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GreenField Health’s Health Matters: March 2006
A New GreenField Family Member
Your Referrals and GreenField’s Growth
More on Prostate Cancer Screening
Avian Flu and the Run on Tamiflu
GreenField Introduces E-Prescribing
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A New GreenField Family Member
We are delighted to announce that GreenField Health’s Dr. Elizabeth Hays and her husband Dave (who is a wonderful family physician by the way) have welcomed their second child. Thomas Anthony Hays was born on February 10 after an incredibly brief and uneventful labor. Elizabeth, David, Harper (almost 2 years old now) and Thomas are all doing well. We are all delighted to welcome Thomas into our GreenField family. Dr. Hays will remain on maternity leave until approximately early May.
Your Referrals and GreenField's Growth
People frequently assume that GreenField is full and not taking new patients. All of our physicians continue to see new patients, and we will be adding physicians as growth permits. Our desire is to grow cautiously and slowly by adding the right physicians and clinical staff in order to enhance our services to you. For example, as we grow, we will expand our hours, provide additional clinical expertise, and offer other clinical services such as additional preventive health procedures performed at GreenField.
Your continued referrals will help us to grow intelligently, and will help us to serve you better. Please keep them coming. We truly appreciate it, and we believe that you will benefit from it in the years ahead.
More on Prostate Cancer Screening
In our February Health Matters, we discussed prostate cancer screening and the conundrum that it presents. This piece has received a remarkable amount of positive feedback from readers. We are glad that many of you found the piece informative. For those who did not have a chance to read it, you can find it at the link above.
Last month we discussed Prostate Specific Antigen (PSA) testing, but did not discuss what has been called “PSA Velocity”. Another approach to prostate cancer screening is to look not just at the PSA level, but to watch for a general rise in the PSA irrespective of whether or not the PSA is in the “normal” range. PSA velocity tracks the rate of increase in the PSA over time. This is important because a PSA that rises over time is more likely to reflect prostate cancer than one that is stable. In one important study, an increase in PSA of more than 0.75 per year was very effective at distinguishing men with prostate cancer from those with either BPH or no prostate disease – even if the PSA values remain in the normal range.
At least three consecutive measurements should be performed because any one measurement could be elevated due to a variety of issues discussed last month. Any rise in the PSA should always be substantiated by re-measurement after a short period of time.
PSA velocity is diagnostically helpful when it is present, but a high percentage of men with cancer do not have a PSA increase of over 0.75 per year. So it is helpful when present, but not as helpful when it is absent. For many, this simply adds to the overall confusion around prostate cancer screening.
As stated last week, whether or not prostate cancer screening overall is of value in improving quality of life or extending life remains an area of debate in the medical community – even with PSA velocity.
Avian Flu and the Run on Tamiflu
Health care is a fascinating profession. We are faced with challenges every day – difficult clinical situations, major life events for individuals that we must help with, and, at times, difficult ethical dilemmas.
The recent scare posed by avian flu is an example of this. As noted in our prior Health Matters, the scientific data suggests that the true risk of an avian flu pandemic is very, very low. Nonetheless, people are bombarded with information from news reports and other sources, some of which is reliable and reasonable, but a good deal of which is overly dramatic or apprehensive. A lot also depends on how people interpret what they are hearing.
We understand the wide variety of ways that people respond to such potential threats – they can obviously be quite scary. To provide you with an insight into some of the challenges that we face in dealing with such situations, our GreenField Health team thought that you would find the following recently published article interesting. The article comes from the highly respected New England Journal of Medicine and addresses the issue of whether physicians should prescribe medications on demand. Avian flu and Tamiflu represent just one example of such challenging situations – we certainly do not blame anyone for the way they react to these situations. We know that it is our job to help you see the real threat and the real risk or benefit of any possible treatment.
The tile of the article is “The Run on Tamiflu – Should Physicians Prescribe on Demand?” written by Allan S. Brett MD, and Abigail Zuger, MD. Dr. Brett is a professor of medicine at the University of South Carolina School of Medicine in Columbia, SC, and Dr. Zuger is an internist and infectious-disease specialist at St. Luke's–Roosevelt Hospital Center, New York. Their article was very well received and we believe thoughtfully written. The complete unedited article and its references are included here, from the New England Journal of Medicine:
"Doctor, I need a prescription for that bird flu drug." If recent newspaper headlines are any indication (Reference 1), this request has been repeated tens of thousands of times around the country this fall. So much oseltamivir (Tamiflu) has been prescribed presumably for personal stockpiling in case of an avian influenza pandemic, given that the human influenza season has not yet begun that at the end of October, the drug's manufacturer stopped shipping it to the United States.
