Embarrassing problems

May 2013

Up front

Letters to the editor

Volume 42, No.5, May 2013 Pages 263-264

The opinions expressed by correspondents in this column are in no way endorsed by either the Editors or The Royal Australian College of General Practitioners

Topical nitrates in painful diabetic neuropathy

Dear Editor

I wish to thank Drs Votrubec and Thong1 for their comprehensive review of pharmacological management of neuropathic pain (AFP March 2013). I wish to raise the question of the use of topical nitrates in painful diabetic neuropathy.

Three small double blind placebo-controlled studies have shown significant improvement in pain scores with the use of glyceryl trinitrate or isosorbide dinitrate spray in painful diabetic neuropathy.2–4 One group of authors subsequently reported similar benefit with the use of glyceryl trinitrate patches in a non-placebo controlled audit.5 The proposed mechanism of action was increased generation of nitric oxide promoting vasodilation with secondary improvement in microvascular blood flow.

The responders in these studies often noted benefit within days of commencing treatment, contrasting with the time usually required to see a reduction in neuropathic pain with anticonvulsant and antidepressant medications. In addition, the use of topical nitrate sprays is associated with minimal side effects compared with oral medications, and is inexpensive.

Dr Adam Morton
Senior Staff Specialist
Endocrinology and Obstetric Medicine
Mater Hospital, Brisbane, Qld

References

  1. Votrubec M, Thong I. Neuropathic pain: a management update. Aust Fam Physician 2013;42:92–6.
  2. Agrawal RP, Choudhary R, Sharma P, et al. Glyceryl trinitrate spray in the management of painful diabetic neuropathy: a randomized double blind placebo controlled cross-over study. Diabetes Res Clin Pract 2007;77:161–7.
  3. Yuen KC, Baker NR, Rayman G. Treatment of chronic painful diabetic neuropathy with isosorbide dinitrate spray: a double-blind placebo-controlled cross-over study. Diabetes Care 2002;25:1699–703.
  4. Agrawal RP, Goswami J, Jain S, Kochar DK. Management of diabetic neuropathy by sodium valproate and glyceryl trinitrate spray: a prospective double-blind randomized placebo-controlled study. Diabetes Res Clin Pract 2009;83:371–8.
  5. Rayman G, Baker NR, Krishnan ST. Glyceryl trinitrate patches as an alternative to isosorbide dinitrate spray in the treatment of chronic painful diabetic neuropathy. Diabetes Care 2003;26:2697–8.

Work related hypertension

Dear Editor

Thank you for the issue on ‘Workplace’ (AFP April 2013). One topic that was not covered is that of blood pressure. High stress work conditions result in a significant increase in systolic and diastolic blood pressure.6 This means that blood pressure is a crucial early indicator in identifying work related stress, and job strain in particular. Employees’ blood pressure readings should therefore be taken as part of any studies on work related problems or preventive occupational medical check-ups. Twenty-four hour blood pressure monitoring is a diagnostic method, which may be appropriate for the evaluation of work associated employee blood pressure levels.7

Dr Martin Hofmeister
Consumer Centre of the German Federal State of Bavaria
Munich, Germany

References

  1. Lüders S, Hammersen F, Kulschewski A, et al. Stress-associated hypertension in the work place: results of the STARLET project. Dtsch Med Wochenschr 2006;131:2580–5.
  2. Schumann B, Seidler A, Kluttig A, Werdan K, Haerting J, Greiser KH. Association of occupation with prevalent hypertension in an elderly East German population: an exploratory cross-sectional analysis. Int Arch Occup Environ Health 2011;84:361–9.

Pateint confidentaility

Dear Editor

I refer to the interesting article by Thuraisingham and Nalliah8 based on a potential employee (PE) seen by a company doctor for a pre-employment medical examination (PEME) (AFP April 2013).

In their case study, examination reveals clinical signs leading to tests confirming hyperthyroidism. The doctor takes the PE as a patient, starts treatment, and certifies her employable. With the PE’s consent, the doctor makes partial disclosure to the employer that the she has a non-life threatening illness that requires treatment until stabilised. Six months later, the company questions the doctor’s decision that declared her fit for employment, as this has incurred recurring medical expenses for her management.

The authors then highlight three ethical dilemmas that may arise during a PEME:

  1. Is it ethical for employers to use physicians’ reports to select workers based on ‘absence of illness’ rather than ‘fitness to work’?
  2. Should physicians divulge the illness of potential employees to third parties?
  3. What are the boundaries of a clinician’s duty of care in the PEME setting?

