Archive for the 'Progress Notes' Category

My Triple Aim of Medication Assisted Treatment for Opioid Addicted Patients

My second foray into Suboxone treatment has evolved in a way I had not expected, but I think I have stumbled onto something profound:

Almost six months into our in-house clinic’s existence, I have found myself prescribing and adjusting treatment for about half of my MAT patients for co-occurring anxiety, depression, bipolar disease and ADHD as well as restless leg syndrome, asthma and various infectious diseases.

Years ago, working in a mental health clinic, we had strict rules to defer everything to each patient’s primary care provider that wasn’t strictly related to Suboxone treatment. One problem was that many of our patients there didn’t have a medical home or had difficulty accessing services. Another problem was that primary care providers unfamiliar with opioid addiction treatment were uncomfortable prescribing almost anything to patients on Suboxone.

This time around, the majority of my patients come to our clinic for all of their health care, or decide after being in our program to establish as primary care patients. I am the PCP for a good portion, and as the Medical Director for my clinic I not only have access to their medical records, but I am thoroughly familiar with my primary care colleagues’ preferences, practice styles and personal clinical strengths and weaknesses. That allows me to know when it works best to steer patients toward separate appointments for, say, their anxiety, and when it works better to establish a treatment plan right then and there as they become increasingly stable on their Suboxone.

Being involved in our group sessions, seeing clients on a weekly basis, even if briefly sometimes, and sharing impressions in post-group debriefings with my substance abuse counselor, Behavioral Health Director and our dedicated MAT coordinator has given me a profound insight into the personalities and circumstances of my Suboxone patients. The sheer depth of my insight from our comprehensive approach has allowed me to initiate life changing medication treatments for a large handful of patients beyond merely Suboxone.

Through a new grant we will soon also have a case manager, who will help our patients navigate their way back into mainstream society.

It’s funny: I had pictured Suboxone treatment as a carve-out niche in my practice, but it has become the most comprehensive, integrated thing that I do.

Doctors and CEOs Need Time to Think

I’ve always likened the job of a primary care physician to that of a Chief Executive Officer of a small business. Family doctors manage the “business” of delivering and coordinating care for more than a thousand patients at an average cost, in the United States, of $8,500 per year – an $8-$12 million business. Because the actions or inactions of the PCP impact the need for, and cost of, specialist and hospital care “downstream” from the primary care office, I think of this as “our” business.

Because of this, I subscribe to the Harvard Business Review. I figure doctors must have some degree of common business sense. And in my medical education, the slant of the business education I got was mostly relevant in the context of Socialized Medicine. I think that is helpful and useful in my practice in a medically underserved area, but there’s more to primary care than serving the underserved on a national level.

Reading the article “How CEOs Manage Time” in the current issue of HBR, I was struck by how light the “grueling” schedule of an American CEO is compared to that of an ordinary family practitioner: 9.7 hours of work each weekday and 3.9 hours on each weekend day.

I was also intrigued by the statistic that 61% of CEOs’ time is spent face to face and 24% on electronic communication. Only an unspecified fraction of 15% is spent on reading written reports.

Undocumented as far as both CEOs and physicians, as far as I know, is how much time we spend researching and thinking. A pullout quote rings true for doctors as well:

I do think it is crucial for primary care doctors to consider the value of their time in a businesslike manner. I know our employers do, but I suspect there is much confusion and disagreement about how to make the best use of our time. In simpler times, doctors just saw patients and brought in professional fees commensurate with their efforts.

But in today’s climate, where outcomes data is starting to determine office revenue and where the health of casual or infrequent visitors to our offices affects our bottom line, we need to claim the value of our time – and I feel strongly that we must leverage our knowledge for the biggest possible impact within our organizations and for our patient populations.

That impact will be less and less determined by line worker type activities such as traditional face to face office visits, and more and more by how we guide and coordinate more and more aspects of our enrolled patients’ health care.

We have added layers of staff to do this coordination work, but in many cases physicians have been peripheral, remaining too heavily involved in the traditional physician activities and not lending their medical common sense and “street smarts” to what could easily become a bloated and disconnected layer of bureaucracy.

Just like a CEO can be the originator and spokesperson for a corporate philosophy while making sure there are middle managers who can reinforce the message on a daily basis, we must be able to shape the overarching medical philosophy and the clinical pathways within our organizations. By doing that, we can more safely delegate tasks while also constantly overseeing and officially promoting and supporting the work that is done by care managers, health educators, nurses and medical assistants.

But just like CEOs, we can’t be spending all our time in meetings, face to face encounters and answering electronic messages. We need some time to research, consider and create. And the more our routine tasks spill over into nights and weekends, the less chance there is that we can think creatively and leapfrog our organizations into the next level of healthcare delivery.

