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.

Thou Shalt Do More Physicals

Not long ago, I wrote a piece about the futility and waste of annual physicals. Soon after that, I suddenly saw the light. Or, rather, my CEO and COO educated me about why so many people still want physicals so badly: Obamacare is still with us.

When the Government regulates health care, medical sense is often disregarded and Medicine is replaced by Metamedicine.

Medicare has it own sets of parallel realities, and in my type of clinic Medicare is the largest health insurer we deal with.

Medicare covers a talk session they call the “Annual Wellness Visit” but doesn’t pay for physicals at all, except the HMO-like “Medicare Advantage” plans that survive through rationing diagnostic tests and also through extra reimbursement from the Government. They pay us a fee every year for providing them with a list of the specifics of our patients’ diseases and disease complications. This is what helps them get the extra money from the Government to cover their patients’ health care costs.

All the commercial insurances, like Anthem, Aetna, Cigna and the Obamacare companies put together, make up a smaller piece of our practice than Uncle Sam’s insurance for older Americans.

Those are the people that call for physicals and the people my bosses want me to provide them for.

This is why, and I kind of missed this ten year old fact:

Many people have lousy insurance with high deductibles, but under Obamacare “Annual Physicals” and many tests that can be construed as “screening” are FREE. So I have to pay more attention to the realities of health insurance today.

If a patient with newly diagnosed extremely high blood pressure and exertional chest pain needs lots of blood work, stress testing and imaging, he or she may pay thousands of dollars out of pocket. Or if a patient has abdominal pain, weight loss and severe diarrhea and needs a colonoscopy, it is considered a “diagnostic” test and potentially quite costly to the patient.

If, on the other hand, a healthy person with no symptoms wants a baseline electrocardiogram (proven useless and not recommended by the US Public Health Service Taskforce on Prevention), a PSA test (not recommended), breast, testicular or digital rectal exam (not recommended), an annual instead of biannual mammogram (not proven more effective) or random blood panels (of unproven value), there is no cost. I have read, in business literature, that the most powerful word in marketing is FREE. In American healthcare, very few things are.

After I was spoken to by my superiors about how people want physicals, how they bring in more revenue than sick visits and how doing them is often counted as a “Quality Indicator”, I realized I can’t live in my Evidence Based bubble any longer. I now understand that the realities of practicing medicine trump science and clinical judgement. How could I have been so blind as to think otherwise?

I did some research. The key issue is what constitutes “Prevention”.

There is great confusion about what “prevention” means. I always thought the word referred to not smoking, not eating junk food or drinking dirty water, not being permanently parked in front of the television and so on.

Anthem says 85% of illnesses can be prevented, inferring that the Annual Physical accomplishes that. This is of course total garbage, unless you believe that the only opportunity to get people to eat right and exercise is by having their Annual Physical.

But there are several types of prevention. Listening to a lecture recently, my own sense of prevention has sharpened. I always thought of it as PRIMARY (not smoking) or SECONDARY (stopping after you get diagnosed with COPD). But there is more to it. Here is what I learned about the World Health Organization’s definition of prevention :

PRIMARY PREVENTION is, for example, not smoking. It is also taking aspirin just beacause you are a male over 50.

SECONDARY PREVENTION is, for example, finding asymptomatic disease through screening, like low dose chest CT for lung cancer or cardiac CTs to demonstrate coronary atherosclerosis.

TERTIARY PREVENTION is treatment to minimize the effects and progression of symptomatic disease, like taking aspirin or Lipitor because you already had a heart attack.

I just never thought of screening as a form of prevention. I guess I took the word too literally.

So right now, we are working on my schedule and patient “panel management”: How many physicals can I do in a year, how many patients am I responsible for and, if the numbers don’t match, should I relinquish some physicals or some sick visits? Where is my 30+ year experience best utilized – by screening and motivating the well or caring for the sick?

I used to know the answer…

Hanging Up the Stethoscope

My senior colleague and former personal physician, Dr. Wilford Brown III, whom I have mentioned often in this weblog, appeared at the nurses station during my Saturday clinic.

He wanted to talk, and started walking toward my office, where I had just hung photographs of Sir William Osler, Uppsala University’s original anatomy building, Marcus Welby, the St Elsewhere crew, the lead actors from the British TV series “Doctor in the House”, and the M*A*S*H crew.

