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Should Surgeons Outsource Patient Relationships To Psychiatrists?

“Psychiatrists may be the last batch of physicians who are still granted a luxurious amount of time with patients.”

So says Maria, a psychiatrist who blogs over at intueri.

And because time is so undervalued in our health system, some doctors are relying on psychiatrists to counsel patients in the hospital. She cites an example with surgeons, saying that “it is entirely unfair to both the patient and the psychiatrist for the surgeon to completely emotionally ‘turf’ the patient.”
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*This blog post was originally published at KevinMD.com*

When Your Teen Starts Dating

After you get over the urge to run and hide, lock your teen in the bathroom, shave his or her head, and save yourself, take a deep breath and think about what is important here. You are likely panicked because you know that sooner or later someone will break your teens heart – and there is nothing you can do about it, or is there?

Talk to your teen and share what you are feeling as well as what you know. Being new to the world of love/lust/hormones, there are some really great conversations to be had now about balance, friendship, and healthy relationships! First, your teen may be overwhelmed with how wonderful it feels to be in love and you can help remind your teen about balance, and the importance of not losing themselves for love. Your teen needs to stay “true to self” instead of becoming an appendage to the new love. Encourage your teen to stay connected to friends, school, outside activities, family, and sports, while making room for the new love.

You might mention that if that becomes an issue, you can help by setting limits on the amount of hanging out at home, phone, text, and computer time, to help her learn to balance life and love/lust/hormones. This is not a threat – just a supportive way to help your teen transition in the world of love!

Together you can set the expectations that honor this new part of life, make your teen feel listened to and involved with the new contract – the new couple spends time with the family, grades stay up, activities continue, chores, whatever else her life includes must all continue – because your teen has to be a “person” first before a girlfriend or boyfriend. The We’re Talking web site has a great section called the abcs of healthy relationships, which will provide many reminders about knowing when a relationship is not healthy.

Along those same lines, it is important to talk about the importance of friendship – and how you want the first few months together to be spent with family – because early in relationships the goal is to learn to trust each other, find things that you have in common, and become parts of each others lives. Friendship is stronger in the long run than hormones – and if either member of the couple is motivated by anything else other than love – s/he will not make it through the “getting to know all about you” phase.

P.S. Remember that the greater the age difference, and the more time alone they share, the more likely teens will take new love to sexual realms, so be aware and good luck!

This post, When Your Teen Starts Dating, was originally published on Healthine.com by Nancy Brown, Ph.D..

Teen males: Getting their minds out of the gutter

By Stacy Beller Stryer, M.D.

I read an interesting article in the New York Times last week, “Inside the Mind of the Boy Dating Your Daughter.” When I saw the title, I was instantly drawn to it because my older daughter is going to enter high school in the fall (yikes!) and has recently begun talking about boys. She currently attends a magnet school where most of her classmates are female. She just mentioned, for the first time, that there are no boys to like in her program, which makes for boring sleepover talks (but makes her mother exceedingly happy). Given that I think she’s the cat’s meow, I thought I could get a little “inside information” from reading the article before throwing her into the world of male testosterone and upperclassmen.

However, the article totally surprised me. Coming from a family of 3 girls and having 2 daughters, myself, I am much more comfortable figuring out what a girl might be thinking or feeling than a boy. I must admit that I believed the folklore that teen boys basically have sex on their brains. But, according to a study recently published in the Journal of Adolescence, this is not the case.   Researchers had 105 10th grade teens complete a survey about sex, love and relationships. Reportedly, most boys said the main reason they would date someone was because they “really liked her.” The second most common reason they wanted to date someone was to get to know her better, and because they were physically attracted to her. Of note, 40% of the boys stated that they had already been sexually active and 14% wanted to have sex to lose their virginity. We must remember, however, that this was a relatively small sample size done in one school.

As a follow-up, the New York Times asked people to send in their comments about the article, and they discussed the results in the Week in Review Many of the comments sent in were from adult men, who didn’t believe the teens answered honestly because, as these adults remembered, (?is their memory correct) they thought about sex, and only sex as teens.

An important and notable comment made by Dr. Andrew Smiler, the author of the study, is that parents are less likely to talk to their sons about relationships than their daughters. He stressed the need to talk to boys frequently about relationships, respect, trust and sex.

This gives me some hope that my daughter won’t be bombarded with a storm of testosterone the moment she enters high school. Actually, I am not too worried because I have been preparing her for the world of “boys” since she was much younger. For years we have talked about puberty, and as she has become older we have added relationships, values, possible uncomfortable situations, and waiting to have sex. I believe that this will carry her a long way. And, according to research, I am right, because telling a teenager to wait to have sex actually makes it more likely that they will.

As parents, we must remember to talk to both our daughters and our sons. Our discussions should start early. In elementary school, they should know what puberty is and how boys and girls develop. They should also learn about love and respect. As preteens, they should have talks regarding dating, relationships, and sex. If you wait too long, they will not hear you, or they will already have had to deal with a sexual situation and may not have known how to handle it. Amy Mirion and Charles Miron, authors of How to Talk With Teens About Love, Relationships, and S-E-X, also discuss how important it is to have small, ongoing dialogue rather than the one “big sex talk.” They suggest that, when parents talks with boys, they be direct and simple, and that they include topics such as love, respect, and values. They also stress the need for boys to actually be told to wait before having sex.

Just in case, maybe I’ll send some pepper spray to school with my daughter next year …

For more information on how to talk to your children about relationships, sex, and other risky behavior, check out the following websites:

4parents.gov

WebMD

Children Now

Brilliant JC Penny Viral Marketing Campaign: Men vs. Women

Men in Dog House

h/t to Dr. Wes

Bonus: try to hear the “messages” being voiced in the background.

Medical Morale Hits New Low

I was catching up on my Wall Street Journal blog reading, when I came across a post about a physician who was sued for prescribing painkillers to a patient who proceeded to crash her car. The crash killed a pedestrian, and the victim’s wife is now suing the driver’s doctor. Obviously, this case sends chills down physician spines – as it seems that we are now held responsible for patient behavior outside of the the doctor-patient relationship or hospital setting. 

Beyond the outrageousness of the case itself, is the sad subtext found in the comments section. Physician after physician respond that they are leaving medicine or have ceased clinical practice. They say that they’d never allow their children to become doctors, and that no amount of compensation is worth the risk and sacrifices of a career in medicine. It’s really depressing to read about such low morale.

For those physicians remaining – I do see a couple of bright spots. First of all, concierge medicine (or “micropractices” where patients pay cash for services) permits the doctor to see fewer patients at the same salary. Removal of the administrative headaches associated with insurance reimbursement as well as the frenetic pace of “volume uber alles” dramatically improves quality of life and patient satisfaction. The physicians I know who have switched to cash-only businesses are very happy.

Second, working as a physician for the US military has one major advantage: you cannot be sued. The idea is that military physicians do their very best to take care of the troops, but it is recognized that military personnel are at great risk for physical harm due to the nature of their job. The Feres Doctrine stipulates that military personnel cannot sue the government for perceived (or real) poor medical outcomes related to active duty. In cases of medical negligence (for veterans and off-duty military personnel), the government may be sued, but not the individual physician

So, if the tyranny of medical malpractice attorneys becomes unbearable, one might consider practicing in a VA or military hospital. Sounds crazy, I know… but it’s worth a look! Of course, a better solution would be for the next administration to take on Tort Reform in a serious way, and promote tax breaks and facilitate health savings accounts for Americans who’d like to have more control in how they spend their healthcare dollars. Maybe then they could sign up for an affordable concierge practice and at last both doctors and patients could be happy again?

What do you think?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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