On a Personal Note

In the ten years since I first clicked “Publish” and posted my first piece on “A Country Doctor Writes”, I have published roughly the quantitative equivalent of Moby Dick and War and Peace combined. Not that I claim to be quite in their league, but have written quite a lot.

During this decade I have recertified twice as a Family Physician. I have buried both of my parents and several cats, dogs and horses. I have grayed significantly at the temples and I have gained and lost two pants sizes.

This week I received news that I passed my Board examination, 34 years after my first one, and I got an email that “A Country Doctor Writes” is one of the top 25 doctor blogs in the country.

On the day of my ten year anniversary I will be in Boston at a Harvard course for medical writers. Such a coincidental symbol of my milestone as a writer.

Listening to Audio Digest’s Family Medicine Review course on my way to and from work gave me a sense of renewal, and the other events this month make me feel that I am preparing for a professional growth spurt at an age when some of my contemporaries are retiring.

One of my purposes when I started this blog was to inspire the next generation of doctors and counterbalance some of the negativity I see among my colleagues today. I have seen that my writing has been republished and commented on in student doctor circles, and I have had some of them comment here, first as students and later as new doctors.

I have also tried to paint a picture of how rural medicine today is a soulful endeavor, allowing you intimate access into the lives of people in a way that is not very different from how doctoring was a generation ago.

I have created a fictional version of my community, its citizens, my colleagues, the nearby hospitals and the specialists in the city. But the essence of all of what I have written is pure truth. “Only the names have been changed”, as they say.

Thanks very much for reading.

(P.S. Because my senior colleague did retire, and because one of my contemporaries is planning to do so, I’m looking for one or two new partners. My email is in the sidebar on the right.)

Brilinta or Clopidogrel, Maximum Benefit or Social Responsibility?

Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix, which costs 50 cents per pill, once a day. But only a little – 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less.

Put differently, if 100 patients were treated with Brilinta for a year, at a cost of $4,680 for each patient, 10 patients would still have an event. With clopidogrel, 100 patients, each one at a cost of $180, 12 events would occur. That means two fewer events would happen per 100 patients on Brilinta at an extra cost of $450,000, or $225,000 per avoided cardiovascular emergency (Number Needed to Treat, NNT=50).

This is described in a New York Times article as a profound ethical dilemma in medicine today:

“Some of us believed that a doctor’s job is to deliver the best possible care, period. Others argued that doctors should aim to find some balance between medical benefit, financial cost and social responsibility. It’s the kind of question that we aren’t really trained to solve. Are costs something that an individual doctor should do something about? What is a doctor supposed to do?”

As a Swedish born and trained physician, even though I now work in the United States, I guess I would claim that I was trained to solve this kind of question. Therein lies the fundamental dilemma of American medicine.

The American ethic of wanting to do absolutely everything possible for each patient has its roots in a different era from the one we live in now. It is a relic of a time when diagnostic tests, surgical interventions or medicines for everyday diseases didn’t cost multiples of average people’s annual incomes. It also came about in he era before the Government (Medicare and Medicaid) or risk pools of ordinary people (insurance companies, in stewardship of employers’ and wage earners’ premiums) became the payers of health care expenses. Back then, patients paid for their own health care, or it was offered as more or less charity care.

Americans don’t like to use the term Socialized Medicine, but that is what it works like when someone else pays for our care. We may use different words, like Socially Responsible Medicine. But “social” is part of it.

If I had just survived a heart attack and had a choice between clopidogrel and Brilinta, would my choice be different if I had to pay an extra $4,500 per year myself than if I could have someone else pay for it?

Would the latter choice possibly deprive other people of medicines, surgeries or vaccines they needed because of the vast number of people making the same choice at their fellow citizens’ expense?

Would my choice indirectly be someone else’s death sentence? All for a jump from an 88% chance of me being okay to a 90% chance? I could get the more expensive drug and make bad dietary choices, or forget a dose here and there and the nuance in efficacy between the two drugs might be moot – but certainly not the cost differential.

