A Very Careful Driver

“I don’t know why Dr Brown took my license away”, the 92-year old man said. He was visibly shaking with anger. “I’ve been driving since I was a young boy, and I could find my way to California without a map”.

My associate, Dr. Wilford Brown, had sent in a State Driver Profile a few months ago, and made reference to an attached letter by a family member, which in his words would be “very damning, if true”. Apparently, the Department of Motor Vehicles had thought so too, as the elderly man explained their action through clenched jaws.

“I called them up, and they said that if you wrote to them, they would give me my license back”.

“They did, huh…” I said, while mousing and clicking my way back and forth in the documents section of the electronic medical record in search of the damning letter. I could not find it.

“How could Dr. Brown say that I’m not a good driver? What does he know about that?” The man raised his trembling hand and pointed in the general direction of Dr. Brown’s office.

“He says I have memory problems. My memory is excellent. I remember everything!”

I looked at his problem list, where “Dementia” was the first diagnosis.

“Maybe someone contacted the DMV about your driving”, I said cautiously, thinking I wouldn’t want to cause conflict or mistrust in the family by revealing everything I knew about the letter. “Maybe someone didn’t like the way you drive”, I tried, wondering if perhaps the missing letter might have been inaccurate or exaggerated.

I looked at his birth date on the computer screen and did a quick search in my memory bank about old cars.

They were still making Model T Fords when he was a little boy. Maybe he even learned to drive in one. I pictured traffic around here in those days, and my mind suddenly switched to the tourist traffic on Route One every summer weekend.

“My memory is excellent”, Mr. Gordon said again.

“Well, it’s not just memory, it’s eyesight, hearing, reaction time, judgement and reflexes”, I started.

“I am a very careful driver”, he interrupted. “When I come to an intersection, I stop, even if the light is green, and I look both ways before I go”.

As in a movie flashback, I saw him as a young boy, sitting next to his father, honking a rubber and brass horn and proudly maneuvering a Model T on an empty country road, surrounded only by cow pastures and potato fields.

“Well, Mr. Gordon”, I began. I knew what I had to do.

“And Stay Away From Doctors”

Earnest Tipp was very overdue for his blood pressure follow-up. Almost a year and a half overdue, as a matter of fact. The last few times I had refilled his medications, I had added “needs follow up” to the signum on his scripts.

The other day I finally saw him in my schedule. I thought about him all morning. A tall, muscular 90-year old widower with an appetite for golf and fine food, he always exuded contentment and gratitude over his good health.

After Autumn had checked him in, I looked at his vital signs screen. His weight was stable and his blood pressure was still well controlled.

“He’ll tell you why he didn’t come back sooner”, she said. “And he’s pretty smug about it, because you had joked with him about staying away from doctors!”

I remembered. Somehow, the topic of health screenings and medicalizing common ailments had come up and I had jokingly, as I often do, said “and stay away from doctors“.

As I entered the exam room, Earnest told the story of how he had taken my advise seriously and stayed away from all doctors, including me.

It didn’t take long to establish that Earnest seemed to be in good health, and, at age 90, how you seem to be is generally all that matters. No screening tests are indicated at that age, even whether and how to treat many diseases and risk factors for disease is usually controversial in that age group.

I remember the nephrologist I send my toughest hypertension patients to sometimes points out how little we actually know about treating people over 80 years old. That is even more true when it comes to 90-year-olds.

The other thing I remembered about my previous visit with Earnest was how he had told me he was about to have lunch with his prom date from seventy years ago. I asked him if he was still seeing her.

“Yes, we see each other almost every week”, he smiled.

I renewed his prescriptions and asked him to come back in a year. “Keep your good diet, play lots of golf this summer, enjoy your prom date…”

“And stay away from doctors”, he interrupted.

“Yes, by all means”, I answered. He stood up and offered a firm handshake. I have nothing to teach this man, I thought to myself.

