Guest guest Posted November 23, 2004 Report Share Posted November 23, 2004 Rian, Reading your post, I recall the words of my family physician mentor ( Millman, who unfortunately passed away from pancreatic Ca a few years ago) who told me when I was a 3rd year medical student: " You can't help someone who doesn't want to be helped. " I repeat this phrase to myself every week, if not every day, whenever a patient doesn't want to take their medications, exercise, stop smoking, drinking, etc. If you don't give her what she wants, she'll move on to another doctor who will. Perhaps that will make each of you happier. Eventually, you'll end up with a group of patients who agree to your way of thinking. Or else you will reach some sort of understanding with your nonadherent/noncompliant patients. I've decided for my own practice that my goal is not to get patients to do the right thing every time. It's to help them do as much as they can for themselves as they are willing or able to (consistent with my own values, of course). And sometimes, after they get to know you better and learn to trust you, they are able or willing to make changes they wouldn't have when they first met you. I'd agree with your approach to do a month-by-month prescription and push/coax for bupropion or some other antidepressant. Sometimes, when patients see that you care, they are more likely to come back to you and follow your advice. It's a lot more work, but more rewarding, in the end. Good luck. Happy Thanksgiving, everyone. Thanks for making this listserve an invaluable resource for this solo FP. Seto > A patient with diagnosed and symptomatic C.O.P.D. has moved to my > area, and > asks me to be her primary care physician. She started a consultation > with a > pulmonary medicine specialist, a few months earlier, but aborted that > after > just one visit, and before completing the P.F.T. which was > recommended for > her. She has been using Advair 500/50 inhaler, and Spiriva, as well as > occasional Albuterol M.D.I. and nebulizer treatments. She has history > of > depression, and suicidal ideation. She refuses to see a psychiatrist, > or to > resume her pulmonology consultation. She asks me to give her new and > refillable Rx's for her > bronchodilating/anticholinergic/corticosteroidal > inhalers ... I am strongly opposed to facilitating this addiction, in > general. It is my suspicion that arming smokers with these drugs will > increase the alveolar delivery of carcinogens, and chemicals toxic to > the > circulatory endothelium - I have felt that physicians who give these > customers what they want are facilitating their uninintentional > suicide ... > The kicker for me, though, with this patient, is that she is already > depressed, with suicidal ideation. I am inclined to negotiate some > kind of > compromise, with a month-by-month allowance for some of her > medications, and > a push to get her to allow Bupropion, and nicotine replacement > strategies... > I think she should get away from the beta-adrenergic stimulants ... I > can't > find any support in the literature I have found, confirming my > theories > about how these drugs might kill patients... I have lost patients who > hit > this stalemate in our visits, and fired me; I have also seen strokes > and > heart attacks in my smokers, and of course lung cancer, etc. Mostly, > I see > AECB. I have seen 2 of my patients die from squamous cell cancers of > the > sinus. Before this, I thought there is no evangelist like an > ex-smoker (yes, > I am that), but now, I see the more fervent preaching coming from the > doctor > who keeps seeing patients killing themselves, and does not want to > share any > more guilt for that. If all doctors stopped prescribing Ventolin to > smokers > at the same time, this strategy might be more effective - in my > community, > these patients need only register once at the Prompt Care Clinic > across > town, see one of the P.A.'s there for an episode of bronchitis, and > then > call back ad lib to get one of the M.A.'s to call-in infinite > supplies of > these drugs to the pharmacy... I feel like a lone voice. It does not > help, > that I am trying to build a practice, and all of the numbers > connected to > dollar signs with black ink are small/ with red ink are big ... I am > feeling at risk of losing my religion, and selling out a principle to > fend > off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 24, 2004 Report Share Posted November 24, 2004 This falls into the realm of not seeing patients who believe in abortion, not seeing pt’s with diabetes who are obese, not seeing alcoholics who continue to drink, I guess not seeing hypertensives who don’t exercise, not filling prescriptions for morning after pill, etc. You must evaluate how you feel about your role as a physician and what it means to you. Smokers suffer from an addiction (I know first hand also) and should be treated as such. It is a tough question to deal with and I have heard of doctors who don’t accept any patients who smoke. Personally, I feel it is not our job to live someone else’s life and if we show caring and compassion instead of adversity we will help more people. Nobody said being a doctor was all good and easy. But I definitely see your point and somedays feel just like you. If you think your procedure is the best way to help these people then go for it. I personally have decided to see these