A patient I’ve treated for more than 18 years came to me recently and told me this story of a prostate biopsy he underwent. He began:

 “So one of my other doctors tells me to basically ‘man up’ and have this prostate biopsy without general anesthesia (like the one you get for a colonoscopy). So against my better judgment I scheduled it. Little did I realize how wrong I would be.

“I get there a little early and they take me in almost right away,” he continued. “They lead me to the exam room where the doctor and technician are and they introduce themselves. Next thing they are telling me to get undressed and get on the table. Now comes the fun part. I am told to slide my butt to the edge of the table and put my feet in the stirrups. They give me one lousy Valium to relax me. They start the torture, I mean procedure.  I am still waiting for the local anesthesia I was promised. Next there was a camera of sorts, some sort of ultrasound thing, just a little bit smaller than the camera the astronauts had on the moon.  I politely ask where my anesthesia is. I am told it is on the way. Finally, the tech is done photographing everything at every angle and I finally get anesthesia. After a couple of minutes, the doctor approaches with the biopsy tool. I call it a tool because it seemed just like the hole punch tool we used for spot welding on cars.  After 30 to 40 holes are punched into my prostate, it is finally over.

 “The whole experience,” he concludes, “has left me with I have a couple of lessons that I should never forget.  (1) Never believe anything the doctor tells you. (2) It hurts much worse than you can ever imagine. And (3) always demand drugs!”

This patient obviously has some sense of humor but the story made me keenly aware that informed consent is more than just getting a patient to agree to a procedure and sign a form. We all must do a better job of understanding patients’ expectations and explaining to them the details of the procedures they are about to undergo. The old adage is true: You can’t understand a man until you’ve walked a mile in his shoes, or in this case, his prostate biopsy.
 

A CDC survey released this month shows significant increases in the number of teens who are getting vaccinated.  The 2009 survey of 20,000 teens ages 13-17 found that 56% of teens were getting the Tdap vaccine, up 15 percentage points; 54% of teens received the meningococcal vaccine, up 12 points; and the number of girls who received at least one dose of the HPV vaccine increased 7 points to 44%. Although the news is positive, why don’t we see higher rates, such as 80%-90% of teens?

I suppose the currently uninsured 15% of the population, who soon will have access to insurance under the new reform laws, will help increase this percentage, but what are the other reasons?  In New Jersey, a child entering the 6th grade must show proof of having received the Tdap and the meningococcal vaccines. Are pediatricians and family physicians doing their job of anticipatory guidance to get the 11- to 18-year-olds to update their vaccines? As osteopathic physicians we pride ourselves in being proactive in the practice of preventive medicine, but are we doing it? 

In my office, if you are between the ages of 11 and 64 and have not had a tetanus booster in the last 5 years or an allergy to tetanus, you will likely leave my office with a sore arm. This conversation takes about two minutes. Once you tell a patient the benefits of the vaccine and then reinforce that you recommend the vaccine, very few patients or their parent will refuse to adhere to your advice. I feel this applies to most vaccines for teens or adults: HPV vaccine for boys and girls; the pneumococcal vaccine for high risk individuals 19 to 64 years; the shingles vaccine for those 60 and older. The administration of these vaccines will be a health benefit to the patient and to the public at large. Take the time. It’s worth it.

See the CDC Web site for the latest vaccine schedules and help increase the vaccine percentage rate for 2011
 

I have a 17-year-old female patient who was born with her left hand third and fourth distal phalangeal digits noticeably deviated to the radial side. Since early childhood she had expressed a desire to her mother to have these fingers surgically corrected because they "look ugly" and people have repeatedly commented on her disfigurement.  The child has full use of her hand and no pain physically, but emotionally she is very bothered.  Her mother is concerned that surgery opens up the potential for more disfigurement if there is a complication and since the child has full use her hand, her mother has delayed a potential surgical opinion. The patient's mother was also concerned her health insurance would rule that the surgery was cosmetic, not functional, and not pay for the procedure.  This case opens a big debate: Should patients delay treatment for fear of insurance nonpayment? Is psychological and emotional distress on the child enough of a reason for the insurance to pay when no physical impairment is found?  Do you have patients with similar concerns who have delayed treatment?  If this were your patient, would you suggest surgery?

