"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

Pheo or not a pheo,that is the question.

The current fault-based tort system assumes that claims made against physicians are inversely related to the quality of care they provide. In this study we identified physician characteristics associated with elements of medical care that make physicians vulnerable to malpractice claims. A sample of physicians (n = 248) thought to be at high or low risk for claims was surveyed on various personal and professional characteristics. Statistical analysis showed that 9 characteristics predicted risk group. High risk was associated with increased age, surgical specialty, emergency department coverage, increased days away from practice, and the feeling that the litigation climate was "unfair." Low risk was associated with scheduling enough time to talk with patients, answering patients'' telephone calls directly, feeling "satisfied" with practice arrangements, and acknowledging greater emotional distress. Prediction was more accurate for physicians in practice 15 years or less. We conclude that a relationship exists between a history of malpractice claims and selected physician characteristics.     

Quality of Care Provided to Patients with Diabetes Mellitus in Puerto Rico: Managed Care Versus Fee-for-Service Experience

ObjectiveTo evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico.MethodsThis retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects—226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed.ResultsFrom the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A1c testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits.ConclusionThe quality of diabetes management and the subsequent outcomes are related to patient and healthcare provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes. (Endocr Pract. 2005;11:376-381)     

Concomitant Secretion of Glucocorticoid,Androgens, and Mineralocorticoid by an Adrenocortical Carcinoma: Case Report and Review of Literature

ObjectiveTo present a case of concomitant secretion of cortisol, androgens, and 11-deoxycorticosterone (DOC) by an adrenocortical carcinoma and review the literature in an attempt to identify similar cases.MethodsThe patient’s medical history, physical examination, laboratory data, computed tomographic scan, and histopathologic results were analyzed and summarized in a case report, and an extensive review of the literature was performed.ResultsEndocrinologic data showed excess cortisol production, substantially elevated testosterone and androstenedione levels, and profoundly increased DOC in the setting of suppressed aldosterone. An abdominal computed tomographic scan showed a left adrenal tumor. A left adrenalectomy was performed, and the histopathologic diagnosis was stage II adrenocortical carcinoma. The review of the pertinent literature revealed the absence of any identical cases in the past.ConclusionOur patient presented with a rare case of cosecretion of cortisol, testosterone, androstenedione, and DOC by an adrenocortical carcinoma, resulting in a clinical picture consistent with Cushing’s syndrome, hyperandrogenism, and primary hypermineralocorticoidism. We recommend the routine performance of a DOC assay in the setting of mineralocorticoid excess in association with low plasma aldosterone levels. (Endocr Pract. 2007;13: 408-412)     

Referral Patterns for Patients With High-Risk Thyroid Cancer

ObjectiveKnowledge of referral patterns for specialty cancer care is sparse. Information on both the need and reasons for referral of high-risk, well-differentiated thyroid cancer patients should provide a foundation for eliminating obstacles to appropriate patient referrals and improving patient care.MethodsWe surveyed 370 endocrinologists involved in thyroid cancer management. From information in a clinical vignette, respondents were asked to identify the reasons they would need to refer a high-risk patient to a more specialized facility for care. We performed multivariable analysis controlling for hospital and physician characteristics.ResultsThirty-two percent of respondents reported never referring thyroid cancer patients to another facility. Of those that would refer a high-risk patient to another facility, the opportunity for a patient to enter a clinical trial was the most common reason reported (44%), followed by high-dose radioactive iodine (RAI) with or without dosimetry (33%), lateral neck dissection (24%), and external beam radiation (15%). In multivariable analysis, endocrinologists with a higher percentage of their practice devoted to thyroid cancer care were significantly less likely to refer patients to another facility (P = .003).ConclusionsThe majority of endocrinologists treating thyroid cancer patients report referring a high-risk patient to another facility for some or all of their care. Knowledge of the patterns of physician referrals and the likelihood of need for referral are key to understanding discrepancies in referral rates and obstacles in the referral process. (Endocr Pract. 2013;19:638-643)     

Effects of a Computerized Order Set on the Inpatient Management of Hyperglycemia: A Cluster-Randomized Controlled Trial

ObjectiveTo determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia.MethodsWe conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital’s computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL.ResultsBetween April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose < 40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58).ConclusionThe use of an order set built into a hospital’s CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program. (Endocr Pract. 2010;16:209-218)     

Addressing the conflict between partner notification and patient confidentiality in serodiscordant relationships: How can Ubuntu help?

