Archive for the 'Progress Notes' Category

Everybody is Special

I was scheduled to attend a Medical Director’s Retreat the other day, but because of a horse emergency the day before, I had to stay home, so I offered to skip the retreat and see patients instead.

It would have been almost an entire day hearing about “Trauma Informed Care” and the lifelong impact of Adverse Childhood Events. As a primer, the conveners of the seminar emailed a “Dear Doctor” letter from a woman with a horrific childhood trauma history. One of the many vignettes in that letter was about her heart murmur, which disappeared when she started understanding and dealing with her trauma history.

I remember how, many years ago, a patient leaned forward in the exam room and blurted out at me “You don’t know me!” I think many of my patients could say that, but hopefully most see me at least honestly trying.

Over my career, I have seen many diagnoses and many minorities grab public attention for a limited time, demand special treatment and claiming to be severely misunderstood by the medical establishment and by individual practitioners. Every few years there is another medical condition and one more misunderstood minority to attend webinars, conferences and collaboratives about. Just when you feel you’ve integrated that one in your practice, another one comes along.

We have already, and I’m dating myself here, dealt with codependency, adult children of alcoholics, recovered memory, fibromyalgia and bipolar illness, brushed by narcissistic mothers and alexithymia, struggled with bulimia and anorexia, not to mention cultural and religious minorities. We are right now scrambling to become politically correct with every form of transgenderism there is.

What’ll be next? I don’t know, but I do know this: These are not issues we can tackle one by one. There will always be new ones that never managed to get their fifteen minutes of fame. So, maybe some more of the airtime needs to be devoted to the fundamental fact that every patient we see comes to us with their own story, their own journey, their own wounds, dreams, hopes, fears and demons.

We will never know everything there is to know about any fellow human being, and we need to be very careful when we see a general pattern in any one of our patients, not to pigeon hole them as being a classic example of whatever category they seem to fit into. Stereotyping is bad when we do it, and we should not steer our patients into stereotyping themselves.

We need to meet every fellow human being with an open mind, on their own terms, their own turf and in their own reality.

Sir William Osler said it a century ago: “The good physician treats the disease; the great physician treats the patient who has the disease.”

A Bug in His Ear

It was a small deer tick, hidden by the Crus Helix, embedded in the Cymba Conchae, the crevice just above the ear canal of my seven year old patient halfway through my Saturday clinic.

He was worried that it would hurt. His parents hadn’t wanted to try removing it on their own. I had a hard time even seeing the small tick as it was sitting at an angle where I saw it from straight behind.

“Let me get some stuff”, I said.

I drew up a couple of milliliters of Xylocaine with epinephrine and discarded the needle, grabbed some 2″ by 2″ gauze pads and rummaged among my autoclaved instruments for the finest foreign body forceps we have.

Back in the exam room, I explained my strategy:

“This syringe doesn’t have a needle on it. I’m just going to pour some Novocain over the tick, then we’ll wait a few minutes before I gently pull him out with this instrument.”

The boy looked worried.

“Piece of cake”, I said, “it won’t hurt a bit”.

I asked the boy to lie on his side with his tick-ear facing upward. Holding his head at just the right angle, I expressed enough Xylocaine from the syringe to completely fill the cone shaped crevice in his ear where the tick was submerged . I then held his head firmly but gently to make sure the tick stayed under the surface of the anesthetic.

“I’ve seen a lot of tick bites already the last two weeks”, I said as we waited. “I haven’t seen any new cases of Lyme disease yet, though.”

“You know the rash of Lyme disease was actually first described in Sweden, way back in 1909, by a doctor named Arvid Afzelius. And it was discovered a long time ago that penicillin could be used to stop it. I remember hearing that was routine when I started medical school in 1974. But it wasn’t until the early 1980’s that doctors in Lyme, Connecticut saw the connection with all the other symptoms we now call Lyme disease.”

As I prepared to finally remove the tick, I added:

“We vaccinate dogs for Lyme disease here, but not people, but in Sweden, all my relatives have been vaccinated.”

I grabbed the handles of the forceps, pointed the tip away from me, reached into the Cymba Conchae while still holding the boy’s head in place. Then I closed the tip of the forceps gently, without locking the instrument, and pulled. The tick offered no resistance. It was intact.

“See, here he is, legs, jaw and all, out of where he doesn’t belong.”

The boy and his parents squinted as they looked at the tiny deer tick.

“And he didn’t feel a thing”, I added. The boy finally smiled.