The operative word here, in English, is stewardship. I can’t even remember what it is in Swedish: Spending resources wisely, especially when those resources belong to all of us.

From EMR to Paper to EMR

I can’t help myself from telling patients how things really work in health care. But I feel they have a right to know.

When I see new patients their jaw usually drops when I sit down with them next to the computer with a stack of papers held together with a rubber band or a gigantic clamp and with yellow sticky notes protruding here and there with words like LAB, ER and X-RAY.

Patients always assume that medical records transfer seamlessly between practices. They don’t, even between clinics that use the same EMR vendor. The stack of papers gets scanned in, as images or PDFs, but they don’t appear in searchable, tabular or report-compatible form. Often, they don’t each get labeled, but are clumped together under headings like “Radiology 2010-2017”.

In one of the clinics I work in, a Registered Nurse enters patients’ medical history in the EMR before each new patient’s first appointment. In the other, it is my job.

In both cases, only a fraction of he information is usually carried over from one EMR to the other, and the patient’s life story risks getting diluted, even distorted.

It doesn’t take much imagination to understand why things work this way:

Once upon a time, the Rulers of a great country handed out money to all the medicine men so they could start using computers to document what they did (and what they charged for, which was the real reason the Rulers handed out money the way they did).

This was a gift, not only to the medicine men but also to a lot of computer companies, who quickly geared up and made EMRs that the medicine men needed to buy before the deadline the Rulers had imposed.

Soon the medicine men gave all their newfound money to the computer makers. One of the things they thought they remembered hearing about was “interoperability”, but the computer makers were no fools. By making it just about impossible to transfer data between EMRs, the computer companies figured they could keep their respective customers hostage, because no matter how much they hated the slapped-together systems, it would be too costly to start over with another system.

Eventually, each vendor secretly hoped they would end up with the most users and thereby becoming the industry standard when the medicine men and the Rulers caught on to the lack of interoperability.

That, I explain to those of my patients who were around for it, is like the early days of VCRs – Betamax or VHS – more than 100 times over or, think about it, 100 times worse.

(I wrote this on April 1, but I’m not fooling…)

Triage at the Front Desk

It happened again the other morning.

As I left the conference area and crossed the main lobby I saw a young woman approaching the front desk, leaning on an older woman. I didn’t think much of it, and unlocked the clinic door. I did what I had to do, and as I returned to the lobby, I heard an overhead page “Triage at the front desk”. As I reentered the lobby, the young woman was on the floor and a lab tech was just leaning down over her. A medical assistant almost pushed her way through the door with me, emergency box in hand.

“What’s happening with you?” I asked the woman, who is my patient and has several chronic health problems.

“I need my blood pressure checked”, she answered.

“We’ll do that”, I said as we opened the box. “Why do you need your blood pressure checked?”

“I just need my blood pressure checked.”

“She passed out in the kitchen”, the older woman said.

“She’s a diabetic, check her blood sugar”, I said to the medical assistant as I placed the blood pressure cuff on the woman’s arm.

“Your blood pressure is fine”, I said. “Now, did you just pass out again?”

“160”, the medical assistant announced. Normal for a diabetic. Her pulse rate and oxygen saturation were also normal.

“I don’t think I passed out.”

“Do you hurt anywhere?”

“My behind is sore and my chest hurts.”

“She had chest pain this morning when she walked across the kitchen and fell to the floor”, said the older woman, who turned out to be her mother.

“Call the ambulance”, I called out.

“No, I want to go home”, the young woman mumbled.

“Listen, we don’t know why you passed out, and we don’t know yet what this chest pain is from. You need more testing.” I held my hand on her pulse for a while to make sure it was regular.

As the ambulance crew entered the lobby with their stretcher, she sat up and protested. The crew listened to my rapid fire description of her medical background and today’s events.

“You need to be checked out further”, one of the attendants pronounced.

They were in charge now, and I returned to my office and called the hospital to let them know what was coming.

