A Week with no Lab Coat

Something very interesting happened to my patient visits when I changed my office attire.

My clean long cotton lab coats, hanging on the back of my office door, suddenly all seemed dingy when I set out to change lab coat about a week ago. I decided to pretend it was Saturday.

On Saturdays I usually wear a pocketed button-down shirt instead of one of my usual Jermyn Street ones. I skip the lab coat, hang my stethoscope around my neck, put some pens in my breast pocket and attach my magnetic name tag. I still wear a tie, but sometimes with a doctor motif or Snoopy (I miss my beagles).

On Saturdays I seldom have very serious visits. Most are physicals for working people and sick visits, sore throats, earaches and such. Nobody from the administration, lab or X-ray is in, there are fewer messages, no faxes and no meetings. It’s just me, a medical assistant and the patients. It’s all very basic.

So there I was, deciding to go coatless. I put the magnet inside my pocketless English shirt and the name tag lined up outside, draped the stethoscope around my neck, clipped a pen inside my pants pocket and entered the exam room to greet my first patient of the day.

“Nice shirt”, said the sixty-something man. He was chattier than usual, I noted quietly. I had two more similar compliments that day and I started to feel something was different about the dynamic in the exam room.

Since then, I have had the distinct impression that my visits are more laid back, more intimate and less demanding. It’s as if my patients are relating to me in a more personal way, even though I’ve always felt very close to my patients. I have also not had a single patient try to cram in a long shopping list of concerns I couldn’t possibly address in one single visit. I feel as if everyone is viewing me as more human, just as competent, but not a healthcare robot or action hero.

I still delivered good and bad news, I still explained the inner workings of the body in plain English and I still typed away with only two fingers on the computer or my iPad. But I felt as if a veil had been lifted and my patients saw me as more than just their doctor, or dared to treat me that way.

Alarm Fatigue

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.

After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.

There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.

On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.

I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?

So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.

It reminds me of the story about the boy who cried wolf…

Medical Records for Amnesiacs

I wish CMS and my EMR would stop treating me and everyone who reads my office notes as if we were all amnesiacs.

I also wish they would recognize that primary care is not something that happens only once, in a fifteen or thirty minute visit, and never again.

If we accept these two premises, we are a long way toward health care, or at least primary care, reform.

Before EMRs I used to secretly smirk inside at how much better family physicians’ medical records were than internists’:

Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.

Internists, I thought, were like bag people. They carried all their belongings with them, or, they told each patient’s story over from the beginning in every visit, like this:

“This 62 year old male with a 40 pack year smoking history, psoriasis on methotrexate, well controlled diabetes, hypertension, prior myocardial infarction with two bare metal stents and ongoing Plavix therapy, current EF 59%, has a history of mild GERD managed with OTC omeprazole and a history of a normal colonoscopy at age 50 has a baseline hematocrit of 39 but was recently rejected at a company blood drive due to a low hematocrit. He comes in today for a swollen left knee.”

(Every office visit would start about the same way, and almost every visit would touch, at least briefly, on each diagnosis.)

Oh well, when EMRs came into being, the internists’ office note, albeit in bullet form, came to be the model we all follow. Sure, we have side bars with some background information, but all the background information shows up in every single office note, even though all that history is visible on the same computer screen or only a click away.

Somebody seemed to think doctors are all amnesiacs, and that we really need the thumbnail sketch of every patient, every time. Or (Gasp!) some of us may have wanted to give the impression that we truly ask about all that history from scratch at every visit just to score a higher reimbursement.

Of course, the internist way of story telling is modeled after the hospital record, which tells the story of a distinct “episode of care”. And now hospital thinking has crept into and contaminated primary care with disastrous consequences.

The primary care record doesn’t just tell stories of separate “episodes of care”; it is more like a quilt of many story lines, which play out simultaneously and over extended periods of time at different speeds.

Why, then, are our office notes modeled after institutions that deliver nothing but episodic care, and who view a returning patient as a treatment failure?

Primary care is practiced over time; we have more than one opportunity to ask those sensitive questions, offer that immunization or have that talk about smoking or obesity. In fact, there is a right time and many wrong times for most things in life. The right intervention at the wrong time can be insensitive, insulting and counterproductive.

In today’s office visits, we force our way through laundry lists of items our patients never asked us to cover, and we are obligated to fill up our office notes with them.

The cumulative effect of bulking up the office note with historical data that belongs in a sidebar, and the misguided idea that primary care doctors may have only one single shot at delivering preventive care and all the social interventions the Government has now shifted from the public health sector to the health care sector have caused primary care to slow down to a crawl.