Saturday Clinic

I volunteered to work Saturdays. And to do walk-ins. And to take all comers, not just our patients.

It has been an interesting journey.

Some clinics put their newest, least experienced clinicians on the very front line of doing urgent care. Here, it’s the opposite. I’ve got 39 years under my belt and I see everything from sore throats to people who left the emergency room in the middle of a workup because their anxiety kept them from waiting for their CT scan to rule out a blood clot in their lungs.

The waiting room fills up, and it’s just me and a medical assistant.

It’s refreshing and rewarding to see things that can be fixed in a matter of minutes: embedded ticks, corneal foreign bodies, pieces of hearing aids deep inside ear canals, bursitis cases and nursemaid’s elbows.

My very first paychecks as a doctor came from weekend stints back in Sweden while I was still in medical school. At least back then, they had a system where senior medical students could be given temporary privileges as locum tenens physicians with minimal supervision. I worked weekends, Friday night to Monday morning, seeing patients that weren’t sick enough to need the full resources of the emergency room in a hospital about an hour away from my medical school.

Already then, I thrived on not knowing what challenge was next up. Whatever it is, I’ll do my best, I figured. And at that point, the resources of the emergency room were right down the hall.

Here, the emergency room is 20 miles away, but the ambulance is only a couple of miles away and I’m not the stand-in EMT the way it was when I first came here.

Primary Care is turning into a specialty of chronic care and public health. Some of the chronic care we do is really what internal medicine specialists used to do before they all wanted to subspecialize or go into hospital medicine. And much of the acute care we trained for is now being done by emergency and urgent care physicians as well as PAs and Nurse Practitioners.

And Public Health is a very different thing from what doctors of my generation trained for. I still feel it is better suited for nurses than doctors. I didn’t attend medical school for 5 1/2 years and do two residencies just to blindly follow rules; I trained to know when rules and guidelines do and don’t apply.

Doctors are trained to identify the exceptions from the rule, which is a useful skill on the front lines. Which migraine is really a brain tumor? Which asthma attack is a foreign body in the trachea? Which rash is a sign of leukemia?

I worked hard today, but I don’t feel drained; I feel energized, because I cured a few people, and closed a few cases. Chronic care with no acutes wears on you. The extra work I do may seem like a burden to some, but I find it rejuvenating. It brings a healthy balance to my work week.

Self-Driving Cars are Like Most EMRs

Drivers are distracted klutzes and computers could obviously do better. Self driving cars will make all of us safer on he road.

Doctors have spotty knowledge and keep illegible records. EMRs with decision support will improve the quality of healthcare.

The parallels are obvious. And so far the outcomes are disappointing on both fronts of our new war against human error.

I remember vividly flunking my first driving test in Sweden. It was early fall in 1972. I was in a baby blue Volvo with a long, wiggly stick shift on the floor. My examiner had a set of pedals on the passenger side of the car. At first I did well, starting the car on a hill and easing up the clutch with my left foot while depressing and then slowly releasing the brake pedal with my right forefoot and at the same time giving the car gas with my right heel.

I stopped appropriately for some pedestrians at a crosswalk and kept a safe distance from the other cars on the road.

A few minutes later, the instructor said “turn left here”. I did. That was the end of the test. He used his pedals. It was a one way street.

Three times this spring, driving in the dark between my two clinics, I have successfully swerved, at 75 miles (121 km) per hour, to avoid hitting a moose standing in the middle of the highway. Would a self driving car have done as well or better? Maybe, maybe not.

Every day I get red pop up warnings that the diabetic medication I am about to prescribe can cause low blood sugars. I would hope it might.

Almost daily I read 7 page emergency room reports that fail to mention the diagnosis or the treatment. Or maybe it’s there and I just don’t have enough time in my 15 minute visit to find it.

For a couple of years one of my clinics kept failing some basic quality measures because our hasty orientation to our EMR (there was a deadline for the incentive monies to purchase EMRs) resulted in us putting critical information in the wrong “results” box. When our scores improved, it had nothing to do with doing better for our patients, only clicking the right box to get credit for what we had been doing for decades before.

Our country has a naive and childish fascination with novelties. We worship disrupting technologies and undervalue continuous quality improvement, which was the mantra of the industrial era. It seems so old fashioned today, when everything seems to evolve at warp speed.

But the disasters of these new technologies should make us slow down and examine our motives. Change for the sake of change is not a virtue.

I know from my everyday painful experiences that EMRs often lack the most basic functionalities doctors want and need. Seeing a lab result without also seeing if the patient is scheduled to come back soon, or their phone number in case they need a call about their results, is plainly speaking a stupid interface design.

I know most EMRs weren’t created by doctors working in 15 minute appointments. I wonder who designed the software for self driving cars…

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.

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?


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