients emotionally by addressing:
• Background (What has been going on in your life?);
• Affect (How do you feel about that?);
• Trouble (What troubles you the most about this situation?);
• Handling (How are you handling this?) and
• Empathy (That must be difficult).
As a young physician, I judged my success by my patients’ success in “getting well.” After a decade in practice, I realized that patients change at their own pace, not mine. There is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories. This insight helped me to relax and avoid becoming frustrated when my patients did not adhere to their medication regimen or failed to overcome their depression, anxiety, chronic fatigue, substance abuse, or you-name-the-condition. I have also learned that there is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories.
And finally, I am keenly aware that we must develop—and cultivate—a deep knowledge of the difficult conditions we confront daily as family physicians. I used to groan when the third patient of the day with low back pain walked in. Not anymore. That’s because I have thoroughly studied the excellent body of research on low back pain. I now know the natural history of low back pain, and I know what to do and what not to do for my patients. The same is true of my approach to depression, anxiety, substance abuse, and patients with a “positive review of systems.”
As family physicians, we must be experts in the diagnosis and management of chronic conditions, which are present (to some degree) in nearly 50% of the patients we care for. The art of medicine is essential, but not sufficient. Art plus science equals optimal outcomes for patients and physicians.
In ”Challenging cases: How can we better manage difficult patient encounters?” (which begins on page 414), Dr. Teo and his colleagues offer excellent advice. Based on my 38 years in family practice, their 3-principle approach to difficult patient encounters (focus on the relationship between doctor and patient, incorporate the patient’s emotional experience, and let the patient’s perspective be your guide) rings true.
The practical strategies Teo et al recommend should be standard tools in every pri- mary care physician’s medical bag. I especially like the BATHE mnemonic, a reminder to engage patients emotionally by addressing:
• Background (What has been going on in your life?);
• Affect (How do you feel about that?);
• Trouble (What troubles you the most about this situation?);
• Handling (How are you handling this?) and
• Empathy (That must be difficult).
As a young physician, I judged my success by my patients’ success in “getting well.” After a decade in practice, I realized that patients change at their own pace, not mine. There is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories. This insight helped me to relax and avoid becoming frustrated when my patients did not adhere to their medication regimen or failed to overcome their depression, anxiety, chronic fatigue, substance abuse, or you-name-the-condition. I have also learned that there is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories.
And finally, I am keenly aware that we must develop—and cultivate—a deep knowledge of the difficult conditions we confront daily as family physicians. I used to groan when the third patient of the day with low back pain walked in. Not anymore. That’s because I have thoroughly studied the excellent body of research on low back pain. I now know the natural history of low back pain, and I know what to do and what not to do for my patients. The same is true of my approach to depression, anxiety, substance abuse, and patients with a “positive review of systems.”
As family physicians, we must be experts in the diagnosis and management of chronic conditions, which are present (to some degree) in nearly 50% of the patients we care for. The art of medicine is essential, but not sufficient. Art plus science equals optimal outcomes for patients and physicians.
In ”Challenging cases: How can we better manage difficult patient encounters?” (which begins on page 414), Dr. Teo and his colleagues offer excellent advice. Based on my 38 years in family practice, their 3-principle approach to difficult patient encounters (focus on the relationship between doctor and patient, incorporate the patient’s emotional experience, and let the patient’s perspective be your guide) rings true.
The practical strategies Teo et al recommend should be standard tools in every pri- mary care physician’s medical bag. I especially like the BATHE mnemonic, a reminder to engage patients emotionally by addressing:
• Background (What has been going on in your life?);
• Affect (How do you feel about that?);
• Trouble (What troubles you the most about this situation?);
• Handling (How are you handling this?) and
• Empathy (That must be difficult).
As a young physician, I judged my success by my patients’ success in “getting well.” After a decade in practice, I realized that patients change at their own pace, not mine. There is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories. This insight helped me to relax and avoid becoming frustrated when my patients did not adhere to their medication regimen or failed to overcome their depression, anxiety, chronic fatigue, substance abuse, or you-name-the-condition. I have also learned that there is no therapeutic substitute for providing a setting in which patients are encouraged to tell their life stories.
And finally, I am keenly aware that we must develop—and cultivate—a deep knowledge of the difficult conditions we confront daily as family physicians. I used to groan when the third patient of the day with low back pain walked in. Not anymore. That’s because I have thoroughly studied the excellent body of research on low back pain. I now know the natural history of low back pain, and I know what to do and what not to do for my patients. The same is true of my approach to depression, anxiety, substance abuse, and patients with a “positive review of systems.”
