Commentary

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

In this issue of the Journal, Millstein et al provide an elegant, practical, and up-to-date review of insulin pump therapy (also known as continuous subcutaneous insulin infusion), emphasizing its benefits and comparing it with multiple daily insulin injections.¹

See related article

NOT FOR EVERYONE

While insulin pumps make the lives of many patients much easier, we should be careful when generalizing their indications. These devices have been with us for 4 decades, during which they have progressively been made more precise and more intelligent—and smaller. The technology may be attractive to some patients but undesirable to others (Table 1).

Many healthcare providers are unfamiliar with pump technology, and some are intimidated by it because it involves a dynamic device-user interface that is more complex than that of other concealed programmed devices such as pacemakers. Inadequate glycemic management is complex and may result from factors such as fear of hypoglycemia, difficulty with insulin dose adjustment, and poor math skills.²

Unfortunately, some patients are given a pump without proper screening and education, and they tend to call the pump manufacturer’s help line or their provider often for help with technical problems. Selecting the right patient for this technology is more important than the converse.

Indications for an insulin pump vary by country. In some countries, a pump is started as soon as type 1 diabetes is diagnosed. In the United States, the indications are very rigorous and restrictive, especially for patients with type 2 diabetes, in whom a lack of endogenous insulin production must first be proved.

There is no question that a pump should be offered to every patient with type 1 diabetes who demonstrates good motivation to improve his or her glucose control, but only after a rigorous education program. This option is too costly to be tried just to see if the patient likes it.

ADVERSE EVENTS WITH INSULIN PUMPS: MORE DATA NEEDED

A worrisome aspect of continuous subcutaneous insulin infusion at a population level is a lack of information on the root causes of adverse events (diabetic ketoacidosis or severe hypoglycemia) in patients who use it. These events may be serious and sometimes even fatal.

Outside of a controlled environment, it is difficult to ascertain whether an adverse event represents device error or user error, since pumps contain different components (electronic, mechanical, and pharmacologic) that interface with the human user.³ How adverse events are tracked or categorized is unclear, and given the risks associated with this technology, better postmarketing evaluation is needed. Furthermore, we do not know if the precision of insulin delivery decreases over the life of a pump.

While most pump manufacturers have good customer service and make every effort to provide the patient with a replacement pump in case of failure, we do not know if anyone maintains a database of such failures or adverse events, and if those failures can be analyzed to improve safety.³

INTERFACES ARE NOT STANDARD

When one buys a new car, little time is needed to learn how to operate it because most cars use the same basic features.

The situation is different with insulin pumps. To compete with each other, pump manufacturers create different looks, different insulin delivery methods, and different ways of administering a bolus. Switching from one pump to another is difficult without detailed education on the “bells and whistles” of the new pump.

Most patients use just a few features of the pump. They look at it as more of a convenience. They sometimes forget they are wearing it, and even forget to take a bolus before a meal.

PATIENT SATISFACTION DEPENDS ON THE PATIENT

For years, we thought insulin pumps were better at improving hypoglycemia awareness. But in a prospective study, multiple daily injections with frequent self-monitoring of blood glucose provided identical outcomes without worsening hemoglobin A_1c compared with continuous infusion with real-time continuous glucose monitoring, although satisfaction with treatment was better in the latter group.⁴

Patients’ satisfaction with continuous subcutaneous insulin infusion depends on their baseline hemoglobin A_1c level. Patients with relatively low hemoglobin A_1c tend to take an active approach to self-care, describe the pump as a tool for meeting glycemic goals, and say the pump makes them feel more normal. Patients with high hemoglobin A_1c tend to have a more passive approach to their self-care and have more negative experiences with the pump. Women are more concerned than men with the effect of the pump on body image and social acceptance.⁵

DOLLARS AND CENTS

According to 2012 estimates, 29 million Americans had diabetes mellitus, of whom 1.25 million had type 1. The direct medical costs of diabetes are estimated at $176 billion, of which 12% covers overall pharmacy costs.⁶ About 31% of adults with diabetes use insulin.⁷

For a device that costs $6,000, has a life span of only 4 years, and requires supplies that cost $300 per month, rigorous interpretation of superiority data would be needed to confirm that this technology would have a positive impact on public health if every insulin-using patient with diabetes were to say yes to it. It is true that switching from multiple daily injections to a pump leads to a significant reduction in insulin expenditures in patients with type 2 diabetes, according to a retrospective analysis of claims data.⁸