This study evaluates the conflict between patient confidentiality and partner notification in sero‐discordant relationships, and argues the thesis that based on a theoretical formulation of Ubuntu, a health provider is obliged to facilitate friendly relationships in which individuals are true subjects and/or objects of communal friendship. In serodiscordant relationships, the health professional can fulfil this obligation by notifying “others” (particularly a partner with whom an HIV positive patient has a “present” and “actual relationship”) of their spouse's HIV seroconversion, since without such relevant information a partner (subject) of an HIV positive patient cannot “appropriately” care for the patient's condition (object). There is a need to move away from the medical traditional emphasis that has for so long put primacy on doctor‐patient confidentiality as is the case with the Health Professions Council of South Africa Guidelines (Booklet 12) which favours patient confidentiality over partner notification. Given empirical evidence to support effectiveness of partner notification amongst sero‐discordant couples, there is thus, a need to focus emphasis on latter. This shift is necessary for achieving the United Nations’ Sustainable Development of Goal of ending HIV/AIDS epidemic by 2030. I proposed in this study that African ethics, specifically Ubuntu, will do a better job than current ethical frameworks at ensuring that partner notification receives more emphasis in the care of serodiscordant couples. If this framework is integrated into ethical guidelines and codes, it would significantly enhance the care of serodiscordant couples, as well as further boost global effort at ending HIV/AIDS epidemic by 2030.     

Adverse Event Reporting in Patients Treated With Levothyroxine: Results of the Pharmacovigilance Task Force Survey of the American Thyroid Association,American Association of Clinical Endocrinologists,and The Endocrine Society

ObjectiveTo survey physicians to determine whether potency and consistency issues with levothyroxine sodium (LT₄) have been resolved and to assess current experience regarding safety of substituting LT₄ products.MethodsMembers of the American Association of Clinical Endocrinologists, American Thyroid Association, and The Endocrine Society collaborated to create a survey instrument that would effectively sample the clinical experience of their society members and frequent prescribers of LT₄. More than 18 000 e-mailed requests for information were generated, and the Web sites of each society provided links to the data collection form. The survey provided an opportunity to collect clinical observations of adverse events or product availability problems from physicians caring for patients with thyroid disease who required use of contemporary LT₄ preparations.ResultsAfter adjustment for known reasons for unstable results from thyroid function tests, 199 reports of adverse events associated with changes in thyrotropin values were further analyzed. One hundred seventy-seven reports (88.9%) were associated with a change in the source of LT₄; no change was noted in 21(10.6%). Details regarding the circumstances of the change were provided in 167 of the 177 reports (94.4%), The reporting physicians themselves or their office staff had changed the LT₄ preparation in only 1 of the 167 cases (0.6%). The remainder of changes had been made by the patient’s pharmacy, either with the physician’s knowledge (in 13 of 167 cases [7.8%]) or without his/her knowledge (in 153 of 167 cases [91.6%]). Fifty-four of 199 cases (27.1%) described serious adverse events; 52 of these (96.3%) were associated with a substitution of one LT₄ preparation for another.ConclusionsThe clinical use of contemporary LT₄ products continues to be associated with some adverse outcomes. A small number of reports were associated with continued use of the same LT₄ products. The most frequently reported adverse outcomes were associated with the approved generic substitution of LT₄ products, frequently without the prescribing physician’s knowledge.(Endocr Pract. 2010;16:357-370)     