I'm an avid reader of The Journal of Family Practice monthly column "What's The Verdict?"  Each installment gives the details behind a medical malpractice case: the plaintiff's claim, the defense and the jury verdict and award.

One case from the July issue is appropriate for this time of year, involving pre-participation sport physicals. An 18-year-old visits his internist for a physical before starting college and asks that the physician fill out the college's health form. The physician documented a "systolic murmur" on the form followed by a question mark.  The remaining parts of the exam were unremarkable and the student was stated to be in "excellent health" and fit to participate in all college activities without restriction. Four years later, the student, now a senior and a star basketball player, collapses and dies during a game. The cause of death was sudden cardiac death related to hypertrophic cardiomyopathy (HCM). The plaintiff claimed the physician found a systolic murmur, which is often associated with HCM, and should have ordered more testing to diagnose and treat the problem. The defense argued that the physician ordered an EKG but the patient did not keep the appointment. Also in the subsequent four years, he was examined by five other health care providers, who also had the internist's initial report, and cleared the young man to participate in athletics. The Massachusetts jury verdict was $1.6 million. The case at the time made the national news. News reports from the trial say that the athlete's lawyers argued that the young man didn't know about the EKG appointment and the physician never followed up.

As a physician who clears students to participate in sports regularly, this really hit home. Even the smallest of physical findings can result in a serious problem. Patient follow-up is key, but so is patient responsibility. What practices do you put in place for patient follow up and at what cost? If you don't follow up with every patient, are you making a decision between paying for follow up or ultimately paying the verdict?

We all were once osteopathic students and residents. Whether it was just last year or 30 years ago, who can forget the anxiety of your first day of school, your first rotation or your first night on call when “you were it”?  As your training progressed, moonlighting was one way to gain additional knowledge and also earn extra money to help support yourself and your family after incurring the large debt of medical school.  When I was a PGY-2, I moonlit in my father’s family practice office and also at our local hospital. I often think that I learned more moonlighting two nights a week and on weekends when I had to think on my feet, than I did on some of my residency rotations.

Since then, the moonlighting guidelines have changed.  Residents must be in their third year to moonlight, and they are not permitted to work more than 80 hours a week including the time spent working at their residency program. When I think about the current class of residents—and all that I learned during my year-two work experiences— I lament that these young doctors will not have that extra year to gain experience as working physicians. As the newest class of residents start their careers this summer, I’d like to hear from them. How do you feel about these restrictions and their impact on your career?

What role does the pharmaceutical sales representative play in your office? At my office, we welcome the lunch detail appointment so that we can have time blocked off to listen to new information on current products or new medications. I always hope that the representative understands the disease state that they are talking about and has an appreciation for the patient compliance side to the medication dispensing process. When they don't, it can be a very long lunch.

Many sales representatives change territories or companies multiple times in their career. It's not uncommon for me to find that once a rep has an understanding of my office procedures, someone else comes in and we are "training" a new person. There are distinct advantages to building relationships with sales reps, although it can sometimes seem a chore. They are generally a reliable source of important product information and they bring samples that can be used to benefit patients, although I have noticed that sample quantities have diminished lately. How do you interact with pharmaceutical representatives in your office?  What works best for you?

At AROC this year, I told all of you that I wanted to spread the word that “DOs do it better.” I included magnets in every AROC registration bag with the slogan. My goal is to have that slogan known all around the state.  Where do we start? Right in the exam room.

When I take the time with a patient to help solve their problem, or when I perform OMT and the patient feels instant relief from acute pain, I explain to that patient that they are able to benefit from my unique brand of care because I am a DO, which makes the care I provide special. I also ask the patient to fill out a short patient testimonial that will help NJAOPS bring osteopathic medicine in New Jersey to the front page. These testimonials will help NJAOPS publicize our good work and excellent patient care.

You can help us spread the word. Visit the patient testimonial page to dowload a copy of the form or ask your patients to come to njosteo.com to fill one out online. Help NJAOPS continue to spread the message “DOs do it better!”