As family physicians, we must be experts in the diagnosis and management of chronic conditions, which are present (to some degree) in nearly 50% of the patients we care for. The art of medicine is essential, but not sufficient. Art plus science equals optimal outcomes for patients and physicians.
Words—not scores—inspire me
Being a physician does not seem as rewarding today as it did 30 years ago.
Under constant pressure to focus on production, meaningful use, and compliance with myriad regulations, it’s easy to lose sight of the most rewarding part of our work—caring for our patients. And most are highly satisfied with our care.
The modern rendition of patient satisfaction is the “patient experience” score, with the data tracked and disseminated by firms specializing in such reports. I do see some value in these reports, as they can help us pinpoint areas of our office operations or personal interactions that could be improved. But on an emotional level, they just don’t cut it. Patient experience scores, and the form in which they’re presented, are too much like report cards. They don’t inspire me.
What inspires me is receiving a heartfelt “thank you” from a grateful patient, and I’m reasonably sure the same is true for you. Which is why I offer the following excerpts from a truly inspiring “thank you” speech delivered by Sam Miller, an emeritus trustee of the Cleveland Clinic, at the clinic’s 2012 Professional Excellence Awards:
“You mean a lot to me personally and you mean a lot to each other, for you are, as far as I’m concerned, the veritable guardians of this community.
“Someday after enough DNA tests, they will discover the gene in doctors making you walking hearts, perennial consciences, and empathetic human beings. And when they do, they will look for this gene in all humanity, and we will have found the answer to wars and to peace and to love. Love means reaching towards neighbors and the world with the same care, regard, generosity and empathy we normally reserve for ourselves and those closest to us,” he said. “This is the gene that a doctor has inherited.”
“You will not have to wait for your reward in heaven,” Miller said. “Every day when you see the smiles of the sick, the poor, the look of hope and momentary happiness of that particular unfortunate that you’ve been able to help, that is heaven by itself. That is the magnificent gene that you possess.”
I offer heartfelt thanks to Mr. Miller for his deeply moving words, and I invite you, my fellow family physicians, to share your stories of patients whose expressions of appreciation have truly inspired you.
Being a physician does not seem as rewarding today as it did 30 years ago.
Under constant pressure to focus on production, meaningful use, and compliance with myriad regulations, it’s easy to lose sight of the most rewarding part of our work—caring for our patients. And most are highly satisfied with our care.
The modern rendition of patient satisfaction is the “patient experience” score, with the data tracked and disseminated by firms specializing in such reports. I do see some value in these reports, as they can help us pinpoint areas of our office operations or personal interactions that could be improved. But on an emotional level, they just don’t cut it. Patient experience scores, and the form in which they’re presented, are too much like report cards. They don’t inspire me.
What inspires me is receiving a heartfelt “thank you” from a grateful patient, and I’m reasonably sure the same is true for you. Which is why I offer the following excerpts from a truly inspiring “thank you” speech delivered by Sam Miller, an emeritus trustee of the Cleveland Clinic, at the clinic’s 2012 Professional Excellence Awards:
“You mean a lot to me personally and you mean a lot to each other, for you are, as far as I’m concerned, the veritable guardians of this community.
“Someday after enough DNA tests, they will discover the gene in doctors making you walking hearts, perennial consciences, and empathetic human beings. And when they do, they will look for this gene in all humanity, and we will have found the answer to wars and to peace and to love. Love means reaching towards neighbors and the world with the same care, regard, generosity and empathy we normally reserve for ourselves and those closest to us,” he said. “This is the gene that a doctor has inherited.”
“You will not have to wait for your reward in heaven,” Miller said. “Every day when you see the smiles of the sick, the poor, the look of hope and momentary happiness of that particular unfortunate that you’ve been able to help, that is heaven by itself. That is the magnificent gene that you possess.”
I offer heartfelt thanks to Mr. Miller for his deeply moving words, and I invite you, my fellow family physicians, to share your stories of patients whose expressions of appreciation have truly inspired you.
Being a physician does not seem as rewarding today as it did 30 years ago.
Under constant pressure to focus on production, meaningful use, and compliance with myriad regulations, it’s easy to lose sight of the most rewarding part of our work—caring for our patients. And most are highly satisfied with our care.
The modern rendition of patient satisfaction is the “patient experience” score, with the data tracked and disseminated by firms specializing in such reports. I do see some value in these reports, as they can help us pinpoint areas of our office operations or personal interactions that could be improved. But on an emotional level, they just don’t cut it. Patient experience scores, and the form in which they’re presented, are too much like report cards. They don’t inspire me.