Sitting there against the backdrop of my other medical heroes and my alma mater, he told me he had been doing a lot of thinking. “My family has been bugging me to get done and, you know, during that staff meeting we had a couple of weeks ago about the quality indicators for the ACO and the EMR optimization, I thought to myself this is not medicine.”

He sat quiet for a few moments. Our eyes met and I frowned a little.

“I’d like to stop before my abilities fail me, I wouldn’t want to see my name on the front page of the newspaper for something I missed or didn’t do right.”

“How do I do this, I mean how much time…” his voice trailed.

“Well, we don’t have contracts, but the personnel policies say providers need to give three months notice”, I said. “But nobody has been held to that. How soon do you want to get done?”

“As soon as you think it’s all right.”

“You mean, the sooner the better?”

“Yes.”

“Do you want to write something, like a letter of resignation to the CEO?”

“Can you tell him?”

“I’ll tell him Monday morning.”

“Remember when I came here to be your patient and you asked me if I wanted to fill in a little? That was almost fifteen years ago…”

“I remember. It’s been a real pleasure to work with you.”

“Thanks”, he said, unceremoniously. “I’ll let you get back to seeing patients.”

He stood up. I was still sitting down, in my own thoughts about our years together. For a brief moment his face was right next to Sir Willam Osler’s face, and it was as if both men were looking down at me where I was sitting, feeling just a little bit lost.

(Three posts about Dr. Brown, all from 2008, are “The Doctor’s Doctor”, “My Senior Colleague” and “A Concurring Second Opinion”.)

Pneumonia is a Disease. Is High Cholesterol or Osteoporosis?

So much of what we do today in medicine falls in the gray zone between treating disease and manipulating risk. I am not sure how many “patients” and how many “providers” fail to ponder or make the distinction.

(I put “patients” in quotation marks, because I wonder if we should use that word for people who aren’t sick…)

In many cases, we have ended up with disease-like names, and drug based treatments, for these risk factors. In reality, many other things besides drugs can modify these risks, but our “scientific” paradigm mostly recognizes double blinded trials of medications and undervalues other approaches.

Cholesterol and heart disease are prime examples of how simplistic and ignorant we have been and how “medicalized” our thinking has been:

While extremely high cholesterol sometimes is a genetically determined abnormality, for example Friedrichsen’s hyperlipidemias, garden variety high cholesterol is a laboratory abnormality that evolves and can change according to a person’s diet and lifestyle.

For decades now, we have treated “high” cholesterol with statin drugs, and we now have statistical “proof” that they reduce a person’s risk for strokes and heart attacks. This is the case even for people with “perfect” cholesterol, but the absolute risk reduction isn’t as impressive as the relative one. After all, half of next to nothing isn’t as impressive as half of a very large number.

But, and we know all this although we don’t talk enough about it, since non-statins like ezetimibe (Zetia) can also lower cholesterol without giving anywhere near the same degree of risk reduction, it’s not really about the cholesterol reduction at all. Every day I rattle off to patients that the statins stabilize and prevent rupture of cholesterol plaque, prevent plaque buildup in the first place, prevent blood clots via a mechanism different from aspirin and prevent contraction of the little muscles in the walls of coronary arteries that cause coronary spasm. And I explain that although we know these mechanisms exist, we can’t measure their effects in patients. I also mention that in older persons, a Mediterranean diet causes about the same risk reduction as statin drugs do in middle aged people. It lowers cardiovascular mortality by 30% compared with the old standard low-fat diet.

The new lipid guidelines have a calculator that provides a ten year cardiovascular risk. That helps people by providing a risk number they can relate to, but then the “experts” arbitrarily decided that people with 5 or 7.5% ten year risk should be on low or high dose statins, respectively. The only problem is that all men over 67 or so should be on drugs. Common sense gets in the way of adopting that one, at least in my book. When age as a risk factor outweighs the truly variable measures, like blood pressure, shouldn’t we modify or scrap our disease paradigm?

Another example of a questionable “disease” is osteoporosis. The average woman’s bone density enters the osteoporosis range somewhere around age 80, and the average 60 year old woman has osteopenia. The universality accepted “T-score” compares everybody to a 30 year old. The “Z-score”, on the other hand, compares women to individuals their own age. Today’s guidelines suggest labeling the average baby boomer woman as having a disease, and also many women with better than average bone density. So we are told they are candidates for more or less scary but certainly not innocuous medications.

