Patient physical characteristics and primary care physician decision making in preconception genetic screening.

BACKGROUND: There has been growing emphasis on preconception care as a strategy to improve maternal and child health since the 1980s. Increasingly, development of genetic tests will require primary care providers to make decisions about preconception genetic screening. Limited research has been conducted on how primary care providers interpret patients' characteristics and use constructs, such as ethnicity and race, to decide whom to offer preconception genetic screening. OBJECTIVE: This report assessed the influence of patient characteristics on decisions to offer preconception genetic screening. METHODS: A web-based survey of family physicians was conducted. Physicians reviewed a clinical vignette that was accompanied by a picture of either a black or a white patient. Physicians indicated whether they would offer genetic screening, and if yes, what tests they would offer and what factors influenced their decisions. RESULTS: The majority (69.2%) of physicians reported that they would not offer genetic screening. Respondents who reviewed the vignette accompanied by a picture of the black patient were more likely to offer screening (35% vs. 26%, p = 0.0034) and rated race as more important to their decision to offer testing than those who viewed the picture of the white patient (76% vs. 49%, p < 0.0001). CONCLUSIONS: Our findings suggest that patient race is important to physicians when making decisions about preconception genetic testing and that decision making is influenced by patients' physical characteristics. The reticence of physicians in this sample to offer preconception screening is an important finding for public health and clinical practice.

Primary care guide to managing a breast mass: a legal perspective on risk management.

Failure to diagnose breast cancer in a timely manner is the most common reason for malpractice litigation in the US, and it is the most costly claim made against physicians. Common reasons for delay of diagnosis include unimpressive physical findings, failure to follow up with the patient, and a negative mammogram report. Equally important for quality patient care and for defense against malpractice suits is thorough documentation of history, examination, test results, recommendations, and patient interactions. This article provides guidelines with case studies that stress the importance of effective documentation and communication with the patient and offers recommendations for risk management.

Primary care guide to managing a breast mass: step-by-step workup.

Missed breast cancer is the most common malpractice suit filed in the US. But even without a biopsy of every mass, clinicians can reduce the risk of failed diagnosis to 1% by using a triple-diagnosis method to working up a breast mass, according to these experts, who offer a step-by-step guide. Includes QuickTimeTM video of breast exam. Failure to diagnose breast cancer in a timely manner is the most common reason for malpractice litigation in the US. Unless the potential for false-negative results of physical examination, mammography, ultrasound, and fine-needle aspiration biopsy (FNAB) is recognized, delay in the diagnosis of breast cancer will continue to occur. A systematic, thorough approach to the workup of any breast mass-- including a careful history, clinical breast examination, and documentation--is crucial. Upon detection of a mass, distinguishing the cyst from the solid mass (often by fine-needle aspiration or FNAB) is one of the most important tasks facing the clinician. Although most cysts resolve upon aspiration, solid masses require further workup to rule out cancer. Because of the false-negatives associated with individual methods of diagnosis, the authors recommend the triple-diagnosis method of detection. Simultaneous evaluation of a breast mass using clinical breast examination, radiography, and FNAB can lower the risk of missing cancer to only 1%, effectively reducing the rate of diagnostic failure and increasing the quality of patient care.

Gag rules and trade secrets in managed care contracts. Ethical and legal concerns.

Gag rules-clauses in managed care contracts that prevent physicians from disclosing information that the plan may find disparaging, but that could relate directly to the patient's health-have recently been the subject of ethical condemnation and legislative prohibition. Another serious problem in managed care contracts, trade secrets, or guidelines and quality assurance mechanisms that are imposed on physicians while their origins are shrouded in proprietary secrecy, have by contrast received little attention. Responses to these ethical challenges to the physician's integrity must involve individual physicians, managed care organizations, professional organizations, and public policymakers.

The timely diagnosis of breast cancer. Principles of risk management for primary care providers and surgeons.

Alleged delay in the diagnosis of breast cancer is one of the most common reasons for medical malpractice claims in the United States, accounting for the largest indemnity payments of any single medical condition. Although the diagnosis of breast cancer can be challenging and sometimes difficult, principles of management exist to assist health providers in pursuing a resolution of any breast complaint. Studies have shown that when litigation is pursued for alleged failure to diagnose breast cancer, multiple specialists are named in the suit. In most cases, patients filing claims of alleged failure to diagnose breast cancer are premenopausal, while the majority of women diagnosed with breast cancer are postmenopausal. This reflects, in part, the challenge of diagnosing the disease in women who have difficult clinical exams to interpret, as well as dense parenchyma on mammograms, which decreases the sensitivity of the radiograph interpretation. Principles of risk management to avoid a delay in diagnosis include (1) pursuing every breast complaint to resolution, (2) following breast cancer screening guidelines, (3) establishing an office tracking system for breast cancer screening reminders, (4) tracking results of all mammograms and follow-up studies ordered, (5) referring premenopausal women for the evaluation of any breast mass that persists through a menstrual cycle, (6) considering any asymmetrical breast finding as a cause for concern, (7) referring every woman with a breast finding on physical examination for consultation, regardless of the mammogram report, and (8) carefully documenting patient history, physical exam findings, clinical impression, and follow-up plans.