Because we are so stuck on the idea that we must provide comprehensive care in every single visit with extensive documentation of what is almost a spinal reflex for experienced physicians, we are seeing many fewer visits than we used to.

We are turning away patients in need of primary care and we are limiting patient access to timely care by making it too cumbersome for primary care practices to see patients for simple problems like sore throats, ankle sprains and rashes. This results in unnecessary emergency room visits and fragmentation of care through the use of unconnected urgent care facilities.

Here is a solution to the mess we are in:

Put those items that are not immediately relevant to the chief complaint or diagnosis of today’s visit in side bars and flowsheets, which would give summaries and timeline documentation of all our efforts at comprehensive care over time. Then, let us refer to these when we make an entry or simply review their contents, but please deliver us from the onus of including every detail of it in every visit. Even if we auto-import them, it makes our own office notes too long to even have time to review the next time we see a patient. And when we get outside records on patients transferring in, it is impossible to find anything relevant in the reams of printed notes we get, because every visit runs 6-8 pages and each one contains virtually the same information.

Let us do well by the patients we are entrusted to care for by paying enough attention to the problem they’ve come to see us about, instead of touching everything in a superficial, perfunctory manner and accomplishing little or nothing except creating an illusion of comprehensive care only meant to impress or placate insurance billing people and public health bookkeeping types. You can only cover so many topics in fifteen minutes.

A Lesson Learned

It was late afternoon. The woman who had seen my colleague, Dr. Wilford Brown, a few days earlier was sitting in my exam room. Her chart note read like a typical unnameable virus: Headache, bodyaches, fatigue, low grade fever. She had always seemed like a level-headed resolute woman, but she had called three days in a row for medical advice because she felt so poorly. And it all sounded like a simple virus that a few more days of rest would take care of.

She did have a good sized boil in the middle of her back, but that wouldn’t make her feel that sick. The rest of her exam was perfectly normal.

“Let’s check your blood count to see if this looks viral”, I suggested.

“Anything”, she answered.

I moved on to the next patient. A few minutes later I was handed a printout of her CBC. Her white blood cell count was 1.88, almost critically low and without the “right shift” that often accompanies a low WBC in certain viral illnesses. Her platelet count was 68, not far above where spontaneous bleeding might occur.

“I need to send you to the hospital for more testing. I don’t know what’s going on. It could still be a virus, but you need to be checked for blood poisoning”, I explained.

She felt well enough to drive herself to Cityside. For a split second I agonized about that decision. If she was going septic, could she suddenly drop her blood pressure on the way? But I agreed to have her drive.

I called the ER and spoke wih one of their regulars about her case.

“Ok, we’ll be looking for her”, the seasoned but still young physician answered after my thumbnail description of her.

Fifteen minutes later I got another printout. Her ALP, ALT and AST were all about three times the upper normal limit. What wold cause that kind of liver irritation, I thought to myself.

“Fax it to Cityside ER”, I told Autumn, and I called back and left a message for Dr. Waterman about the new information.

I told Dr. Kim about her and, without hesitation, he said “I’ll bet she has anaplasmosis”.

I’ve seen plenty of Lyme Disease. I grew up with ticks in the country where Erythema Chronicum Migrans was first described. But I hadn’t had any experience with anaplasmosis, another tick borne disease, also treatable with doxycycline. I had thought of that as a near tropical disease.

I checked UptoDate and a few other sources, and certainly all the symptoms matched, as well as the low white count and platelets and the elevated liver enzymes. A rash can occur but not usually. The description “summer flu” stuck in my mind from my brief reading.

The next morning I got the admission history and physical. The hospitalists at Cityside suspected a tick borne illness but worked my patient up for sepsis to be safe.

Two hours later, Monica, our new nurse practitioner, asked me to look at a rash. The patient was a woman in her late sixties. The rash consisted of several blanching maculae, each measuring 4-5 inches. None of them were itchy. She was feeling fairly well, but when I asked her about recent illnesses, she said she had been to the ER at Mountain View Hospital the week before with a headache, fever and body aches.

Monica got called away for a telephone call. I sat down by the computer and pulled up the woman’s ER report. The labs they had done showed a low white count, a low platelet count and liver enzymes twice the normal limit. I printed up the report.

“I know what this is”, I said to Monica when she came back, and handed her the ER note. “It looks like a tick borne illness, possibly anaplasmosis. Why don’t you get a tick panel and put her on doxycycline.”

(Thanks, Dr. Kim.)

IMG_0304.JPG

(Cases per 100,000. Source: Maine CDC,
http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/vector-borne/anaplasmosis/documents/Anaplasma-2015.pdf)

P.S. This afternoon, Monica alerted me to a patient I will see in followup later this week, a middle aged man who had also been to Mountain View ER recently with flu-like symptoms and abnormal lab work. They had called it viral, but Monica had ordered a tick panel today and put him on doxycycline.