patients and do my best to gain their trust and then help them to quit. In the meantime, I still prescribe the medications they need to breath better. Good luck with your soul searching. Housecall Family Practice, PC J. Weber, MD PO Box 820044 Memphis, TN 38182 www.memphishousecalls.com smokers with asthma A patient with diagnosed and symptomatic C.O.P.D. has moved to my area, and asks me to be her primary care physician. She started a consultation with a pulmonary medicine specialist, a few months earlier, but aborted that after just one visit, and before completing the P.F.T. which was recommended for her. She has been using Advair 500/50 inhaler, and Spiriva, as well as occasional Albuterol M.D.I. and nebulizer treatments. She has history of depression, and suicidal ideation. She refuses to see a psychiatrist, or to resume her pulmonology consultation. She asks me to give her new and refillable Rx's for her bronchodilating/anticholinergic/corticosteroidal inhalers ... I am strongly opposed to facilitating this addiction, in general. It is my suspicion that arming smokers with these drugs will increase the alveolar delivery of carcinogens, and chemicals toxic to the circulatory endothelium - I have felt that physicians who give these customers what they want are facilitating their uninintentional suicide ... The kicker for me, though, with this patient, is that she is already depressed, with suicidal ideation. I am inclined to negotiate some kind of compromise, with a month-by-month allowance for some of her medications, and a push to get her to allow Bupropion, and nicotine replacement strategies... I think she should get away from the beta-adrenergic stimulants ... I can't find any support in the literature I have found, confirming my theories about how these drugs might kill patients... I have lost patients who hit this stalemate in our visits, and fired me; I have also seen strokes and heart attacks in my smokers, and of course lung cancer, etc. Mostly, I see AECB. I have seen 2 of my patients die from squamous cell cancers of the sinus. Before this, I thought there is no evangelist like an ex-smoker (yes, I am that), but now, I see the more fervent preaching coming from the doctor who keeps seeing patients killing themselves, and does not want to share any more guilt for that. If all doctors stopped prescribing Ventolin to smokers at the same time, this strategy might be more effective - in my community, these patients need only register once at the Prompt Care Clinic across town, see one of the P.A.'s there for an episode of bronchitis, and then call back ad lib to get one of the M.A.'s to call-in infinite supplies of these drugs to the pharmacy... I feel like a lone voice. It does not help, that I am trying to build a practice, and all of the numbers connected to dollar signs with black ink are small/ with red ink are big ... I am feeling at risk of losing my religion, and selling out a principle to fend off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 24, 2004 Report Share Posted November 24, 2004 We all see patients like this. Nowadays, patient autonomy and personal choice must be respected, so “Doctor’s Orders” have evolved into “Doctor’s Suggestions”. (Since doctors are not “God”, this is not equivalent to the “Ten Commandments” evolving into the “Ten Suggestions”.) I see my role as selling my time to provide my honest professional advice and opinion. The patient, as an equal partner in our therapeutic relationship, is free to take it or leave it. Neither of us is in an authoritative position over the other, and neither of us will accept any role or task unwillingly from the other. This does not obligate us to drive the patient away (unless there is an irreconcilable personality conflict). If all physicians, attorneys, clergy and parents demanded perfection from their patients/clients/parishioners/children, they would all be out of business. By your professional example and honest advice with caring and compassion, you can help even the nicotine/ethanol/eating addict who is not ready to quit (yet). We can’t save them all from their human imperfections (and none of us is perfect), but we can still potentially help make their lives better just by being there for them. That means not turning them off by being “judgmental” or “preachy”, while still being diplomatically honest with our medical opinions about medical consequences. This is a fine line for a healer to walk. Our role demands acknowledging the patient’s own weaknesses, inadequacies, goals, and ethical and moral values, even though ours may differ. When we have done our honest best, while respecting the patient’s autonomy, we have fulfilled our mission, regardless of the outcome. The patient’s failure is then not ours. Ultimately, we never save a patient; we only attempt to delay the final outcome and/or provide comfort and relief while he/she is here. Only in our beginning medical training can we dream of saving everyone from every disease. Wes Bradford -----Original Message----- From: J. Weber Sent: Wednesday, November 24, 2004 10:07 AM To: Subject: RE: smokers with asthma This falls into the realm of not seeing patients who believe in abortion, not seeing pt’s with diabetes who are obese, not seeing alcoholics who continue to drink, I guess not seeing hypertensives who don’t exercise, not filling prescriptions for morning after pill, etc. You must