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December 8, 2011 – Vol. 6 • No. 4

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Honesty at heart of good medical partnership


Dr. Julien Dedier, a doctor of internal medicine at Boston Medical Center, readily admits that much has changed in medicine over the years, especially among primary care physicians (PCPs).

And that’s a good thing, according to Dedier.

While PCPs are still busy diagnosing and treating a litany of illnesses, gone are the days when paternalism ruled the medical approach. Health care is now more of a partnership.

“I’m part of a team,” he said. “They have to know that I am working on their behalf. My job is to know my patient and my patient’s overall health well enough to establish trust and confidence.”

For Dedier, that means being aware of more than just his patients’ height, weight and blood pressure levels. “I need to know the total picture,” he explained.

PCPs like Dedier are in high demand these days. According to the 2008 National Ambulatory Medical Care Survey, more than 60 percent of the 956 million physician office visits that year were for primary care.

That’s not unusual. Primary care — considered the portal of entry to the health care system — encompasses the greatest number of patients and provides the widest array of services. People flock to their doctors for colds, aches and pains, immunizations, screening tests and medication. Coughs that don’t abate, rashes that persevere, even broken bones all wind up in a doctor’s office or clinic.

PCPs have their hands full. They diagnose everything from high blood pressure to diabetes to cardiovascular diseases and make referrals to other providers. In a sense, PCPs are CEOs, having the overall responsibility of managing their patients’ total care.

But the biggest job, at least according to Dedier, is to listen and pay attention.

The PCP needs to know, for instance, why a person shuns flu shots or refuses to take medication for an illness when he or she feels fine. “I have to understand where my patient is coming from and take each concern seriously,” he said.

Dedier demands one thing in return from his patients. “Honesty,” he said. “I want patients to feel comfortable telling me what they have or haven’t done. My role is to help them improve their health.”

But he has to know the truth. “If I prescribe a medicine and a patient swears up and down that they have taken it when they have not, it causes a problem,” he explained. The patient’s response could cause him to alter the dose or try another medication when either move is not necessary or worse, could be harmful.

Though PCPs are essential to the health care system they are in diminishing supply. The 2011 Physician Workforce Study by the Massachusetts Medical Society determined that the shortage of family practitioners and internists in the Commonwealth is severe and critical. The waiting times for an appointment range from 36 to 48 days.

And it’s only expected to get worse. Medical students are not choosing primary care as their area of clinical interest, as noted in a recent study published in the Archives of Internal Medicine. Furthermore, the health care reform bill enacted by President Barack Obama expands coverage to millions of uninsured Americans, making the PCP central to meeting the increased demand and the law’s success.

An important function of the PCP is screening. And that is not always as straight forward as it would seem. Screening guidelines can fluctuate and PCPs — and patients — have to keep pace. The U.S. Preventive Services Task Force (USPSTF) is a group of PCPs charged with examining research and making recommendations of the types and frequency of screening tests to be followed by PCPs.

The group’s decisions are not taken lightly and can determine those tests for which insurance plans will pay. Some of their decisions are controversial and cause uproar and confusion.

The USPSTF recently released a new draft recommending against prostate-specific antigen (PSA), the blood test used to screen for prostate cancer, stating that there is “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” The task force thus discourages the use of PSA screening even for men of high risk, which include African Americans and those with a family history of the disease.

The group’s position is that many prostate cancers are slow growing and ultimately not fatal, and that the aggressiveness of the cancer cannot always be accurately predicted. Consequently, the medical treatment prescribed is often excessive. Also, false-positive results can lead to unnecessary — and often harmful — medical care.

Dr. David Wang, a urologist at Boston Medical Center, said that he adheres to the standards of the American Urological Association (AUA) and respectfully disagrees with the USPSTF recommendation. “The PSA is not a perfect test,” he acknowledged. “But it’s the best we have. We don’t want to turn the clock back 25 years when the majority of men were diagnosed after the cancer had spread.”

Wang said that he recognizes that over-treatment of prostate cancer exists. “But to deny the test to African American men or men with a family history is a disservice,” he said. “Some men want to know and the decision for PSA testing should be a decision made by the patient after discussion with his doctor.” The AUA further affirms that “when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.” As for Wang, he will continue to discuss the test with his patients.

The task force is recommending changes in the guidelines for Pap smears as well, which screen for cervical cancer. It is advocating testing every three years between the ages of 21 and 65 in women who have had sex and have a cervix. Prior recommendations called for screening within three years of vaginal intercourse and repeat tests every one to two years.

For Dedier, keeping an open mind should always be the rule rather than the exception. Take alternative medicine, for example. The 2007 National Center for Health Statistics found that almost 40 percent of adults and 12 percent of children used some form of complementary or alternative medicine, such as acupuncture or herbs.

Dedier said that he is not opposed to different forms of medicine. “I just need to make sure that the patient is not being harmed,” he explained. If a patient prefers garlic over medication to bring down cholesterol, it might be worth a try, according to Dedier, but he is quick to point out that if the cholesterol is not down in three months’ time it’s best to have another discussion.

Sensitive topics that a patient prefers not discussing are not overlooked. Like obesity.

He starts with the BMI, a measure of healthy weight based on height. “I present it in medical terms,” he said. “Your BMI is one that doctors would consider obese and it’s a cause of mortality and morbidity.”

That starts the conversation on the health impact of weight and measures to take to reduce it.

More than most, Dedier says he is keenly aware that while he is examining a patient, he too is being carefully examined as well.

He welcomes the scrutiny. “They have to figure out if I’m the right one,” he said.

Comments on Be Healthy? Contact Karen Miller at kmiller@bannerpub.com