topic: Dr. Ken's Corner

Has the Power of the Bedside Exam Been Forgotten?

There was a time when the doctor's black bag, filled with its assortment of diagnostic tools, was indispensable. It was a time when medicine was "high touch, low tech." Today, the reverse is true. Too many of us have abandoned the thorough bedside examination in favor of sending the patient off for an MRI or CT scan!

This is unfortunate, says Dr. Abraham Verghese of Stanford University's School of Medicine. In his keynote address at the recent Texas Medical Association meeting in San Antonio, Dr. Verghese told his colleagues to "pick the low-hanging fruit," to first do a thorough diagnostic exam at the bedside. Then decide what further studies are needed.

Although making an astute diagnosis is important, says Dr. Verghese, there's another reason for a thorough bedside exam -- "the power of the doctor's touch" -- what he refers to as a ritual and the "pinnacle" of the physician-patient relationship.

To make his point, Dr. Verghese has gone back to carrying a black bag on hospital rounds. In addition to its usual tools, he's added two more -- an iPad and a hand-held ultrasound. The iPad has proven to be a valuable teaching tool, not only for his medical students, but for patients as well. And, although the hand-held ultrasound does not take the place of additional imaging studies, it has added another dimension to the physician's capacity to make an accurate diagnosis at the bedside.

(To sharpen your bedside skills, I highly recommend The Stanford 25Website, "an initiative to revive the culture of bedside medicine,")

Ken Teufel is the Medical Director for Interim Physicians

Between a Rock and a Hard Place

"If I don't do this test and something goes wrong, how do I defend myself?" We've all done it: ordered certain tests or procedures, many quite expensive, "just in case." The fear and threat of a malpractice claim is probably the main driver of "unnecessary" testing, oftentimes to simply document what we already know and oftentimes to the detriment of the patient.

With input from a number of specialty organizations, the American Board of Internal Medicine Foundation has put together a list of 90 commonly used medical tests and treatments that it deems overused. Here are a few examples:

Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer diseases.
American Board of Family Physicians

Don't indiscriminately prescribe antibiotics for uncomplicated acute sinusitis.
American Academy of Allergy, Asthma and Immunology

Don't perform EEGs for headaches.
American Academy of Neurology

Don't order antibiotics for conjunctivitis ("pink eye").
American Academy of Ophthalmology

Cough and cold medications should not be prescribed or recommended for respiratory illnesses in children under four years of age.
American Academy of Pediatrics

Don't perform annual stress cardiac imaging as part of routine follow-up in asymptomatic patients.
American College of Cardiology

Don't schedule elective, non-medically indicated induction of labor or Cesarean deliveries before 39 weeks 0 days gestational age.
American College of Obstetricians and Gynecologists

Don't obtain imaging studies in patients with non-specific low back pain.
American College of Physicians

Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
American College of Radiology

Do not repeat colorectal cancer screening (by any method) for 10 years after a high quality colonoscopy is negative in average-risk individuals.
American Gastroenterological Association

Don't order coronary artery calcium scoring for screening purpose on low-risk asymptomatic individuals except for those with a family history of premature coronary artery disease.
Society of Cardiovascular Computed Tomography

To see the complete list and the reasons behind the recommendations, go to www.choosingwisely.org.

Ken Teufel is the Medical Director for Interim Physicians

The Patient Handoff: A Risk-Filled Few Minutes

In football, what are the chances of a fumble when the quarterback hands off to the running back? In medicine, what are the chances of a “fumble” when one doctor hands off the patient to another doctor? Quite high in both situations, and becoming more frequent in medicine.

The increasing fragmentation of patient care is a big part of the problem. Not too long ago, the primary care physician would follow the patient from hospital admission to discharge. Today, the patient may be cared for by five or six physicians during one hospitalization: an emergency room doctor, three or four hospitalists, perhaps two or three consultants. Each exchange increases the risk that vital information will be overlooked.

