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Monday, December 27, 2010

Why I Can't Tell You This Story...

This week, I had many interesting cases in my clinical practice.  One posed an interesting ethical dilemma, and 2 others were interesting medical cases in pediatrics that are relatively rare in primary care.

So, since I have not been posting much lately, I figured these cases would be great blog posts.
...Until I realized that I actually did not feel right about sharing the details of these cases.   Because it is my ethical obligation to adhere to privacy practices. Because I have a duty to protect the anonymity of my patients. Because there is no way to change the story enough for it to be unrecognizable.  Even though the general dialogue would make for an excellent discussion.  Even though you would find it interesting.  Even if it gave me a topic for a needed blog post.

So I was out of luck...or was I?
I then realized it would be (just as?) interesting to talk about privacy practices and the physician-writer dilemma.

You may (or may not) know it, but one of the forms buried in the pile of  paperwork that you get upon registering with your physicians office is their HIPPA policy statement.  HIPAA stands for the "Health Insurance Portability and Accountability Act" and was put into effect in 1996.  It basically states that your medical record is confidential, and details cannot be shared with others without your explicit permission.  You, not your doctor, are the owner of your medical information.  And this is how it should be.

So, then the question arises, who owns a patent's story?

A patient comes in to the office with a complaint, a problem, a story.  I sift through their words, translate them into medical jargon, pick out the important information by asking pointed questions.  I may get all the information I need in a short sentence from the patient (this would make my job easy).  But, more often their story is tangled in a web of (seemingly) unimportant detractors details that I must sort through to get to the gist of the problem.  Once we have clarified the problem (the history), we move on to a physical exam and pair that with laboratory or imaging tests that help us arrive at a diagnosis.  It's a bit more complicated than that, but you get the idea.

So, I can synthesize all of this information into a succinct "case presentation".  I would take the pertinent portions of the history, physical exam and lab tests and present them.  I would formulate a short "differential diagnosis" (a list of diagnostic possibilities for the patient) and ultimately arrive at a conclusion that would hopefully give the patient treatment options and a prognosis.

The patient owns the story.  And their signs and symptoms.  But, after all this medical manipulation, I have crafted it into something quite different than its original form.  So, am I then the owner of that case as the treating physician?

Physicians talk candidly quite often about patients, and, unless they are shared patients, anonymity is typically preserved.  The reason for the sharing of information is to get another physician's opinion about a case and allow for a transfer of ideas.  I believe that most patients would not take issue with the sharing of anonymous medical information between professionals as a point of academic interest.

But, what if I decided to share some patient stories with you, my readers on my blog?  What if I protected my patients by changing the names and details of the story?  What if I decided to write a book that included interesting patient stories?  Are those stories mine to share?

What would you, or the patient, think about that?  Would you be honored that your story was interesting enough to share?  Would you feel that sharing your story in this way may help other patients or doctors?  Or, would you feel betrayed?  That a trust had been broken in this important professional relationship?  Do I have an obligation (ethically, legally) to inform the patient that I plan to share the case?

I do not know the answers to many of these questions, I am just posing them for the sake of conversation.  I suppose the answers are quite personal and different for all physicians.  Right now, as a new physician-writer, I will be erring on the side of caution and keeping these stories to myself.  Or letting enough time pass and wait for other similar cases to come along that can be "combined" to adequately disguise the story.

So, for now, my lips are sealed.
So, what do you think?  Would you take issue with your physician sharing your 'story'?

Friday, December 24, 2010

Happy Holidays...

Happy Holidays from The Doctor Mom....

Still testing my feed with my social media 'mentor' from White Coat Underground.

Saturday, December 11, 2010

Bedtime Woes & Bad Dreams...

We have been undergoing quite a bit of transition in the house.  After a tough couple of weeks and a shake-up with the girls school situation, things seem to be,  And this is never more obvious than at bedtime.

The hot pocket's (now almost 3) previously easy and seamless bedtime routine is now turning into a nearly 1 hour drama, filled with cajoling, books, back rubs and crying.  Oh, and snuggles; she requires lots of them.  And she has worn down my husband's patience, which is very difficult to do.

The Boober (4), on the other hand, has always been quite a handful at night.  The problem, we have determined....she is resistant to sleep.  She lays in bed for a while, and just when you think she may be sleeping, she pops her head in our room to let us know that she is still awake.  And scared.  This can go on until 11 pm.

At first I thought she was "faking" the whole scared thing.  What could she possibly be afraid of in her safe and cozy room?  Well, last night I became convinced that her fears are real.  She was getting ready to go to sleep and her blinds were open and she said "scary tree" and made me close them.  And, in thinking about it, I realized that the winter trees with no leaves and scary shadows may very well be intimidating.  Then, as she does every night, she screams out in the night in the middle of a bad dream.  A couple of ear piercing cries later, I checked on her.  She said..."too many monsters mommy...".  Poor girl...Disney movies are haunting my baby.  I think she may even be afraid to go to sleep.  What solves this problem...of course, someone laying in bed with her.

So, what is a good parent to do?

This brings me to the frequent conundrum between PARENT and PEDIATRICIAN, the difference between DOCTOR and MOM.

The Pediatrician would say...

  • These are classic nightmares
    • Appropriate age (commonly 3-6 when imaginations run wild but the distinction between fantasy and reality is not clear).
    • They happen late in the sleep cycle (not in the deep stages of sleep like night terrors).
    • The child remembers (vividly) what the dream was about and may be afraid to go back to sleep.
  • Do NOT let this be the start of a NEW bad habit...
    • Do NOT let her sleep in your bed because it may make her scared of her own bed
    • Do NOT begin sleeping in her bed because it will become difficult for her to sleep alone
  • Reassure her and let her know that she is safe.
  • Reassure the parent that this is a common stage for children, and it will improve.
The PARENT would say:
  • Go to her when she needs you.  Reassure her and stay until she is asleep, or no longer afraid.  If you are exhausted, may end up sleeping there. Or you may just find her in your bed in the morning.
  • Let her know that dreams and nightmares are a part of every person's active IMAGINATION.  
  • Try to prevent them by not watching scary movies or reading scary books (umm...every Disney movie has a good villain).
  • Think of ways to keep the "bad guys" away...
  • Let her have a security object to keep her feeling safe...or 20 animals/blankets/pillows to fill the bed.
  • If all else your DOCTOR (ha!)
So...calling all mommies out there, any other suggestions for me?