illegal or just unethical?

[denverpilot]

I disagree. Bad medicine in my humble opinion. There are better options. Why not get a home health nurse to go check on the patient and call the doc?

My wife's a home care nurse. They're required to have a Doctor's orders to even show up. As Doc B said, it's usually some form of rehabilitation or wound care.

Karen's working on a new certification in wound care as we speak, on her own dime. Since nursing salaries tend to cap out mid-career, the certification for her is just specialization. It may pay itself off eventually, but she really likes wound care. Kinda like a Type Rating, for an aviation mentality.

I can't tell you how many on-call calls she's gotten from patients with new symptoms where I've heard her say the standard late night line, "If it's an emergency, you'll have to go to an ER or contact your Doctor." The nursing staff aren't allowed to do anything about it. (Not that she hasn't helped someone call for an ambulance before, either.) She also gets the irate calls from those people's kids, "Why don't you do something for him/her?!"

With the patience of Job, she explains she's not authorized to do anything more than what's on current orders from the doctor. Get her new orders, she can go over. If someone is seriously ill, get them to an ER. (She could hand me the phone after doing this for as many years as she has, and I could recite this verbatim to anyone, if she needed to leave or something. Seriously.)

When she did true home nursing, the stories of how people live is appalling. If you've ever caught an episode of "Hoarders" on one of those cheap cable channels, multiply it times ten, add never taking out the garbage, and a whole lot worse.

The home care nursing staff already has to sometimes get far more involved than should be necessary, and even call social services or even just family who's 20 minutes away, to get elderly people out of their own filth.

Worst one to date was the day she walked in on an elderly gentleman with a firearm on his kitchen table, fumbling with it... He was at the onset of Alzheimer's and maybe thankfully, that day, couldn't remember how to load the weapon. She had to back out of his apartment, and call the police. Next step for him was a psych eval, and admittance to a locked Alzheimer's nursing facility. He had no family, and depending on your world view, waited too long to do what he wanted to do.

Today she works for a company that originally owned elderly care real-estate, both of the senior living and skilled nursing variety, often in the same building or complex. She works for the wholly owned division that handles Medicare "home" health visits in the elderly living side of the facilities, mainly. There is another division that handles the skilled care side of the facilities. They're run as separate companies, separate books, to make sure the Medicare and other government requirements aren't broken. They discharge patients and or admit them back and forth between facilities as their health fades or returns. It's an interesting business.

Sadly, it's a growth industry. The population is becoming elderly. Wounds don't heal up at 70 like they did at 40 or even 50 or 60, and her specialty she likes, is experiencing steady growth along with the aging population, even right through the recession.

The reality is, the generation that gave us the first wave of "latch-key kids" is also now attempting to care for elderly parents, and the situation will get nothing but worse. Folks accustomed to 60+ hour workweeks of both spouses in a household have great difficulty transitioning to less hours and all their free time utilized in simple things like taking mom or dad grocery shopping. Mom and/or dad want their independence and don't want to move in. Etc.

Next it'll be my generation's turn. The generation of kids from the generation that all divorced and remarried and maybe did it again. Which kid gets which parent? Nightmare. I have a step-sister and a half-sister. Step-sister already had to become the parent and take her mom out of drug addiction. Half-sister moved and stays physically as far away as possible from the relationship insanity as possible. (Step-dad and mom are not together anymore, and I probably won't have a new legal step-dad, but it's still parental-grouping number four for me. Dad's also re-married and divorced and now a retired bachelor. Don't even ask me about family holidays, they've been a scheduling nightmare since as long as I can remember. There's five people I can call "mom" or "dad" and I care about them all. But it's nutty 'round the Holidays.)

And then there's folk like us... No kids, we'll be darn lucky if a couple of kind nieces and nephews visit from time to time when we get truly elderly. And trusting in government to not just lock us away in a room to die, is not a good plan either. Private pay insurance is going to go extinct or at least be so outrageously priced, that paying in advance for care won't be much of an option. Better make sure the bank account is huge.

So... be happy if you only have to think about the well-being of one parent, or two. Heh. And home nurses, aren't the best solution for anything other than specific events where someone just needs some skilled specific care a Doctor can't provide.