evaluate how you feel about your role as a physician and what it means to you. Smokers suffer from an addiction (I know first hand also) and should be treated as such. It is a tough question to deal with and I have heard of doctors who don’t accept any patients who smoke. Personally, I feel it is not our job to live someone else’s life and if we show caring and compassion instead of adversity we will help more people. Nobody said being a doctor was all good and easy. But I definitely see your point and somedays feel just like you. If you think your procedure is the best way to help these people then go for it. I personally have decided to see these patients and do my best to gain their trust and then help them to quit. In the meantime, I still prescribe the medications they need to breath better. Good luck with your soul searching. Housecall Family Practice, PC J. Weber, MD PO Box 820044 Memphis, TN 38182 www.memphishousecalls.com -----Original Message----- From: Mintek Family Sent: Tuesday, November 23, 2004 11:30 AM To: Subject: smokers with asthma A patient with diagnosed and symptomatic C.O.P.D. has moved to my area, and asks me to be her primary care physician. She started a consultation with a pulmonary medicine specialist, a few months earlier, but aborted that after just one visit, and before completing the P.F.T. which was recommended for her. She has been using Advair 500/50 inhaler, and Spiriva, as well as occasional Albuterol M.D.I. and nebulizer treatments. She has history of depression, and suicidal ideation. She refuses to see a psychiatrist, or to resume her pulmonology consultation. She asks me to give her new and refillable Rx's for her bronchodilating/anticholinergic/corticosteroidal inhalers ... I am strongly opposed to facilitating this addiction, in general. It is my suspicion that arming smokers with these drugs will increase the alveolar delivery of carcinogens, and chemicals toxic to the circulatory endothelium - I have felt that physicians who give these customers what they want are facilitating their uninintentional suicide ... The kicker for me, though, with this patient, is that she is already depressed, with suicidal ideation. I am inclined to negotiate some kind of compromise, with a month-by-month allowance for some of her medications, and a push to get her to allow Bupropion, and nicotine replacement strategies... I think she should get away from the beta-adrenergic stimulants ... I can't find any support in the literature I have found, confirming my theories about how these drugs might kill patients... I have lost patients who hit this stalemate in our visits, and fired me; I have also seen strokes and heart attacks in my smokers, and of course lung cancer, etc. Mostly, I see AECB. I have seen 2 of my patients die from squamous cell cancers of the sinus. Before this, I thought there is no evangelist like an ex-smoker (yes, I am that), but now, I see the more fervent preaching coming from the doctor who keeps seeing patients killing themselves, and does not want to share any more guilt for that. If all doctors stopped prescribing Ventolin to smokers at the same time, this strategy might be more effective - in my community, these patients need only register once at the Prompt Care Clinic across town, see one of the P.A.'s there for an episode of bronchitis, and then call back ad lib to get one of the M.A.'s to call-in infinite supplies of these drugs to the pharmacy... I feel like a lone voice. It does not help, that I am trying to build a practice, and all of the numbers connected to dollar signs with black ink are small/ with red ink are big ... I am feeling at risk of losing my religion, and selling out a principle to fend off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 25, 2004 Report Share Posted November 25, 2004 Rian and all what a fascinating glimpse into the mind and heart of the caring doctor! thanks for great reading all of you. I am reminded of the maxim learned when dealing with one's rebellious teenagers: "they don't care what you know, until they know that you care" We have the privilege as Primary care doctors to interact deeply with our patients - inside their walls built for protection, for conformity; for acceptance, for safety. What we sometimes see is the awful desperation of a lost soul blundering around in drug, alcohol or addiction-addled confusion. Yes, it is right for us to "shine the light" and call them "up and out" - to show them a way out. We have empathy for those who have been in pain and darkness. And some will respond. But, some will shun the light , and choose strange paths that lead them further downwards... And it is hard to understand why. And harder still is it to have any further empathy for those who choose a dark or destructive path. That is so foreign to our natures as "healers", teachers, guides, bearers of light. Every once in awhile we reach one. A long term diabetic was new to me. Last HbA1c was 9.8. So I lectured, coached, taught, and counselled until I was "blue in the face". The next HbA1c was 10.1 He did not answer our calls for return. We track our diabetics and he missed the next 2 appts. Then I got a call from a podiatrist. The infected toe would have to be amputated. That had been the problem for months. The podiatrist complimented me and said he had known this patient for a long time but only since the patient had seen me, had the