Getting it Right

There are many days in primary care when you feeel like you are treading water; nobody gets substantially better as time and disease progression seem to always win over your own and your patients’ efforts.

But sometimes you hit a winning streak. The past few weeks seemed to bring me one diagnostic or therapeutic coup after another.

There was the depressed man who came in smiling and said “I’m shaving again”.

There was the woman who was obviously doubting my assessment that the lip rash she had struggled with for two months was just a simple yeast infection.

I remember another woman with a moist, burning rash in every skin fold of her body. Because she also had some rough patches on her elbows, I suspected she didn’t have yeast at all but a bad case of inverse psoriasis. My seemingly counterintuitive choice of systemic steroids worked like a charm.

I thought back to the man with a stubborn back pain, who couldn’t even tolerate the simple exercises his physical therapist had suggested. Because he admitted to feeling depressed, at least about his chronic pain, I had given him a low dose of duloxetine. The other day, he told me he had felt better already after the first dose; he was spending time with his family again and his back hardly bothered him at all.

Then there was the woman who had fired the doctor who took her off hydrocodone. She certainly had a fair number of orthopedic issues, but her pain was really everywhere. This, along with tender trigger points and her history of poor sleep and profound fatigueabilty, led me to believe most of her pain was actually from fibromyalgia. On two capsules daily of the lowest dose of gabapentin, she had half the pain and double the hours of useful sleep. She was beaming at me the other day and shook my hand with he power of a lumberjack.

I also remember the man who came in depressed and angry with a tale of how everyone around him was withdrawing because of his pricklishness. He fit the criteria for Bipolar disorder, type 2, and between his new mood stabilizer and low dose antidepressant, he was back at work and back in his relationship.

All these small victories added up and gave me a renewed sense of being an effective catalyst through the basic application of observation, knowledge and, for lack of a better word, salesmanship.

It’s not enough to know what to do. How we present facts and formulate treatment plans is part of the therapy. A half-hearted “you might try this” is a lot less likely to work than explaining the diagnosis, describing the mechanism of action behind the symptoms and the medication and even the history behind the treatment.

I believe I made some very good treatment choices, but I also know that what we disparagingly call the placebo effect is always present to a degree, just like the opposite force, the nocebo effect.

I believe that presenting a medication as a very powerful tool that can both help or hurt, and emphasizing the need for skillful dosing and monitoring, you can create expectations and instill hope that helps build the neurobiological foundation for healing. There is more and more literature on that.

And as a doctor with a recent winning streak, I was at least a little bit emboldened over the last few days.

I remember talking with a new patient with longstanding anxiety, who didn’t want medication but seemed at least lukewarm to cognitive therapy. I explained quite a bit about how it works and what the evidence has shown about its effectiveness compared to unstructured forms of talk therapy. Near the end of our visit, he revealed his original intent: He wanted a letter for his landlord so he could get a dog, because he believed that would quell his anxiety.

I love dogs and I worry about people wanting dogs more for their own needs than the dog’s.

I leaned back, looked him in the eyes and said:

I’ll make a deal with you. You start therapy, and I’ll write you a note.

He was silent for a moment, then answered “okay”.

I was on a roll.

Primary Care Needs a New Business Model

Primary Care visits are never quick; we don’t give much advice over the phone or online; and we prioritize the Government’s and insurance companies’ public health agenda over our own patients’ concerns.

Imagine healthcare as a retail customer experience for a few minutes:

Imagine you’re going to Walmart to buy a bag of dog food, a new coffee maker or to equip a small kitchen in your newly built mother-in-law apartment.

1) You’ve bought dog food there before, so you know exactly where it is. You just want to quickly grab a bag and get out of there.

2) You have a rough idea of where the coffee makers are; you know some brands you trust, but you might have one or two questions before you select one, and if they don’t have one you like, you might get it somewhere else. Or, you might even check their website to see which models they carry.