A Case of Nonischemic Cardiomyopathy Associated with Autoimmune Polyglandular Syndrome Type III

Objective:To report a case of nonischemic dilated cardiomyopathy associated with autoimmune polyglandular syndrome (APS) type III.MethodsA review of our patient’s medical records was undertaken, and her clinical history, investigations, and outcome are described. In addition, a literature review of nonischemic dilated cardiomyopathy occurring in association with autoimmune polyendocrinopathies was performed.ResultsAPS is diagnosed once a patient has developed at least 2 organ specific autoimmune diseases. APS III involves a combination of autoimmune diabetes and Graves’ disease without adrenal insufficiency. Autoimmune cardiomyopathies are not described as a feature of this condition; however, there are a few reported cases of patients with autoimmune polyendocrinopathies developing a nonischemic dilated cardiomyopathy. In this case, a 30-year-old female developed vitiligo, Graves’ disease, and latent autoimmune diabetes of the adult (LADA) over a 5-year period before presenting with conscious ventricular tachycardia (VT). This evolved into acute severe biventricular failure within a few weeks, which failed to resolve after adequate treatment of her other autoimmune conditions.ConclusionAlthough nonischemic cardiomyopathies have been associated with APS in a few published cases, this is the first case to our knowledge in a patient with APS III. (Endocr Pract. 2014;20:e183-e186)     

对临床输血病案文书质量的调查与分析

目的 探讨临床输血病案文书的内涵质量。方法 采取随机抽查的方法对某院2009—2010年已经归档的输血病案,按卫生部“医院管理年和医疗质量万里行”活动内容进行调查。结果 发现多份病历不合格。结论 临床输血病案文书是临床医师对患者治疗过程的原始记录,是当时事态的真迹,是医疗事故或纠纷在认定是非、判明责任,以及医疗技术鉴定或司法鉴定时赖以立论的依据。因此,写好病案文书可减少医疗纠纷的发生。     

Cultural Competence in Diabetes Mellitus Care: An Urgent Need

Background:Multicultural societies exist worldwide. Two important challenges can be appreciated in this scenario. Minority populations, due to a combination of genetic and lifestyle factors, have a particularly high risk for developing type 2 diabetes mellitus (DM). In addition, the quality of health care provided to minority populations, including that for DM, has lagged behind that provided to the white population. Because multiple medical, social, and cultural factors influence the development and progression of type 2 DM, management of patients becomes even more challenging if health care providers cannot identify and address the many contributing factors.Objective:The objective of this article was to raise awareness about the most common social and cultural factors that may influence the development of type 2 DM, progression of the disease, and adherence to treatment plans in patients from culturally diverse populations.Methods:A PubMed search of English-language articles published primarily between 1996 and 2006 was conductedusing the search terms Latino, Hispanic, culture, and diabetes, and a list of social and cultural factors associated with type 2 DM was created based on relevant articles and on the author's expertise and experience in the Latino Diabetes Initiative at the Joslin Diabetes Center.Results:There is increasing evidence that social and cultural factors such as body image, educational level, fears, general family integration and support, health literary, language, myths, and nutritional preferences, among others, may affect the success of the physician patient relationship and influence patients' adherence to treatment. Specific strategies to help clinicians remember to address multiple factors in the day-to-day management of patients with type 2 DM who are from culturally diverse populations include asking questions about patients' personal goals, ascertaining what behaviors they have adopted from mainstream culture, understanding how family ties may affect DM care and prevention, and being aware of patients' educational level when implementing any educational activity.Conclusions:The standards of DM care apply to every individual with this disease and should continue to be the core of every clinicians practice. However, improving health care providers' cultural competence may help improve the quality of care provided to minority groups and may ultimately reduce health care disparities. Increased cultural competence may also improve patient-provider trust and communication, as well as help patients adhere to prevention and treatment plans.     