In answer to questions 1 and 2, the American Medical Association’s9 opinion is that where a physician’s services are limited to performing an isolated assessment of an individual’s health or disability for an employer, the information obtained by the physician as a result of such examinations is confidential and should not be communicated to a third party without the individual’s prior written consent, unless required by law. If the individual authorised the release of medical information to an employer or a potential employer, the physician should release only that information which is reasonably relevant to the employer’s decision regarding that individual’s ability to perform the work required by the job. However, the potential employer could provide a written guideline to the PE ahead of time that clearly details the PEME and tests required as a pre-condition of employment. This form should include a paragraph to be signed by the PE giving consent to the doctor to disclose all findings to the company. The doctor should satisfy himself that the PE has sufficient information about the scope, purpose and likely consequences of the examination disclosure, and understands that the relevant information cannot be concealed from the potential employer.11 The doctor should also offer to show the PE or provide a copy of the report to be forwarded to the employer.

With respect to question 3, the Malaysian Medical Association Code of Medical Ethics10 states that when a company doctor finds on examination that an employee is unfit to work, the doctor shall advise the employee to consult their own doctor or may, in an emergency, send them directly to a hospital. Likewise, in the case study, the doctor should have informed the PE that his examination suggests hyperthyroidism that requires the attention of her doctor. He should not invite or influence the PE to become his patient. He should offer to refer the PE to a hospital should she not have her own doctor. The patient however, has autonomy to choose or change her doctor at any time.  

In providing only partial information about the PE’s examination to the employer, the doctor respected patient confidentiality. Annoyance of the employer over lack of full disclosure should be managed by educating the employer on medical ethics, confidentiality and professionalism. Should the company desire more detailed disclosures on PEs, it should provide written guidelines to PEs ahead of time, clearly detailing the PEME and the tests required, and written consent of the PE to disclosure of the required information by the doctor to the employer. This would absolve the doctor from seeking further consent for disclosure. 

Professor Davendralingam Sinniah
Department of Paediatrics
International Medical University
Seremban, Malaysia

References

  1. Thuraisingham C, Nalliah S. The pre-employment medical: ethical dilemmas for GPs. Aust Fam Physician 2013;42:249–51.
  2. American Medical Association. Code of Ethics. Opinion 5.09. Confidentiality: industry-employed physicians and independent medical examiners. Issued July 1983, updated June 1994; updated June 1996; updated December 1999 based on the report ‘Patient-physician relationship in the context of work-related and independent medical examinations,’ adopted June 1999. Available at www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion509.page? [Accessed 5 April 2013].
  3. Malaysian Medical Association. Code of Medical Ethics (Online). Available at www.mma.org.my [Accessed 5 April 2013].
  4. British Medical Association. Medical ethics today. Oxford: BMJ Books, Wiley-Blackwell, 3rd edn. 2012. Ch. 5, pp. 183–228. Employment, insurance and other affairs, pp. 217–8.

Reply

Dear Editor

In Professor Sinniah’s comments related to the first two ethical dilemmas in our case study, he states that patient confidentiality takes precedence over an employer’s interest.

With due respect, the patient in our case study was required by the doctor to sign a consent letter authorising disclosure for the presence of any medical condition, but not details, to the employer. The doctor had simultaneously certified the patient fit for employment in the letter to the employer, as the employee’s medical condition did not merit him to do otherwise.

Although her medical condition did not affect her employability, this information was reasonably relevant to the employer, as treatment of her medical condition would incur recurring medical costs during her tenure of work. It was as much a dilemma to the employer as it was to the doctor.

In the case study, the patient informed the examining doctor that she did not have a regular doctor. Therefore, referring the patient to a hospital would not only have been tantamount to absolving his professional responsibility to his patient, but would also have delayed a long-needed solution to the patient’s problem. After all, the hospital would also be another parallel third party. The examining doctor was competent enough in this relatively trivial medical problem, and would have been her legitimate doctor once she became an employee of the company 6 weeks later. It may not have been a question of choice in this unique patient-doctor relationship. Of course, the patient has autonomy to choose or change her doctor at any time, but she had given her prior informed consent to the examining doctor.

In response to Professor Sinniah’s views on the third ethical dilemma, I would like to refer to Section 3.D under Doctors in Relationship with Third Party Payers of the Code of Medical Ethics of the Malaysian Medical Association, which states that ‘the position of the company doctor is such that without constant care, a conflict of loyalties is liable to arise, for, while he holds his appointment from the management, the object of his duties is the welfare of the workers, individually and collectively. As a doctor, his paramount concern must be for the patient, and his behaviour should be guided by the customary and ethical rules of his profession’.12 In this regard, the doctor did not stop at just certifying her fit, as her medical condition did not affect her employability, but went on to address her neglected medical condition in his duty of care.

