Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

Management of the schizophrenic patient.

Schizophrenia is a continuing and relapsing disorder that begins in early adulthood and lasts indefinitely. Effective treatment, therefore, needs to be long-term and comprehensive. The physician must be able to control disabling symptoms while minimizing the side effects of neuroleptic medication. The lifetime risk remains of depression and suicide, paranoid crisis, social distress and frequent rehospitalization. It is a medical responsibility not only to look after the schizophrenic patient''s health but also to coordinate social and emergency services, improve the quality of life, support the family and anticipate problems in offspring. At the time, the physician needs to consider the welfare of the community in which the schizophrenic patient lives.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.     

Antihypertensive Pharmacology

Although drug treatment of hypertension is associated with improved survival and decreased vascular complications, drug compliance is a major problem in the control of hypertension. All antihypertensive medications are associated with side effects; thus, it is a physician''s responsibility to explain to each patient the side effects of the drugs he prescribes to treat hypertension, and to instill in the patient a sense of necessity for the treatment of hypertension. The choice of antihypertensive drug should be made based on each patient''s lifestyle, overall health and ability to tolerate the drug. Ideally, the antihypertensive regimen should be simple, effective, convenient to take and have very few side effects.     

Disparity in Physician Perception of Patients' Adherence to Medications by Obesity Status

Physician perception of medication adherence may alter prescribing patterns. Perception of patients has been linked to readily observable factors, such as race and age. Obesity shares a similar stigma to these factors in society. We hypothesized that physicians would perceive patients with a higher BMI as nonadherent to medication. Data were collected from the baseline visit of a randomized clinical trial of patient–physician communication (240 patients and 40 physicians). Physician perception of patient medication adherence was measured on a Likert scale and dichotomized as fully adherent or not fully adherent. BMI was the predictor of interest. We performed Poisson regression analyses with robust variance estimates, adjusting for clustering of patients within physicians, to examine the association between BMI and physician perception of medication adherence. The mean (s.d.) BMI was 32.6 (7.7) kg/m². Forty‐five percent of patients were perceived as nonadherent to medications by their physicians. Higher BMI was significantly and negatively associated with being perceived as adherent to medication (prevalence ratio (PrR) 0.76, 95% confidence interval (CI): 0.64–0.90; P = 0.002; per 10 kg/m² increase in BMI). BMI remained significantly and negatively associated with physician perception of medication adherence after adjustment for patient and physician characteristics (PrR 0.80, 95% CI: 0.66–0.96; P = 0.020). In this study, patients with higher BMI were less likely to be perceived as adherent to medications by their providers. Physician perception of medication adherence has been shown to affect prescribing patterns in other studies. More work is needed to understand how this perception may affect the care of patients with obesity.     

Sexual Therapy of Patients with Cardiovascular Disease

Physical illness or disability inevitably has a damaging effect on sexual relationships. Physicians are usually unaware of the sexual consequences of illness on their patients, and lack experience in treating sexual dysfunctions.The report of treatment of a couple with serious cardiovascular disease illustrates the potential efficacy of brief sex therapy for improving the quality of a patient''s life. If a primary physician lacks the skills to conduct sex therapy, he may collaborate with nonphysician therapists. The physician''s knowledge of the physiological and psychological effects of a specific illness on his patient is essential to successful therapy. Often, simple education, encouragement or reassurance by the physician is enough to overcome the damaging effects of illness on a patient''s sex life.     

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient''s functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient''s anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.     

PSYCHOTHERAPY—A Concept for the Nonpsychiatric Physician

Patients tend to repeat with their physician, as with other significant people in their lives, their earlier previous patterns of behavior. The physician as well as the patient is involved in the physician-patient relationship. He will tend to respond to his patients in accordance with his earlier life experiences and his characteristic repetitive behavioral pattern. For both physician and patient, the relationship between them extends beyond the immediate reality situation.Psychotherapy is the utilization of psychological measures in the treatment of sick persons and the deliberate utilization by the physician of the physician-patient relationship for the benefit of the patient. The kind of psychotherapy that is practical and utilizable by the nonpsychiatric physician is that which uses education, reassurance, support and the management of the patient''s problems either directly or indirectly or through the intermediary of other people or agencies.The symbolic aspect of the physician-patient relationship is based essentially on the fact that a sick person, because of his anxiety and because of the threat to his physical and psychic integrity, is more dependent and more anxious than he would be if he were well, and therefore he has a correspondingly greater need for the authoritative and protective figure he finds in the physician.Psychotherapy is not directed exclusively to the treatment of flagrantly or obviously neurotic or psychotic patients. It should be and is directed to all sick persons. Limitations in psychotherapy are set by various determinants, among which are the nature of the precipitating factor in the illness, the nature of the sick person, the skill, knowledge and abilities of the physician, and the nature of the physician-patient relationship. In psychotherapy, as in all medicine, the physician should not do anything which may disturb the patient if the disturbance is of no value or if it cannot be followed through with special skills.     