However, not all studies comparing pumps and multiple daily injections in type 2 diabetes have shown an advantage of one over the other in terms of a reduction in fasting glucose, hemoglobin A_1c, or incidence of hypoglycemia.⁹ A meta-analysis¹⁰ found that the two therapies had similar effects on glycemic control and hypoglycemia. Continuous infusion had a more favorable effect in adults with type 1 diabetes.¹⁰

Neither continuous infusion nor multiple daily injections can mimic physiologic endogenous insulin secretion. Endogenous insulin is secreted into the portal system, and its main site of action is the liver. As a result, there is more hepatic glucose uptake and thus a lower peripheral plasma insulin concentration with endogenous secretion than with systemic administration. Endogenous insulin secretion also suppresses hepatic glucose production and reduces the risk of hypoglycemia.¹¹

PROGRESS, BUT NOT PERFECTION

Diabetes mellitus constitutes a big burden on patients and on society. The discovery of insulin was a giant leap forward; the insulin pump was another great advance. We are getting closer to an integrated bionic pancreas. We are far from achieving a perfect system, but we are much better off than we were 50 or 80 years ago. And although insulin pump technology is sophisticated and precise, it still interfaces with a human user, and the human user still must press its buttons.

In this issue of the Journal, Millstein et al provide an elegant, practical, and up-to-date review of insulin pump therapy (also known as continuous subcutaneous insulin infusion), emphasizing its benefits and comparing it with multiple daily insulin injections.¹

See related article

NOT FOR EVERYONE

While insulin pumps make the lives of many patients much easier, we should be careful when generalizing their indications. These devices have been with us for 4 decades, during which they have progressively been made more precise and more intelligent—and smaller. The technology may be attractive to some patients but undesirable to others (Table 1).

Many healthcare providers are unfamiliar with pump technology, and some are intimidated by it because it involves a dynamic device-user interface that is more complex than that of other concealed programmed devices such as pacemakers. Inadequate glycemic management is complex and may result from factors such as fear of hypoglycemia, difficulty with insulin dose adjustment, and poor math skills.²

Unfortunately, some patients are given a pump without proper screening and education, and they tend to call the pump manufacturer’s help line or their provider often for help with technical problems. Selecting the right patient for this technology is more important than the converse.

Indications for an insulin pump vary by country. In some countries, a pump is started as soon as type 1 diabetes is diagnosed. In the United States, the indications are very rigorous and restrictive, especially for patients with type 2 diabetes, in whom a lack of endogenous insulin production must first be proved.

There is no question that a pump should be offered to every patient with type 1 diabetes who demonstrates good motivation to improve his or her glucose control, but only after a rigorous education program. This option is too costly to be tried just to see if the patient likes it.

ADVERSE EVENTS WITH INSULIN PUMPS: MORE DATA NEEDED

A worrisome aspect of continuous subcutaneous insulin infusion at a population level is a lack of information on the root causes of adverse events (diabetic ketoacidosis or severe hypoglycemia) in patients who use it. These events may be serious and sometimes even fatal.

Outside of a controlled environment, it is difficult to ascertain whether an adverse event represents device error or user error, since pumps contain different components (electronic, mechanical, and pharmacologic) that interface with the human user.³ How adverse events are tracked or categorized is unclear, and given the risks associated with this technology, better postmarketing evaluation is needed. Furthermore, we do not know if the precision of insulin delivery decreases over the life of a pump.

While most pump manufacturers have good customer service and make every effort to provide the patient with a replacement pump in case of failure, we do not know if anyone maintains a database of such failures or adverse events, and if those failures can be analyzed to improve safety.³

INTERFACES ARE NOT STANDARD

When one buys a new car, little time is needed to learn how to operate it because most cars use the same basic features.

The situation is different with insulin pumps. To compete with each other, pump manufacturers create different looks, different insulin delivery methods, and different ways of administering a bolus. Switching from one pump to another is difficult without detailed education on the “bells and whistles” of the new pump.

Most patients use just a few features of the pump. They look at it as more of a convenience. They sometimes forget they are wearing it, and even forget to take a bolus before a meal.