An estimated 80% of serious medical errors are caused by miscommunication between caregivers during the patient handoff, according to the Joint Commission’s Center for Transforming Healthcare. ”There are 4000 handoffs a day in a typical teaching hospital,” says Joint Commission President Dr. Mark Chassin. ”If 90% go flawlessly, that’s still 400 failures per day.” When a lawsuit occurs, everyone whose name is in the chart will have to defend their actions, including how effectively they communicated with their peers at the time of handoff. “Almost all claims have multiple defendants and points of contact,” says Dr. Alan Lembitz of the liability carrier COPIC.

How can we make handoffs less prone to error? First, we have to acknowledge that this is a really serious problem. When our colleagues in the operating room started using checklists, their error rates went down significantly. Creating a standardized checklist to be used at the time of a handoff could help as well. For example, a handoff checklist might include this basic information:

~ differential diagnosis
~ medications and the patient’s reaction to these medications
~ pending laboratory and imaging studies
~ names and contact numbers of all caregivers
~ names of key family contacts
~ physician now assuming primary responsibility for the patient

Other suggestions: Make every effort to communicate with the next provider face to face, and make sure the next caregiver not only receives and reads your report but understands it. Remember: Information is not communication.

(Reference: Malpractice Threats in Well-Intended Patient Handoffs. Medscape, October 4, 2012).

Ken Teufel is the Medical Director for Interim Physicians

Limited Work Hours for Physicians-in-Training... Or Not

The battle lines were drawn a decade ago, but the controversy is far from being over. A recent article in The Wall Street Journal returns to the question, “Should Medical Residents be Required to Work Shorter Shifts?” (February 19, 2013). Here are some of the rules now governing their work schedules:

An 80-hour weekly work limit, averaged over 4 weeks.
A minimum of one day off every week, averaged over 4 weeks.
A 16-hour limit on continuous duty for first-year residents.
A 24-hour limit on continuous duty for other residents.
In-house call no more than once every 3 nights, averaged over 4 weeks.

To keep their accreditation, residency training programs must report regularly to the Accreditation Council for Graduate Medical Education (ACGME) to show they they are following the rules. “I think we should challenge the whole idea of having a central committee dictate work limitations for all residency programs,” says Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons.

But, they don’t comply with the guidelines anyway, says Dr. Steven Lockley, sleep medicine specialist at Harvard Medical School. “A study by our research team [at Harvard] found 85% of residency programs were non-compliant with the work-hour rules.”

A survey done by the ACGME found only 5% non-compliance.

So what about patient safety? “When hours are reduced,” says Dr. Lockley, medical error rates fall enormously. No other simple solution comes as close as a way of cutting errors.” He adds that longer shifts affect physicians health and safety as well. “In surveys conducted by our group, residents working 24 or more hours in a row reported sticking themselves with needles 60% more often … as compared with [those working] shorter shifts.” “Yes,” says Dr. Orient, “people do tend to make more mistakes when tired. But the bigger reason for mistakes by physicians-in-training is lack of experience.” Dr. Orient believes that shorter shifts short-change the learning experience: “Many physicians, myself included, think new physicians are less well-trained. They have seen fewer patients and have done fewer procedures. [Consequently], future patients may pay the price when the less-experienced physician is working without close supervision.”

It’s almost impossible to take a neutral stance on this issue. As might be expected, older physicians are more likely to see the so-called “shift-work culture” as a threat to the traditional doctor-patient relationship in which doctors are customarily available outside “office hours.” Younger physicians are more likely to see patient care as “the collective responsibility of the team, rather than primarily the responsibility of ‘their doctor’.” Since this controversy is in part driven by differing attitudes between generations, it will take a while before it’s resolved.

Ken Teufel is the Medical Director for Interim Physicians

Physician Online Ratings: Good or Bad?