3) For the new kitchen, you have a list, but know you probably haven’t thought of everything, so you plan to walk down the aisles in the kitchen and home departments. You plan to spend a fair amount of money, so you might be on the lookout for special sales or promotions. But, you definitely don’t want someone else to choose all the items for you.

Can Walmart meet your needs in all these situations? Probably yes.

Now, think about how your doctor’s office works:

1) Can you quickly get in and out if you have a simple problem like conjunctivitis?

2) Are they able to give you information on what your options are for a recurring shoulder dislocation; could they refer you to a shoulder specialist without first waiting weeks to see your primary care doctor?

3) You have lots of issues and try to get an appointment to deal with them all at once; you think of it as a physical, but last time you had a physical, your doctor brought up all kinds of things you don’t particularly see as priorities for yourself.

Here are the existing realities of Primary Care:

We can’t afford to just see you for something quick. Our quality indicators, which more and more will determine how we get paid, will go down if we don’t screen you at every visit and offer interventions for depression, smoking, alcohol misuse, hypertension, weight management, immunization needs and much more.

We won’t refer you without seeing you, and we often hesitate giving you medical advice over the phone. Our providers are not scheduled for anything else besides seeing patients, because the rules of how we are paid still emphasize face-to-face visits over “population management”. So our providers are busy all day long seeing patients for visits that could have been simple but are loaded up with mandatory screenings and interventions and our medical assistants, besides being busy with all our screening questionnaires, are discouraged from giving medical advice they aren’t formally trained to provide.

Is there a doctor shortage?

We are said to have a doctor shortage. We have an aging population with more and more chronic diseases, like diabetes and heart disease. The need for skilled and experienced medical providers is continually increasing.

We have no Public Health system to speak of in this country, so the Government, through Medicare and Medicaid, has mandated that health care providers do the things the Public Health system does in other countries.

This is, plain and simple, what is clogging up the works in healthcare today: Too much non-doctor work is crammed into each patient visit, and we can’t charge for giving advice or directing care except in a face-to-face visit.

You don’t need to go to medical school to give immunizations, tell people smoking is bad for you, explain that “low fat” foods cause obesity, or promote regular exercise. You don’t even need to be a doctor, PA or NP to screen for high blood pressure – only to treat it. (Some pundits, in utter desperation, have suggested we send pharmacists to school to learn how to treat hypertension, but there are of course plenty of licensed medical providers who are able and willing to do that if we get freed up from the less-skilled tasks I just listed above.)

Patients and doctors have no control

Now, why are we doing all those things we do if they are so inefficient? Quite simply, whoever pays us has the power to define our work. We call that “Health Insurance”, but that is not exactly what we are dealing with. Insurance, for home, auto or employer liability, has nothing to do with predictable events or minor issues. Your car insurance doesn’t pay for oil changes or tire wear, not even for a minor paint scratch. But somehow that is what we expect health insurance to cover for our bodies. In terms of auto insurance, most people probably figure an insurance job carries an inflated price tag and lots of paperwork. The same is true for health care, which should not be a surprise to anyone.

For example, years ago the overhead cost of insurance billing for each primary care doctor was reported to be $80,000. That, put very plainly, is money that patients and employers are ultimately paying through premiums and deductibles.

And all the mandated screenings are there because Medicare in particular has the right to micromanage doctors’ work because they are paying for healthcare visits, which could be quicker and less costly if patients had control over their healthcare spending.

How could we do better?

We do three things in primary care, each with its own workflow and, really, each with its own economics.

1) We could do our part of Public Health more effectively. Allow us to promote immunizations and other primary preventions outside our already crammed fifteen-minute visits. Pay us a per patient per year stipend to reach out to target populations through mail, phone web or, when appropriate, in person about general health issues. Stop imagining we can do all of it and still treat diseases, acute and chronic, in our measly fifteen minutes. Right now, that is just clicking boxes with little actual substance. Use some of the Government money that should have been spent on a working Public Health system if you want us to step in and do the Government’s work.