 

[douglas393]

OP here.


The pattern is usually a couple of colds a year--usually just a cold--but she -demands- antibiotics, because she's simply convinced that she needs them, even when the doc says she doesn't.

And here is the crux of the problem. No offense to your mom, or the non doctors on the thread, but there is a huge number of people in this country with little or no actual medical education other than what they see on TV, read on the internet, magazines, and books, who think they know what is better for them than their doctors or physician extenders. Many doctors are afraid of upsetting the patient when the patient demands something that they know is not indicated, but may prescribe it just to placate the patient or their family. I know I will now get bombarded with all the stories where you or someone you knew either sore a bunch of doctors and they were all wrong, or they made the diagnosis when the doctor could not. Yeah I know that happens, but that is another discussion for another thread and probably another forum.

 

[Gary F]

Ever heard of an after hours clinic?

Although not my typical method of handling phone calls, this happens all the time, so don't act naive that some great law has been broken.

We fight this everyday on both sides. "Mrs. X called and wants a z-pack called in" or the " I paid my copay and I expect an antibiotic, its the only thing that fixes this!" This happens every single day in America. The public is under the conclusion that medicine is a service they can handle on their own with a phone call. Parents and caretakers conclude that their loved ones received sub par care because an antibiotic wasn't given.

We don't like dealing with calls, time spent on a phone instead of a room doesn't pay the bills. My nurse on a phone with some one not willing to come to the office takes away from the person who respects the appt. process and is waiting on me to come in. Healthcare isn't the easiest business in America to make a dollar and like any business you spend your time on things that help you earn a living for your staff.

Sending a home health nurse to see a probable head cold would only occur in Fantasy land!

Agree. We use them for our chronically ill patients. The point I was making is that if someone is really sick it's not good to treat them at home over the phone.

I don't applaud the physicians action but I understand them completely. Nurses can ask the same questions I would pertaining to the medical history. The nurse may know the patient very well and offered the prescribing physician very good information. What kind of response would you have given to her being told to use nasal saline and an anti-inflammatory throughout the weekend until she could be seen Monday?

Cipro is a very good antibiotic for sinus and pulmonary maladies along with urinary and certain GI situations so odds are in the rare instance she even needed an abx it's probably covered. C. Difficile can occur with many antibiotics and usually doesn't occur with a short single course.

Tell that to my mom who almost died from c. diff. I guess that's why her primary physician and GI consultant never ordered the test in the first place and she suffered greatly because of that assumption.

 

[Gary F]

Your mom has a cold which likely there is no help for at this point besides the usual symptom relief stuff. They could likely have done nothing, however on the odd chance that there was a bacterial element developing he prescribed a solid antibiotic that at her age will have no deleterious effect if she did not need it and will save her life if she did. So in the end of it, there was a doctor on the other end of the phone writing a prescription and assuming liability, likely for no recompense, just looking out for your moms best interest.

Both of those assumptions are not always true, the second one is really a stretch.

 

[Gary F]

My wife's a home care nurse. They're required to have a Doctor's orders to even show up. As Doc B said, it's usually some form of rehabilitation or wound care.

We use them all the time. Many of our elderly patients with heart problems have them come by on a regular basis.

I can't tell you how many on-call calls she's gotten from patients with new symptoms where I've heard her say the standard late night line, "If it's an emergency, you'll have to go to an ER or contact your Doctor." The nursing staff aren't allowed to do anything about it. (Not that she hasn't helped someone call for an ambulance before, either.) She also gets the irate calls from those people's kids, "Why don't you do something for him/her?!"

I get stupid " My husband is having chest pain" calls in the middle of night all the time. I guess people expect me to be able to fix a heart attack over the phone when they have not even been in to see me or any of my partners for years. If the symptoms are bad the ER is the way to go.

Visiting home nurses are very valuable in assessing patients. They have a good sense if a patient needs to be seen by a physician or even just a change of meds. I agree that family members can occasionally be unreasonably demanding or ungrateful.

With the patience of Job, she explains she's not authorized to do anything more than what's on current orders from the doctor. Get her new orders, she can go over. If someone is seriously ill, get them to an ER. (She could hand me the phone after doing this for as many years as she has, and I could recite this verbatim to anyone, if she needed to leave or something. Seriously.)