It seems like everyone is looking over your shoulder these days. Patients, hospital administrators, private insurance companies, licensing boards, government insurers (not to mention your fellow physicians). If you haven't done so already (but I'll bet you have) Google search yourself and your practice. You're likely to find very few ratings which means that "the ratings can be easily skewed by 1 or 2 very happy (or unhappy) patients, rendering them unreliable," says Chandy Ellimoottil, M.D., of Loyola University Medical Center. "Our findings suggest that consumers should take these ratings with a grain of salt." [Reference: Physician Online Ratings Unreliable, Easily Skewed. December 10, 2012. Journal of Urology.]

"There is nothing we can do to protect ourselves except to provide good, high-quality patient-focused care," says Dr. Scott Manaker of the University of Pennsylvania Health System. Speaking recently at the annual meeting of the American College of Chest Physicians, Dr. Manaker noted that we need to recognize publicly reported data as part of today's medical landscape, "whether good or bad, accurate or biased." [Reference: Who Is Rating You Online and What Can You Do About It? Medscape.com. November 9, 2012.]
Dr. Ellimoottil's survey of online ratings of 500 urologists found that patients submitted comments that were extremely negative 3% of the time (e.g. "He needs to retire as he can barely walk"), 22% were negative, 39% were positive, and 14% were extremely positive (e.g. "One of the best checkups in a long time!!"). By the way, the top physician rating Web sites are Healthgrades.com and Vitals.com.

It takes only one disgruntled patient to give you a negative online image. But, "it's not all beyond one's control," says Dr. Burt Lesnick of Atlanta. When interviewed for the Medscape article, Dr. Lesnick urged doctors to build their online presence on social networking sites, referring to them as "the mother of all physician ratings." He says that Facebook and Twitter are good ways to tell patients about yourself and your practice, plus "it's good marketing." When all is said and done, it's important to be proactive instead of trying to defend yourself against a few nasty comments.

Ken Teufel is the Medical Director for Interim Physicians

What happens when patients read their doctors' notes?

The doctors were apprehensive about opening their notes to their patients. "It will only lead to confusion," said some. "My practice will be overwhelmed by phone calls," they said. Yet 105 doctors agreed to open their records to more than 13,000 patients in an experiment called OpenNotes, published online in the Annals of Internal Medicine (October 1, 2012).

The doctors' concerns didn't pan out after all. In fact, after the study ended, not one of the doctors elected to stop sharing their notes with their patients. From the patients' perspective, "we were thrilled by what we learned," said Dr. Tom Delbanco, one of the study's lead authors. "We had no clue that so many patients would read their notes, and that they would be as enthusiastic and report so many clinically important changes in their behavior" (Reuters Health).

This study isn't the first to open doctors' notes to patients. Dr. Thomas Feeley said it confirms what he and his colleagues have experienced over the past several years at M.D. Anderson Cancer Center in Houston. "There are no downsides to doing it -- patients don't get worried [or] anxious about it," Dr. Feeley told Reuters Health. He adds that this new evidence should reassure doctors who have been "on the fence" about opening up their notes to their patients.

In some practices, this may mean making notes available to patients online. In others, the policy might be to mail doctors' notes to patients after every visit or simply print them out as the patient goes out the door.

Ken Teufel, M.D.
Ken Teufel is the Medical Director for Interim Physicians

Tired of Being a Doctor?

What do Tess Gerritsen, Robin Cook, and Michael Palmer have in common? Known for their best-selling medical suspense novels, they are all physicians. If attendance at writing workshops is an indication, a growing number of doctors would like to follow in their footsteps.

"Physicians are generally well-suited to almost anything they want," says Dr. Heather Fork, an Austin, Texas-based career coach. "If they've made it far enough to become a physician, it means they're intelligent, dedicated, hardworking, and able to work under stress and pressure. These are qualities that can be applied to any career."