Over the years I have seen countless patients who in a medical emergency have a specific idea of just what they need and whose medical care is delayed because of that.

When I first started practicing in this area, we didn’t have advanced EMTs on our volunteer ambulance corps. It was the on-call doctor’s duty to fill that role, which meant I would sometimes get paged after hours to meet the ambulance at somebody’s house or at one of the local motels.

Later, even when the ambulance service was upgraded, I would get calls from patients in the middle of the night, demanding that I open up the office, singlehanded, and do an EKG because the person figured that was the full extent of a medical assessment for chest pain. A few times my refusal to do so caused complaints to the management and the board of directors.

Ten years ago, we ended our longstanding free blood pressure checks. Until then, when we were titrating blood pressure medications, we would simply tell patients to drop in and have their blood pressure documented. We would then look over the numbers to make sure we got the medications right. But what started to happen more and more was that people who felt poorly and couldn’t get an appointment soon enough or were offered a time that was inconvenient for them would simply show up for a “free blood pressure check”.

Once in a room with the medical assistant, they would say, “I’m having chest pain”, or “I think I’m going to faint”, forcing the doctors to interrupt their schedules. Some patients event went so far as to threatening on the phone “if you can’t give me an appointment this morning, I’ll just come in for a blood pressure check and then you’ll have to see me”.

We are not the only practice that has to balance access with medical appropriateness. Most clinics and pharmacies, even Cityside Cardiology start their automated telephone attendant system with “If this is a medical emergency, please hang up and call 911…”

I’m grateful I’m not expected to meet the ambulance in the middle of the night or open up the office alone for someone who could collapse in front of me. I’m not complaining that people think we can do more than we are equipped to do. I am only puzzling about why, in this era of ever increasing sophistication in emergency care, so many people think they know exactly what they need.

Like the woman in the lobby – she had passed out and had chest pain, but her blood pressure was okay, so she wanted to go home.

My Suboxone License is Capped at 100 Patients, Should My Opioid License Also Be?

I can prescribe Suboxone for 100 patients in opioid addiction treatment. You start with 30 and can upgrade after two years. Some Suboxone prescribing doctors have a waiting list; only when a patient “graduates” or gets dismissed from the practice can a new one enter.

In the State of Maine, there are now limits on the doses of opioids we can prescribe, and as a result of the efforts to reduce, some patients have come off pain killers completely. But providers regularly get emails from the Prescription Monitoring Program telling us whether we have more opioid patients or prescribe higher doses than our colleagues.

The handwriting is on the wall: Doctors are continually and systematically shamed into reducing their opioid prescribing. It is an unpleasant situation.

Maybe, since Big Brother is obviously involved here anyway, we should just be issued quotas: Don’t make us guess how many patients on opioids are “too many”, just spell it out. The DEA already does it for Suboxone. That would be cleaner. And it would make it easier for patients to understand:

“Sorry, Jim, I had to cut 35 patients from my opioid roster this year and you turned out to be one of them. Nothing personal…”

One More Question

“Any recent antibiotics? Steroids?” I asked my last patient of the day, a healthy looking young woman with what she described as a yeast infection that was driving her crazy. She’d had many of them, and they were always coming back, but she had only used over the counter topicals.

I knew she needed oral medication, but I asked one more question:

“Any trouble with high blood sugars?”

Her answer eliminated any late day drowsiness or fatigue I might have harbored.

“No, my sugars have always been fine, even during my pregnancies, but I always have sugar in my urine.”

“That’s why you get all these yeast infections. Has anyone ever looked into why you have sugar in your urine?”

“No.”

We got a fingerstick blood sugar, which was low normal, and a urinalysis which showed 4+ glucose, no protein, a pH of 5 and normal specific gravity.

I took a deep breath.

“When the blood is filtered in the kidney, a lot of valuable stuff ends up in the urine, but then we reabsorb things like sugar, because the body is thrifty. You have a kidney disease that keeps you from reabsorbing the sugar. I’m not smart enough to know exactly which variety of disease you have but I’d like to get some more labs tomorrow and refer you to a nephrologist.”