Sometimes we just order vital signs and a weight. Many nurses can tell if something needs to be done and will call us for additional instructions.

When she did true home nursing, the stories of how people live is appalling. If you've ever caught an episode of "Hoarders" on one of those cheap cable channels, multiply it times ten, add never taking out the garbage, and a whole lot worse.

The home care nursing staff already has to sometimes get far more involved than should be necessary, and even call social services or even just family who's 20 minutes away, to get elderly people out of their own filth.

Worst one to date was the day she walked in on an elderly gentleman with a firearm on his kitchen table, fumbling with it... He was at the onset of Alzheimer's and maybe thankfully, that day, couldn't remember how to load the weapon. She had to back out of his apartment, and call the police. Next step for him was a psych eval, and admittance to a locked Alzheimer's nursing facility. He had no family, and depending on your world view, waited too long to do what he wanted to do.

Today she works for a company that originally owned elderly care real-estate, both of the senior living and skilled nursing variety, often in the same building or complex. She works for the wholly owned division that handles Medicare "home" health visits in the elderly living side of the facilities, mainly. There is another division that handles the skilled care side of the facilities. They're run as separate companies, separate books, to make sure the Medicare and other government requirements aren't broken. They discharge patients and or admit them back and forth between facilities as their health fades or returns. It's an interesting business.

Sadly, it's a growth industry. The population is becoming elderly. Wounds don't heal up at 70 like they did at 40 or even 50 or 60, and her specialty she likes, is experiencing steady growth along with the aging population, even right through the recession.

The reality is, the generation that gave us the first wave of "latch-key kids" is also now attempting to care for elderly parents, and the situation will get nothing but worse. Folks accustomed to 60+ hour workweeks of both spouses in a household have great difficulty transitioning to less hours and all their free time utilized in simple things like taking mom or dad grocery shopping. Mom and/or dad want their independence and don't want to move in. Etc.

Next it'll be my generation's turn. The generation of kids from the generation that all divorced and remarried and maybe did it again. Which kid gets which parent? Nightmare. I have a step-sister and a half-sister. Step-sister already had to become the parent and take her mom out of drug addiction. Half-sister moved and stays physically as far away as possible from the relationship insanity as possible. (Step-dad and mom are not together anymore, and I probably won't have a new legal step-dad, but it's still parental-grouping number four for me. Dad's also re-married and divorced and now a retired bachelor. Don't even ask me about family holidays, they've been a scheduling nightmare since as long as I can remember. There's five people I can call "mom" or "dad" and I care about them all. But it's nutty 'round the Holidays.)

And then there's folk like us... No kids, we'll be darn lucky if a couple of kind nieces and nephews visit from time to time when we get truly elderly. And trusting in government to not just lock us away in a room to die, is not a good plan either. Private pay insurance is going to go extinct or at least be so outrageously priced, that paying in advance for care won't be much of an option. Better make sure the bank account is huge.

So... be happy if you only have to think about the well-being of one parent, or two. Heh. And home nurses, aren't the best solution for anything other than specific events where someone just needs some skilled specific care a Doctor can't provide.

Nurses are not a substitute for a caring family member but they can be a very valuable member of the medical team for patients that can't come in to be evaluated by a physician very easily.

 

[Gary F]

And here is the crux of the problem. No offense to your mom, or the non doctors on the thread, but there is a huge number of people in this country with little or no actual medical education other than what they see on TV, read on the internet, magazines, and books, who think they know what is better for them than their doctors or physician extenders. Many doctors are afraid of upsetting the patient when the patient demands something that they know is not indicated, but may prescribe it just to placate the patient or their family. I know I will now get bombarded with all the stories where you or someone you knew either sore a bunch of doctors and they were all wrong, or they made the diagnosis when the doctor could not. Yeah I know that happens, but that is another discussion for another thread and probably another forum.

 

[Gary F]

...and so the tale is told. there is no solution to this. As our economy declines into the 3rd world stagnation reminiscent of Harold Wilson's England, it will only get worse.

There are always two sides to every story, in this case three or four....