Dr. Fork speaks from experience. After nine years as a dermatologist, she decided to sell her practice. "I wasn't enjoying dermatology as much as I thought I would." After some soul-searching, she completed an accredited coach-training program and then established her coaching practice called Doctor's Crossing. Dr. Fork was interviewed by Medscape for one of the "top ten" articles read by physicians in 2012: Tired of Being a Doctor? Choices for Opting Out of Medicine. February, 2012.

The Medscape article cites a 2010 survey of 2400 practicing physicians: 24% said they plan to quit clinical practice in one to three years. Of this group, half said they plan to leave healthcare entirely, and the other half plan a nonclinical but healthcare-connected career. No doubt, some will be taking on leadership roles in hospitals or other clinical settings. Over the past ten years, this career option has become increasingly popular as hospitals and health systems have expressed growing interest in hiring physicians for these jobs (American College of Physician Executives).

"A lot of doctors come to me confused and unhappy, and they aren't sure what they could or should do," says Dr. Fork. Although they often shortchange themselves, "the door is wide open," she adds. [A personal note: I'm concerned that some physicians wanting to opt out of clinical practice will act impulsively, "jumping ship" without a life preserver. KT]

Dr. Fork's advice in the Medscape article: "People need to have a firm grasp of bread-and-butter issues: How long can I afford not to work? Do my spouse and family support my decision? How much do I need to earn? But they also need to have a firm grasp of their skills and interest."

Dr. Ken Teufel
Ken Teufel is the Medical Director for Interim Physicians

Medical Schools: Friend or Foe of Primary Care?

"There's a crisis in primary care, probably much worse than most people realize," says Dr. Steven Berk, Dean of the Texas Tech University School of Medicine (The New York Times, September 9, 2012). Interestingly enough, on the first day of medical school, almost half of U.S. students surveyed intend to go into primary care. Why is it then that fewer than 20 percent actually end up in a primary care field like family or general medicine? What changed their minds between year 1 and year 4 of medical school?

Finances certainly play a role. U.S. primary care physicians earn $140,000 to $150,000 a year, but specialist can double or triple that amount. Add medical school debt to the equation and primary care becomes less attractive.

But, it's not just about money. "There's a culture of discouragement that exists in most medical schools around primary care," says Dr. Andrew Morris-Singer of Primary Care Progress. "A lot of medical schools disparage primary care." Quoted in the same New York Times article is Dr. Marjorie A. Bowman, the Chair of the Department of Family Medicine and Community Health at the University of Pennsylvania: "It is absolutely clear that [practicing primary care] is a lower prestige thing to do; if you're looking for prestige, family medicine is not where you go." Dr. Bowman adds that medical school deans and leaders need to show more respect for family medicine.

By 2020, the U.S. will have a shortage of 45,000 primary care doctors; by 2025, the projected shortage is 65,000 (Association of American Medical Colleges). To address this shortfall, our medical schools must become part of the solution. Right now, they're part of the problem.

Ken Teufel, M.D.
Ken Teufel is the Medical Director for Interim Physicians

Is Solo Practice Dead?

Is Solo Practice Dead?

Solo practitioners have read the obituary. And, just like Mark Twain, they have answered: “The reports of my death are greatly exaggerated.”

No one can deny that certain forces are threatening the future of solo practice. The hassle factor is at all-time high: more rules and regulations; rising malpractice premiums; bigger medical school debts; challenging information technology demands; flat or declining reimbursement. It’s hard to resist the attractive salaries and signing bonuses now being offered by hospitals and physician-directed groups. For many physicians, it’s a seductive alternative to building a practice “from scratch.” For other physicians, it represents a loss of autonomy, the underlying motivation for physicians seeking a more entrepreneurial lifestyle.

Having been a solo practitioner, I would argue that solo practice is not dead, just different from its traditional image. As hospitalists take over the inpatient responsibilities, today’s solo practitioner is more likely to have an “office-only” practice. Many solo practitioners are devoting more time and effort to patient wellness programs. Many have taken on the role of patient advocate, helping their patients navigate their way through an increasingly complex healthcare system. The growing interest in “concierge medicine” also falls into the domain of the solo private practitioner.