A Moving Target

He was a new patient. His medical records described him as severely hearing impaired and suffering from a rare movement disorder. He arrived with a caseworker for his 11:30 first appointment and I was running late.

“Why is a new patient or a minor surgery procedure ever scheduled at the end of the morning instead of at the beginning”, I asked Autumn, rhetorically.

The man seemed to be bouncing around in the small exam room. His head bobbed randomly and his body moved like waves in a wading pool full of three-year olds.

I introduced myself. His caseworker, clipboard in her left hand, shook my right hand. The man floated toward me, cocked his head suddenly and hollered while pointing to his right ear:

“I can’t hear!”

“For how long?” I asked.

He didn’t seem to hear me.

“At least a few years from what I know”, his caseworker answered, drowned out by the man’s repetition, “I can’t hear, I can’t hear!”

He seemed irritable, frustrated, and there was an air of desperation in the room. The caseworker looked helpless.

It was 12:35.

“Let me check your ears”, I said, gesturing with the wall mounted otoscope.

“I can’t hear!” the man shouted.

As I leaned toward him I could smell the odor of ear wax. I tried to gently grab and pull his right ear upward and back while I held the otoscope head between my right thumb and index finger and leaned the pinky-side of my hand against his cheek.

His head moved back and forth, up and down. Pushing my right hand firmly into his cheek, I moved with him, as if we were both bouncing on an underinflated air mattress.

All I saw was ear wax.

I repeated the procedure with his left ear. It, too was impacted with black, smelly cerumen.

“Let me flush your ears”, I said, loudly, into his right ear.

“I can’t hear!” he hollered back.

“I’ll be back”, I said and gestured with my index finger straight up as in “one minute”.

So followed an awkward dance with the man sitting in the exam room chair by the sink, Chux pad on his shoulder, the caseworker holding the cup under his ear and me flushing his right ear with lukewarm water from a large plastic syringe. All three of us moved in near-unison, again and again in what looked like multiple attempts to master a Tango step, sometimes rising at the end, sometimes sinking down or pausing mid-movement, all three of us.

The ear wax poured into the cup and large amounts of water saturated the Chux pad and the side of the man’s neck. Some of it landed on me.

As I eased myself away each time from our virtual embrace to empty the cup of clumpy wax soup into the sink, I watched through my splattered glasses for a reaction.

After the fifth or sixth serving, the man’s movements stopped suddenly. He shook his head like a wet dog. Slowly, he cocked his head and I could sense how he was trying to listen.

The aura in the room changed. Everything seemed quiet and peaceful. He was perfectly still for what seemed like half a minute. The caseworker picked up her clipboard and clicked her ballpoint pen. The ceiling air vents blew their gentle, artificial breeze. Someone walked down the hall outside the exam room.

“I can hear again. Thank you”, he said in a normal voice.

“Fantastic. Are you ready for the other ear?” I gestured with the otoscope. It was 12:49.

His head started to gently move again.

“Let’s roll!” he grinned.

Quality Medicine: Showing the Math

Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answer doesn’t matter anymore.

If you ask a patient with a given symptom, like tremor, lameness or a skin eruption, only a few questions and then conclude that they have a rare disease you happen to have seen before during your years of training and experience or read about in your diligent study of the leading medical journals, you get paid next to nothing. If, on the other hand, you ask a hundred questions and examine them from head to toe and then decide to refer them on to someone who knows more than you do, you can charge a bigger fee, at least a 99214 instead of a 99213.

We get reimbursed for complexity that is sometimes a result of incompetence. That is one definition of value in health care delivery.

These days, quality in healthcare is also measured in “outcomes”; how many people comply with our recommendations by eating better, quitting smoking or exercising more. Or at least whether we documented that we told them to.

Of course, you could talk about more things in greater depth in your precious fifteen minutes together if you didn’t also have to document everything you touched on in a Byzantine electronic record better suited for billing than patient care. But, if you didn’t document it, it didn’t happen.

Diagnostic accuracy doesn’t figure prominently in the quality literature, only sometimes when it comes to missing heart attacks and cancer, but in my world, primary care, you can still achieve great quality scores from documenting sometimes meaningless housekeeping tasks like annual microalbumen tests for diabetics, even if you don’t manage to decrease the kidney damage.

Good quality measures are ones that are easy to collect and manipulate statistically. But does a good and tidy measure convey better quality?

We are still stuck in the Deming manufacturing mindset. But people are not machines and diseases are not manufacturing processes.