Missing the Old A&P

Sometimes, after crafting an important or complex plan of care with a patient, I say: “Let me type all this into the computer so that, in case I run into that big bull moose up on Vaillancourt Hill on my way home tonight, the next doctor who sees you will know what we were thinking today.”

Patients sometimes squirm or laugh nervously at that, but then they usually indicate understanding and appreciation of what I am doing.

I am a physician who started out in the era of handwritten office notes. I often reminisce about the pediatricians who simply charted “LOM Amox” when a child had come in with a left-sided ear infection and received amoxicillin. From a medical point of view, there’s usually still little more to say, but now we don’t document for ourselves or other doctors anymore. These days we have to document for the insurance companies, the government, the legal system and for all kinds of lay people. And what we document isn’t just the medical facts of each visit, but also to what degree we did our job as the eyes and the voice of the government.

Treating the sick or counseling the well, we now have our agenda dictated by the government, from what we do when a patient’s body mass index is in the obese range all the way down to the sources of our patient education handouts – if I provide the best written information I have gathered over years of practice, instead of the rudimentary boilerplate materials from my EMR, I fail at “Meaningful Use” (of my EMR)!

I have seen the documentation requirements of what we do to fulfill the government’s public health agenda grow so much that what we think, beyond the patient’s ICD-9 (soon 10) diagnosis code, has become harder and harder to discern in many colleagues’ medical records, possibly also in my own.

Just before our clinic bought an electric medical record system, I walked through a much larger office with their Executive Medical Director. He and one of the clinic doctors explained, “with the EMR, we start with the superbill and work backwards”. I was used to start with the undiagnosed symptom or the presenting known diagnosis and work forward, carefully crafting a plan of action.

I didn’t quite grasp at the time how significant his statement was. Now, years later, I see the depth of this: In the first few years that we used our new system, I and all our doctors in our organization lost our quality certification with NCQA for diabetes and cardiovascular care because our new EMR didn’t track what we did for our patients. It wasn’t enough to do foot exams and to write (type) when patients last saw their eye doctor: Anything we do or even think we might track must appear as an “order” in the superbill, because our EMR is hardly a medical records system at all, but essentially an accounting or bookkeeping program. (We did re-qualify with NCQA last year.)

Referrals, imaging and lab tests are all “ordered” from pick-lists in the “superbill”. If I want to send a patient to a specialist in Connecticut, where my patient will be visiting with her family, I can’t enter the order, even though I have the doctor’s name, address, phone and fax number. I must call the EMR coordinator on call to have the specialist entered in the master list so I can “order” by clicking. Anything just typed in doesn’t exist in a bookkeeping sense.

When I do a foot exam, I also have to “order” it. And later, when I sign off all my incoming test results, there are all the foot exams I did myself, requiring my electronic signature, as if I hadn’t already noted what the findings were. Such ordering and sign-off becomes central in our new “workflows” – a word I never needed to contemplate until I started to understand my new role as a medical line worker, feeding the government-imposed computer.

When eye doctor reports come in from doctors who have been following my patients since long before our EMR, my nurse has to create a “non-billable encounter” for each one, and “order” the eye exam, so she can scan and “attach” the report to the order.

Between rooming patients, she is supposed to be “working her pending orders“, starting at the list of electronic orders I have entered, not organized by patient, but by order type, devoid of any personal connection: First all the X-Rays, then all the lab tests, and so on.

My nurse has a lot less time these days to read my office notes, so when patients call with questions, she isn’t as aware of what’s going on with them as she was before the computer.

And with all this “ordering”, there is simply less time for me, too – not only to think, but also to document what I am thinking. There is only so much you can accomplish in fifteen minutes!

Which brings me back to the A&P, or Assessment and Plan. In the beginning, documentation of those two things was the purpose of the medical record. Clinical notes were just that, clinical, not billing instruments or government compliance documents. So many other things got piled on top of the purely clinical agenda that we have almost lost what we all set out to do as doctors.

No wonder I feel a little sentimental sometimes and wish for a system that serves the clinical process more than today’s EMR.