Diabetic Ketoacidosis Critical Care Pathway Implementation: Incorporation into EMR Significantly Decreases Length of Stay

Objective: We discuss the implementation and outcomes of a diabetic ketoacidosis (DKA) critical care pathway (CCP) at a 462-bed teaching hospital.Methods: A multi-disciplinary team implemented a DKA CCP that was translated into 3 computerized physician order entry (CPOE) order sets corresponding to the phases of DKA care. Historical and postintervention data were obtained via automated queries of the electronic medical record (EMR) and further analyzed by manual chart review.Results: Average length of stay decreased from 104.3 to 72.9 hours (P = .0003) after implementation of a DKA CCP.Conclusion: Outcome data supports the use of a DKA CCP at our institution.Abbreviations:DKA = diabetic ketoacidosisCCP = critical care pathwayEMR = electronic medical recordCPOE = computerized physician order entryICD-9 = International Classification of Diseases, ninth revisionLoS = length of staySQL = standard query language     

Hypoglycemia: Minimizing Its Impact in Type 2 Diabetes

ObjectiveTo review and discuss the risks and impact of hypoglycemia and provide guidance for the prevention of hypoglycemia in type 2 diabetes (T2DM).MethodsWe review and discuss the risks and impact of hypoglycemia, providing specific guidance regarding the prevention of hypoglycemia and judicial selection of glucose-lowering agents in individuals with T2DM.ResultsHypoglycemia in T2DM is underrecognized and underreported. Emerging evidence from large clinical trials suggest that hypoglycemia may be an important risk factor for morbidity and mortality in T2DM. In addition, hypoglycemia is associated with reduced quality of life, greater healthcare utilization costs, and poor adherence to medical regiments.ConclusionThese findings have led professional organizations to emphasize the prevention of hypoglycemia as an important consideration when initiating or intensifying treatment regimens. In clinical settings, particular attention should be paid to a patient’s risk for hypoglycemia when initiating or intensifying the pharmacological treatment regimen. The endocrinologist can play an important role in educating not only the patient, but also other members of the diabetes-management team regarding the need for individualized therapy. (Endocr Pract. 2013;19:526-535)     

An Interesting Case of Peripheral Vascular Disease,Vascular Reperfusion,and Subsequent Development of Pain Due to Paget's Disease of Bone

ObjectiveTo present a case of Paget’s disease of bone that was unmasked after vascular reperfusion.MethodsIn this case study, we review the presentation, evaluation, diagnosis, and management of a patient with Paget’s disease and peripheral vascular disease.ResultsA 79-year-old-woman with a history of coronary artery heart disease and recent finding of a T5 compression fracture was hospitalized for evaluation of right lower extremity claudication. Angiography demonstrated a focal complete occlusion of the distal right femoral and popliteal arteries. A self-expanding stent was placed in the distal femoral and popliteal arteries. Approximately 48 hours after the procedure, the patient developed severe, right lower leg pain. On endocrine evaluation, the patient was found to have clinical signs suggesting Paget’s disease of bone, which was subsequently confirmed by imaging.ConclusionThis patient’s development of severe pain following reperfusion of distal femoral and popliteal arteries is in keeping with the known and aforementioned hypervascularity of pagetic bone. The finding of increased warmth over an area of skeletal deformation should always raise the possibility of Paget’s disease of bone.(Endocr Pract. 2013;19:e61-e63)     

Inpatient to Outpatient Transfer of Diabetes Care: Planning for an Effective Hospital Discharge

ObjectiveTo review data on diabetes discharge planning, provide a definition of an effective diabetes discharge, and summarize one institution’s diabetes discharge planning processes in a teaching hospital.MethodsWe performed a MEDLINE search of the English-language literature published between January 1998 and December 2007 for articles related to the inpatient to outpatient transition of diabetes care. Regulatory guidelines about discharge planning were reviewed. We also analyzed our institution’s procedures regarding hospital discharge.ResultsWe define an effective diabetes discharge as one where the patient has received the necessary skills training and been provided with a clear and understandable postdischarge plan for diabetes care that has been clearly documented and is accessible by the patient’s outpatient health care team. Diabetes is one of the most common conditions managed in the hospital, yet how to transition a patient with diabetes to the outpatient setting is understudied, and the outcome of patients with diabetes after discharge is unknown. Strategies that can be used to ensure an effective diabetes discharge are early identification of patients in need of education, implementation of a clinical pathway, and clear instructions about medications and follow-up appointments at the time of discharge.ConclusionsEffective transfer of care from the inpatient to the outpatient setting remains a priority in the United States. Studies are needed to better define how best to ensure that patients with diabetes are successfully transitioned to ambulatory care. (Endocr Pract. 2009;15:263-269)     

