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Tuesday, September 8, 2009

The Nanny Practice

Due to pelvic pain without a clear etiology by history and physical exam, you schedule an abdominal ultrasound for your patient at a different facility the next morning. Which of the following best describes your personal responsibility for follow-up of this test?

    a. You tell the patient to call for a report next week if she hasn’t received results by phone.

    b. You tell the patient to call for a report the next afternoon if not contacted by your nurse.

    c. You ask the ultrasonographer to call you on your cell phone when results are available, and then you call the patient personally.

    d. You set your PDA alarm to notify you 60 minutes after the scheduled sonogram, and you call the ultrasonographer for results.

    e. You set your PDA alarm to notify you to call the facility to see if the patient shows up at the time of the exam.

    f. You set your PDA alarm to remind you to call after breakfast to remind the patient about the test.

    g. If the patient does not answer or show up, you call her work, and if she is not there, you notify the police to put out an APB and escort her to the facility.

From that spectrum of choices you can catch my drift. It is not a simple choice, because it involves two competing values: to do your best to assure a good medical outcome, and to do your best to encourage and empower the patient to take responsibility for her own care.

Last night I watched a DVD of The Soloist, the story of a schizophrenic Juilliard dropout homeless on the streets of Los Angeles, and the reporter who tries to “help” him. It is a frustrating task, because society refuses, as a matter of law, to force a psychotic to take the medicine that would allow him to function.

It’s a story I saw played out before my eyes in 1975, when I was an intern in charge of psychiatric services at a medical school emergency room. The ACLU in those days was judicially emptying the long-term psychiatric facilities, arguing that patient autonomy trumped imposed medical care.

On March 20, 1981, Bradley Boan marched into the emergency room and murdered a doctor, a nurse and a patient. I had admitted him several times, only to see him exercise his right to be crazy the next day. The lawyer for the families of the victims considered naming me in a lawsuit, but reconsidered.

Go figure. No one ever said value judgments were easy.

So where do you stand on the Nanny State paradigm? The legal profession, and society in general, is deeply conflicted on this issue. Are you going to make 14 phone calls to track down a patient who fails to deliver a follow-up urinalysis?

Because there are so many variables, general rules are impossible. That’s not going to stop me from offering a general opinion, in the hope it will inspire young family physicians to think deeply about this issue.

I believe that I have an obligation to do my best to assure that tests I obtain in my office are tracked back to my office, and acted on appropriately. For that reason, one of our staff members maintains a log of these tests.

Once the patient leaves my office, though, I think the responsibility is on him. We do our best to grease the skids, making specific appointment times when possible. But I’m not going to follow him around town or serve as his alarm clock.

From the first day I opened my practice, every family has been given a loose-leaf notebook with educational materials and dividers to organize their health information. They get copies of all their lab and x-ray reports, and my handwritten progress note sheets include a punched NCR copy for them to file away. Do they do it? Some do, some don’t. I don’t check. But I send them a message from the start: This is your health, and I expect you to be the lead partner in this relationship.

At the other end of the spectrum in our town is a pediatrician, an excellent and dedicated clinician and a nice person. She fosters dependency in her patients to a degree I would not have thought humanly possible. When I see her in her car, she is on her cell phone. She was evicted from her group practice because she didn’t produce her overhead, and her partners couldn’t tolerate taking calls from her patients. (She doesn’t have a family).

Do I encourage patient self-care and independence because it is more profitable, and lets me sleep at night? Only God knows. I do know this: The biggest health care crisis involves the American lifestyle, not coverage for the uninsured.

And I’m not going to be there to help my patients make good choices at the grocery store, the restaurant or the refrigerator. It’s on them, and I think we’d better get that straight.

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About the Author

Doug Iliff, MD, is a family physician in solo practice in Topeka, Kan., and a former member of the FPM Board of Editors.

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