2) Make it economically feasible for medical providers to oversee patient care by acknowledging that reading incoming reports, answering phone or web inquiries and coordinating care with specialists and hospitals are essential parts of being a medical home for patients. Such activities should not be unpaid services eked out at the expense of lunch, bathroom breaks or dinner with our families.

3) Allow us to define each office visit together with our patients. It is insulting to everyone involved to have to interrogate someone with a splitting headache, twisted ankle or bleeding laceration about their diet and alcohol habits. I could see many more patients if I could delegate those things to outreach staff or simply not do it every visit. Right now we are made to act as if we will never see that patient again. I was trained to provide care over time, in a relationship based practice. That is proven to be an effective and fiscally sound way to deliver healthcare.

The third task is the only one that makes sense to pay us for on a per-visit basis, whereas the first two deserve their own payment method. Personally, I wonder if the first few hundred dollars worth of Primary Care visits are worth churning through the expensive bureaucratic insurance machinery, or if it wouldn’t make more sense to just allow each patients a set amount of spending at their discretion.

I am not writing about privately financed, Direct Primary Care or Concierge Medicine. Those obviously exist, and may work well for many people, but the healthcare payment options for most Americans are what desperately need fixing.

Only if we acknowledge that Public Health, Population Health and Face-to-Face visits are three separate aspects of health care can we move forward in reforming Primary Care. And only if we recognize and reimburse physicians’ non-face-to-face work fairly will we see the improved customer service and doctor-patient communications we are now only paying lip service to.

(This would also help reduce physician burnout, in case anyone didn’t realize that!)

Where would Google be if we had to make an appointment to sit down with a search consultant and pose our questions, fifteen minutes at a time? It may be an outlandish analogy, but healthcare needs some shaking up…

My Neurology Professor’s Migraines

He spoke with an aura of superiority, in a slightly nasal voice, and his topic was migraines. It was in the late 70’s, a time when there were few options to treat migraines.

“Most people who claim to have migraines just have simple tension headaches”, he scoffed. And in a move that seemed unorthodox at the time, he disclosed that he himself suffered from “real migraines”, so he knew all about this exclusive disease. He made it sound almost desirable by virtue of how rare it was.

At a Continuing Medical Education course in Boston twenty five years ago, I heard a different neurologist, this one a Dutchman, pronounce that most headaches are in fact migraines.

Today I read in The New York Times that, according to a study (published in Headache fourteen years ago) “primary care providers who diagnose a patient’s headaches as something other than migraine were usually wrong”.

The same article also points out that “sinus headaches” are not a medical reality, and are never diagnosed in Europe. Now that I think of it, I never did hear about this type of headache until I came here.

The whole notion that one explanation for a symptom is somehow more prestigious than another is bizarre, but I see this phenomenon here and there. Also, Americans seem to delight in using technical diagnostic terms instead of describing symptoms to each other or their doctors.

People come into my office all the time with “colitis”, “vertigo”, “eczema” or “bronchitis”, not just diarrhea, dizziness, rashes or coughs. It’s like somehow they don’t need me to do anything except release my power and prescribe for the condition they already know they have. Never mind that the real explanation may be giardiasis, a cerebellar stroke, psoriasis or lung cancer.

One of the reasons for the seemingly increasing prevalence of certain disease is, of course, the drug company ads for medications that come to market for rare or previously untreatable conditions.

Ironically, as an example of that, back at Uppsala University, I remember a cursory mention of Restless Leg Syndrome. “You can prescribe a little diazepam, that usually helps”, was the take-home message. Nobody mentioned that our own neurology professor, Karl-Axel Ekbom, who had retired he same year I started medical school, had described the syndrome, which had been alluded to by Willis in the 1600’s, and nobody seemed to make much of its association with iron deficiency.

It was with the introduction of medications like Mirapex and Requip that RLS rose from obscurity to everyday parlance.