A busy outpatient office is no place to think through complicated ethical dilemmas. But a request for oseltamivir is just that, and it must be examined from both the perspective of individual patient–physician encounters and that of public health. From the first perspective, such requests raise a more general question: What is the physician's obligation to grant patients' requests for specific interventions? As an outgrowth of the patient-autonomy movement, patients' preferences have come to play an important role in clinical decision making. It is widely accepted that, in nearly all clinical circumstances, patients may refuse unwanted interventions proposed by physicians. Less straightforward, however, are clinical encounters in which patients insist on interventions that are deemed inappropriate by physicians. These encounters have been discussed both in the context of common problems in primary care (e.g., when patients demand antibiotics for viral infections) and in the context of life-sustaining treatment near the end of life (in cases in which physicians have deemed further treatment to be futile). The literature on ethics in the clinical setting and professional guidelines generally support the conclusion that physicians are not obligated to honor requests for nonbeneficial tests and treatments although what should count as nonbeneficial or inappropriate may remain problematic.
Physicians are trained and licensed to practice medicine according to scientific evidence and professional standards. When there is at least a modicum of benefit from the perspective of conventional medicine, physicians should generally defer to patients' requests, and a patient's weighing of benefits and harms should drive the decision. But if a patient requests an intervention that falls outside the boundaries established by scientific evidence, a physician is not obligated to provide it.
In the case of avian influenza, a human outbreak in any given geographic area is currently a purely hypothetical concern; physicians are not required to dispense medications for hypothetical scenarios when it is not yet possible to determine who is at risk. If a human outbreak occurred, it is unclear whether the virus would be generally susceptible to oseltamivir and whether this drug would still be the treatment of choice. Moreover, in an epidemic, any indicated drug could be used in several different ways for preexposure prophylaxis, postexposure prophylaxis, or treatment after symptoms have appeared. If oseltamivir were dispensed well in advance of an outbreak, patients would probably use their stockpiles in a chaotic fashion, rather than optimally for any of these indications. Indeed, some or most of it would no doubt be wasted on viral illnesses other than influenza.
From the perspective of the individual patient–physician encounter, these factors suggest that physicians have no obligation to prescribe oseltamivir to patients who request it for a hypothetical outbreak of avian influenza: the threshold for a modicum of benefit has not been reached. The relative lack of side effects does not constitute a sufficient reason for prescribing oseltamivir.
From a public health perspective, preventive or therapeutic interventions should be optimally allocated across a population. Accordingly, a major focus of public health ethics is maximizing the health of the population while minimizing infringements on individual liberty. (Reference 2) Ethical dilemmas arising from the tension between the two are typically posed by cases in which a person refuses to comply with a public health imperative (such as mandatory vaccination or quarantine). Less common are cases in which a person demands an intervention that is perceived as conferring individual benefit but that might contribute to net harm to the public health. The personal stockpiling of oseltamivir for a potential avian influenza pandemic represents just such a case.
The current supply of oseltamivir is inadequate to meet the demand that would arise in the event of an avian influenza pandemic. Moreover, personal stockpiling of oseltamivir depletes the supply available for patients who could benefit from the drug during the usual human influenza season: a person who is assertive enough to ask for a prescription does not necessarily need the drug more than unassertive people do. The likely confusion about whether to use stockpiled oseltamivir for prophylaxis or treatment and the probability that much will be used for illnesses other than influenza are relevant from the public health perspective as well. Finally, the inappropriate or chaotic use of oseltamivir will increase the risk that resistant strains of influenza virus will develop. These considerations strongly suggest that random stockpiling of oseltamivir would confer no benefit to the overall population and would probably confer harm.
Thus, an individual physician has no obligation to prescribe oseltamivir in response to a patient's request — a position that discourages prescribing of the drug but does not prohibit it. In contrast, the public health perspective clearly suggests that the physician has an obligation not to prescribe oseltamivir — a position that is tantamount to a prohibition against prescribing it. The public health perspective need not always trump the individual perspective, but since both point in the same direction in this instance, the prohibition should prevail.