Incidently, Gary F, I did a U of Chicago Infectious Disease Fellowship. The principal reservoir of resistive bacteria is in our stockyards where the cattle go after three years of erythromycin containing feed. That's not to minimize inappropriate antibiotic use, either.

But I think the tone of my post, #12, does capture the problem. I was only "hard" on the OP because I wanted him to see the view from hoof and knee level, not from the high horse. I think everyone here "gets it", including Okie182, who knows the problem with the after hours clinic- no access to the history of repetitive tough times with bronchitis/bronchiectasis or repetitive micro aspiration or WHATEVER the source of the repetitive difficulty has been.

(Former disciple of Sidney Feingold MD)
FACP, Asst. Prof. of Medicine U of I.

Agree.

 

[write-stuff]

Yeah, I'm with Dr. Bruce on this one. The physician almost certainly looked over her info and tried to do something to help her. I'd much rather have that than have your mother suffer because no one can see her.

 

[Geico266]

Yeah, I'm with Dr. Bruce on this one. The physician almost certainly looked over her info and tried to do something to help her. I'd much rather have that than have your mother suffer because no one can see her.

110%

 

[Gary F]

Yeah, I'm with Dr. Bruce on this one. The physician almost certainly looked over her info and tried to do something to help her. I'd much rather have that than have your mother suffer because no one can see her.

We are beating a dead horse but I doubt that the physician did much other than to tell the nurse to give the patient an antibiotics to make the patient happy. There are many potential adverse consequences of this type of medicine both to the patient and society. I have seen instances where patients had infected heart valves that were diagnosed as upper respiratory infections and inappropriately treated with oral antibiotics which masked the symptoms until the disease had gotten out of hand. If the patient is sick enough to really need the antibiotics they should be seen in person with a few well defined exceptions for patients with properly diagnosed recurrent bacterial infections. I don't blame primary care physicians. They did not create the system that led to this type of medical care. Unless you want to experience what life was like in the pre-antibiotic era we must be much more careful in how antibiotics are used.

 

[Geico266]

We are beating a dead horse but I doubt that the physician did much other than to tell the nurse to give the patient an antibiotics to make the patient happy. There are many potential adverse consequences of this type of medicine both to the patient and society. I have seen instances where patients had infected heart valves that were diagnosed as upper respiratory infections and inappropriately treated with oral antibiotics which masked the symptoms until the disease had gotten out of hand. If the patient is sick enough to really need the antibiotics they should be seen in person with a few well defined exceptions for patients with properly diagnosed recurrent bacterial infections. I don't blame primary care physicians. They did not create the system that led to this type of medical care. Unless you want to experience what life was like in the pre-antibiotic era we must be much more careful in how antibiotics are used.

95% Agree.

Maybe the son should have taken her into see the DR?

Okay, maybe I would dismiss the charges if he makes his mom's lunch everyday for the next year.

I have an elderly mom also, but I live 500 miles away. Both my brothers live next to her, but she will lie to all of us about taking her blood pressure & meds. She does the opposite of the OP's mom and refuses to take meds because she just gets tired, and tells us what we want to hear. She had a stroke because of it. Thankfully, she recovered and still lives at home, with my brothers stopping in once a week to check on her.

OP, be thank full your mom has the presence of mind to self care. The opposite can be life altering or worse.

 

[Unregistered]

95% Agree.

Maybe the son should have taken her into see the DR?

Okay, maybe I would dismiss the charges if he makes his mom's lunch everyday for the next year.

I have an elderly mom also, but I live 500 miles away. Both my brothers live next to her, but she will lie to all of us about taking her blood pressure & meds. She does the opposite of the OP's mom and refuses to take meds because she just gets tired, and tells us what we want to hear. She had a stroke because of it. Thankfully, she recovered and still lives at home, with my brothers stopping in once a week to check on her.

OP, be thank full your mom has the presence of mind to self care. The opposite can be life altering or worse.

I am. And by the way, I already make her dinner almost every evening.

 

[Doggtyred]

Are you kidding me? Be damn glad the DR. And Nurse have a brain. Antibiotics were appropriate.

Were they? Kinda hard to make that call. Unless she has a solid history of what very likely could be a viral infection becoming a secondary bacterial infection, they were at the very least - premature...