Over the years, we develop a bond with most of our patients. Many of my own patients have become like extended family to me as we spend a portion of our visits sharing stories — both happy and sad — about our own families. I was honored when one patient, an 83-year-old woman whom I'd seen for more than 12 years and had no living family members, made me the executrix of her estate when she died last June. She not only entrusted me with her physical and emotional health during her life, but with her finances after.

I must admit I was a little overwhelmed by the process: finding where she kept her money, selling her car and home and sorting through her other possessions with little knowledge of their value — either financial or sentimental. This experience made me learn more about estates than I ever wanted to know, but it also has given me valuable information to help my patients who have to go through a similar situation.

In 16 years of practice, this was the first time that I was asked to do anything this personal and unrelated to a patient's health and it made me think about how far the doctor-patient relationship should go. What is the most unusual thing a patient has asked of you that went outside the realm of health care? 

Osteopathic Graduate Medical Education programs around the country are in place to train the next generation of osteopathic physicians, but there is a longstanding concern that there is a kink in the current OGME system.

Instead of going into an osteopathic post-doctorate training program, many COM graduates take positions in ACGME programs (the MD equivalent), leaving AOA-approved slots vacant. If these positions remain unfilled, the federal funding for OGME could be retracted, according to the AOA. This is one reason why the AOA is considering allowing MD candidates to fill these slots. A resolution (H-207) on the issue is on the agenda for the AOA's annual meeting this week in Chicago.

How do you feel about allowing MD graduates into DO residencies?  Will admitting MDs to DO residency programs help or hurt our uniqueness as osteopathic physicians? How will an MD handle the training without having the background of four years of osteopathic philosophy and principles? What's your gut reaction?

Chronic pain, glaucoma, pain from terminal illness -- all are conditions that many physicians run across in their daily practice. Just this year, the New Jersey Legislature passed a law that may help physicians treat the pain that these patients endure: medically prescribed marijuana. The law delineates who is eligible for medical marijuana and how and where the patient will obtain it, but many physicians, including myself, are still apprehensive about making such a recommendation. I believe physicians and patients need more information if this new prescribing ability is going to benefit the patient. Even though the legislators recently voted to delay implementation of the law until January 2011, patients are already asking about it. I have had a handful of patients already approach me about prescribing the drug. What are your intentions if asked by your patient for this new legalized treatment? Will you offer it before the patient asks?
 

Every day I try to provide the best medical care possible to all my patients. I make judgment calls on diabetes, atrial fibrillation, hyperlipidemia, thyroid disease and more.  I take into account the patient's medical history, family history, finances, current medications and more and attempt to make the best recommendations possible. Have you ever had a patient who completely ignores your advice for medication, testing or need to consult with a specialist? Have they just not returned for a follow-up appointment?  How many times do you attempt to contact that noncompliant patient to let them know that they have missed their appointment or not complied with medical advice? Do you send them a risk letter explaining their medical condition or do you discharge them from your practice to decrease your malpractice risk? Whose responsibility is it for the patient to care about their health: yours or the patient?  I want to hear how you provide patient care to those who seem to not care about their own health.

I booked my airline ticket for the AOA House of Delegates meeting recently. As I began reviewing all the “extras” I would be paying for on my flight (extras that only two years ago were free), it made me think about payment for services rendered. What “extras” do physicians offer that they don’t get paid for? I don’t charge patients to get a same-day appointment or when I return a phone call on a Sunday afternoon. These “extras” are all part of our patients’ expectations and part of the cost of practicing medicine. In light of the current economic recession, doctors may begin to charge for services that until now have been free. Like many other practices at this time of year, I get flooded with requests from patients to fill out health record forms for camp and school. I began to charge a $10 form fee and I have had minimal patient push back.  Do you do this?  Do you charge for any other services above the patient co-pay responsibility?  What other services do provide for your patients that you’ve never charged “extra” for?  Please share your thoughts.

SGR “Sustainable Growth Rate.” I hope you all know these letters by now. For any physician accepting Medicare patient payments, you better. For years, we have been at the mercy of the federal government and the SGR, which is the formula used to calculate the payments we receive for providing services to Medicare patients.