As in 2001, when physicians were besieged with demands for ciprofloxacin after the anthrax attacks, this year's run on oseltamivir should stimulate public health experts to consider more generally the dilemma encountered by physicians who have simultaneous obligations to individual patients and to public health. Physicians who faced demands for oseltamivir in the early fall of 2005 would have welcomed explicit directives from public health institutions such as the Centers for Disease Control and Prevention and state departments of health. Such directives were helpful in the fall of 2004 when physicians were forced to ration influenza vaccine. (Reference 3) In the absence of formal guidelines from the government, some professional societies (Reference 4) and private medical groups (Reference 5) have stepped in to issue statements that are consistent with our conclusion: physicians should decline any request for a prescription for the purpose of stockpiling oseltamivir, optimally with an explanation that reflects the reasoning here.
References
1. Brown D. Run on drug for avian flu has physicians worried. Washington Post. October 22, 2005:A1.
2. Kass NE. An ethics framework for public health. Am J Public Health 2001;91:1776-1782.
3. Lee TH. Rationing influenza vaccine. N Engl J Med 2004;351:2365-2366.
4. Infectious Diseases Society of America. Joint position statement of the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America on antiviral stockpiling for influenza preparedness. (Accessed November 17, 2005, at http://www.idsociety.org/Template.cfm?Section=Home&Template=/ContentManagement/ContentDisplay.cfm&ContentID=14635.)
5. Harvard Vanguard Medical Associates. Avian influenza (bird flu): frequently asked questions. (Accessed November 17, 2005, at http://www.harvardvanguard.org/flu/avian.asp.)
Screening GreenField Introduces E-Prescribing
We are pleased to announce that as of early March, GreenField is again pioneering new technology to improve your healthcare experience. Using technology developed by Kryptiq and SureScripts, we are now able to send prescriptions to some pharmacies via our secure electronic connection. For the security buffs out there, this new technology is HIPAA compliant, and as an added bonus, it will allow us to track the communication we’ve had with the pharmacies, which will help to speed things along.
We will be the first practice in the state to implement this kind of technology, and ask that you bear with us as we work out the inevitable kinks. As always, if you arrive at your pharmacy expecting to pick up a prescription and are told that it is not there, please call us right away from the pharmacy, or ask the pharmacy technician to call us directly so that we may place the order for the prescription in real time.
GreenField will be actively working with area pharmacies, Kryptiq and SureScripts to troubleshoot any problems that arise, so please let us know if you experience any difficulties.
We are delighted to bring this new technology to bear to better serve you, our patients. We hope that you appreciate our work to continue bringing you new innovations to improve your care.
Thanks to our corporate partners
Kryptiq Corporation
Baker-Ellis Asset Management, LLC
Stahancyk, Gearing, Rackner, & Kent Law Firm
Go to our website to learn more about these corporate sponsors https://securemail.greenfieldhealth.com/Portal/General+Info/Corporate+Partners/Default.aspx
First Tuesday Reminder
The schedule for our upcoming GreenField Health First Tuesday Open House is April 4th, May 2nd, and June 6th. This is a good introduction to our practice for relatives, friends or coworkers who might be interested in becoming a GreenField patient. The sessions begin promptly at 5:30 PM on the first Tuesday of each month. Learn more about our First Tuesday Open House Online at: https://securemail.greenfieldhealth.com/Portal/General+Info/First+Tuesdays/default.aspx
Sincerely,
Your GreenField Health Team:
Beth Davis, your Benefits Coordinator and Biller- beth.davis@greenfieldhealth.com
Chuck Kilo, MD - chuck.kilo@greenfieldhealth.com
Cynthia Ferrier, MD - cynthia.ferrier@greenfieldhealth.com
Dia Gaede, CMA, your Health Coordinator - dia.gaede@greenfieldhealth.com
Elizabeth Hays, MD - elizabeth.hays@greenfieldhealth.com
Eric Murray, MD - eric.murray@greenfieldhealth.com
Jill Arena, your Clinic Administrator - jill.arena@greenfieldhealth.com
Joel Swartzmiller, IT Manager - joel.swartzmiller@greenfieldhealth.com
Pam Mockenhaupt, CMA, your Health Coordinator - pam.mockenhaupt@greenfieldhealth.com
Paula Koeller, MD - paula.koeller@greenfieldhealth.com
Shelly Banta, your Clinic Manager - shelly.banta@greenfieldhealth.com
Tiana Schmitt, CMA, your Health Coordinator - tiana.schmitt@greenfieldhealth.com
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GreenField Health System
9427 SW Barnes Road,
Suite 590
Portland,
OR 97225
Phone: 503-292-9560
Fax: 503-292-9510
Web: http://www.greenfieldhealth.com
Questions, concerns, comments appreciated:
questions@greenfieldhealth.com
copyright 2003-2006 GreenField Health
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