She asked for some information about the kinds of kidney disease she might have and added, “well, you’re smart enough to know what my basic problem is. I’ve had it all my life and nobody has said anything about any of this, they were just happy that my blood sugar was okay.”

A seemingly ordinary symptom, one additional piece of history and distant memories from medical school, never touched since then…

How can you not be fascinated by this job?

Doceo, Ergo Sum

One of the ways a doctor can document the value of an office visit is by keeping track of the number of symptoms the patient has and the number of items included in both the review of systems and the physical exam of the patient.

This way, for example, we can get paid more if we do an extensive evaluation of a dizzy patient by looking for both inner ear, cardiovascular and, for example, cerebral and psychiatric causes, rather than zeroing in on the most common cause while immediately disregarding the less common ones.

The other way we can charge is according to how much time we spend on “counseling and education” of our patient.

I reflected on that a lot this week. It seems most of what I do is counseling and education.

I have been working with a nurse practitioner student the past few months. I make these “externships” a mixture of independent work and observation with collaboration.

In my view, an almost-ready clinician needs to both hone their clinical skills and develop their own style of communication during these rotations.

In some cases, I introduce the student, leave the room and then get briefed on history and physical findings. We then wrap up the visit with me just reinforcing the plan and supporting the student and the patient in how this is supposed to work.

In some cases I conduct a good portion of the visit myself and then include the student in a three way conversation with the patient about the disease or the treatment. This allows students to see me and their other attendings’ way of diagnosing and different ways of sharing information or suggesting treatments to patients.

With an extra person in the interaction, I constantly reflect on my own style.

I usually talk a lot. In many cases I explain a great deal about how the body works and how diseases manifest. I also talk about the history of how they were discovered or how we used to treat them. I think that is a reflection of my own love and fascination with medicine. It is also an expression of my fundamental belief that I shouldn’t tell my patients what to do but instead empower them to choose between options and direct their own care.

Coming from another continent and, by now, another era, I can tell patients firsthand that there are and have been many ways of thinking about even the most straightforward seeming medical problems. I think this depth and context works for many patients. Only once in a while in my career have I had a patient say, “I wish you would just tell me what to do”.

I try very hard to “read” how each patient approaches their health problems, and over the years I have learned who wants a quick “here’s what we’ve got and here’s what to do” visit and who enjoys and grows from knowing the bigger context of what they have.

In some visits I say a lot less. I sometimes emulate Dr. Marty Samuels or my own Dr. Wilford Brown and use my silence to draw out the patient’s history. And sometimes I use open ended questions disguised as reflections to get more information – statements like “I wonder why you noticed this while…” or “I don’t know exactly how this is connected with that”.

When I teach clinical practice, I try to share my repertoire of ways to connect and ways to convey, not just how to diagnose and what treatment to choose. You can read that in a book or online. But you need to see how other people do things so you can choose how to behave yourself in the role of healer we are asked to live up to.

I don’t often save lives by performing sophisticated or intricate medical procedures. But I do think I change lives every day in small and subtle ways through how and what I communicate.

I believe in my heart that I need to fill different needs in different situations where my patients are looking for certain aspects of the archetypal “doctor” we all carry in our consciousness and our culture.

“Doctor” is derived from “docere”, a word for “to teach”. “Doceo” means “I teach”. “Ergo sum” means “therefore I am”.

That is really why am here, in this clinic, in this community and on this planet. I could probably bill 80% of my visits as time spent on counseling and education and forget about how many “bullets” I checked off from my history and physical exam. Those things seem rudimentary in comparison with the personal connection that allows my patient to take my explanations and my treatment options and make their own choice of how to proceed.

Orthopedic surgeons probably do most of their work in a form of silent solitude in the operating room.

I do most of my work in conversation.

All of it, really.


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A Country Doctor Writes’ Ten Year Anniversary

April 28th, 2018
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