The lengths to which a doctor would go with the employer in a PEME would depend very much on his terms of reference. The terms of reference will depend on whether he is any ‘licensed general practitioner’, a ‘panel doctor registered with the company’, or, in cases where there is an in-house medical facility, an’ in-house company doctor’.

Dr Chandramani Thuraisingham
Department of Family Medicine
International Medical University
Seremban, Malaysia

Reference

  1. Malaysian Medical Association. Code of Medical Ethics (Online). Available at www.mma.org.my/Portals/0/pdf/MMA_ethicscode.pdf [Accessed 22 April 2013].

Correspondence afp@racgp.org.au

10 May 2013 11:23

Re: Code of Ethics Applies Equally to All Doctors

Davendralingam Sinniah

Professor

International medical University Kuala Lumpur

In Thuraisingham & Nalliah's response (1) to my letter (2), they state in para2 that the potential employee "was required by the company doctor to give written consent authorising the doctor to disclose the presence of any medical condition to the employer." It is to be inferred from this statement, that the potential employer did not provide the potential employee with a company generated standard pre-employment medical examination form detailing the information it expects from the examination, nor did it attach a written consent form signed by the potential employee authorising the doctor to release information derived from that examination to the employer. The reason for this disclosure as given by Thuraisingham and Nalliah is its "relevance to the employer as the potential employee's medical condition would incur recurring medical costs during the tenure of the potential employee's tenure of work."
In this action, the doctor is clearly acting in the interest of his own employer rather than the potential employee. It is apparent the doctor did not act in the interest of the patient and in accordance to the AMA's code of ethics (3).
In the matter of the company doctor deciding to conduct "unscheduled" medical tests on the potential employee, this in itself raises suspicion of improper conduct. The suspicion would arise whether the doctor is attempting to recruit a new patient by declaring the patient fit for employment on the understanding that the doctor would then become the potential employee's "legitimate doctor" once she becomes an employee of the company 6 weeks later.
This "tidy" arrangement can lead to suspicions that are best avoided in the doctor's own interest. Even in the matter of an employee selecting a doctor from the company's panel of doctors, this should be left to the potential employee to decide, without undue influence from the doctor conducting the pre-employment medical examination.
Thuraisingham et Nalliah state in para 4 that the patient has a trivial medical condition (hyperthyroidism). Yet, this very condition (hyperthyroidism) caused the potential employee to leave her 2 previous jobs, and is serious enough to be of concern to the employer because of recurring medical costs incurred, leading to a request for an explanation from the doctor by the company.
Campbell and Doogue (1) state that while the classic clinical manifestations of thyrotoxicosis are often easily recognised by general practitioners, however, the presenting symptoms of thyrotoxicosis are varied, with atypical presentations common in the elderly. Following biochemical confirmation of thyrotoxicosis, a radionuclide thyroid scan is the most useful investigation in diagnosing the underlying cause. The selection of treatment differs according to the cause of thyrotoxicosis and the wishes of the individual patient. They state that the preferred treatment for Graves' disease is usually antithyroid drug therapy, almost always carbimazole. The primary treatment of a toxic multinodular goitre or toxic adenoma is usually radioactive iodine therapy. They add that specific therapy is usually not warranted in cases of thyroiditis; however, treatment directed at symptoms may be required. Referral to an endocrinologist is recommended if thyroiditis is unlikely or has been excluded.
In view of the above advice, referral to an endocrinologist in a hospital would not be tantamount to the company doctor absolving his professional responsibility "to his patient" as this would be in keeping with good medical practice.
I disagree with Thuraisingham and Nalliah's statement that the lengths to which a doctor should go would depend on whether he is a licensed general practitioner, a panel doctor registered with the company or an in-house company doctor. The code of medical ethics applies equally to all doctors.

Reference
1. Chandramani Thuraisingham and Sivalingam Nalliah. Reply to editor. Australian Family Physician Vol 42 no5, page 264, May 2013
2. Davendralingam Sinniah. Patient confidentiality. Australian Family Physician Vol 42 no5, page 263-4, May 2013
3. Opinion 5.09 - Confidentiality: Industry-Employed Physicians and Independent Medical Examiners - Issued July 1983; Updated June 1994; updated June 1996; updated December 1999 based on the report "Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations," adopted June 1999. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion509.page? (Accessed on 5 April 2013).
4. Kirsten Campbell, Matthew Doogue. Evaluating and managing patients with thyrotoxicosis. AFP. Volume 41, No.8, August 2012 Pages 564-572.

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Letters to the editor

2013