Dangerous? No.. possibly contributing to an overall resistance problem - definitely.

Were they trying to provide responsive, prompt customer service? absolutely.

 

[Henning]

Were they? Kinda hard to make that call. Unless she has a solid history of what very likely could be a viral infection becoming a secondary bacterial infection, they were at the very least - premature...

Dangerous? No.. possibly contributing to an overall resistance problem - definitely.

Were they trying to provide responsive, prompt customer service? absolutely.

Most doctors and nurses can listen to a cough on the phone as well which is the majority of the determinant on whether to treat for pneumonia.

 

[skippers]

As a physician I have a concierge practice, a total of 350 patients. Our motto is sick today seen today. If my elderly patients cannot make it to the office, I make a house call the same day. As Obamacare evolves programs such as this are only going to become more prevalent. The cost is 4 dollars per day. That is not even a gallon of AVGas or the price of a Starbucks. The poster's Mom would have been seen and a determination as whether to Rx Cipro would have been made by her physician.

 

[bbchien]

As a physician I have a concierge practice, a total of 350 patients. Our motto is sick today seen today. If my elderly patients cannot make it to the office, I make a house call the same day. As Obamacare evolves programs such as this are only going to become more prevalent. The cost is 4 dollars per day. That is not even a gallon of AVGas or the price of a Starbucks. The poster's Mom would have been seen and a determination as whether to Rx Cipro would have been made by her physician.

I had a similar setup before I quit and said, "to heck with this". To do this you have to go w/o hospital staff privileges which invariably floods your practice with patients who say, "YOU MEAN THIS IS GOING TO COST ME SOMETHING?!!?

There is no solution for the nation.

 

[upstateny]

I had a doctor tell me, "I can prescribe a drug that will have you better in 7 days, or we can do nothing, let it run its course and you'll be fine in a week."

Found out later it's a standard joke.

 

[skippers]

I had a similar setup before I quit and said, "to heck with this". To do this you have to go w/o hospital staff privileges which invariably floods your practice with patients who say, "YOU MEAN THIS IS GOING TO COST ME SOMETHING?!!?

There is no solution for the nation.

As I am a senior physician greater than 30 years on staff I have met all my "On Call" responsibilities for the ER so I am not required to take call. I do maintain my hospital privileges and admit all my own patients. The patients love it because all the young bucks and buckettes in town turn all their patients over to the hospitalists which disrupts their quality of care. The young Docs want no night and weekend call or work. I am so glad that I am in the twilight of my medical career but worry for the future of all the patients.

 

[bbchien]

...and that is a "hey no kiddin....".

Most of the time I wouldn't even need the chart to make a decision....but I'd look anyway. NO audex on the phone. Sigh.

 

[ElPaso Pilot]

95% Agree.

Maybe the son should have taken her into see the DR?

Okay, maybe I would dismiss the charges if he makes his mom's lunch everyday for the next year.

I have an elderly mom also, but I live 500 miles away. Both my brothers live next to her, but she will lie to all of us about taking her blood pressure & meds. She does the opposite of the OP's mom and refuses to take meds because she just gets tired, and tells us what we want to hear. She had a stroke because of it. Thankfully, she recovered and still lives at home, with my brothers stopping in once a week to check on her.

OP, be thank full your mom has the presence of mind to self care. The opposite can be life altering or worse.

The guy that lives 500 miles away from mom (with health care, known self-discipline, and stroke issues) delivered the following rants to the OP who visits and cooks for his mom every day?

WTF???

The OP stated in the first sentence of his post that she said "she needed to go to the doctor". He chose work over taking an elderly person to the doctor. That is neglect in my book.

She was scared enough about her condition that she called the DR instead of waiting for her son to come home from work. This is more neglect in my book.

Then the OP gets all ethical and wonders if the DR / nurse did something wrong.

JMHO.

I take child and elderly abuse / neglect very seriously. Way too much of it.

I just call um as I see um. 3-6 months in jail would send a strong message to pick the health care of an elderly person over work. Harsh? So is dying of a preventable disease.

 

[douglas393]

Most doctors and nurses can listen to a cough on the phone as well which is the majority of the determinant on whether to treat for pneumonia.

Really???!!!

