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What is our responsibility to patients?

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Dear

 

How do you feel, about this: A 27 year old female patient comes to the

clinic, and in the course of the consultation she mentions that she has

polydipsia, polyphagia and polyuria. I asked her if her western

physician had tested her for diabetes and she indicated that the spot

test came out out negative. My immediate response was to suggest to her

that she ask him to order a 4 hour glucose tolerance test. My

supervisor, hit the roof, and said that I had no business giving a

western diagnosis nor suggesting tests. I ate humble pie and kept my

mouth shut, but is it not in our scope of practice to " first do no harm " ,

and if something is missed by a Med, is it not my moral responsiblity to

offer direction? (Oh well, just 1 month more till I graduate, anyway.)

 

Yehuda

 

On Thu, 26 Feb 2004 05:38:25 -0000 " " < writes:

> , " Teresa Hall " <

> Teresa.bodywork4u@w...> wrote:

> >

> >

> >

> >

> > > If we are primary care practitioners then there is no reason to

> not train

> > in doing pelvic or any other exam.

>

>

> we are only primary care in CA and perhaps FL and NM.. However, the

> soon to

> be released report from the little hoover commission will finally

> clarify the

> matter of L.Ac. being primary care in CA. As I understand it, there

> was NEVER

> any legislative intent to confer to us the right to make western

> diagnosis as

> primary care providers. The intent was that we can practice without

> referral,

> but our primary care was meant to be in the form of TCM and we are

> only

> expected and allowed to make referrals for patients who we SUSPECT

> of

> needing a WM dx. We are absolutely prohibited from making western

> dx and

> prescribing therapy upon that basis. This area has been somewhat

> gray for

> many years, though I believe a close reading of the CA law is not

> vague at all

> on this point. Nowhere are we explicitly granted the right to make

> western dx.

> Therefore it is not in our scope. CSOMA and the asian language

> associations

> have long argued differently, but it appears they will be ruled

> incorrect in the

> coming months.

>

 

>

>

>

> Chinese Herbal Medicine offers various professional services,

> including board approved continuing education classes, an annual

> conference and a free discussion forum in Chinese Herbal Medicine.

>

>

>

>

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My immediate response was to suggest to her

that she ask him to order a 4 hour glucose tolerance test. My

supervisor, hit the roof, and said that I had no business giving a

western diagnosis nor suggesting tests. I ate humble pie and kept my

mouth shut, but is it not in our scope of practice to " first do no harm " ,

and if something is missed by a Med, is it not my moral responsiblity to

offer direction? (Oh well, just 1 month more till I graduate, anyway.)

>>>>It is also in our scope to order a glucose tolerance test, although that is

not the one i would order

Alon

 

 

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Yehuda,

In the clinic you have dual responsibilities. First to your

supervisor, and secondly to your patient. The reason you caught hell

from your instructor is that you are not a licenced practitioner and

by taking it upon yourself to make biomedical suggestions you have

put

your instructors licence to practice on the line. It may seem like a

small thing to you but you've got nothing to loose yet. So respect

your instructors willingness to let you practice and learn under

their

licence. As far as your moral reponsibilty to the patient is

concerned

the proper course of action would have been:

1. Consult with your instructor.

2. Get the patient's written permission to correspond with their MD,

assuming your insructor concurrs.

3. Write to the MD of your concerns including your outline of the

problem in a Chinese medicine framework and ask if further testing is

warranted.

4. Follow up with a call if you recieve no response, for that matter

even if you do. In future you'll find personal correspondence opens

many doors.

5. Treat your patient according to your ddx and inform them of the

result of your communication.

 

If you take this tack then you've done several things that truly

enhance your profession and your professionalism.

1. You respected your teacher and your limits as a neophyte

practitioner.

2. You have shown your patient that you respect their MD's diagnosis

and at the same time you are following up for them. By doing this

you

are initiating a team care approach in which the patient can put even

more trust.

3. You are initiating a professional dialog that allows the MD to

learn more about you and your profession, and visa versa.

 

As a practitioner it is your duty to follow up on suspected

misdiagnosis but only in the context of your scope of practice. So

respect other professions and communicate your concerns and then

everybody is served.

 

I hope this helps and good luck upon graduation.

 

Michael

 

, yehuda l frischman

<@j...> wrote:

> Dear

>

> How do you feel, about this: A 27 year old female patient comes

to the

> clinic, and in the course of the consultation she mentions that she

has

> polydipsia, polyphagia and polyuria. I asked her if her western

> physician had tested her for diabetes and she indicated that the

spot

> test came out out negative. My immediate response was to suggest

to

her

> that she ask him to order a 4 hour glucose tolerance test. My

> supervisor, hit the roof, and said that I had no business giving a

> western diagnosis nor suggesting tests. I ate humble pie and kept

my

> mouth shut, but is it not in our scope of practice to " first do no

harm " ,

> and if something is missed by a Med, is it not my moral

responsiblity to

> offer direction? (Oh well, just 1 month more till I graduate,

anyway.)

