Dr Plainslove

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Dr Plainslove
Or How I Learned to Stop Worrying and Love the
Family in Family Medicine
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http//maps. google.com/
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Brush!
Population (2005) 5,357 Median household
income 31,333 (year 2000) Median house value
86,500 (year 2000) The racial makeup of the
city was 75.81 White. Hispanic or Latino of any
race were 37.21 of the population
Data from http//www.brushcolo.com/ and
http//en.wikipedia.org/wiki/Brush,_Colorado
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BHS Wrestling Takes State
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Family Medicine

• Preceptor Marc Ringel, MD
• Site Brush Family Medicine (BFM) and East
  Morgan County Hospital
• Includes Hospital and services, Alonzo Petteys
  Rehabilitation Center, Brush Family Medicine and
  Specialty Clinics

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Specialists in Brush

• Cardiology
• Neurology
• Pulmonology
• Rheumatology
• Oncology
• Urology
• Orthopedics
• Gastroenterology
• Endocrinology
• leaving this month, no replacement
• Podiatry
• Prosthetics/Orthotics
• Wound Clinic (weekly NP and monthly tele-clinic
  with wound MD)
• Coag Clinic

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The Practice

• 2 Family Medicine MDs
• 1 Med/Peds MD
• 1 General Surgeon
• 1 FNP
• 1 PA
• Many nurses
• MDs and FNP cover ER, MDs round on their clinic
  patients who are hospitalized
• MDs, NP and PA alternate visits to nursing homes

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The Patients

• Primarily adults, rather geriatric population
• Multiple nursing homes and assisted living
  facilities
• Dr. Ringel is Medical Director at facility across
  the street
• Some children and adolescents (more seen by other
  providers in the clinic)
• Very little Well-Woman and Well-Child care by the
  MDs
• Well-Woman Exams done almost exclusively by the
  NP and PA
• No Obstetrics

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The Common Problems

• Chronic Pain especially back neck
• Depression
• Hypertension
• Diabetes Mellitus Type II
• Acute Upper and Lower Respiratory Illnesses
• Workmans Comp Evaluation and F/U
• Dementia

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Chronic Disease Patient

• Mary, 89 year-old woman
• Lives alone, 3 houses down from daughter, Susan,
  who always accompanies her to clinic
• New patient to Dr. Ringel (one prior visit)
• Seen 3 times during rotation
• Daughter seen once as new patient for chronic
  disease management
• Names have been changed

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Chronic Disease Patient

• Chronic Medical Problems
• First seen in 2004 Uncontrolled HTN (referral
  from cardiologist)
• COPD on 02 since 2004
• Osteoporosis
• Hypothyroidism
• Hyperlipidemia
• Urinary Incontinence
• Valvular Heart Disease
• Severe Diverticulosis Constipation
• Pain

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The Encounters

• The First Encounter
• Mary first saw Dr. Ringel 1 week ago.
• Mary hardly speaks, her daughter does all the
  talking, very rapidly, and is somewhat hostile.
  She disparages EMCH, did not like the last
  provider they saw at BFM and drove her mother all
  the way to Greeley for emergency treatment for
  abdominal pain, bloating and nausea.
• Mary was hospitalized there for diverticulosis
  and partial bowel obstruction.

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The Encounters

• The First Encounter
• Mary is constipated
• She is having lower back pain.
• Susan is worried about her mothers loss of
  appetite. Mary has made threats to move to
  assisted living.
• Start treatment for constipation and suggest ways
  to increase caloric intake.
• Schedule tramadol from PRN to try to keep ahead
  of back pain.
• TSH checked at last visit was high?increase
  levothyroxine.

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The Encounters

• The Second Encounter 1 week later
• Susan still dominates but Mary speaks more. She
  is not feeling significantly better. She is very
  constipated, sometimes feels her abdomen is
  distended, MoM causes large uncontrolled BMs.
• Back pain is better controlled but still
  problematic. They are confused by X-Ray reads
  and want explanation for LBP.

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The Encounters

• The Second Encounter
• Susans concerns
• Mary is not eating well.
• Mary is becoming confused. Susan threatened to
  put Mary in assisted living. She thinks her
  mother is depressed but Mary does not agree.
  Susan repeatedly notes that Mary has been healthy
  until now and has never experienced chronic
  illness or chronic pain.
• We start low dose of long-acting morphine and
  continue tramadol for breakthrough pain, also
  scheduled psyllium and lactulose instead of PRN
  MoM. We order bone scan to evaluate for possible
  fx.

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The Encounters

• The Second-and-a-Half Encounter
• Susans first appointment
• Speech is slowed from first encounter but still
  rapid. She talks about her mother, fears she is
  dying. Difficult to steer conversation toward
  her own care.
• She has typed list of chronic complicated
  medical problems, dx dates and Drs. as well as
  typed list of current meds. Problems include
  thyroiditis, anxiety, depression w/ hx of suicide
  attempt, HTN, chronic pain. Today she wants to
  d/c BZD she has taken for years.
• Mentions several times Marys upcoming next
  visit. Is now more trusting of our care, seems
  to look forward to our input.

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The Encounters

• The Third Encounter
• Completely different from first
• Mary speaks for herself, Susan offers additional
  information when Mary cant recall. Mary jokes
  with us.
• Still constipated, worse than before and went to
  the EMCH ER last week.
• Her pain is well controlled when she remembers to
  take tramadol.
• She thinks she may be depressed.

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The Encounters

• The Third Encounter
• We order supine abdominal X-Ray and have results
  from next door by lunchtime and tweak bowel
  regimen
• Pain is well controlled if Mary takes meds, Susan
  continues to type daily med checklist.
• Start citalopram for depression
• Will see them again in 2 weeks.

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The Issues

• Forming a trusting patient-physician
  relationship.
• Having come to know and trust us, both the
  patient and her daughter had very different
  attitudes by the 3rd encounter, gave better
  history, relied more on local resources and were
  more compliant.
• Learning to negotiate patient encounters with
  family members present parents speaking for
  children, children who take over for parents,
  spouses who dominate interview.
• Community resources
• Good access to medical care including
  specialists, home health care available, but
• Poor community resources for depressed (or
  lonely) patients other than assisted living/SNFs
  and
• Scarcity of psych services outside the Family
  Doctors office.

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The Family in Family Medicine
It takes a caring and skilled physician to find
the balance between focusing on the patient while
meeting the needs and concerns of the family
because out here, they are ALL your patients!