Grand Junction Tales From A Simple Nascar Loving Doctor, aka Lil Q

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Grand JunctionTales From A Simple Nascar Loving
Doctor, aka Lil Q

• James Quackenbush, M.D.
• Primary Care Partners

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Family Practice in Grand Junction

• The city
• The practice
• The preceptor
• Patient population/Chief complaints
• Patient presentation

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The City
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The City

• Located in the Grand Valley of western Colorado
  (aka Wine Country), Grand Junction is the
  largest city between Denver and Salt Lake City.

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The City
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The City

• Located at the confluence of the Gunnison River
  and the Colorado River, hence Grand Junction.

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The City
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The City

• Population 48,141
• Including outlying towns 126,445
• Elevation 4586 feet

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The City
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The Practice

• Primary Care Partners- A large institution
  comprised of merged pediatric and family
  practices from around town.
• In house pharmacy, lab, diagnostics,
• physical therapy, social work, wellness
  clinic, diabetes educator, after hours clinic

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The Practice

• After hours clinic DOCS on Call
• Clinic in same building open from 5-10pm
  weeknights and both weekend days until 10pm.
• Staffed by two full time physicians
• (See attached article)

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The Preceptor

• Dr. James Quackenbush (Lil Q)
• Dr. Q is CU Medical School alumni, and also
  played football as an undergrad at CU Boulder.
  He is a large person, both physically and in
  personality. Who else takes his students home
  everyday for lunch carefully and lovingly
  prepared by his wife? Who else makes house calls
  these days? His patients LOVE him! (Oh, and he
  loves NASCAR)

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Patient Population

• Majority Caucasian women aged 19-64
• Chief Complaints mostly routine health
  maintenance exams, also frequent URIs, HTN
  checks, DM checks, prenatal care, depression,
  anxiety, other mood disorders
• Procedures skin lesion excisions/biopsies,
  joint injections, vasectomies

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Chronic Disease Management Patient presentation

• CC I have been taking pictures of my genitals
  and showing them to random people and having
  phone sex with strangers.

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Patient Presentation

• HPI This is a 35 year old woman who is married
  and has one daughter. For the last 2-3 weeks she
  has been feeling out of control sexually and
  engaging in very risky sexual behavior.

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Patient Presentation

• She has not actually physically engaged in sexual
  activity with anyone but her husband, however she
  has phone sex regularly and shows strangers
  pictures of her genitalia.
• Her behavior quite concerning, and she is
  normally very shy, quiet, and church-going.

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Patient Presentation

• She states that her husband is concerned because
  she wants to have intercourse 1-2 times per day
  whereas in the past it has only been once a week.
  She also is extremely uninhibited during sex,
  which is also new for her.
• (Yes, even though her husband likes aspects of
  this, he is concerned!)

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Patient Presentation

• She has also been shopping much more frequently,
  especially online, and has been quite irritable
  lately. (Not as interesting as the sexual
  behavior, is it?)

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Patient Presentation

• PMH The patient has a long history of
  depression and has been treated in the past with
  Zoloft and Prozac with moderate success. Since
  becoming pregnant 5 years ago, she stopped all
  antidepressants and has not used them since.

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Patient Presentation

• About 5 weeks ago, the patient had a visit with
  Dr. Quackenbush because she was feeling depressed
  again. Due to her history of depression and
  previous use of antidepressants, Dr. Q
  appropriately started her on Zoloft again.

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Patient Presentation

• However, this time we induced MANIA in this
  bipolar patient! (Oops!)

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Patient Presentation

• In retrospect, the patient recalled a time about
  ten years ago when she felt like this and also
  demonstrated risky sexual behavior. At the time,
  however, she attributed this to being young and
  wild.

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Patient Presentation

• Plan Dr. Q immediately called his favorite
  psychiatric colleague who suggested starting
  Zyprexa and Lamictal and tapering the Zoloft. We
  took his advice and scheduled to see the patient
  back in 3 days.

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Patient PresentationChronic Care Model

• Self Management
• This patient was already demonstrating self
  management by coming in for help. She also read
  about bipolar disorder because she suspected she
  may have itI wonder what tipped her off

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Patient PresentationChronic Care Model

• Decision Support
• As Dr. Q does not manage a large number of
  bipolar patients, we did not have an in-office
  protocol of research supported guidelines.
  Being the resourceful physician that he is,
  however, Dr. Q acted quickly and called a
  psychiatrist.

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Patient PresentationChronic Care Model

• Delivery System Design
• We carefully explained to the patient how to
  change her medications and wrote it out for her
  as well.
• We also told her that shed be referred to a
  psychiatrist, but wed also continue to follow
  her during this acute stage.
• Dr. Q and this particular psychiatrist have a
  great working relationship and share several
  patients.

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Patient PresentationChronic Care Model

• Clinical Information System
• PCP uses a great electronic medical records
  system that also very efficiently communicates
  with physicians outside of PCP. Dr. Q can also
  send himself reminders about patients via the
  system that pop up on a certain date. (i.e. a
  reminder to check in with patient after appt.
  with psychiatrist)

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Patient PresentationChronic Care Model

• Organization of Health Care
• PCP itself is an amazing organization that very
  efficiently takes care of patients with chronic
  illnesses.

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Patient PresentationChronic Care Model

• Community
• PCP has strong alliances with many specialists
  in town, and Dr. Q himself is very involved with
  church groups, the public schools (he gives the
  puberty talk), and other various groups around
  town.

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Patient PresentationChronic Care Model

• Back to the patient
• She returned in 3 days and felt a little more
  sedated, but still had phone sex that day.
• She returned again 1 week after the first visit
  and felt about the same.

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Patient PresentationChronic Care Model

• She returned 2 weeks after first visit and
  stated that she felt better but had had phone
  sex the day before. She was starting to feel
  guilty about the things she was doing and
  wondered if she should tell her husband.

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Patient PresentationChronic Care Model

• She will continue to follow up with Dr. Q and
  her psychiatrist but also has other resources
• support groups
• church groups
• family

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Pop Quiz

• What is the population of Grand Junction?

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Pop Quiz

• What is Dr. Qs favorite hobby outside work?

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Pop Quiz

• What were some things we did for our patient that
  may have improved her outcome?

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Pop Quiz

• What is one way in which PCP is effectively
  managing patients with chronic diseases?