Deciding about mechanical ventilation in end-stage chronic obstructive pulmonary disease: how respirologists perceive their role

OBJECTIVE: To determine when respirologists approach patients with end-stage chronic obstructive pulmonary disease (COPD) to decide about the use of mechanical ventilation, what information they provide to patients and how they provide it. DESIGN: Self-administered national survey. PARTICIPANTS: All Canadian specialists in respiratory medicine; of 401 eligible respirologists, 279 (69.6%) returned a completed questionnaire. OUTCOME MEASURES: Timing and content of doctor-patient discussions regarding mechanical ventilation; physicians'' perception of their level of involvement in the decision-making process; and patient and physician characteristics that may influence decisions. RESULTS: Discussions were reported to occur most often at advanced stages of COPD: when the patient''s dyspnea was severe (reported by 235 [84.2%] of the respondents) or when the patient''s forced expiratory volume in the first second was 30% or less than predicted value (reported by 210 [75.3%]). A total of 120 respondents (43.0%) stated that they discuss mechanical ventilation with 40% or less of their COPD patients before an exacerbation necessitates ventilatory support. Most (154 [55.2%]) described the decision-making process as a collaboration between patient and physician; 83 (29.7%) reported that the patient decides after he or she has considered the physician''s opinion. Over half (148 [53.0%]) of the respondents indicated that they occasionally, often or always modify the information provided to patients in order to influence their decision about mechanical ventilation. CONCLUSIONS: Discussions with COPD patients concerning end-of-life decisions about mechanical ventilation are reported to occur in advanced stages of the disease or not at all, with patients'' input where possible. Information presented to patients is often modified in order to influence the decision. Future studies should explore ways to involve patients further in the decision-making process and to improve the process for both patients and physicians.     

Pharmacologic features and effects of neuroleptics.

Neuroleptic drugs reduce the severity and prevent the recurrence of symptoms of schizophrenia. Recent studies indicate that these drugs probably produce their antipsychotic effects by blocking dopamine receptors in the brain, although they also block acetylcholine and norepinephrine receptors. The potency of commercially available neuroleptics in blocking dopamine receptors varies widely, being related to the compound''s lipid solubility. Neuroleptics predispose the patient to short-term and long-term medical hazards that must be weighed against the benefits of reduced symptom intensity, shortened psychotic episodes and lessened likelihood of recurrence of acute schizophrenic epidoses. The side effects associated with short-term therapy are either extremely rare or are treatable by dose change, medication change or the use of additional drugs. In long-term therapy the risks are more problematic in that they are sometimes irreversible. These include tardive dyskinesia, skin discoloration and corneal deposits. The clinician must consider the pattern aand severity of each patient''s present and past psychotic episodes before deciding whether maintenance therapy with neuroleptics is justified. If it is, doses should be re-evaluated frequently and kept as low as possible. Concomitant administration of anticholinergic agents should be avoided if possible. Most important, the long-term administration of neuroleptics should be prescribed only for patients with schizophrenia and not for those with conditions that respond to other treatments.     

Cultural Aspects of Health and Illness Behavior in Hospitals

Health care attitudes reflect the basic world view and values of a culture, such as how we relate to nature, other people, time, being, society versus community, children versus elders and independence versus dependence. Illness behavior determines who is vulnerable to illness and who agrees to become a patient—since only about one third of the ill will see a physician. Cultural values determine how one will behave as a patient and what it means to be ill and especially to be a hospital patient. They affect decisions about a patient''s treatment and who makes the decisions. Cultural differences create problems in communication, rapport, physical examination and treatment compliance and follow through. The special meaning of medicines and diet requires particular attention. The perception of physical pain and psychologic distress varies from culture to culture and affects the attitudes and effectiveness of care-givers as much as of patients. Religious beliefs and attitudes about death, which have many cultural variations, are especially relevant to hospital-based treatment. Linguistic and cultural interpreters can be essential; they are more available than realized, though there are pitfalls in their use. Finally, one must recognize that individual characteristics may outweigh the ethnic and that a good caring relationship can compensate for many cultural missteps.     

AIDS in children

The application of medical quality assurance principles to ambulatory patient care using the traditional methods of medical chart audit, process review, and physician education has yielded generally disappointing results in improving patient care and physician performance. Newer methods assist physicians by providing patient and medical reference data at the time of a patient''s visit. Techniques for tracking treatment outcomes and patients'' test results and for providing instructions to patients may improve both care and patients'' and physicians'' satisfaction.This feature appears regularly in THE WESTERN JOURNAL OF MEDICINE. It is intended to cover recent developments in a broad range of issues that will have an impact—either directly or indirectly—on clinical practice. Occasionally the seminars may include informed speculation about likely future developments.     

IS IT NEUROSIS?

So-called “minor psychiatry,” the treatment of neurosis in persons who are not psychotic, may well be undertaken by the general practitioner.The first duty of the physician in dealing with a neurotic person is to determine whether psychosis may develop. He must be patient and thorough in hearing the history of the case and should have full information on the patient''s life and family.A recent classification of the neuroses is given and the more generally recognized symptoms of these conditions are described.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Moderate drinking: an alternative treatment goal for early-stage problem drinking.

Family physicians are in a particularly good position to identify problem drinking in its early stages through the recognition of various psychosocial and medical indicators. Thorough history-taking or the use of a specific questionnaire should provide confirmation. Patients so identified can then be offered treatment designed to help them moderate their drinking, if not to achieve abstinence. The treatment strategy described in this paper involves specifying a safe drinking pattern, instructing the patient in the use of aids to appropriate drinking and seeing the patient at 1- to 2-month intervals for follow-up assessment. In a pilot study of this strategy 16 of 17 patients reduced their drinking substantially, and 8 were abstinent at the last follow-up visit. Only 1 of the 17 dropped out of treatment; the high rate of compliance may have been primarily due to the patient''s need to see the family physician for other problems. Visits to the family physician for other medical problems provide an opportunity to motivate patients to continue monitoring their drinking.