Return Visit: Changing the Subject

One of the new requirements for Patient Centered Medical Home recognition is tending to patients with chronic illnesses, like diabetes, by making sure we document, before the deadline, what their self management goals are.

That sounds reasonable, even patient centered, discussing goals and all. But is it? The other day I saw an infrequent visitor who is a very reluctant diabetic. He had come in with a new symptom, unrelated to his diabetes. Autumn seemed to take forever checking him in, so I finally just walked in the room and saw what she was doing. She was trying to recapture what should have been done in the diabetes visit he canceled last month.

His unwillingness to come in for his diabetes visits, to test his blood sugar, to keep his weight down and to have his blood and urine tests and to see his eye doctor and podiatrist all weigh down our quality scores.

He has other priorities, and if I were truly patient centered, I would work on the issues he feels are most important for him while gently trying to convince him about the importance of tighter blood sugar control. But now my certification as patient centered hinges on documenting his answers to questions he would rather not answer, at least not today.

That’s medicine today, even more paternalistic now than during Marcus Welby’s era. Back then, doctors perhaps tended to feel they knew what was the most important issue for each of their patients. But now it is the Government and NCQA that decide what is most important for every patient that belongs to a certain population – patients’ individual preferences don’t matter very much, because it is all about collecting and polishing the data.

Here is my original post from 2011 about when doctors decide to change the subject:

Mrs. Blouin was new to our practice. Her previous doctor, in the next town up the road, had left the area just over a year ago. Her presenting complaint was “Wants Reclast infusion”.

Reclast is a once-yearly $1,200 intravenous infusion for osteoporosis, primarily for patients who cannot tolerate the older treatment alternatives.

I have many misgivings about osteoporosis treatment, and have not yet prescribed Reclast. It has a long list of drug interactions and side effects, and it is still very new.

It didn’t take me long to realize that there were other issues afflicting Mrs. Blouin. She was fatigued, her blood pressure was very high, she had no idea what her cholesterol was, and she had a foreboding family history of cancer and heart disease.

Dr. Greyson’s notes mentioned her blood pressure being up a bit, ongoing fatigue, breathing problems and several other symptoms. Reading through them, I wasn’t sure how osteoporosis came to be the predominant concern.

“How did you and Dr. Greyson come to focus on your bones?” I asked.

“I don’t know”, she answered. “I guess he thought they were really that bad.”

“It sounds like we need to look at the whole picture right now. You couldn’t get your infusion now anyway without some fresh bloodwork. We might as well see if we can find out why you’re tired, check you for anemia and thyroid problems. We could also check your cholesterol if you’d like. And I’d like to check your blood pressure one more time, since it’s higher today than it was last year at Dr. Geyson’s.”

I had moved the focus of our visit away from what Mrs. Blouin had come to see me for. So had Dr. Greyson, but in the opposite direction.

Physicians change the subject of patient visits all the time. Sometimes we do it because we feel there is a more pressing issue than the one a patient came to see us for, like correcting a high blood pressure or screening chronically ill patients for depression, which may be a barrier to achieving better health. Other times we may be guilty of shifting the attention away from a symptom we are unfamiliar or uncomfortable with in favor of something we find easier or more satisfying to deal with. Sometimes we may avoid or postpone issues that aren’t easily solved in a fifteen-minute-visit.

I sometimes hear patients say about other doctors: “He didn’t seem concerned about my symptoms”. Some people may say that about me too; I know I don’t pay as much attention to arthritis pain and old sports injuries as some patients might expect when they come in for physicals and have unmet screening needs for cancer and cardiovascular risk that I feel a need to cover in my half-hour with them.

But where do we draw the line? When is it fair to change the agenda for a patient visit and when is it not? When are we doing the right thing by steering our patients toward issues they may not have thought of as priorities, and when are we doing the wrong thing by not making them equal partners in their own health care?

3 Responses to “Return Visit: Changing the Subject”

  1. 1 meyati September 9, 2016 at 1:48 am

    His unwillingness to come in for his diabetes visits, to test his blood sugar, to keep his weight down and to have his blood and urine tests and to see his eye doctor and podiatrist all weigh down our quality scores.

    This is the wrong article for me to be pleasant about. Tomorrow, I’ll be asking my oncologist why he ever told me 3 times to contact him if I had a problem, and then made me promise to do so. His nurses never gave him a message as far as I can tell, the other oncologist was never given any messages by his staff either.

    We didn’t talk about what he planned, as I explained that the only times I ever called his office was because the lab didn’t have the work order, to confirm or reschedule appointments. He worked out a method of me contacting him. I believe that he raised hell with his staff too.

    Mon I went to Urgent Care with hot strep and a temp of 97.7. I will be talking to him how this affects my care even with him. What makes it hard is that many nurses just put down 98.8. I have lab values to go with my temp.. Will it make any difference? of course not. That’s because the network-hospital owned EMR doesn’t have things like my temp for doctors to see. It does not even list prescription meds -AS NEEDED-to help a doctor sort through the garbage.

    I know he’ll want to talk about my high glucose–I am trying to stop the lab from running or posting those. The military had mercy on me and my disabaled vet son. They note on the front of charts things like roller coaster glucose levels, low BTs-things that keep us from being injured from medical care in giant facilities. There is nothing like a nurse coming after you with insulin after surgery- and having a fit- Then they do another glucose-and they lecture. Then the lab says that the untreated glucose levels are now hypo. They take their insulin and scrurry off.

    I’m sorry that my doctors have their quality scores ruined by me. It shouldn’t be that way. Why can’t civilians cope with this without punishing doctors for treating a patient for what the patient wants treated?

    I’m taking in a tattooed biker grandson in with me tomorrow. I’m tired–
    I’m surprised that my doctors keep me around-

  2. 2 si baker-goodwin September 9, 2016 at 12:21 pm

    Dear Country Doctor:

    In the case of the woman described in this post, did you ever think to ask her about her sleep? For women, especially middle-aged, their “tiredness” is OFTEN responded to with thyroid checks, depression medications, anemia, etc, when the first danged thing ought to be — do they have insomnia, how many hours of sleep are they obtaining, how do they feel on awakening, do they snore/wake up repeatedly in the night, has their bed partner (human) noticed they seem to stop breathing then resume with a large noisy breath? The literature repeatedly says men have more sleep apnea than women. I rather wonder about that. Instead, I think men are DIAGNOSED more often with sleep apnea than women are — because for whatever reason, in women, docs think thyroid and anemia, not sleep.

    I very much enjoy your posts and treatment approach. I do wonder what you think about sleep, however.

    Best wishes,

    Si Baker-Goodwin

  3. 3 meyati September 9, 2016 at 3:06 pm

    Doctors think of men as snorers. It’s another form of gender bias medicine. My grandmother put a recorder under the bed so her husband’s snoring could be used in divorce proceedings. She took it to the lawyer, who was happy until he heard her snoring..

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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