Another viable option for those with a solo practice mindset is locum tenens medicine. It offers the appeal of autonomy, flexibility, good income, and paid malpractice insurance, backed by the support of a caring team of experienced professionals.

Is solo practice dead? Not really.

Ken Teufel, M.D.
Ken Teufel is the Medical Director for Interim Physicians

Physician Burnout: Common But "Curable"

"My wife and I had come to realize one of the chief difficulties of the family doctor -- the constant drain upon the emotions. To stand helplessly while relentless organisms destroy a beautiful mother, a fine father, or a beloved child creates terrible emotional distress; and this feeling is increased by the necessity of suppression. That is why the average lifetime of family doctors is 55 years, most of them succumbing to functional impairment."

How depressing is that? It was written in 1939 by Dr. Joseph A. Jerger. Today, we might say that he and his physician colleagues succumbed to a bad case of "burnout," characterized by a loss of motivation, ideals, and hope. Untreated, it can lead to disengagement and even depression.

"Burnout is a gradual process that occurs over an extended period of time," says Dr. Jeanne Segal. "It doesn't happen overnight, but it can creep up on you if you're not paying attention to the warning signals."

Some signs and symptoms of impending burnout:

~ feeling of being trapped
~ sense of failure and self-doubt
~ decreased sense of accomplishment
~ withdrawal from responsibilities
~ taking out your frustrations on others
~ increasingly cynical and negative in outlook
~ use of alcohol and/or drugs to cope with daily living

Insidious as it may be, burnout can almost always be prevented or "cured." Here are three tips from Dr. Segal:

1. Set boundaries. Don't overextend yourself. Learn how to say "no" to requests on your time.

2. Take a daily break from technology. Set a time each day when you completely disconnect. Put away your iPad and stop checking email.

3. Nourish your creative side. Creativity is a powerful antidote to burnout. Try something new. Start a fun project, or resume a favorite hobby. Choose activities that have nothing to with work.

"As I learned through hard experience, the practice of medicine is a black hole that can absorb every moment you will give." (M. Foster, M.D., Medical Economics, October 23, 1995).

The practice of medicine may be your calling and your very identity, but it doesn't have to be your downfall.

Ken Teufel, M.D.
Ken Teufel is the Medical Director for Interim Physicians

The Non-Compliant Patient, Dismissing Should be a Last Resort

Not long ago, a pediatrician colleague and I were discussing the current recommendations for childhood immunizations. The conversation soon drifted toward the issue of parents who refuse to immunize their children against certain illnesses. This particular pediatrician, one of a six-member practice, said he and his partners had decided that children of parents who refused to have their children immunized would no longer be seen in their practice.

This issue of non-compliance is probably more prevalent than ever. More diagnostic and treatment options for more illnesses have made decision-making for doctors, as well as their patients, increasingly complex. Patient access to medical advice on the internet sometimes creates confusion and conflicting alternatives.

When a patient refuses a procedure or recommended treatment, is it ethical or appropriate
for a physician to drop the patient? It's my personal opinion that dismissing a patient should be a last resort. Every effort needs to be made to understand the patient's perspective and tactfully explain our own position.

If all else fails, and the decision is made to terminate the relationship, it's important to document that the patient has been informed of the possible consequences of failing to follow medical advice. To avoid being sued for abandonment, it's critically important to carefully follow our medical society's protocol for discharging a patient from our practice.

Every doctor has made a commitment to care for their patients as best as we know how. In the end, however, it's still the patient's decision whether or not to follow our advice.

Ken Teufel, M.D.

Hanging Up the Stethoscope

Which is more difficult: taking away Grandma's car keys or telling a doctor he's "too old" to practice medicine anymore? Should there be a mandatory retirement age for surgeons as there is for commercial airline pilots?