“People use all kinds of different oils and things to suffocate the tick”, I said. “I prefer Xylocaine, which by the way was in developed in Sweden in 1943.”

To myself, I reflected that I don’t even remember when I first decided to try Xylocaine. I know people have had good luck with oils, but we don’t keep any of them in the office. But we always have Xylocaine. And that does add more of an air of medical magic than just plain olive oil.

The Power of ACT

She didn’t seem obviously depressed as I entered the room.

“So, we have you taking a good dose of both antidepressants now”, I said. “How are you doing?”

“I feel about the same.”

“Have you done anything lately that could have made you feel a little better?”

“I’m not sure…”

“I’ll give you some examples. They can be different things for different people. It could be reaching out to a friend, helping a neighbor, watching the sunrise…”

“I listen to music. John can tell what kind of mood I’m in depending on what I’m playing. And I watch my shows on cable TV. I feel better when I do those things.”

“Are there things in your life that are more important than music and TV?”

“Our grandkids. Our youngest daughter lives here in town and her kids really light up my life.”

“And you see them quite often, right?”

“Yes, we babysit them every weekend. You should see John with them. He’s such an awesome grandfather. It warms my heart…”

“You’ve started seeing Betty now, right? Did you notice over in the Behavioral Health wing that there is a white board that’s divided in four rectangles with a little circle in the middle?”

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“Yeah, I think I’ve seen that…”

Has Betty talked with you about that yet?”

“No…”

“She probably will. It’s a great way to organize your thoughts and your feelings. It’s called ACT. Let me tell you about one aspect of it. It’s the difference between away moves and toward moves.”

She shifted a little forward in her chair.

“The bottom right is what’s really, really important to you, like your grandkids. And the bottom left is all the stuff inside your mind that keeps you away from what’s important. The top left is all the moves you make that take you away from your sadness, anxiety, pain and so on, but that don’t actually bring you closer to what’s important. We call that Away Moves, almost like escapes. That’s where music and TV might belong, unless they are in the box on the lower right. But those things don’t bring you any closer to your grandkids and the happiness they give you, right?”

“I see what you mean…”

“The horizontal line has arrows at each end. By the arrow to the left it says Away and to the right it says Toward. And in the top right rectangle are little things, steps you can take, that bring you closer to what’s important.”

“I see the difference…”

“So, other than your grandchildren, who or what else is important to you?”

“My daughters in Lewiston and Bar Harbor.”

“Anything else?”

“I don’t know…”

“You have a cross on that chain. What’s your faith?”

“I was raised Baptist. My daughter in Lewiston sings in the church choir there and I used to do that many years ago…”

“How often do yo see these two daughters? How often do you go to church?”

“Not often enough…”

“Could you do more of that?”

“I don’t think John would want to go.”

“He might, or he might want to take care of the grandkids while you do those things, right?”

“I never thought of that…”

“It sounds like you have a lot of love inside you that hasn’t been expressed often enough, and it sounds like your faith hasn’t had enough space in your life lately.”

She nodded.

“I know you as a very caring and soulful person and I think of you as someone who thrives on connecting with others. Maybe your bond with your other daughters could be a lot stronger, and maybe that would help you feel happier and less depressed. You and Betty could talk more about that in your next session…”

“I really hope we can.”

“Because there is more to treating depression than picking the right medicine”, I said.

She smiled and locked her gaze straight at me. Her eyes were moist and she smiled faintly.

[”Acceptance and Commitment Training/Therapy (ACT) is an an evidenced-based way of helping people let go of struggling and get moving toward valued living. “Traditional” ACT is complicated and hard to learn. The ACT Matrix is easy.” Dr. Kevin Polk]
https://www.theactmatrixacademy.com/

Peer to Peer

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each one is a sure time robber. Even with today’s talk about paying for value and quality, I still live in a world where my “opportunity cost” is $7 per minute. That is what I must generate every minute of my work day. A five minute call could mean one less patient visit for a skin rash or an ear infection or a patient call to communicate an important test result instead of sitting in a phone queue, listening to Barry Manilow tunes.

The other day, my “peer” was a nurse, a “near-peer” human filter, who listened to my story about why the abdominal and pelvic CT was necessary for my patient with abdominal pain, diarrhea and elevated liver function tests but otherwise unremarkable blood work, including hepatitis titers. She instantly gave me an authorization number. Afterward I asked, “don’t you read our office notes these days?”

“No, we stopped doing that. In this case we were told the patient had a lump.”

“I coded for the three symptoms.”