PATIENT SATISFACTION DEPENDS ON THE PATIENT

For years, we thought insulin pumps were better at improving hypoglycemia awareness. But in a prospective study, multiple daily injections with frequent self-monitoring of blood glucose provided identical outcomes without worsening hemoglobin A_1c compared with continuous infusion with real-time continuous glucose monitoring, although satisfaction with treatment was better in the latter group.⁴

Patients’ satisfaction with continuous subcutaneous insulin infusion depends on their baseline hemoglobin A_1c level. Patients with relatively low hemoglobin A_1c tend to take an active approach to self-care, describe the pump as a tool for meeting glycemic goals, and say the pump makes them feel more normal. Patients with high hemoglobin A_1c tend to have a more passive approach to their self-care and have more negative experiences with the pump. Women are more concerned than men with the effect of the pump on body image and social acceptance.⁵

DOLLARS AND CENTS

According to 2012 estimates, 29 million Americans had diabetes mellitus, of whom 1.25 million had type 1. The direct medical costs of diabetes are estimated at $176 billion, of which 12% covers overall pharmacy costs.⁶ About 31% of adults with diabetes use insulin.⁷

For a device that costs $6,000, has a life span of only 4 years, and requires supplies that cost $300 per month, rigorous interpretation of superiority data would be needed to confirm that this technology would have a positive impact on public health if every insulin-using patient with diabetes were to say yes to it. It is true that switching from multiple daily injections to a pump leads to a significant reduction in insulin expenditures in patients with type 2 diabetes, according to a retrospective analysis of claims data.⁸

However, not all studies comparing pumps and multiple daily injections in type 2 diabetes have shown an advantage of one over the other in terms of a reduction in fasting glucose, hemoglobin A_1c, or incidence of hypoglycemia.⁹ A meta-analysis¹⁰ found that the two therapies had similar effects on glycemic control and hypoglycemia. Continuous infusion had a more favorable effect in adults with type 1 diabetes.¹⁰

Neither continuous infusion nor multiple daily injections can mimic physiologic endogenous insulin secretion. Endogenous insulin is secreted into the portal system, and its main site of action is the liver. As a result, there is more hepatic glucose uptake and thus a lower peripheral plasma insulin concentration with endogenous secretion than with systemic administration. Endogenous insulin secretion also suppresses hepatic glucose production and reduces the risk of hypoglycemia.¹¹

PROGRESS, BUT NOT PERFECTION

Diabetes mellitus constitutes a big burden on patients and on society. The discovery of insulin was a giant leap forward; the insulin pump was another great advance. We are getting closer to an integrated bionic pancreas. We are far from achieving a perfect system, but we are much better off than we were 50 or 80 years ago. And although insulin pump technology is sophisticated and precise, it still interfaces with a human user, and the human user still must press its buttons.

In this issue of the Journal, Millstein et al provide an elegant, practical, and up-to-date review of insulin pump therapy (also known as continuous subcutaneous insulin infusion), emphasizing its benefits and comparing it with multiple daily insulin injections.¹

See related article

NOT FOR EVERYONE

While insulin pumps make the lives of many patients much easier, we should be careful when generalizing their indications. These devices have been with us for 4 decades, during which they have progressively been made more precise and more intelligent—and smaller. The technology may be attractive to some patients but undesirable to others (Table 1).

Many healthcare providers are unfamiliar with pump technology, and some are intimidated by it because it involves a dynamic device-user interface that is more complex than that of other concealed programmed devices such as pacemakers. Inadequate glycemic management is complex and may result from factors such as fear of hypoglycemia, difficulty with insulin dose adjustment, and poor math skills.²

Unfortunately, some patients are given a pump without proper screening and education, and they tend to call the pump manufacturer’s help line or their provider often for help with technical problems. Selecting the right patient for this technology is more important than the converse.

Indications for an insulin pump vary by country. In some countries, a pump is started as soon as type 1 diabetes is diagnosed. In the United States, the indications are very rigorous and restrictive, especially for patients with type 2 diabetes, in whom a lack of endogenous insulin production must first be proved.

There is no question that a pump should be offered to every patient with type 1 diabetes who demonstrates good motivation to improve his or her glucose control, but only after a rigorous education program. This option is too costly to be tried just to see if the patient likes it.