What inspires me is receiving a heartfelt “thank you” from a grateful patient, and I’m reasonably sure the same is true for you. Which is why I offer the following excerpts from a truly inspiring “thank you” speech delivered by Sam Miller, an emeritus trustee of the Cleveland Clinic, at the clinic’s 2012 Professional Excellence Awards:
“You mean a lot to me personally and you mean a lot to each other, for you are, as far as I’m concerned, the veritable guardians of this community.
“Someday after enough DNA tests, they will discover the gene in doctors making you walking hearts, perennial consciences, and empathetic human beings. And when they do, they will look for this gene in all humanity, and we will have found the answer to wars and to peace and to love. Love means reaching towards neighbors and the world with the same care, regard, generosity and empathy we normally reserve for ourselves and those closest to us,” he said. “This is the gene that a doctor has inherited.”
“You will not have to wait for your reward in heaven,” Miller said. “Every day when you see the smiles of the sick, the poor, the look of hope and momentary happiness of that particular unfortunate that you’ve been able to help, that is heaven by itself. That is the magnificent gene that you possess.”
I offer heartfelt thanks to Mr. Miller for his deeply moving words, and I invite you, my fellow family physicians, to share your stories of patients whose expressions of appreciation have truly inspired you.
Have family physicians abandoned acute care?
Not long ago, I had a conversation with a colleague—a residency director and family physician—about the unique contributions family doctors make to health care. He believes FPs are best trained to provide chronic disease care and address prevention. And he’s proud that his program trains residents in motivational interviewing to guide patients to healthy behaviors and adherence to medications and recommended screening tests.
I agree that these health-coaching skills are important for FPs and that we should strive to nudge our patients toward healthier lifestyles. But is that the heart of family medicine? I don’t think so.
I was dismayed by the fact that my colleague did not mention caring for people who are sick: those who have aches and pains and those who just don’t feel well and need careful evaluations that could lead to a diagnosis of cancer—or to the realization that the symptoms are related to psychological distress.
At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”
Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.
I did not go to medical school to be a health psychologist, even though my college major was psychology. I wanted to be a doctor, and I still do. I want to diagnose illness or wellness accurately and efficiently and help patients feel better—to offer reassurance to the worried well and the right treatments to those who are sick. The “number needed to treat” to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!
My beliefs about family medicine are reflected in the contents of JFP. We publish articles about chronic illness, prevention, and acute care in a balanced fashion. Family physicians need to be triple threats, not health psychologists.
Not long ago, I had a conversation with a colleague—a residency director and family physician—about the unique contributions family doctors make to health care. He believes FPs are best trained to provide chronic disease care and address prevention. And he’s proud that his program trains residents in motivational interviewing to guide patients to healthy behaviors and adherence to medications and recommended screening tests.
I agree that these health-coaching skills are important for FPs and that we should strive to nudge our patients toward healthier lifestyles. But is that the heart of family medicine? I don’t think so.
I was dismayed by the fact that my colleague did not mention caring for people who are sick: those who have aches and pains and those who just don’t feel well and need careful evaluations that could lead to a diagnosis of cancer—or to the realization that the symptoms are related to psychological distress.
At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”
Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.
I did not go to medical school to be a health psychologist, even though my college major was psychology. I wanted to be a doctor, and I still do. I want to diagnose illness or wellness accurately and efficiently and help patients feel better—to offer reassurance to the worried well and the right treatments to those who are sick. The “number needed to treat” to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!
My beliefs about family medicine are reflected in the contents of JFP. We publish articles about chronic illness, prevention, and acute care in a balanced fashion. Family physicians need to be triple threats, not health psychologists.
Not long ago, I had a conversation with a colleague—a residency director and family physician—about the unique contributions family doctors make to health care. He believes FPs are best trained to provide chronic disease care and address prevention. And he’s proud that his program trains residents in motivational interviewing to guide patients to healthy behaviors and adherence to medications and recommended screening tests.
I agree that these health-coaching skills are important for FPs and that we should strive to nudge our patients toward healthier lifestyles. But is that the heart of family medicine? I don’t think so.
I was dismayed by the fact that my colleague did not mention caring for people who are sick: those who have aches and pains and those who just don’t feel well and need careful evaluations that could lead to a diagnosis of cancer—or to the realization that the symptoms are related to psychological distress.
At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”
Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.
I did not go to medical school to be a health psychologist, even though my college major was psychology. I wanted to be a doctor, and I still do. I want to diagnose illness or wellness accurately and efficiently and help patients feel better—to offer reassurance to the worried well and the right treatments to those who are sick. The “number needed to treat” to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!
