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

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

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

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

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

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

One More Question

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

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

“Any trouble with high blood sugars?”

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

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

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


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

I took a deep breath.

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

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

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

How can you not be fascinated by this job?

Doceo, Ergo Sum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I do most of my work in conversation.

All of it, really.

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?”


“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.


“Are you short of breath?”

“A little.”

“Did you eat okay yesterday?”


“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?”


“Did you have any diarrhea or vomiting?”


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.

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A Country Doctor Writes’ Ten Year Anniversary

April 28th, 2018
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