Over the past few months I have encountered several patients who, even though they knew they had migraines, had never sought or been offered preventive treatment. There is much awareness of the many medications that treat attacks, and several of those have been cash cows for the pharmaceutical industry, whereas the preventative medications are generally old and inexpensive generics, which require patience and persistence to work.

With many diseases, and very much so with migraines, knowing the diagnosis and the names of some famous medications to treat it is not enough. How to select and titrate them is what we call the Art of Medicine.

Facial Recognition in My Own Practice?

After a Harvard Endocrinology course several years ago, I walked out into the weak afternoon spring sunshine and crossed the street to the Boston Public Garden. Among the multitude of faces of the other flaneurs I was certain I saw scores of people suffering from endocrine diseases – probably undiagnosed, I thought to myself:

I saw tall men with big jaws, typical of acromegaly; stout women with skinny extremities and flushed, puffy cheeks so typical of Cushing’s syndrome; hirsute, heavy set younger women sure to have polycystic ovary syndrome; long-legged beardless men, who seemed classic for Klinefelter’s; and other people I suspected to have Graves’ disease, Turner syndrome, hyperaldosteronism, Addison’s disease, and, oh, so many other obvious endocrinopathies.

Then back home, as the months and years passed, and as the never ending presentations of Chief Complaints continued, my internal search for and classification of possible endocrine diagnoses began to take second place in my hierarchy of what I needed to do.

Yes, Ellen W. does look like she might have Cushing but she has so many issues that it feels a little esoteric to bring this up, too, when her diabetes and mood are out of control, her mother is dying and her husband is still unemployed and her insurance isn’t paying for any of her medicines.

And even if Doreen Fish has primary hyperaldosteronism, she’s already on spironolactone for her low potassium and her blood pressure is okay; a CT scan would cost her so much out of pocket, never mind surgery, and what are the odds she has surgical disease – an adenoma and not just adrenal hyperplasia?

But then I read the news and I get curious again:

Artificial Intelligence and facial recognition are being used to diagnose or screen for genetic syndromes like DiGeorge and Williams; people are claiming to have identified facial features linked to autism spectrum disorders; psychiatry and general practice colleagues are sending out cheek swabs to help them prescribe psychiatric medications where I am “just” going by experience and intuition; and patients themselves are now looking into their own genetic profiles.

Shouldn’t I try to be more precise in this era of “precision medicine”? Definitely, with all the extra, mandated, ingredients in the primary care visit – screening for depression and alcohol use, clicking off BMI management and tobacco cessation counseling (not just doing them) – it is easy to slip away from just looking at your patients carefully into just glancing at them while also paying attention to the computer screen.

It takes some effort to consistently really look away from the computer, to clear your mind of all its distracting requirements, and to just observe the person in front of you – as if you just walked out of an Endocrinology lecture and looked at the faces of strangers, wondering:

What makes you look the way you look? Do you have a syndrome that guides your health and your appearance? Wouldn’t you, and your doctor, benefit from knowing that?

The Case For Professional, Not Just Personal, Resilience

Medicine Today is Full of Distractions. The secret Behind Resilience is Rising Above Them.

-Yours Truly

The answer to physician burnout is purported to be Resilience Training. That’s like glorifying the natural ability of frogs to tolerate gradually heating and boiling water.

Unfortunately, healthcare today has some toxic ingredients, and physician burnout is directly related to them. Some forms of resilience training I have been exposed to are no more than mental escapes away from medicine, such as art, music and personal relationships.

Those types of activities may in some way, for some people, balance the toxicity that has infiltrated our workplaces, but they don’t change the fact that every day as a practicing physician could be hazardous to one’s mental, or even physical, health.

It’s fine to have a rich and rewarding life outside of medicine, but that doesn’t negate the fact that medicine could and should be a rewarding career and calling in and of itself, too.

There is a different kind of resiliency that should be promoted and cultivated. That is the professional resiliency that comes from embracing the true, timeless and archetypal role of the physician. Every time we make someone feel better, every time we comfort or instill hope, every time we empower a fellow human being to take steps toward a better life, we need to, humbly, celebrate our accomplishment.