That reminds me of my residency days, when I would get my hand slapped if I didn’t put every postmenopausal woman on estrogen, because she was obviously estrogen deficient, and we even had the blood tests to prove it. The theory was that since older women had more heart attacks than younger women and the biggest difference(?) between them was their estrogen levels, all we had to do to wipe out heart disease in postmenopausal was to supply them with a lifetime supply of estrogen.

What happened, as the Women’s Health Study demonstrated, was that older women on estrogen plus progesterone (to protect from overstimulation of her uterus lining and subsequent endometrial cancer) had MORE heart attacks, strokes, breast cancers and blood clots than those who allowed their natural aging process to continue.

Today, the same thinking takes place with men and testosterone as the pharmaceutical industry continues its quest for the fountain of youth.

The ultimate question is to what degree aging is a disease and whether it should be the priority of the medical professions, pharmaceutical industry and our insurance system to fight it.

A G.O.M.O.

In Emergency Room vernacular, a G.O.M.E.R. is someone whose frequent visits are unwelcome, often an elderly and noncommunicative patients who is sent or dropped off with vague complaints not easily remedied in the ER. The acronym stands for “Get Out of My ER”, and it comes from Samuel Shem’s novel “House of God”.

In my line of work, we have what I think of as G.O.M.O. patients. I don’t know if anybody else uses the term, but in my mind it means “Get Out of My Office”, specifically “and to the ER instead”.

The other day I was called to the lab to see an elderly looking main, who turned out to be my own age (that gave me pause, and maybe I need to do some introspection here…), who looked a little peaked as two phlebotomists were trying to coax him into the phlebotomy chair and off his feet.

“He feels lightheaded”, I was told.

“Are you fasting this morning?” I asked.

“Yes”, he answered after he landed in the chair.

“Are you a diabetic?” I continued.

“Yes”, he said.

“Let’s get a finger stick blood sugar”, I said. It was 188.

I grabbed a blood pressure cuff. His pulse was 80, and so was his blood pressure. His oxygen saturation was 96%.

“Are you having any chest pain?” I asked.

“No.”

“Are you short of breath?”

“A little.”

“Did you eat okay yesterday?”

“No.”

“Why not?”

“I didn’t feel good.”

I thought of my blog post “Twenty Questions” as I continued my interrogation.

“In what way did you not feel good?”

Finally, he uttered two dozen words at once:

“I did some yard work yesterday morning and when I came back inside I felt really weak and nauseous so I didn’t eat all day.”

“Did you have any chest pain then?”

“No.”

“Did you have any diarrhea or vomiting?”

“No.”

By that time it was clear this man was a G.O.M.O. that needed to go to the ER by ambulance. His EKG was normal, his blood pressure remained low at 80/60 and by the time the EMTs rolled him out of the lab on a stretcher, I had called the ER and we had faxed his medical history to Cityside.

Sometimes all we do is triage, I thought to myself as I sat down at my desk with the M*A*S*H* poster in front of me.

Talk, Think, Listen and Type

Four and a half years ago I read an editorial in JAMA, the Journal of the American Medical Association, that etched a short phrase into my memory. These five words seemed so profound and poignant that I really think they almost define primary care medicine today, perhaps with the alliterative addition of the word “teach”.

Dr. Abigail Zuger wrote of how the computer had changed the dynamic in the exam room and of the communication skills physicians now need to master:

“The physician will know the highly technical vocabulary of relevant research agendas well enough to encourage patients to get involved. The physician will also keep up with popular culture, tracking popular direct-to-patient communications and incorporating them into the clinical dialogue. In addition, and most importantly, the physician will have virtuoso data entry and retrieval skills, with an ability to talk, think, listen, and type at the same time rivaling that of court reporters, simultaneous interpreters, and journalists on deadline. The physician will do all of this efficiently and effectively through dozens of clinical encounters a day, each one couched in a slightly different vernacular.”

We’ve come a long way since Sir William Osler advised “Look wise, say nothing and grunt”. In his day, arriving at the right diagnosis was the most important task of a physician. Treatment options were usually limited. Today, even the most mundane diagnosis has myriads of treatment options. And in spite of all the advances of medicine, today’s false prophets and practitioners promote the medical equivalents of “alternative truths”. This is where the “teach” comes in. In rural medicine in particular, the village doctor may be the most learned person for miles around and we do need to promote scientific common sense to our patients and our communities.