 

[Gary F]

Most doctors and nurses can listen to a cough on the phone as well which is the majority of the determinant on whether to treat for pneumonia.

Not this one. One day you can teach me how it is done. You are truly a Renaissance man.

Were they? Kinda hard to make that call. Unless she has a solid history of what very likely could be a viral infection becoming a secondary bacterial infection, they were at the very least - premature...

Dangerous? No.. possibly contributing to an overall resistance problem - definitely.

Were they trying to provide responsive, prompt customer service? absolutely.

Less true than in the past due to Clostridium Difficile which is being diagnosed with increasing frequency. For the non medical types here, C. Diff. is a possible complication of antibiotic use. Normal bacteria in the intestinal tract is often severely depressed by certain antibiotics allowing the bad actor bacteria C. Diff. to take over. It can be hard to eradicate and can be passed on to others. It can be fatal.

Clostridium difficile is an anaerobic, gram-positive bacillus that can cause considerable disease, including diarrhea, colitis, and septicemia, resulting in death (1). C. difficile–associated disease (CDAD) primarily affects persons >65 years. Risk factors include residence in hospitals and long-term care facilities and the use of antimicrobial medications (1–3). Incidence of CDAD has been increasing, and severe cases are becoming more common http://wwwnc.cdc.gov/eid/article/13/9/06-1116_article.htm

 

[douglas393]

Were they? Kinda hard to make that call. Unless she has a solid history of what very likely could be a viral infection becoming a secondary bacterial infection, they were at the very least - premature...

Dangerous? No.. possibly contributing to an overall resistance problem - definitely.

Were they trying to provide responsive, prompt customer service? absolutely.

Comments concerning to your first two points made and it would be redundant for me to reiterate what others have said.

As to your third point, medicine has got to stop thinking about patients as customers. They are not customers they are patients. Doctors are not running burger joints where have it your way is the motto of the day. Doctors are treating patients and giving them what they need takes precedence over what they think they want or need everyday. A little bit of patient education will often go a long way but not always.

Unfortunately, as government control over medicine is solidified, the Hippocratic Oath and Oath of Maimonedes is going take a back seat to making sure the patient is happy.

Doug

 

[Henning]

Do you culture every time you suspect pneumonia? Because all I have ever received was listening to my cough and a script. I don't think I have had an infection cultured since I was a child.

 

[Gary F]

Do you culture every time you suspect pneumonia? Because all I have ever received was listening to my cough and a script. I don't think I have had an infection cultured since I was a child.

It's been a while since I did internal medicine but I will give it a shot. Physical exam including eyeballing the patient, taking the vital signs including temp, HR, BP and oxygen saturation and auscultation (listening to the chest and heart with a stethoscope) is essential. Sputum cultures are rarely used (except for suspected tuberculosis) since they are contaminated by upper respiratory flora. Blood cultures should be obtained in sicker and immunocompromised patients. Chest x-rays can be very helpful to document the presence and extent of a pneumonia. These things are hard to do over the phone.

 

[TMetzinger]

Comments concerning to your first two points made and it would be redundant for me to reiterate what others have said.

As to your third point, medicine has got to stop thinking about patients as customers. They are not customers they are patients. Doctors are not running burger joints where have it your way is the motto of the day. Doctors are treating patients and giving them what they need takes precedence over what they think they want or need everyday. A little bit of patient education will often go a long way but not always.

Unfortunately, as government control over medicine is solidified, the Hippocratic Oath and Oath of Maimonedes is going take a back seat to making sure the patient is happy.

Doug

First, I agree with everything you say. HOWEVER, in this country and our current culture, everyone believes that they are a customer and are always right. So your doctor (or lawyer or accountant or other professional) who gives someone bad news and doesn't make the person feel like a valued customer will find that the person will go elsewhere, EVEN IF IT MEANS THEY GET WORSE CARE/ADVICE, if they feel they're getting better customer service.

Educating the patient that "no, really, you shouldn't take any antibiotics for this, as it won't help and in the long run will make you more susceptible to serious resistant infections", will likely only work on a very small number of patients.