The Man With the Shrinking Lung

I see some odd things in my clinic. One recent diagnostic dilemma was a man in his late fifties with shortness of breath.

He had been born with a Ventricular Septal Defect and had undergone surgery for this in his infancy. During his lifetime, he had seldom gone to doctors, and always thought he was in fairly good health, maybe just of a weak constitution. A smoker since age 13, he had a morning cough and got a little winded running up and down the basement stairs or shoveling snow in the winter.

A while ago he came to see me because he felt he was getting more short of breath over the winter. On exam, his vital signs were normal and his oxygen saturation was 97%. He had a systolic heart murmur and his breath sounds were diminished in his entire left lung. I didn’t see any swelling of his legs and his neck veins were not distended when he laid down flat on my exam table. His EKG was normal.

I ordered a chest X-ray and some basic blood work. His X-ray report said his left lung looked normal but his mediastinum was shifted a little to the left. His heart was not enlarged. Routine labs were normal.

The day he came in to follow up on his testing he looked ashen. He had suddenly become much more short of breath the day before, just brushing snow off his car. He had had some vague chest pressure that lasted ten or fifteen minutes.

His physical exam and repeat EKG were essentially unchanged; perhaps he had even weaker breath sounds in his left lung. This time his oxygen saturation was only 90%.

I ordered a chest CT with contrast for later the same day and also put in for a chemical stress test and an echocardiogram.

A few hours later, one of the radiologists called me. The man’s IV had infiltrated and most of the contrast ended up in the subcutaneous tissues of his right arm. His Pulmonary Embolism protocol CT scan would have to be postponed.

“Ok, have him stop by the office on his way home”, I said.

I gave him samples of one of the new anticoagulant medications that just got approved for initial treatment of blood clots in the lung and gave him a lot of detailed instructions.

Over the next two weeks, I received a normal stress test and an echocardiogram report that said something about decreased flow across the pulmonic valve. I wasn’t sure what to make of that in the context of my working diagnosis of one or multiple pulmonary emboli, and called radiology to please get the chest CT rescheduled.

Finally, this Monday, he had his CT scan done. The chief if radiology called me immediately after the study.

“Your Mr. Faulkner, he doesn’t have a PE, but he has agenesis of his left pulmonary artery.”

I sat back in my chair. I’d never heard of this condition. All his life, I thought, his underdeveloped left lung has been without functioning blood supply, and that’s why his mediastinum was shifted to the left and his breath sounds were so diminished. Finally, all this caught up with him, and he ended up in my clinic one day.

I did an Internet search for pulmonary artery agenesis. It is extremely rare, and usually diagnosed earlier in life. Some cases are diagnosed after an incidental abnormal routine chest X-ray. Symptoms are shortness of breath and productive cough or recurrent respiratory infections, all common concerns among middle aged smokers in this part of the country during the winter months.

I saw him back to explain what I had found, stopped his blood thinner and told him I wanted him to see a cardiologist at Cityside Hospital. He wasn’t so sure he wanted to travel that far, but said he’d think about it.

As a rural frontline primary care doc, you just never know what’s going to walk through your door.

Humming Jeopardy

The last few days have been really busy, but they still felt controlled, almost leisurely and smooth. Patients have been seen on time, my office notes have been completed in real time and my superbills have been submitted before each patient reached the check-out station. Things were really humming.

The new nurse, who is orienting with Autumn, noticed that I was humming each time I dashed back to my desk to grab a printout, my tuning fork or something else. I, too, realized I was doing it again and again – humming the theme song of Jeopardy, the television quiz show.

I haven’t watched Jeopardy since TV went digital a decade ago and we refused to upgrade. But I still find myself humming its theme now and then through the day. In fact, I’ve been doing it ever since, in a gesture of generosity and solidarity, I volunteered to try fifteen minute visits during a lean spell in the clinic about twelve years ago.