The physician workforce is America is not getting any younger; in fact, it's getting older. A recent survey in Virginia found that at age 65 more than one-third of physicians still in practice were working at least part-time.

Dr. Peter Carmel, president of the American Medical Association, is a pediatric neurosurgeon still operating at the age of 75. "America's patient population needs us," says Dr. Carmel (amednews.com, April 30, 2012). "This country is facing a shortage of doctors to meet the needs of our growing and aging population." Filling this gap, however, cannot be a trade-off for making certain that all patients have access to quality care.

The consensus in the medical profession is that clinical performance, not age, should determine whether or not a physician should be asked to step aside. Yet, physicians themselves are probably not the best judge of their competency. If that's the case, how does one "take away the keys" when an older physician wants to keep practicing? Should there be an annual recertification at some point, perhaps age 70? Or, should there be mandatory peer evaluations for all physicians over a certain age?

Facing the "R-word" is not easy, especially when one's personal identity is so tied to their profession.

Ken Teufel, M.D.

About those "45 dubious practices"...

You know it's going to be a bad day when your most challenging patient comes into your office with the list of "45 most dubious tests and therapies." Recently, nine American specialty societies each identified five procedures, tests, or treatments that are routinely used but may not always be necessary.

Among the recommendations: Don't take a "routine" pre-op chest x-ray if the patient has an "unremarkable" history and physical exam. Don't do a cardiac stress test or treadmill on a patient who has no cardiac symptoms or other significant risk factors for coronary artery disease. Don't routinely prescribe antibiotics for mild-to-moderate sinus infections unless symptoms last for seven or more days. Most sinusitis is viral and will resolve on its own.

Do these recommendations reset the standard of care? Will they allow physicians to practice medicine less defensively when ordering tests from their diagnostic toolbox?
Rather than limiting choices, the "45 dubious practices" open the door to new discussions with our patients. After all, even with the most challenging of patients, practicing good medicine is still a matter of shared decision-making between doctor and patient.

Ken Teufel, M.D.

Physicians need coaches, too

Nearly every great tennis player has a coach. Singers, executives, and even applicants trying to get into medical school have coaches today!

General surgeon Dr. Atul Gawande says practicing physicians need coaches, too (New Yorker magazine, October 3, 2011). He got a coach when he felt his career had reached its peak. After eight years in practice, he felt that his surgical skills were no longer improving. That's when he asked a highly respected, retired surgeon to look over his shoulder in the operating room, then give him advice on what he might do to improve his performance. Dr. Gawande is convinced that having a "coach" has made him a better doctor.

In medicine, the presumption is that, after a certain point, you no longer need instruction. You finished your residency. You're done. The coaching model holds that "no matter how well-prepared people are in their formative years, few can achieve and maintain their best performance on their own," says Dr. Gawande.

Coaching is not limited to the operating room. Perhaps a coach could help us improve our communication skills. How to give bad news to patients. How to communicate more effectively with our peers. How to handle the "difficult" patient.

The possible benefits? Fewer malpractice suits. Better patient compliance. Maybe even more satisfaction from doing what we do for a living.

Ken Teufel is the Medical Director for Interim Physicians

Should Physicians Use Email to Communicate with Patients?

It's a "slippery slope," as they say. You either like it or you don't. In today's Wall Street Journal (January 23, 2012), two doctors go head-to-head on this issue.

Dr. Joseph Kvedar is a staunch advocate for using email to communicate with patients:
"...making myself available via email gives my patients a sense of direct access to me. It sends a message that I care and that I'm available to answer questions in a timely manner. It builds a bond between us that has tangible benefits for my patients' health."

Dr. Sam Bierstock takes the opposite view:
"The doctor's office is where medicine should be practiced." He argues that "email raises privacy issues," and it's "a treasure chest for malpractice attorneys." Although Dr. Bierstock says email "can be useful for appointment scheduling and prescription refills...it is no way to practice medicine."