My beliefs about family medicine are reflected in the contents of JFP. We publish articles about chronic illness, prevention, and acute care in a balanced fashion. Family physicians need to be triple threats, not health psychologists.
Failure to spot postpartum danger leads to permanent disability
Failure to spot postpartum danger leads to permanent disability
AFTER 2 HOSPITALIZATIONS FOR HYPERTENSION ordered by her physician, a pregnant 41-year-old woman gave birth to a daughter by cesarean section on December 17. She was discharged 2 days later with a blood pressure of 130/90 mm Hg.
On December 21, the woman went to her doctor’s office, complaining that she didn’t feel well and had severe swelling. A nurse took her blood pressure twice, obtaining readings of 170/88 and 168/90 mm Hg. She sent the patient home without an examination by the doctor. On her way out of the office, the patient passed the doctor in the hallway and, she claimed, told him she wasn’t feeling well and that her blood pressure was high. She said he told her to double her blood pressure medication.
That evening the patient had trouble breathing and was taken by paramedics to a hospital, where she was intubated. She didn’t have a pulse for 15 minutes, leading to permanent brain damage.
The patient can’t walk without help and can’t feed herself because her hands are contorted. She’s legally blind, suffers from short-term memory loss, and has difficulty speaking.
PLAINTIFF’S CLAIM The patient had classic signs of postpartum cardiomyopathy. If the doctor had looked at her blood pressure readings and examined her while she was at the office, she would have received appropriate treatment and avoided injury.
THE DEFENSE The patient went to the doctor’s office to show the staff her baby and have her blood pressure checked, not because she was feeling ill. The doctor would have examined the patient if he had been told of the blood pressure readings.
VERDICT $5 million Georgia verdict.
COMMENT For the vast majority of patients, a blood pressure of 170/88 mm Hg is not a medical emergency or even urgent. But for a woman 4 days postpartum with significant edema, it is. This case illustrates the ultimate challenge of family medicine: identifying and treating the dangerous situations among the many mundane ones.
Persistent pain requires more than medication
PAIN IN HER CHEST AND SHOULDERS prompted a 27-year-old woman to seek medical attention. Her physician attributed the pain to muscle strain and prescribed medication. Six months later the patient returned to the doctor complaining of continuing pain. The doctor concluded that the position in which the patient slept was causing the pain and prescribed painkillers.
After 9 months, the pain still had not resolved. The patient was given a diagnosis of stage II Hodgkin’s lymphoma, which went into remission after aggressive treatment.
PLAINTIFF’S CLAIM The pain was caused by the cancer, which had been present at all of the patient’s visits with her doctor. The doctor was negligent in failing to diagnose the cancer promptly, necessitating more aggressive treatment than would otherwise have been required.
THE DEFENSE The patient’s pain was episodic and varied; it didn’t warrant diagnostic testing. The patient failed to follow through on physical therapy that the physician had prescribed. The patient denied that the doctor had prescribed physical therapy.
VERDICT $800,000 New York verdict.
COMMENT Persistence of symptoms dictates persistence of work-up. After 6 months of pain, the patient should have had a more detailed evaluation. On a personal note, I had a patient just like this one several years ago; a chest radiograph revealed her lymphoma.
Failure to spot postpartum danger leads to permanent disability
AFTER 2 HOSPITALIZATIONS FOR HYPERTENSION ordered by her physician, a pregnant 41-year-old woman gave birth to a daughter by cesarean section on December 17. She was discharged 2 days later with a blood pressure of 130/90 mm Hg.
On December 21, the woman went to her doctor’s office, complaining that she didn’t feel well and had severe swelling. A nurse took her blood pressure twice, obtaining readings of 170/88 and 168/90 mm Hg. She sent the patient home without an examination by the doctor. On her way out of the office, the patient passed the doctor in the hallway and, she claimed, told him she wasn’t feeling well and that her blood pressure was high. She said he told her to double her blood pressure medication.
That evening the patient had trouble breathing and was taken by paramedics to a hospital, where she was intubated. She didn’t have a pulse for 15 minutes, leading to permanent brain damage.
The patient can’t walk without help and can’t feed herself because her hands are contorted. She’s legally blind, suffers from short-term memory loss, and has difficulty speaking.
PLAINTIFF’S CLAIM The patient had classic signs of postpartum cardiomyopathy. If the doctor had looked at her blood pressure readings and examined her while she was at the office, she would have received appropriate treatment and avoided injury.
THE DEFENSE The patient went to the doctor’s office to show the staff her baby and have her blood pressure checked, not because she was feeling ill. The doctor would have examined the patient if he had been told of the blood pressure readings.