patient really started trying to control his diabetes. So we never know what influence for good we can have, even if in the short run we seem to be losing. So Rian, with your patient, are you facilitating or enabling destructive behavior, or building a relationship of trust? It is really your choice. We can't make anyone elses choices for them. But I have found some amazing transformations can start if I will give that patient "plenty of space". And I consciously try to be really non-judgmental with these patients who are somewhat offensive to me. Maybe the "power of love" will eventually shine through. It may help them, and it definitely helps me Dennis Galvon -----Original Message-----From: Mintek Family Sent: Tuesday, November 23, 2004 9:30 AMTo: Subject: smokers with asthmaA patient with diagnosed and symptomatic C.O.P.D. has moved to my area, andasks me to be her primary care physician. She started a consultation with apulmonary medicine specialist, a few months earlier, but aborted that afterjust one visit, and before completing the P.F.T. which was recommended forher. She has been using Advair 500/50 inhaler, and Spiriva, as well asoccasional Albuterol M.D.I. and nebulizer treatments. She has history ofdepression, and suicidal ideation. She refuses to see a psychiatrist, or toresume her pulmonology consultation. She asks me to give her new andrefillable Rx's for her bronchodilating/anticholinergic/corticosteroidalinhalers ... I am strongly opposed to facilitating this addiction, ingeneral. It is my suspicion that arming smokers with these drugs willincrease the alveolar delivery of carcinogens, and chemicals toxic to thecirculatory endothelium - I have felt that physicians who give thesecustomers what they want are facilitating their uninintentional suicide ...The kicker for me, though, with this patient, is that she is alreadydepressed, with suicidal ideation. I am inclined to negotiate some kind ofcompromise, with a month-by-month allowance for some of her medications, anda push to get her to allow Bupropion, and nicotine replacement strategies...I think she should get away from the beta-adrenergic stimulants ... I can'tfind any support in the literature I have found, confirming my theoriesabout how these drugs might kill patients... I have lost patients who hitthis stalemate in our visits, and fired me; I have also seen strokes andheart attacks in my smokers, and of course lung cancer, etc. Mostly, I seeAECB. I have seen 2 of my patients die from squamous cell cancers of thesinus. Before this, I thought there is no evangelist like an ex-smoker (yes,I am that), but now, I see the more fervent preaching coming from the doctorwho keeps seeing patients killing themselves, and does not want to share anymore guilt for that. If all doctors stopped prescribing Ventolin to smokersat the same time, this strategy might be more effective - in my community,these patients need only register once at the Prompt Care Clinic acrosstown, see one of the P.A.'s there for an episode of bronchitis, and thencall back ad lib to get one of the M.A.'s to call-in infinite supplies ofthese drugs to the pharmacy... I feel like a lone voice. It does not help,that I am trying to build a practice, and all of the numbers connected todollar signs with black ink are small/ with red ink are big ... I amfeeling at risk of losing my religion, and selling out a principle to fendoff bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 26, 2004 Report Share Posted November 26, 2004 This is a great thread. I've been working these past two years with some of the greatest folks in the country when it comes to chronic disease: the MacColl Institute from Group Health ative. See their web site: www.improvingchroniccare.org One of the most difficult concepts to understand as physicians is the idea of self management support. Our training in in the mode of self-management manifesto: " You will do these things because I'm the doctor and I know best, (and hopefully I'm up to date on the literature to support my beliefs). " With this usual mode, we wonder why only27% of those in our practice with HTN achieve their goal. Like Wes, I've gotten to the point where I realize I can only bring myself honestly and openly to the interaction, give the best advice I have, then help a person craft a management plan that makes sense to them. If a smoker can only take a baby step in the right direction, I praise their effort and encourage continued work. If I find myself in an adversarial situation with a patient, the relationship is lost, therapeutic intervention is lost. If I find myself unable to accept the path of a patient, I'd be eventually obliged to say so and suggest they seek care with another. Nowadays I find this happens less often, but I also feel much more comfortable stating my own beliefs and values in the context of what I know. I can set the table, but I can't make them eat. Gordon At 03:16 PM 11/24/2004, you wrote: We all see patients like this. Nowadays, patient autonomy and personal choice must be respected, so “Doctor’s Orders” have evolved into “Doctor’s Suggestions”. (Since doctors are not “God”, this is not equivalent to the “Ten Commandments” evolving into the “Ten Suggestions”.) I see my role as selling my time to provide my honest professional advice and opinion. The patient, as an equal partner in our therapeutic relationship, is free to take it or leave