>

> Yehuda

>

> On Thu, 26 Feb 2004 05:38:25 -0000 " "

writes:

> > , " Teresa Hall " <

> > Teresa.bodywork4u@w...> wrote:

> > >

> > >

> > >

> > >

> > > > If we are primary care practitioners then there is no reason

to

> > not train

> > > in doing pelvic or any other exam.

> >

> >

> > we are only primary care in CA and perhaps FL and NM.. However,

the

> > soon to

> > be released report from the little hoover commission will finally

> > clarify the

> > matter of L.Ac. being primary care in CA. As I understand it,

there

> > was NEVER

> > any legislative intent to confer to us the right to make western

> > diagnosis as

> > primary care providers. The intent was that we can practice

without

> > referral,

> > but our primary care was meant to be in the form of TCM and we

are

> > only

> > expected and allowed to make referrals for patients who we

SUSPECT

> > of

> > needing a WM dx. We are absolutely prohibited from making

western

> > dx and

> > prescribing therapy upon that basis. This area has been somewhat

> > gray for

> > many years, though I believe a close reading of the CA law is not

> > vague at all

> > on this point. Nowhere are we explicitly granted the right to

make

> > western dx.

> > Therefore it is not in our scope. CSOMA and the asian language

> > associations

> > have long argued differently, but it appears they will be ruled

> > incorrect in the

> > coming months.

> >

>

> >

> >

> >

> > Chinese Herbal Medicine offers various professional services,

> > including board approved continuing education classes, an annual

> > conference and a free discussion forum in Chinese Herbal Medicine.

> >

> >

> >

> >

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what would you order, then?

 

On Thu, 26 Feb 2004 14:05:58 -0600 " Alon Marcus " <alonmarcus

writes:

> My immediate response was to suggest to her

> that she ask him to order a 4 hour glucose tolerance test. My

> supervisor, hit the roof, and said that I had no business giving a

> western diagnosis nor suggesting tests. I ate humble pie and kept

> my

> mouth shut, but is it not in our scope of practice to " first do no

> harm " ,

> and if something is missed by a Med, is it not my moral

> responsiblity to

> offer direction? (Oh well, just 1 month more till I graduate,

> anyway.)

> >>>>It is also in our scope to order a glucose tolerance test,

> although that is not the one i would order

> Alon

>

>

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Hi Yehuda,

 

I would have done the same, and I ofter refer patients back to their western

docs. I find that I often gather more information than their doctors do, since

I spend a large amount of time (often an hour) exploring history and symptoms -

this means I often get a more complete (and accurate) picture than the docs who

spend 15 minutes. In addition, sometimes I receive patients who don't want to

see a western doc, and need to. I make referrals and " western " recommendations

all the time, sometimes to the patients and sometimes directly to their MDs. I

consider this part of my responsibility as a health care practitioner, as part

of the team of professionals my patients assemble for their best care. And I

will work as if I am part of a team, whether the other professionals do or not.

When my recommendations include concrete observations and information, and come

in the guise of wanting what is best for the patient, I find there are

opportunities not only to help a patient attain

better care, but also to educate about the evaluative powers and value of TCM.

 

I think you're on the right track. Good luck with your licensing exam(s), and

congratulations on your pending graduation.

 

 

 

 

yehuda l frischman < wrote:

Dear

 

How do you feel, about this: A 27 year old female patient comes to the

clinic, and in the course of the consultation she mentions that she has

polydipsia, polyphagia and polyuria. I asked her if her western

physician had tested her for diabetes and she indicated that the spot

test came out out negative. My immediate response was to suggest to her

that she ask him to order a 4 hour glucose tolerance test. My

supervisor, hit the roof, and said that I had no business giving a

western diagnosis nor suggesting tests. I ate humble pie and kept my

mouth shut, but is it not in our scope of practice to " first do no harm " ,

and if something is missed by a Med, is it not my moral responsiblity to

offer direction? (Oh well, just 1 month more till I graduate, anyway.)

 

Yehuda

 

On Thu, 26 Feb 2004 05:38:25 -0000 " " < writes:

> , " Teresa Hall " <

> Teresa.bodywork4u@w...> wrote:

> >

> >

> >

> >

> > > If we are primary care practitioners then there is no reason to

> not train

> > in doing pelvic or any other exam.

>

>

> we are only primary care in CA and perhaps FL and NM.. However, the

> soon to

> be released report from the little hoover commission will finally

> clarify the

> matter of L.Ac. being primary care in CA. As I understand it, there

> was NEVER

> any legislative intent to confer to us the right to make western

> diagnosis as

> primary care providers. The intent was that we can practice without

> referral,

> but our primary care was meant to be in the form of TCM and we are

> only

> expected and allowed to make referrals for patients who we SUSPECT

> of

> needing a WM dx. We are absolutely prohibited from making western

> dx and

> prescribing therapy upon that basis. This area has been somewhat

> gray for

> many years, though I believe a close reading of the CA law is not

> vague at all

> on this point. Nowhere are we explicitly granted the right to make

> western dx.