Primary care is a lot like Jeopardy. You have to quickly think of the right answer, which is often disguised as a question, and then press the buzzer as fast as you can before you are presented with the next challenge:

Is it the thyroid? What will the EKG show? Have you traveled to West Africa? Am I meeting my Meaningful Use targets?

Every day I walk the fine line between well oiled efficiency and letting patients take the time they need to tell their stories. Again and again throughout my day, I switch from nudging things along to slowing them down as my experience and clinical intuition guides me in my work.

The patients who were squeezed in for acute problems appreciate my efficiency in getting them in and out. Those with complex medical problems or maladies of the soul expect me to give them the time it takes to grasp what’s important to them. When I can’t tell the two types of appointments apart I fail miserably in carrying out the visit, and kick myself for my misjudgment.

I guess what I do is like like many other things in life that I personally have never experienced much of first hand, like sailing – you’ve got to consider the elements and never try to go completely against the wind or the current, but find the correct angle, know how to rig your sails and be prepared to zigzag a little to get to your destination.

The challenge in what I do as a primary care physician is to accept the changing winds of each clinic visit, to see time as something more fluid than a Swiss watch, and to remain a little bit above it all – just enough so I don’t feel completely stuck in the muddy waters of our modern healthcare bureaucracy.

I do have to stop humming Jeopardy, though. It completely sets the wrong mood.

Normal Blood Pressure

Dwight Frost had all the risk factors, plus he had already had a stroke several years ago. His blood sugars were too high, his lipid profile was near the top of the class, he still smoked a cigar now and then, and his blood pressure hovered around 200. He also seemed a little vague about which medications he actually took and which ones he didn’t.

He spoke rapidly with a slight tremulousness in his voice and seemed to be eager for the visit to be over.

On his second visit he brought a big bag of medications, not just the neatly written list his wife had sent him in with the first time. Some of the bottles were marked on the lid “AM” or “PM”, others said “BP”, “sugar” and some had a rubber band around them, which seemed to mean he was definitely taking them as prescribed.

His thyroid function and other routine labs were normal. At both visits I recorded his blood pressure in both arms; I had him sit and stand; the first time I saw him, I also checked the pressure in his right leg.

His wife was a retired nurse, he told me, and she also checked her own blood pressure with a stethoscope and a manual sphygmomanometer. She had recorded almost daily blood pressures, all under 140, that she had done on him between his two visits with me. She couldn’t come in with him, because she was actually bedridden from severe arthritis. She rarely got out of the house to see her rheumatologist, the only doctor she had.

I thought for a moment. There was only one way I could resolve this, so I asked:

“Would you mind if I stopped in next Friday afternoon to check your blood pressure when you’re relaxing at home?”

“Anytime, were always home“, he answered.

Friday afternoon I drove across town in a light snowfall. The faint February sun filtered its way between the snowflakes, which seemed to sparkle and rotate in the air ahead of me without ever hitting the windshield.

The Frost home was a tidy ranch house with an ell connecting it to the garage. Dwight saw me drive up and greeted me at the door.

Ada, his wife, was lying on a day bed near a pellet stove in the paneled room. A large Persian cat was sleeping at her feet.

Dwight walked over to a Canadian rocker near his wife’s bed and sat down. As we made small talk, the majestic cat woke up and moved over to Dwight’s lap. Slowly, almost absentmindedly, Dwight patted the cat and told me she was almost twenty years old.

I noticed that Dwight spoke without the tremor in his voice I had heard at the office, and he exuded a calm that I had not seen in him before.

As I watched from the chair he had offered me, a slow ritual unfolded before me. With the cat in his lap, Dwight placed the blood pressure cuff on his arm and gave the stethoscope to his wife. “Ready”, he said to Ada, and when she nodded, he pumped the cuff up and then slowly deflated it.

“134/82”, she said.

I walked over, put my own cuff on his arm instead and pulled out my own stethoscope from the pocket of my tweed jacket.

As I pumped up the cuff, Dwight patted his cat, who started purring, and leaned his head back against the back of his chair.

