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PED-EM-L  April 1998

PED-EM-L April 1998

Subject:

Re: Fever -Reply

From:

Michael Newdow <[log in to unmask]>

Reply-To:

Michael Newdow <[log in to unmask]>

Date:

Fri, 10 Apr 1998 19:13:04 -0700

Content-Type:

text/plain

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Parts/Attachments

text/plain (78 lines)

Thomas Chun wrote:
>
> Dr. Newdow,
>
> I'm curious to know what kinds of responses you get from parents,
> when you present them with this scenario.
 
Well, being a physician, I'm certain my recollections are quite biased.
However, when I think back in general, I think the vast majority
understand quite well and are very satisfied.  (I try to use this style
almost always - peds and adults - with chest pain, lacerations, x-rays,
etc.).  Certainly there are occasions where the interpretation of my
discussion is as you say: "What kind of a doctor is this!?!  Doesn't he
know what to do?" - but that's actually fairly unusual.  I explain that
nobody has the data (or at least I don't know the data if others do),
and that some of the questions involve value judgments for which there
are no answers.
 
I also agree with you that lots of times they ask me to make the
decision - and I make the one I would make for myself or my family.
 
> How do you handle parents who are clearly overanxious?  That is,
> yeah the kid has a fever, but your strong suspicion is that it is due to a
> virus; your impression of the parents is that they'll want "everything"
> done, probably torturing the kid unnecessarily.
 
I think we usually can present the data in such a way as to influence
the patient or parent.  For instance, the "Well, I would do this for my
child" usually seems to be pretty powerful.  But I try to stay fairly
neutral unless I think they are way off the mark.
 
One methodology which I used once seemed to work excellently.  It was an
end-of-life case where I really disagreed with the family, and wanted to
convince them to change their minds.  However, rather than biasing them
unfairly (as I thought I probably could do), I called one of my
colleagues over and we each took opposite views, debating the issue in
front of the caretakers.  I think it was a great way to deal with the
situation.  Of course it requires some time and a location where there
is a colleague available.  But I'm convinced the family truly made an
informed decision.  [By the way, I lost].
>
> I'm also curious to know how you think your approach would stand up in
> court, if the kid should have a bad outcome.
 
MARTIN I HERMAN wrote:
>
> ANd what do you do if there is a significant infection that is missed??
> Do you think the parents are willing to sign a waiver of damages when you
> first talk with them? Suppose there was a urinary tract infection and the
> child winds up with pyelo, and then subsequently renal failure?? Do you
> think your position will protect you?? AND what about the child? Are you
> really doing your job / meeting your professional obligation to help that
> child ???
>
> Many questions, few answers here..
 
Well, we're into philosphy here, and I'm sure we all have our own
ideas.  Mine (for anyone interested) is that our entire problem stems
from this absurd consumerless system that we have allowed to develop.
In every other arena, people make judgments weighing benefits versus
costs - financial plus inconvenience, pain, etc.  But in medicine, we've
taken out the financial concern on the part of the consumer - i.e., the
patient before us.  Thus, we stand as both consumer advocates (who
should order everything in the world for our patient - cost be damned)
and responsible member of society, who has a fiduciary duty to control
medical expenditures.  If we weren't in this situation, those consumers
would be making those decisions - as they do with their food, their
shelter, their vacations, etc.  I try to get them to make the same
rational (at least to me) decisions they would make were that the case.
 
As far as lawsuits - I really try not to even think about them.  I feel
I am protected as well as I can be by rational, justifiable decisions.
Can I lose?  Sure.  Will I?  Don't know.  Have I?  Not yet.
 
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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