Curbside Consultation

A One-Stop Health Care Request

Case Scenario

I work in a multispecialty clinic that serves underinsured and immigrant patients. Recently a woman brought her father to my office for the first time for a "check-up." The elderly man, who had been visiting from Ethiopia for several months, had a blood glucose level that was well over 200 mg per dL. His daughter indicated that her father has had diabetes for the past five years and that so far it had been treated by diet alone. He was returning to Ethiopia the following week, and she requested that I perform a complete physical examination and prescribe diabetes medication for him.

I didn't understand why the family insisted so strongly on starting medication immediately rather than initiating it in Ethiopia. I explained that I was in an awkward position: I was being asked to begin therapy without laboratory test results and medical records, or the possibility of follow-up. I told them a single examination would be of only limited value. "We all do it this way," the daughter explained. She went on to say that other family members had come to this country in the past for check-ups and general medical care before returning to Ethiopia.

I ended up examining the patient, starting him out with a 5-mg dosage of glipizide, and ordering a chemistry panel and a hemoglobin A_1c test. I asked the patient to return for follow-up the day before flying back to his country. He apparently didn't go to the laboratory because I never received a report, nor did I see the patient again.

Please comment on the temporizing use of our health care resources for patients whose resources in their own countries may be limited. Specifically, what would have been appropriate management of this patient?

Commentary

This scenario is likely to be common in clinics such as the one described here. This physician's frustration with the patient, his family members, and the system as a whole is evident. Providing care to a transient visitor with a chronic disease is a difficult proposition. While many physicians want to make decisions guided by the best evidence, this scenario is one of many in medicine where physicians must rely on clinical intuition. We suggest that maintaining a patient-centered approach with culturally appropriate care and evidence-based disease management might provide a reasonable health care visit for the patient and serve to limit frustration on the part of the physician.

Patient-centered care can be defined in a variety of ways. One recent comprehensive description of patient-centered care is found in the Institute of Medicine's (IOM's) "new rules" for health care (see accompanying table).¹ These rules provide direction for health care system reform, and they also are helpful when examining care provided in small systems like the multispecialty clinic serving underinsured and immigrant patients described above.

TABLE Institute of Medicine's 10 Rules for Health Care Reform Rule Description   1. Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times, and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits. 2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences. 3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accomodate differences in patient preferences and encourage shared decision making. 4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information. 5. Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety is a system priority. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system's performance on safety, evidence-based practice, and patient satisfaction. 8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events. 9. Waste is continuously decreased. The health care system should not waste resources or patient time. 10. Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. Information from reference 1.

This patient came with a specific request: a physical examination and medication to treat his diabetes. This is not an unreasonable request, but it is made challenging by the knowledge that the patient soon will be traveling back to Ethiopia and is unlikely to return for follow-up care. At first glance, the IOM's rules, which call for a "continuous healing relationship," show that it is obviously impossible to base the care of this patient on such a relationship. However, other rules are helpful in this situation. For example, this encounter is one where the "patient is the source of control." Although the physician wants to perform a complete diabetes work-up, it would be incongruent with the needs of this patient. Because the patient's random blood glucose level is greater than 200 mg per dL, he meets the diagnostic criteria for diabetes and the need for pharmacologic treatment. As far as we can tell from this brief scenario, he is presenting to initiate, or perhaps to continue, treatment for diabetes.

This is also an opportunity to "customize the care based on patient needs and values," a part of which is providing culturally competent care. This approach recognizes that patients present with distinct values, attitudes, and health beliefs that shape their perceptions and expectations of the care they receive. Two key issues are present in this scenario: a language difference and an inadequate understanding of the need for follow-up after starting a medication.

In this case, it appears that family members act as interpreters. In general, family members should not serve as interpreters in order to avoid bias, difficulty in broaching sensitive topics, and miscommunication related to lack of knowledge of medical terminology.^2-4 It is clear that the patient and family have a different understanding of the process of initiating and monitoring the patient's diabetes medication than that of the physician. An effective response to their request might be to clarify the patient's point of view, accept the family's need for health care, and educate the patient and family about potential side effects from a medication initiated without an opportunity for follow-up. Using a trained medical interpreter or even a telephone interpreter will go a long way toward helping the physician negotiate a care plan with this patient and family.

Although interpersonal interaction in this case requires application of the art rather than the science of medicine, the physician can easily apply evidence-based decision-making to this patient's diabetes care. Guidelines for diabetes care are readily available on the Internet, and some of them are international guidelines that may be helpful in this case.⁵ Using standardized practice guidelines decreases variation in care and increases quality of care.⁶ The bottom line in diabetes care is to maintain a glucose level as close to normal (for nondiabetics) as possible. Eye examinations, foot examinations, measuring hemoglobin A_1c values, determining urine microalbumin levels, and starting therapy with angiotensin-converting enzyme inhibitors are all important, yet secondary to blood glucose control. In this case, starting the patient on a glucose-lowering agent is perfectly reasonable and consistent with current guidelines.

Finally, this case is an opportunity to address the "anticipation of needs" for many of this physician's patients. From the case scenario, we might assume that this type of visit (a one-stop visitor request) is not uncommon in this practice. This case and the frustration that it generated in this physician suggest the necessity to anticipate similar needs in the future. Identifying common threads in these cases and working with others (nurses, administrators, physicians, mid-level providers, volunteers) in the practice can help the physician identify a common plan for these patients. That plan might include everything from providing translator services for cultural groups who generally access the clinic to guidelines on which services will be offered in a one-stop request (e.g., initiating diabetes medication might be reasonable, but ordering a magnetic resonance imaging scan for suspected vertebral disc disease might not be). Anticipating patient needs also helps to eliminate waste in the health system and decrease the frustration generated by these cases.

Cases that cause physicians particular angst provide an opportunity to examine the systems of care in which we work. This case provides insight into a group of patients that is especially challenging, particularly for those in primary care, who understand the importance and value of the continuous healing relationship. Using a framework such as the IOM's 10 rules can help physicians examine the care that is delivered, and work to redesign systems to meet their patients' needs and allow them to feel good about the care they deliver.

GREG OGRINC, M.D., M.S.
White River Junction, Vermont

SUNITA MUTHA, M.D., F.A.C.P.
San Francisco, California

GREG OGRINC, M.D., M.S., is assistant professor of community and family medicine and medicine at Dartmouth Medical School in Hanover, N.H., and on staff of the Primary Care Division at the White River Junction (Vt.) Veterans Affairs Medical Center.

SUNITA MUTHA, M.D., F.A.C.P., is assistant professor of medicine at the University of California, San Francisco (UCSF) School of Medicine and director of The Network program at the Center for the Health Professions at UCSF.

REFERENCES

1. Brier R, ed. Crossing the quality chasm: a new health system for the 21st century. Committee on Quality Health in America, Institute of Medicine. Washington, D.C.: National Academies Press, 2001.

2. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev 2000;57 (Suppl 1):181-217.

3. Riddick S. Improving access for limited English-speaking consumers: a review of strategies in health care settings. J Health Care Poor and Underserved 1998;9(Suppl):S40-S61.

4. Smedley B, Stith A, Nelson A. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. The National Academies Press (Summary). 2002. Accessed January 9, 2004, at: http://www.iom.edu/includes/dbfile.asp?id=4175.

5. Primary care guidelines for type 2 diabetes. St. Vincent Declaration Primary Care Diabetes Group. Web Site. 2003. Accessed January 9, 2004, at: http://www.diabetesinprimarycare.com.

6. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22. *

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