> Therefore it is not in our scope. CSOMA and the asian language

> associations

> have long argued differently, but it appears they will be ruled

> incorrect in the

> coming months.

>

 

>

>

>

> Chinese Herbal Medicine offers various professional services,

> including board approved continuing education classes, an annual

> conference and a free discussion forum in Chinese Herbal Medicine.

>

>

>

>

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I agree with Michael's comments on what actions Yehuda could have taken in

regard to his patient. I also have a question: did the patient actually come

in using the terms " polydipsia, polyphagia, polyuria " ? In my experience,

lots of patients, especially females, think they have excess hunger, are

thirsty, say they have frequent urination, but this doesn't mean they have

diabetes.

 

Julie

 

-

" mpplac " <inquiry

 

Thursday, February 26, 2004 2:19 PM

Re: What is our responsibility to patients?

 

 

> Yehuda,

> In the clinic you have dual responsibilities. First to your

> supervisor, and secondly to your patient. The reason you caught hell

> from your instructor is that you are not a licenced practitioner and

> by taking it upon yourself to make biomedical suggestions you have

> put

> your instructors licence to practice on the line.

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Share on other sites

Dear Julie, Michael, Andrea Beth, et al,

 

Thank you for addressing my question. I want you all to know the

postscript to the story:

My supervisor came over and apologized. This patient had been part of

an acupuncture externship program at USC, had come to our clinic to

receive suplemental treatment, including herbs, which were not part of

the externship, had been encouraged to come to the clinic by my

supervisor, was under the care of an MD at USC, and had specifically

asked to be treated by me. When I was asked to treat her, I of course

went through the ten asking questions to develop a differential Oriental

diagnosis. When she mentioned in passing that she was constantly

thirsty, hungry and had frequent urination, I asked if she had been

checked for diabetes, and merely suggested rather than ordered her to

consider a GTT. The reality is that as some of you noted, the clinical

supervisor is indeed responsible to the actions of his or her interns.

However, that being said I feel that it is MY responsibility to act as a

detective with the patient and or course, with my supervisor to consider

aspects of the complex patient picture which may not have been

considered. That is a major reason why I have decided to practice this

medicine, after successfully being in business for 21 years, raising a

family, and having my significant other stricken with a complex

neurological disorder. I feel that many patients are unable to

articulate their vague complaints and to thoughtfully consider their

suffering, sometimes new and different approaches can be taken which B " H

have been successful for me. I am so in agreement with the quote of

Adlai Stevenson (BTW my father was a delegate for Stevenson in the '56

democratic convention) which Al Stone concludes his posts with, " Pain is

inevitable, suffering is optional. " By being compassionate, advocative,

informative, and of course therapeutic, we make a major difference,

immediately in ending suffering, and later to end pain. I am not a

cowboy out to duel with or discredit MDs, I am not an immature kid trying

to score points for Chinese medicine or myself, but what I did, I would

do again. The abilitiy to express oneself with responsibly and with

finesse and knowledge (hopefully) comes with maturity that is the

approach I try to take.

 

Respectfully,

 

Yehuda

 

On Fri, 27 Feb 2004 14:35:46 -0700 Julie Chambers

<info writes:

> I agree with Michael's comments on what actions Yehuda could have

> taken in

> regard to his patient. I also have a question: did the patient

> actually come

> in using the terms " polydipsia, polyphagia, polyuria " ? In my

> experience,

> lots of patients, especially females, think they have excess hunger,

> are

> thirsty, say they have frequent urination, but this doesn't mean

> they have

> diabetes.

>

> Julie

>

> -

> " mpplac " <inquiry

>

> Thursday, February 26, 2004 2:19 PM

> Re: What is our responsibility to patients?

>

>

> > Yehuda,

> > In the clinic you have dual responsibilities. First to your

> > supervisor, and secondly to your patient. The reason you caught

> hell

> > from your instructor is that you are not a licenced practitioner

> and

> > by taking it upon yourself to make biomedical suggestions you have

> > put

> > your instructors licence to practice on the line.

>

>

>

>

> Chinese Herbal Medicine offers various professional services,

> including board approved continuing education classes, an annual

> conference and a free discussion forum in Chinese Herbal Medicine.

>

>

>

>

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Share on other sites

, yehuda l frischman

<@j...> wrote:

> Dear Julie, Michael, Andrea Beth, et al,

>

> Thank you for addressing my question. I want you all to know the

> postscript to the story:

> My supervisor came over and apologized.

 

Yehuda

 

I think you were correct to suggest further testing. It is most

definitely part of our scope to do this, making it not only our right,

but ALSO our responsibility. If you had NOT sugested further testing,

you would have breached both your legal and ethical obligations, IMO.

good call.

 

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