It occurs to me that I have similar "education" issues when it comes to aviation safety. The folks who "own" their flight safety/proficiency and show up for the safety seminars or seek out a good CFI for a flight review are in the minority, and they're not the ones at risk. It's the ones who expect results with minimal involvement/effort that can't be reached and they're the ones who need it the most.

 

[Henning]

It's been a while since I did internal medicine but I will give it a shot. Physical exam including eyeballing the patient, taking the vital signs including temp, HR, BP and oxygen saturation and auscultation (listening to the chest and heart with a stethoscope) is essential. Sputum cultures are rarely used (except for suspected tuberculosis) since they are contaminated by upper respiratory flora. Blood cultures should be obtained in sicker and immunocompromised patients. Chest x-rays can be very helpful to document the presence and extent of a pneumonia. These things are hard to do over the phone.

Sure, preferable, so if the 70 year old patient with health issues cannot make it in to see you, and is coughing with a deep wet cough when they call you reporting a 102 fever, do you make a house call, insist they come in or go to the emergency room, tell them to take aspirin, bedrest and fluids, or do you call in a prescription for antibiotics in case they have developed pneumonia?

 

[Henning]

How would a patient go about finding a concierge practice?

Move to Europe or Australia where it is the norm (house calls) for primary and follow up care, or find a doctor here who really cares about being a doctor and treating patients.

 

[Palmpilot]

As a physician I have a concierge practice, a total of 350 patients. Our motto is sick today seen today. If my elderly patients cannot make it to the office, I make a house call the same day. As Obamacare evolves programs such as this are only going to become more prevalent. The cost is 4 dollars per day. That is not even a gallon of AVGas or the price of a Starbucks. The poster's Mom would have been seen and a determination as whether to Rx Cipro would have been made by her physician.

How would a patient go about finding a concierge practice?

 

[Henning]

Hmmm, seems my time machine works!

 

[Gary F]

Sure, preferable, so if the 70 year old patient with health issues cannot make it in to see you, and is coughing with a deep wet cough when they call you reporting a 102 fever, do you make a house call, insist they come in or go to the emergency room, tell them to take aspirin, bedrest and fluids, or do you call in a prescription for antibiotics in case they have developed pneumonia?

Any elderly person with a 102 fever should really be seen in person by some type of medical health care provider.

Move to Europe or Australia where it is the norm (house calls) for primary and follow up care, or find a doctor here who really cares about being a doctor and treating patients.

So no house calls equals uncaring physician?

 

[Henning]

Any elderly person with a 102 fever should really be seen in person by some type of medical health care provider.
So no house calls equals uncaring physician?

Yes, as I said, preferable, but impossible, now what?

In general I see the US healthcare system as uncaring, and yes, I believe many if not most physicians in the US either are uncaring or inept and went into medicine for the money. I grew up with a doctor and know a bunch of them and have worked for several, they do not get immediate respect from me, there's only a few I trust with my health.

 

[Gary F]

Yes, as I said, preferable, but impossible, now what?

In general I see the US healthcare system as uncaring, and yes, I believe many if not most physicians in the US either are uncaring or inept and went into medicine for the money. I grew up with a doctor and know a bunch of them and have worked for several, they do not get immediate respect from me, there's only a few I trust with my health.

The compassion score can be probably be modeled as a Gaussian distribution with medical saints on one end and greedy heartless bastards on the other. Most are somewhere in the middle. How can medical schools select more caring people and still maintain a qualified pool of applicants? I believe that people with a more aggressive personality may be better suited for some types of medicine including many of the surgical sub-specialties but the kinder gentler types function better as family medicine and pediatrics physicians.

 

[Henning]

The compassion score can be probably be modeled as a Gaussian distribution with medical saints on one end and greedy heartless bastards on the other. Most are somewhere in the middle. How can medical schools select more caring people and still maintain a qualified pool of applicants? I believe that people with a more aggressive personality may be better suited for some types of medicine including many of the surgical sub-specialties but the kinder gentler types function better as family medicine and pediatrics physicians.

Agree, now the first question if you please, the 70 year old patient on the phone with a 102 who can not make it in to see a doctor: do you go to their home and examine them bringing the likely courses of medication they will require, phone in the prescription on the preponderance of the evidence, or insist they go and see a health care professional and leave it at that?

 

[skippers]

How would a patient go about finding a concierge practice?