it. Neither of us is in an authoritative position over the other, and neither of us will accept any role or task unwillingly from the other. This does not obligate us to drive the patient away (unless there is an irreconcilable personality conflict). If all physicians, attorneys, clergy and parents demanded perfection from their patients/clients/parishioners/children, they would all be out of business. By your professional example and honest advice with caring and compassion, you can help even the nicotine/ethanol/eating addict who is not ready to quit (yet). We can’t save them all from their human imperfections (and none of us is perfect), but we can still potentially help make their lives better just by being there for them. That means not turning them off by being “judgmental” or “preachy”, while still being diplomatically honest with our medical opinions about medical consequences. This is a fine line for a healer to walk. Our role demands acknowledging the patient’s own weaknesses, inadequacies, goals, and ethical and moral values, even though ours may differ. When we have done our honest best, while respecting the patient’s autonomy, we have fulfilled our mission, regardless of the outcome. The patient’s failure is then not ours. Ultimately, we never save a patient; we only attempt to delay the final outcome and/or provide comfort and relief while he/she is here. Only in our beginning medical training can we dream of saving everyone from every disease. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 28, 2004 Report Share Posted November 28, 2004 Dear Brent, Thank you for your encouragement, and advice. I have to say, that the allegory between my asthmatic smoker, who wants Albuterol, and your diabetic/obese/hypertensive who requests treatment for his illnesses, has a key flaw: the Metformin, Orlistat and Lisinopril I would Rx for the man with those diseases do not directly/instantaneously facilitate the lifestyle habits which have hurt him. If I prescribe Albuterol for my patient who smokes, she feels immediately better for 4 hrs after each dose; during those 4 hours, she smokes about 6 cigarettes. I know she is not stupid: rather, she is addicted. I am not telling her that I would refuse to see her; I want to do what I can, to treat her for the most life-threatening diseases in her life. She is not so likely to die from her wheezing - her asthma is not that severe . She is likely to die from heart disease, then stroke, then lung cancer. If I give her a Rx for her Albuterol, I feel like I am sharpening the knife she uses to slash her wrists... only, it is happening slowly, over years, instead of minutes. Re: smokers with asthma Do you not treat the obese with diabetes and htn? Have you not seen patients w permanent brain damage due to their own stupidity. Have you not had an encounter with a doctor that was fruitless and a waste of time? This is where the art of medicine is. Moving a patient along a path to benefit their long term health and make them part of the process. Encouraging what works. With a smoker even a gentle reminder at each visit can go along way. At a sports physical asking the young patient to never start smoking. Have I had great success, NO. Have I had success, Yes. Success was certainly more patient driven as is much in medicine. Primary care with regular followups can help develop a relationship. With that relationshipd you can then encourage that appt with a pulmonologist if you feel it is in her best interest. With that relationship you can visit about her past hx w pulmonologist elsewhere and explore her attitudes and beliefs a bit. This relationship is where empowering a patient to take care of themselves occurs. They may have been used to seeing a doctor once a year and you believe due to the nature of the illness she needs to be seen and monitored every 3 months. They may have been seen monthly and feel cheated if you did not see them that often. Many times it is a weaning process and empowering process coming from another physicians office where all they are concerned about is encounter numbers. The only way they can do that is see people frequently. For more of my chronically ill ,my goal ,see them about 4 times a year. It gives me the time to double check everything including lab, medications, immunizations, monitoring and recommendations. This all takes time and that is what is great about this model. Some problems with this model of practice are however if you are truly solo practicing out of one room the only place to bounce things off of other doctors is here or the doctors lounge. Much training involves the science , meds, principles and little of the art. New physicians going into this model may not have the mentors needed to further develop the art. Each physicians personality will certainly be reflected in their practice. You can see that in general involving many of the specialties and the personalities that go into them. Thank goodness patients and doctors all can make their own choices. brent > A patient with diagnosed and symptomatic C.O.P.D. has moved to my area, and> asks me to be her primary care physician. She started a consultation with a> pulmonary medicine specialist, a few months earlier, but aborted that after> just one visit, and before completing the P.F.T. which was recommended for> her. She has been using Advair 500/50 inhaler, and Spiriva, as well as> occasional Albuterol M.D.I. and nebulizer treatments. She has history of> depression, and suicidal ideation. She refuses to see a psychiatrist, or to> resume her pulmonology consultation. She asks me to give her new and> refillable Rx's for her bronchodilating/anticholinergic/corticosteroidal> inhalers ... I am strongly opposed to facilitating this addiction, in> general. It is my suspicion that arming smokers with these drugs will> increase the alveolar delivery of carcinogens, and chemicals toxic to the> circulatory endothelium - I have felt that physicians who give these> customers what they want are facilitating their uninintentional suicide ...