Yes, we get points for also clicking the box about what counseling was provided; yes, we get points if we printed the hokey patient education page from the EMR; yes, we need to submit our superbill right away and we’re supposed to finish our documentation within 72 hours. Most of the time I get those things done, even if it is in my barn-office at 5 am or by the fireplace with a glass of wine when everyone else is asleep, but, you know what – I have a job that matters, and I’d rather be doing this than anything else.

And I’m a constant, pesky reminderer about the need to automate some of those mundane clerical task.

Keeping the focus on what really matters is a form of professional resilience. That, ultimately, means more than personal resilience, because the latter could result in some of us leaving our careers because we don’t see the value in what we are asked to do.

Administrators and insurers want a lot from us, but if we don’t listen to and communicate effectively and in a healing manner with our patients, there will be nothing for the big guys to micromanage.

We are the doctors. Let us not forget that.

Bread and Butter Medicine

Of all my patient visits since I came back from my CME trip to Boston, the one that lingers in my mind as I do my farm chores on a sunny day off in mid-May is the young woman I had first met on a bitterly cold evening in February. Her face had been covered with acne, small pustules and red papules, so many of them that they almost touched each other. She had tried every over the counter preparation she could get her hands on to no avail.

I saw her again the other day, beaming, smiling and exuding optimism and confidence. Her face was just about clear and she told me she had just posted a closeup photograph, with NO MAKEUP, on Facebook. She pulled her smartphone from her jeans pocket and showed me.

She is graduating this weekend, and she is ready for her adult life to begin, comfortable in her own skin, as we say in America.

“When I first came to see you, I thought you’d prescribe some other cream that wouldn’t work. But the doxycycline is really working. You remember, at first I got sick to my stomach on my morning dose, but you told me to eat something with it and it worked. Now I’m only taking it at night with supper and look at me!”

A common generic medicine, some common sense advice about skin care, some tinkering with how and when to take the medication, and a young person feels better about herself and ready for summer vacation and a big move out of state in the fall. Not like diagnosing a pheochromocytoma or Fanconis syndrome, but in primary care, even the small victories are important. Every patient deserves to get better if it is at all possible.

Upselling in Medicine: Would You Like a Pap Smear with that Ankle Brace, Ma’am?

For many years, I’ve held a brief huddle with my team every morning to make sure we are ready for the day: Anybody with complex problems coming in today? Anybody who’s been in the ER? How is Mrs. Jones’ husband over at the nursing home, is she worried about his condition? Where can we squeeze in more add-on’s?

Now other people have tried to hijack the word “huddle” for a completely different purpose. They want to use it to slow us down instead of helping get us get through the avalanche of issues we’re already expecting. In my other office they call it pre-visit planning. It’s not about having the MRI result available or the recent ER note, but more about who is behind on some aspect of their health maintenance and (unsuspectingly) expecting just a sore throat visit, but consistently avoiding their diabetes followup visits?

My veterinarian colleagues handle this differently. They just send a post card at random times, or hand me a paper, usually part of my exit statement, as I recall, that says which critter is due for what. But in that case I’m already safely close to the door and nobody is expecting me to act on it in that instant.

In human medicine, our quality ratings, and soon our paycheck, will depend on how effectively we convince patients to get caught up on their proscribed health maintenance.

In the retail world, they call that upselling. When I stop at a 24 hour gas station and buy some coffee for my long trip between my two offices, they always ask if I want some donuts or chips with that, maybe a banana or whatever. Same thing at the hardware store, if I buy a flashlight, they ask if I need spare batteries, and so on.

How fair is that to our patients?

I remember seeing a video about the hijacked kind of huddle, where the doctor and medical assistant almost gleefully talk about how to convince a noncompliant female patient to have her overdue Pap smear when she is only expecting something much less involved.

And all the while we are supposed to be patient centered and respect each patient’s own agenda. Too bad not everyone else has to…


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