MDVIP.com

 

[douglas393]

It's been a while since I did internal medicine but I will give it a shot. Physical exam including eyeballing the patient, taking the vital signs including temp, HR, BP and oxygen saturation and auscultation (listening to the chest and heart with a stethoscope) is essential. Sputum cultures are rarely used (except for suspected tuberculosis) since they are contaminated by upper respiratory flora. Blood cultures should be obtained in sicker and immunocompromised patients. Chest x-rays can be very helpful to document the presence and extent of a pneumonia. These things are hard to do over the phone.

Gary sometimes its just not worth the waste of time. Face up to it, some nonphysicians just know more about medicine than physicians.

 

[douglas393]

First, I agree with everything you say. HOWEVER, in this country and our current culture, everyone believes that they are a customer and are always right. So your doctor (or lawyer or accountant or other professional) who gives someone bad news and doesn't make the person feel like a valued customer will find that the person will go elsewhere, EVEN IF IT MEANS THEY GET WORSE CARE/ADVICE, if they feel they're getting better customer service.

I get bad news from accountant, lawyer, and my aircraft mechanic all the time, and still use them. Sometimes they do not even make me feel valued but such is life, I use them because they do a good job and save me from my own stupidity, well most of the time.

Educating the patient that "no, really, you shouldn't take any antibiotics for this, as it won't help and in the long run will make you more susceptible to serious resistant infections", will likely only work on a very small number of patients.

It works in more than I think it would.

It occurs to me that I have similar "education" issues when it comes to aviation safety. The folks who "own" their flight safety/proficiency and show up for the safety seminars or seek out a good CFI for a flight review are in the minority, and they're not the ones at risk. It's the ones who expect results with minimal involvement/effort that can't be reached and they're the ones who need it the most.

Speaking to the choir never gets to those who do not show up.

 

[Henning]

Gary sometimes its just not worth the waste of time. Face up to it, some nonphysicians just know more about medicine than physicians.

The issue here is not medicine, the issue here is ETHICS.

 

[Gary F]

Agree, now the first question if you please, the 70 year old patient on the phone with a 102 who can not make it in to see a doctor: do you go to their home and examine them bringing the likely courses of medication they will require, phone in the prescription on the preponderance of the evidence, or insist they go and see a health care professional and leave it at that?

I will recommend that she be seen by a health professional. We keep phone numbers of family members in our system and I might ask my nurse to call one to see if we can get them to take the patient to their local ER. In rare cases we have called an ambulance to pick up patient to be taken to the ER.

I have patients who live in a large geographic area (about 15,000 sq. miles) so house calls are not a practical option. Every 8 to 10 weeks I spend a week on the road traveling to rural clinics up to 200 miles away. In the summer I might even fly to some of them.

I practiced primary care (internal medicine) for 3 years. One of the reason I left was that patients frequently asked or demanded a treatment that was not in their best interest. I am certain that I would have been held responsible if the patient's treatment plan did not work as intended.

 

[Henning]

I will recommend that she be seen by a health professional. We keep phone numbers of family members in our system and I might ask my nurse to call one to see if we can get them to take the patient to their local ER. In rare cases we have called an ambulance to pick up patient to be taken to the ER.

I have patients who live in a large geographic area (about 15,000 sq. miles) so house calls are not a practical option. Every 8 to 10 weeks I spend a week on the road traveling to rural clinics up to 200 miles away. In the summer I might even fly to some of them.

I practiced primary care (internal medicine) for 3 years. One of the reason I left was that patients frequently asked or demanded a treatment that was not in their best interest. I am certain that I would have been held responsible if the patient's treatment plan did not work as intended.

We've established what your recommendation is, we have already established that is not going to happen. Now, what do you do NEXT, or do you just keep repeating over and over that they should see a doctor? A doctor patient relationship is like any other, you don't always get what you want. The question is what do you do then? That is what defines character, what you do when you don't get your way.

If you call the ambulance leaving that person no option but to go to the hospital, or refusing because they can't pay the bill and they are still stuck with an ambulance charge of a few thousand dollars for it showing up, do you pick up the bill? If not, where did you suppose you had the right to incurr debt for someone else against their wishes?