> The kicker for me, though, with this patient, is that she is already> depressed, with suicidal ideation. I am inclined to negotiate some kind of> compromise, with a month-by-month allowance for some of her medications, and> a push to get her to allow Bupropion, and nicotine replacement strategies...> I think she should get away from the beta-adrenergic stimulants ... I can't> find any support in the literature I have found, confirming my theories> about how these drugs might kill patients... I have lost patients who hit> this stalemate in our visits, and fired me; I have also seen strokes and> heart attacks in my smokers, and of course lung cancer, etc. Mostly, I see> AECB. I have seen 2 of my patients die from squamous cell cancers of the> sinus. Before this, I thought there is no evangelist like an ex-smoker (yes,> I am that), but now, I see the more fervent preaching coming from the doctor> who keeps seeing patients killing themselves, and does not want to share any> more guilt for that. If all doctors stopped prescribing Ventolin to smokers> at the same time, this strategy might be more effective - in my community,> these patients need only register once at the Prompt Care Clinic across> town, see one of the P.A.'s there for an episode of bronchitis, and then> call back ad lib to get one of the M.A.'s to call-in infinite supplies of> these drugs to the pharmacy... I feel like a lone voice. It does not help,> that I am trying to build a practice, and all of the numbers connected to> dollar signs with black ink are small/ with red ink are big ... I am> feeling at risk of losing my religion, and selling out a principle to fend> off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 29, 2004 Report Share Posted November 29, 2004 Do you not treat the obese with diabetes and htn? Have you not seen patients w permanent brain damage due to their own stupidity. Have you not had an encounter with a doctor that was fruitless and a waste of time? This is where the art of medicine is. Moving a patient along a path to benefit their long term health and make them part of the process. Encouraging what works. With a smoker even a gentle reminder at each visit can go along way. At a sports physical asking the young patient to never start smoking. Have I had great success, NO. Have I had success, Yes. Success was certainly more patient driven as is much in medicine. Primary care with regular followups can help develop a relationship. With that relationshipd you can then encourage that appt with a pulmonologist if you feel it is in her best interest. With that relationship you can visit about her past hx w pulmonologist elsewhere and explore her attitudes and beliefs a bit. This relationship is where empowering a patient to take care of themselves occurs. They may have been used to seeing a doctor once a year and you believe due to the nature of the illness she needs to be seen and monitored every 3 months. They may have been seen monthly and feel cheated if you did not see them that often. Many times it is a weaning process and empowering process coming from another physicians office where all they are concerned about is encounter numbers. The only way they can do that is see people frequently. For more of my chronically ill ,my goal ,see them about 4 times a year. It gives me the time to double check everything including lab, medications, immunizations, monitoring and recommendations. This all takes time and that is what is great about this model. Some problems with this model of practice are however if you are truly solo practicing out of one room the only place to bounce things off of other doctors is here or the doctors lounge. Much training involves the science , meds, principles and little of the art. New physicians going into this model may not have the mentors needed to further develop the art. Each physicians personality will certainly be reflected in their practice. You can see that in general involving many of the specialties and the personalities that go into them. Thank goodness patients and doctors all can make their own choices. brent > A patient with diagnosed and symptomatic C.O.P.D. has moved to my area, and > asks me to be her primary care physician. She started a consultation with a > pulmonary medicine specialist, a few months earlier, but aborted that after > just one visit, and before completing the P.F.T. which was recommended for > her. She has been using Advair 500/50 inhaler, and Spiriva, as well as > occasional Albuterol M.D.I. and nebulizer treatments. She has history of > depression, and suicidal ideation. She refuses to see a psychiatrist, or to > resume her pulmonology consultation. She asks me to give her new and > refillable Rx's for her bronchodilating/anticholinergic/corticosteroidal > inhalers ... I am strongly opposed to facilitating this addiction, in > general. It is my suspicion that arming smokers with these drugs will > increase the alveolar delivery of carcinogens, and chemicals toxic to the > circulatory endothelium - I have felt that physicians who give these > customers what they want are facilitating their uninintentional suicide ... > The kicker for me, though, with this patient, is that she is already > depressed, with suicidal ideation. I am inclined to negotiate some kind of > compromise, with a month-by-month allowance for some of her medications, and > a push to get her to allow Bupropion, and nicotine replacement strategies... > I think she should get away from the beta-adrenergic stimulants ... I can't > find any support in the literature I have found, confirming my theories > about how these drugs might kill patients... I have lost patients who hit > this stalemate in our visits, and fired me; I have also seen strokes and > heart attacks in my smokers, and of course lung cancer, etc. Mostly, I see > AECB. I have seen 2 of my patients die from squamous cell cancers of the > sinus. Before this, I thought there is no evangelist like an ex- smoker (yes, > I am that), but now, I see the more fervent preaching coming from the doctor > who keeps seeing patients killing themselves, and does not want to share any > more guilt for that. If all doctors stopped prescribing Ventolin to smokers > at the same time, this strategy might be more effective - in my community, > these patients need only register once at the Prompt Care Clinic across > town, see one of the P.A.'s there for an episode of bronchitis, and then > call back ad lib to get one of the M.A.'s to call-in infinite supplies of > these drugs to the pharmacy... I feel like a lone voice. It does not help, > that I am trying to build a practice, and all of the numbers connected to > dollar signs with black ink are small/ with red ink are big ... I am > feeling at risk of losing my religion, and selling out a principle to fend > off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2004 Report Share Posted November 30, 2004 Such is the frustrations of a medical practice. I am not so sure about the key flaw however. Hang in there. It is great that you care. Use that and project that and it will work. Brent > > A patient with diagnosed and symptomatic C.O.P.D. has moved to my > area, and > > asks me to be her primary care physician. She started a > consultation with a > > pulmonary medicine specialist, a few months earlier, but aborted > that after > > just one visit, and before completing the P.F.T. which was > recommended for > > her. She has been using Advair 500/50 inhaler, and Spiriva, as > well as > > occasional Albuterol M.D.I. and nebulizer treatments. She has > history of > > depression, and suicidal ideation. She refuses to see a > psychiatrist, or to > > resume her pulmonology consultation. She asks me to give her new > and > > refillable Rx's for her > bronchodilating/anticholinergic/corticosteroidal > > inhalers ... I am strongly opposed to facilitating this addiction, > in > > general. It is my suspicion that arming smokers with these drugs > will > > increase the alveolar delivery of carcinogens, and chemicals toxic > to the > > circulatory endothelium - I have felt that physicians who give > these > > customers what they want are facilitating their uninintentional > suicide ... > > The kicker for me, though, with this patient, is that she is > already > > depressed, with suicidal ideation. I am inclined to negotiate some > kind of > > compromise, with a month-by-month allowance for some of her > medications, and > > a push to get her to allow Bupropion, and nicotine replacement > strategies... > > I think she should get away from the beta-adrenergic > stimulants ... I can't > > find any support in the literature I have found, confirming my > theories > > about how these drugs might kill patients... I have lost patients > who hit > > this stalemate in our visits, and fired me; I have also seen > strokes and > > heart attacks in my smokers, and of course lung cancer, etc. > Mostly, I see > > AECB. I have seen 2 of my patients die from squamous cell cancers > of the > > sinus. Before this, I thought there is no evangelist like an ex- > smoker (yes, > > I am that), but now, I see the more fervent preaching coming from > the doctor > > who keeps seeing patients killing themselves, and does not want to > share any > > more guilt for that. If all doctors stopped prescribing Ventolin > to smokers > > at the same time, this strategy might be more effective - in my > community, > > these patients need only register once at the Prompt Care Clinic > across > > town, see one of the P.A.'s there for an episode of bronchitis, > and then > > call back ad lib to get one of the M.A.'s to call-in infinite > supplies of > > these drugs to the pharmacy... I feel like a lone voice. It does > not help, > > that I am trying to build a practice, and all of the numbers > connected to > > dollar signs with black ink are small/ with red ink are big ... I > am > > feeling at risk of losing my religion, and selling out a principle > to fend > > off bankruptcy... Any advice? ... Rian Mintek, M.D. in Michigan. > > > > > Quote Link to comment Share on other sites More sharing options...
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