I appreciate the viewpoints on both sides of this issue. But, one of my concerns (not addressed in the Wall Street Journal article) is that many patients are either not able to communicate effectively by email or prefer direct, face-to-face contact. Then there's the concern about the importance of nonverbal communication that cannot be appreciated in an email message. Even if we support email communication with patients, we must also recognize that not all of our patients have computer skills or English proficiency.

Where do you stand on the use of email in communicating with patients?

2011 has been a year for some real "game changers" in medicine

2011 has been a year for some real "game changers" in medicine. One is the report published in The Lancet this year pointing to a dramatic 34% drop in cancer mortality after five years of regular aspirin use. Another game changer is the Cochrane Review published in September suggesting that probiotics are better than a placebo at reducing the number of acute respiratory infections. But, according to Medscape, the number one game changer this year is...

"Vitamin supplements associated with increased risk of death." Published in October, this study followed 38,000 women over 22 years (hardly a small study). The bottom line conclusion is that there are very few if any benefits from vitamin and mineral supplements.

A study in the British Medical Journal in April 2011 showed a 20% increased risk of heart attack and stroke in people taking both calcium and vitamin D. A report in the October 12 issue of JAMA reports that men taking 400 IU of vitamin E per day increase their risk of prostate cancer by 17%.

In other words, more is not necessarily better. Making matters worse, Americans spend over 20 billion dollars annually on dietary supplements.

Happy new year!

Ken Teufel

Ken Teufel is the Medical Director for Interim Physicians

Locum Tenens Physicians Can Make a Difference in the Developing World

Greetings from Laos!

No, Interim Physicians is not setting up a branch in Southeast Asia. I'm here to help establish a four to six-week study abroad course for U.S. medical students. You may be aware of the unprecedented growth of global health studies in many of our medical schools. My own alma mater, the University of Texas Medical Branch at Galveston, has a well-established global health track that includes required study in developing countries. Duke and the University of Washington (among others) have similar programs.

Of course, interest in spending some time in developing countries is not limited to medical students. Physicians just out of residency training as well as those in established practices are now working abroad for weeks or months, sometimes several times a year. A number of non-government organizations offer such opportunities in Asia, Africa, South and Central America.

Just complete your residency? Why not integrate short-term service abroad with assignments from Interim Physicians when you're here at home? Already in a practice commitment? Ask Interim Physicians to cover your practice until you get back.

"Making a difference" in the developing world has never been easier.

Ken Teufel is the Medical Director for Interim Physicians

How an Interim Physician Helped Change University Policy

What do you do next, doctor?

Interim Physicians has placed you into an assignment at a university student health center. The first day there, you are asked to take care of an unmarried female patient, a 17-year-old freshman complaining of a persistent sore throat. What's the first thing you do?

a) Do a throat culture and wait for the results before deciding whether or not to treat with antibiotics.
b) Do a throat culture but start antibiotics while waiting for the results.
c) Find out if parental consent has been given to treat this young woman.

This a somewhat of a trick question. The best answer is "c." Given this scenario, you need to assume that the patient is a minor: someone under the age of 18 who has never been married and never been declared an adult by a court. (See Neavel and Tyson, Liability and Reporting Issues in Adolescent Medicine.)

Thanks to an Interim Physicians doctor on an assignment, a Texas university recently clarified its policy regarding treatment of minors at its health center. Specifically, the university now requires all students under the age of 18 have parental consent on file before being treated. This avoids the whole issue of having to determine whether or not a patient under the age of 18 can be called an "emancipated minor." (Note: This anecdote is provided as a commentary on the treatment of minors and is not intended to provide advice on any specific legal matter.)

The "take home" message is this: To properly care for adolescent patients, physicians should be aware of the consent and confidentiality laws specific to the state in which they are practicing.

Ken Teufel is the Medical Director for Interim Physicians