Evidence-Based Medicine,Clinical Practice Guidelines,and Common Sense in the Management of Osteoporosis

ObjectiveTo evaluate the benefits and limitations of randomized controlled trials (RCTs), clinical practice guidelines (CPGs), and clinical judgment in the management of osteoporosis.MethodsA review was conducted of the English-language literature on the origins and applications of RCTs, CPGs, evidence-based medicine, and clinical judgment in the management of osteoporosis.ResultsEvidence-based medicine is use of the currently available best evidence in making clinical decisions for individual patients. CPGs are recommendations for making clinical decisions based on research evidence, sometimes with consideration of expert opinion, health care policy, and costs of care. The highest levels of medical evidence are usually thought to be RCTs and meta-analyses of high-quality RCTs. Although it is desirable and appropriate for clinicians to consider research evidence from RCTs and recommendations presented in CPGs in making clinical decisions, other factors—such as patient preference, comorbidities, affordability, and availability of care—are important for the actual implementation of evidence-based medicine.ConclusionDecisions about who to treat, which drug to use, how best to monitor, and how long to treat require clinical skills in addition to knowledge of medical research. The necessity of integrating common sense and clinical judgment is highlighted by the fact that many patients treated for osteoporosis in clinical practice would not qualify for participation in the pivotal clinical trials that demonstrated efficacy and safety of the drugs used to treat them. (Endocr Pract. 2009;15:573-579)     

Basis for Physician Recommendations for Adjuvant Radioiodine Therapy in Early-Stage Thyroid Carcinoma: Principal Findings of the Canadian-American Thyroid Cancer Survey

ObjectiveTo explore physician recommendations regarding radioiodine remnant ablation (RRA) as adjuvant treatment in early-stage well-differentiated thyroid carcinoma (WDTC), their rationale for administration of RRA, and their willingness to involve patients’ opinions in decision making about the use of RRA.MethodsWe surveyed a representative sample of specialty physicians in Canada and the United States and asked survey participants whether they would recommend adjuvant RRA after thyroidectomy for a 1.6-cm papillary thyroid carcinoma (Likert scale of agreement responses from 1 to 7; strong agreement ≥ 6). Factor analysis was performed to explore the rationale for recommendations. We asked whether physicians accepted the role of patients’ preferences in decision making about administration of RRA, and backward conditional logistic regression analysis was used to identify predictors of strong acceptance.ResultsThe effective response rate for the survey was 56.3% (486 of 864), with 62.8% (295 of 470 respondents) strongly recommending RRA. Strong RRA recommendations were founded in opinions that RRA (1) decreases WDTC-related mortality and recurrence and (2) facilitates WDTC follow-up at low risk of adverse effects. Approximately a third of the survey respondents (152 of 474) strongly agreed with incorporation of patients’ preferences in decision making regarding the use of RRA. Physicians without firm convictions about the efficacy of RRA in decreasing disease-related outcomes and those practicing in the United States were most likely to indicate strong support for incorporating patients’ preferences in decision making about RRA.ConclusionThe recommendations of physicians regarding use of adjuvant RRA are founded in beliefs in intervention efficacy and follow-up practices. Physicians in medical practice in the United States and those without strong convictions about RRA efficacy are most likely to incorporate patients’ views in individualizing decisions about RRA therapy. (Endocr Pract. 2008;14:175-184)