Back to Dr Zuger’s quote:

I love the comparison of a physician’s work with court reporters, interpreters and journalists on a deadline. Our need for accuracy is obvious, and an interpreter truly needs to be familiar with both languages; even before I moved to this country I could spot the translation errors in the subtitles of American movies on Swedish television. You probably have to spend some time here to know that a six pack is a quantity of beer, and that half and half is a coffee whitener made up of half milk and half cream. Similarly, we have to be familiar with the worlds and cultures our patients live in. And the time pressures of primary care are obvious.

The ability to listen at the same time as we talk or think about what we want to say is essential if we want to be patient centered. We need to be exquisitely sensitive to our patients’ verbal and nonverbal communication if we are going to be any help to them.

And, as far as the typing goes, I actually do better on the iPad’s virtual keyboard with autocorrect than on a conventional keyboard, especially one with great “travel” of the keys and manual spellchecking (in my case type-checking; my spelling is fine). Then, of course, there is Dragon, Siri, and on my mini, the ultimate two-thumb typing.

And just like Dr. Zuger suggests in her editorial, the iPad allows me to pull up next to my patient so we can both see the reports, lab tests and the evolving office note that we, in many ways, create together.

How I Will Work Smarter in 2018

I don’t regularly make any New Year’s resolutions, but this year I am tossing around a couple of ideas. One reason is that I have so many things going on that I need to be clever about how I use my time.

I work four days a week at my regular clinic and I also work two long days at a clinic in far northern Maine. In addition, there are many farm chores, this blog and three book projects I am working on, or at least pondering.

So here is a first draft of A Country Doctor’s New Year’s Resolutions:

1) I will more systematically listen to Audio Digest and other Continuing Medical Education talks while I drive up North and back. Halfway through the Family Medicine Review, I am noticing how I have adjusted my practice in many small ways to newer information.

2) I will be more diligent about scanning The New England Journal of Medicine on my iPad every Wednesday night. I’m usually on call that night, so it will be easy to remember this resolution.

3) In my Northern clinic, where routine prescriptions are filled by the providers, I will save myself up to an hour a week by refilling routine, non-controlled medications for a whole year and relying on the other existing systems for making sure patients don’t get “lost to followup”. I learned this from Christine Sinsky’s work many years ago, but because my Southern clinic has standing orders for routine prescription renewals, I haven’t had to worry about it so much.

4) In both clinics I will invest a little more time polishing my EMR templates in order to speed up and beef up my documentation. I will also continue to ponder how I can insert a visit snapshot near the top of each progress note so I can get the gist of it without scrolling down to the bottom when rereading it at the next, follow up visit.

5) I will more consistently insert a comment for myself with each lab test I order that requires some action on my part when it comes back, like “calculate ten year cardiovascular risk” after a lipid profile, or “increase lisinopril to 20 mg if labs ok” for a creatinine or chemistry profile.

6) I will work with the EMR coordinators on making the “lab letter” work better in both clinics, and I will make more consistent use of the web portal and smartphone messaging functionality down South in order to communicate results better to patients and also free up my medical assistants’ time (now calling many patients back with normal results) as well as my own.

7) I will firm up my morning huddle up North, where it is designed to do so many things, like catching unsuspecting patients for overdue immunizations, that the basic purpose of the visit could get lost, like “do we have the MRI and consultant report yet?”

8) I will more consistently do all action items with the patient in the room, even if some aspect of the documentation needs to happen later because of time constraints. I’m already at 90% here, but if I tell a patient, “let’s get an MRI of your shoulder”, I will always order it right then and there, so the care can keep moving along, even if I need to polish my note that night or the next day.

9) I need to think more about how I can change the insane EMR convention of making me the first one to lay eyes on incoming results and reports. In every other type of organization, information is sorted, prioritized and sometimes even condensed before it gets to the decision makers. But in medicine, providers see patients all day long without hardly even a bathroom break, while all kinds of important information piles up in their electronic inboxes. Then, when everybody else has gone home, we finally get to the abnormal results that would have taken thirty seconds to handle if someone had interrupted us with them, but often now can turn into a logistical nightmare.

10) This may not sound like a resolution to work smarter, but I will be more cognizant of the influence I have over the people I work with. As my wife once pointed out to me (see my New Year’s post 2012), I sometimes treat family and coworkers less well than I treat my patients. I can and should spread good will and consolation outside the exam room, too.


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A Country Doctor Writes’ Ten Year Anniversary

April 28th, 2018
62 days to go.
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