ADVERSE EVENTS WITH INSULIN PUMPS: MORE DATA NEEDED

A worrisome aspect of continuous subcutaneous insulin infusion at a population level is a lack of information on the root causes of adverse events (diabetic ketoacidosis or severe hypoglycemia) in patients who use it. These events may be serious and sometimes even fatal.

Outside of a controlled environment, it is difficult to ascertain whether an adverse event represents device error or user error, since pumps contain different components (electronic, mechanical, and pharmacologic) that interface with the human user.³ How adverse events are tracked or categorized is unclear, and given the risks associated with this technology, better postmarketing evaluation is needed. Furthermore, we do not know if the precision of insulin delivery decreases over the life of a pump.

While most pump manufacturers have good customer service and make every effort to provide the patient with a replacement pump in case of failure, we do not know if anyone maintains a database of such failures or adverse events, and if those failures can be analyzed to improve safety.³

INTERFACES ARE NOT STANDARD

When one buys a new car, little time is needed to learn how to operate it because most cars use the same basic features.

The situation is different with insulin pumps. To compete with each other, pump manufacturers create different looks, different insulin delivery methods, and different ways of administering a bolus. Switching from one pump to another is difficult without detailed education on the “bells and whistles” of the new pump.

Most patients use just a few features of the pump. They look at it as more of a convenience. They sometimes forget they are wearing it, and even forget to take a bolus before a meal.

PATIENT SATISFACTION DEPENDS ON THE PATIENT

For years, we thought insulin pumps were better at improving hypoglycemia awareness. But in a prospective study, multiple daily injections with frequent self-monitoring of blood glucose provided identical outcomes without worsening hemoglobin A_1c compared with continuous infusion with real-time continuous glucose monitoring, although satisfaction with treatment was better in the latter group.⁴

Patients’ satisfaction with continuous subcutaneous insulin infusion depends on their baseline hemoglobin A_1c level. Patients with relatively low hemoglobin A_1c tend to take an active approach to self-care, describe the pump as a tool for meeting glycemic goals, and say the pump makes them feel more normal. Patients with high hemoglobin A_1c tend to have a more passive approach to their self-care and have more negative experiences with the pump. Women are more concerned than men with the effect of the pump on body image and social acceptance.⁵

DOLLARS AND CENTS

According to 2012 estimates, 29 million Americans had diabetes mellitus, of whom 1.25 million had type 1. The direct medical costs of diabetes are estimated at $176 billion, of which 12% covers overall pharmacy costs.⁶ About 31% of adults with diabetes use insulin.⁷

For a device that costs $6,000, has a life span of only 4 years, and requires supplies that cost $300 per month, rigorous interpretation of superiority data would be needed to confirm that this technology would have a positive impact on public health if every insulin-using patient with diabetes were to say yes to it. It is true that switching from multiple daily injections to a pump leads to a significant reduction in insulin expenditures in patients with type 2 diabetes, according to a retrospective analysis of claims data.⁸

However, not all studies comparing pumps and multiple daily injections in type 2 diabetes have shown an advantage of one over the other in terms of a reduction in fasting glucose, hemoglobin A_1c, or incidence of hypoglycemia.⁹ A meta-analysis¹⁰ found that the two therapies had similar effects on glycemic control and hypoglycemia. Continuous infusion had a more favorable effect in adults with type 1 diabetes.¹⁰

Neither continuous infusion nor multiple daily injections can mimic physiologic endogenous insulin secretion. Endogenous insulin is secreted into the portal system, and its main site of action is the liver. As a result, there is more hepatic glucose uptake and thus a lower peripheral plasma insulin concentration with endogenous secretion than with systemic administration. Endogenous insulin secretion also suppresses hepatic glucose production and reduces the risk of hypoglycemia.¹¹

PROGRESS, BUT NOT PERFECTION

Diabetes mellitus constitutes a big burden on patients and on society. The discovery of insulin was a giant leap forward; the insulin pump was another great advance. We are getting closer to an integrated bionic pancreas. We are far from achieving a perfect system, but we are much better off than we were 50 or 80 years ago. And although insulin pump technology is sophisticated and precise, it still interfaces with a human user, and the human user still must press its buttons.

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].