Do we ask how a teacher managed to inspire a young student to become a great scientist? Do we demand an explanation of how a priest brought a distraught parishioner from the brink of suicidal despair? Do we ask how Da Vinci held his paint brush when he painted Mona Lisa’s smile? Do we value an athlete with “good” technique more than one with good scores?

I think our health care quality debate has a myopic view. We are often ignoring the big picture and the real purpose of caring for the sick. That’s because healthcare is a business now…

Acts of Kindness

As I look back over the past work week I can’t immediately recall any great diagnostic coups or clinical victories. I vaguely remember having to reboot my EMR a lot because it seemed to freeze up, and I certainly remember being locked out of its iPad app for a day and a half.

What I remember best are my trips back to the waiting room pushing wheelchairs with elderly patients at the end of their visit, and I remember the gratitude of the arthritic man, no older than myself, whose toenails I cut as a “by-the-way” after I had excised a suspicious mole on his back.

Again this week I found myself, privately quiet and not much fun, living out my other persona, the secure, reassuring, jovial, gray-templed physician, fatherly to some, a peer to others, and a kind man of the (white) cloth to some.

Sure, it’s great to nail a difficult diagnosis, but we can’t expect to do that every day. What we can and should do every day is connect with and touch every human being we run across in our role as physicians. Otherwise, the new housekeeping tasks of healthcare today will wear us down.

That thought reminds me of a post I wrote nine years ago, six months after I started writing his blog, “A Day Without a Diagnosis”:

“Thursday I saw 29 patients*, but I didn’t make a single diagnosis. I did three physicals and saw several patients with diabetes, hypertension and high cholesterol. A migraineur came in for a shot, and we double booked a few sick people who already knew their diagnosis and what treatment they needed.

One of my physicals was a Registered Nurse, about my age, who left clinical nursing a few years ago and now does research for a group of surgeons at the hospital up the road. Her research focuses on quality of care.

That got me thinking about the differences in health care between my early days in this profession and today. The spectrum of diseases we deal with has changed, and lately also the notion of what constitutes quality in health care.

Physicians today spend more time managing chronic diseases, some of which weren’t even thought of as diseases twenty-five years ago. A cholesterol level we feel obligated to treat today was considered normal back then; Type 2 Diabetes was something our grandmothers developed in their late seventies, not a multisystem disease we looked for in children and young adults; Attention Deficit Disorder wasn’t something primary care physicians concerned themselves with. And who would ever have thought that Fibromyalgia, a term coined in 1976, would be such a common disease, along with Restless Leg Syndrome (Ekbom, 1944), obesity and toenail fungus?

My conversation with my R.N. patient moved toward the issue of what really constitutes quality in medicine. I worry that some things are measured mostly because they are easy to measure: What percentage of heart attack victims is currently taking beta-blockers? What is the average Hemoglobin A1c among a physician’s diabetic patients (as opposed to how is this value trending over time)? I never hear statistics on how often we as doctors make the right or wrong diagnosis, or how difficult it was to move a particular patient from one set of numbers to another.

The practice of medicine has become more a matter of housekeeping, if not downright bookkeeping. The days of brilliant medical mavericks that could ferret out the correct diagnosis and quickly move on to the next heroic act are history; today’s focus is on long-term management according to evidence-based guidelines (“evidence-based”, now there’s another topic for a post…).

There is no point in lamenting the shift over time in what our patients need from us; I am merely reflecting on what has happened during my years in practice. If we as doctors want to see more bad, untreated and undiagnosed diseases, we need to move to more remote places – my underserved corner of Rural America isn’t the place for that anymore.

Managing chronic illnesses can be very meaningful and satisfying, but it isn’t quite what I imagined I would be doing to this extent. But it is one of the reasons we need to hone our skills as physicians; it is no longer enough to be a good diagnostician when almost every patient we see in a given day already has a diagnosis established. Our challenge is to help them manage that diagnosis. That means we need to practice motivational interviewing for our patients with lifestyle-inflicted diseases, serve as our patients’ medical home in a fragmented health care system and be a voice of reason in an era of information overload.

In a brief moment of worry about what I would do if I didn’t get accepted to medical school I had considered teaching, and I worked as a substitute teacher for one semester between my military service and medical school. I don’t think that was a waste of time at all.

Once in a while as a physician, you’ll make a diagnosis. Most of the time you help patients manage a disease they already know they have.”

That, and dispensing a little kindness in the course of each day.

(*That was before EMR, Meaningful Use, PCMH, ACA and all that. Today, between the technology and all the mandated components of every office visit, I rarely see even 25 patients per day.)


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