VERDICT $5 million Georgia verdict.
COMMENT For the vast majority of patients, a blood pressure of 170/88 mm Hg is not a medical emergency or even urgent. But for a woman 4 days postpartum with significant edema, it is. This case illustrates the ultimate challenge of family medicine: identifying and treating the dangerous situations among the many mundane ones.
Persistent pain requires more than medication
PAIN IN HER CHEST AND SHOULDERS prompted a 27-year-old woman to seek medical attention. Her physician attributed the pain to muscle strain and prescribed medication. Six months later the patient returned to the doctor complaining of continuing pain. The doctor concluded that the position in which the patient slept was causing the pain and prescribed painkillers.
After 9 months, the pain still had not resolved. The patient was given a diagnosis of stage II Hodgkin’s lymphoma, which went into remission after aggressive treatment.
PLAINTIFF’S CLAIM The pain was caused by the cancer, which had been present at all of the patient’s visits with her doctor. The doctor was negligent in failing to diagnose the cancer promptly, necessitating more aggressive treatment than would otherwise have been required.
THE DEFENSE The patient’s pain was episodic and varied; it didn’t warrant diagnostic testing. The patient failed to follow through on physical therapy that the physician had prescribed. The patient denied that the doctor had prescribed physical therapy.
VERDICT $800,000 New York verdict.
COMMENT Persistence of symptoms dictates persistence of work-up. After 6 months of pain, the patient should have had a more detailed evaluation. On a personal note, I had a patient just like this one several years ago; a chest radiograph revealed her lymphoma.
Failure to spot postpartum danger leads to permanent disability
AFTER 2 HOSPITALIZATIONS FOR HYPERTENSION ordered by her physician, a pregnant 41-year-old woman gave birth to a daughter by cesarean section on December 17. She was discharged 2 days later with a blood pressure of 130/90 mm Hg.
On December 21, the woman went to her doctor’s office, complaining that she didn’t feel well and had severe swelling. A nurse took her blood pressure twice, obtaining readings of 170/88 and 168/90 mm Hg. She sent the patient home without an examination by the doctor. On her way out of the office, the patient passed the doctor in the hallway and, she claimed, told him she wasn’t feeling well and that her blood pressure was high. She said he told her to double her blood pressure medication.
That evening the patient had trouble breathing and was taken by paramedics to a hospital, where she was intubated. She didn’t have a pulse for 15 minutes, leading to permanent brain damage.
The patient can’t walk without help and can’t feed herself because her hands are contorted. She’s legally blind, suffers from short-term memory loss, and has difficulty speaking.
PLAINTIFF’S CLAIM The patient had classic signs of postpartum cardiomyopathy. If the doctor had looked at her blood pressure readings and examined her while she was at the office, she would have received appropriate treatment and avoided injury.
THE DEFENSE The patient went to the doctor’s office to show the staff her baby and have her blood pressure checked, not because she was feeling ill. The doctor would have examined the patient if he had been told of the blood pressure readings.
VERDICT $5 million Georgia verdict.
COMMENT For the vast majority of patients, a blood pressure of 170/88 mm Hg is not a medical emergency or even urgent. But for a woman 4 days postpartum with significant edema, it is. This case illustrates the ultimate challenge of family medicine: identifying and treating the dangerous situations among the many mundane ones.
Persistent pain requires more than medication
PAIN IN HER CHEST AND SHOULDERS prompted a 27-year-old woman to seek medical attention. Her physician attributed the pain to muscle strain and prescribed medication. Six months later the patient returned to the doctor complaining of continuing pain. The doctor concluded that the position in which the patient slept was causing the pain and prescribed painkillers.
After 9 months, the pain still had not resolved. The patient was given a diagnosis of stage II Hodgkin’s lymphoma, which went into remission after aggressive treatment.
PLAINTIFF’S CLAIM The pain was caused by the cancer, which had been present at all of the patient’s visits with her doctor. The doctor was negligent in failing to diagnose the cancer promptly, necessitating more aggressive treatment than would otherwise have been required.
THE DEFENSE The patient’s pain was episodic and varied; it didn’t warrant diagnostic testing. The patient failed to follow through on physical therapy that the physician had prescribed. The patient denied that the doctor had prescribed physical therapy.
VERDICT $800,000 New York verdict.
COMMENT Persistence of symptoms dictates persistence of work-up. After 6 months of pain, the patient should have had a more detailed evaluation. On a personal note, I had a patient just like this one several years ago; a chest radiograph revealed her lymphoma.