Slowly deflating the cuff from a high of 240, I listened in anticipation. At exactly 132, I heard the first Korotkoff sound. I continued to deflate the cuff and finally had my answer.

“Your blood pressure is fine”, I said, and reached down to record the numbers. “It’s just high when you come in to the office. So, why don’t you come and see me in three months, and just bring your readings from home.”

I gathered my equipment. As I looked up again, Ada and Dwight were holding hands. He was not the same anxious man I had seen in the office twice before. The cat was still in his lap, sleeping.

Medical Anamnestics

“Listen to the patient, he is telling you the diagnosis.”

William Osler

Sir William was right, but listening for the diagnosis when patients speak isn’t quite as straightforward as it may seem. This is particularly the case in the fifteen minute universe of American health care today.

In America we call it “history taking”. Our use of the word “history” somehow implies that there is something very objective about it. This has led people in the medical field to even delegate the listening to and documenting of patient histories to non-professional office staff.

In Sweden we used the word “Anamnes”, derived from the Greek words “ana” (back again) and “mimnesco” (remember). “Anamnesis” is found in Plato’s teachings about memory. There is a subjective quality to the use of the word “anamnesis” for patient or case histories, as the word in English can also mean, simply and non-medically, “recollection”.

Taking a patient history or anamnesis can require a fair amount of finesse.

Sometimes a patient comes in with a diagnosis already in mind. He or she will outline their differential diagnostic thought process and resist getting into what the actual symptoms are, as if they’ve moved beyond that stage. They act as if they wish I would please catch up with where they are. My usual reaction and tactic in such situations is to let go of any seeds of frustration I might feel and declare my inability to skip over any steps in the diagnostic process. I usually say something like “I’m a little slow…” in order to not seem to be challenging my patient’s preliminary efforts.

Other times, I run into patients who offer neither symptoms nor interpretation, but tell convoluted narratives about what others have said about them and what happened years ago that might have set the stage for whatever may be happening now, although I haven’t yet become the least bit aware of any of their present symptoms. Before I became aware of the condition now called alexithymia, I would easily become frustrated with this kind of narrative. Now I am more able to consider this kind of “anamnesis” a warning sign that my patient truly might be unable to recognize and describe both emotions and physical symptoms.

I worry about the idea of delegating listening to someone else; even a highly trained colleague could obtain a slightly different history, and every clinical decision is to some degree based on nuances that go beyond the mere “facts” of the case. It often seems that the way a patient’s history and his demeanor appear congruent or dissonant can move the diagnostic process forward quite dramatically.

I also worry about the therapeutic consequences of eliminating or abbreviating the listening process. I couldn’t count the times a patient has seen a well respected specialist who delivered technically excellent care and come back telling me “he didn’t even listen to me”. Patients have again and again told me that they value simple listening in me and other health care providers they see.

This ties in with something I read recently about the difference Between Care and Cure.

My wife ordered a book a few weeks ago by Henri Nouwen, called “Bread for the Journey”. It was published posthumously and contains daily reflections. Nouwen is perhaps best known for his writings about the “wounded healer”. This morning over coffee, Emma asked me to look at today’s reflection, titled “Care, the Source of All Cure”:

“Care is something other than cure. Cure means “change”. A doctor, a lawyer, a minister, a social worker – they all want to use their professional skills to bring about changes in people’s lives. They get paid for whatever kind of cure they can bring about. But cure, desirable as it may be, can easily become violent, manipulative, and even destructive if it does not grow out of care. Care is being with, crying out with, suffering with, feeling with. Care is compassion. It is claiming the truth that the other person is my brother or sister, human, mortal, vulnerable, like I am.

When care is our first concern, cure can be received as a gift. Often we are not able to cure, but we are always able to care. To care is to be human.”

Nouwen was absolutely right. I think the way we take each patient’s history, the way we elicit their stories and recollections – their “anamnesis” – is at the very foundation of “care” in health care.

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