Each year, almost since the start of the SGR formula, we have faced cuts, followed by miniscule increases, then cuts again and freezes in rates. Now, an unprecedented 21% cut officially went into effect on June 1 – the third time this year a cut went into effect before it could be reversed. Meanwhile, our Medicare claims have been yet again placed on hold until June 14th, to give Congress time to decide if the reduction will be implemented. 

Why do physicians continue to tolerate this meager attempt at government regulation that directly affects our ability to provide patient care? To provide care to our patients, we must keep our practices viable. Accepting cuts in payments, while every other practice cost has gone up, is not conducive to staying in business. Physicians will need to make changes. If these cuts are enacted, will you continue to see Medicare patients?  Will you accept new Medicare patients? What is your game plan?

Stress reaction is a medical condition I diagnose daily in my family practice. Work stress, family stress, relationship stress — you name it and I've seen it. We all have it every day. How you deal with that stress influences your mood and outlook in your daily experiences and your life. Unfortunately, situations beyond our control continue to influence our lives. This is the stress I urge my patients to refuse to take ownership of.  Taking time to do something at least once a week that is only for you is one way to help relieve some of the stress and frustrations that permeate our daily activities. I personally love to be in my flower garden. In the "I needed this yesterday" world in which we live, we all need to take time to smell the roses. What do you do or tell your patients and family to do to help relieve stress?
 

There once was a time when the family physician was the authority on all things health related. But as the healthcare landscape changes, other medically trained professionals are performing roles that once were solely in our job description. Here in New Jersey, for instance, nurse practitioners and physician assistants prescribe medications and DNPs are allowed to introduce themselves as "doctor."

As physicians, we know the difference between a DO and other health professionals who hold doctorates, but does the patient? As the healthcare choices become greater, can we really expect them to? I believe that health professionals have an obligation to make sure their patients understand the qualifications and limitations of the person who is treating them so they can make the best choices for themselves and their family when choosing a practitioner.

How should people who don’t have a DO or MD after their name introduce themselves in a clinical setting? I think they should say, “I am Dr. —, a nurse practitioner (or physician assistant), and I am going to evaluate you today for your problem.”  Only then, can the patient make a truly informed decision in their care.

 

One of the goals I have set for my year in office has to do with our place in the larger medical community and our visibility as osteopathic physicians. I’m sure you have all encountered this: You are at party or some other function and someone says to you: “You’re an osteopathic physician. What’s that?” Why does this still happen? Despite our best efforts, many patients still don’t know what makes us different from other doctors and allied health professionals.

We are the best advocates for our profession, and we need to make sure that those around us know the answer to the question “What is a DO?” We are fully qualified physicians who receive extra training in the musculoskeletal system, the interconnected system of nerves, muscles and bones, and we are known for our focus on patient-centered care, making us a great choice for those seeking a doctor who looks at the whole person in the diagnosis and treatment of illness.

Does your staff, especially your front office, know what makes us different? Ask them and see.

 

Welcome to the President's Forum. As the 2010-2011 President of NJAOPS, one of my primary goals is to encourage you—our members—to become more involved with the association. With this forum, I hope to develop meaningful discussions about the issues, policies and events that affect us as we practice medicine every day.

I plan to cover a diverse array of topics. Whether writing about the latest flu outbreak, a business tip that I found helpful in my practice or new healthcare policies, I will always look to you for your ideas. I hope you will visit this forum every week to read my thoughts and share your own. You can look for a new posting every Friday.

So with that said, tell me, what is on your mind? What are some of the topics you would like me to write about?

—Lee Ann Van Houten-Sauter, DO

Navigating the first years of practice can be challenging. Without the proper resources, you may be left with unanswered questions and lingering concerns. NJAOPS' New Physicians in Practice (NPiP) group is available to help, offering guidance and advice to osteopathic physicians who have been in practice less than 10 years. Recognizing new physicians have unique needs, NPiP seeks to provide the support and assistance necessary for you to thrive in the medical profession.

Have a question or concern? Post it here and we will respond.