“But we need to know what you are looking for.”

“A rule out?”

“Yes.”

“But you can’t code for a diagnosis the patient doesn’t have, that’s insurance fraud.”

“Well, that’s what we need to know.”

“So I need to spell that out, if you don’t read my notes. You know, in many offices the one whose job it is to call you is a lay person.”

“And so is the person who answers the call at our end.”

And I thought my notes were still read by a medical person. I should have asked if they stopped reading the notes because they have gotten too long and cumbersome for them to read. I’m sure a radiologist who reviews imaging requests has an opportunity cost, or a must-save-the-company-per-minute cost, of a whole lot more than $7.

Note to self: Always add “R/O” after describing the symptoms.

Of course, in cases where there is no time for the Barry Manilow queue, it is a well known fact that the emergency room doesn’t have to worry about prior authorizations.

All or Nothing

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

Stop Excessive Measurement

“Stop Excessive Measurement.”

Those three little words were music to my ears. The fact that they were spoken by Don Berwick, creator of the Institute for Healthcare Improvement and former head of Medicare, made them even more significant.

I was in our state capital today for a regularly occurring conference by Maine Quality Counts. The theme was “Achieving Excellent Patient & Provider Experience”. There was a lot of talk about provider burnout. Dr. Berwick spoke of the central role of the provider-patient relationship and the failures of the current quality movement.

He told a touching vignette about his brother, who is a patient in a rehabilitation facility. All his brother wants right now is to go outside for a few minutes and experience spring, but the rehabilitation hospital is so focused on keeping their falls statistics down that they haven’t been able or willing to work with him to see how he can safely meet his goal.

Berwick more or less said that if you serve your patient well and keep his or her needs in sharp focus, quality will improve, waste will decrease and provider burnout will diminish. How refreshing.

His remarks were originally made at the IHI and published in JAMA a year ago today, during a time when I fell behind in my journal reading.

He describes three eras in medicine.

The first era was the autonomous physician, serving a calling and belonging to a self-regulating profession. Science exposed variation and inconsistencies in the healthcare of the first era, and a second era was born.

That second era, which we now live in, is the era of accountability, measurements and incentives.

The ideals of those two eras are incompatible, but they point the way to a possible third era, which he calls the moral era, where providers are subject to fewer measurements because organizations trust their commitment to their patients and to the principles of quality.

I need to hear things like that now and then.

Watch Don Berwick speak about the third era:

Medicine is a Love that Finds Us

Medicine is a love that finds us wherever we happen to be.

It snatched me, a quiet four year old boy, almost sixty years ago. I don’t know how it happened. I remember being in the hospital and having stomach X-rays and I have also been told we had a family doctor who made house calls. I couldn’t have seen doctors on TV, because television was only introduced in Sweden when I was three and I saw my first program at age 5, a show about an infantile doll named “Andy Pandy”.

At age four I simply announced that I was going to become a doctor and I never hesitated after that. It seems everything I did from that moment on prepared me for what I do now: Being a Boy scout who made do with what I had on hand; learning discipline as a military recruit in basic training; working as a substitute teacher for fifth to ninth grade students; spending a summer as the pastor’s assistant with confirmation students and in his parish, and traveling the world to interview people from other cultures.

In my day to day work I always look for the story behind each patient’s symptom and even behind their laboratory values. I often find myself circling around the concept of Narrative Medicine.

The other day I happened to read the Swedish journal for general medicine (Allmän Medicin). A doctor, who seemed to be about my age, had written about his experiences with Narrative Medicine and the tension he used to feel between it and today’s Evidence Based Medicine.

The writer’s name was Christer Petersson, and he looked and wrote as if he was someone I had known from High School. I Googled his name and found another article he had written, in 2009, in the Swedish Medical Journal, Läkartidningen.

That article was titled “I worked as a Doctor for 20 Years. Then I Became a Doctor”.

I did a quick double take and continued to read, finding exactly what the title suggested: He had studied medicine because the science interested him and it seemed like a good thing to do. He was a young man with big thoughts and big ideas. But he felt uninspired by learning about the digestive system and was uncomfortable with the notion of treating mundane things like bleeding, boils and open wounds.

He writes:

“It took about 10 years and quite a bit of agonizing before I discovered that I was exactly where I was supposed to be, and it took another 10 years to understand that I actually was a doctor and didn’t just work as one. During that time I learned that man is more than his digestive system and the most important events in life often happen in the seemingly uninteresting space where blood flows, boils burst and wounds heal.”

And then, he paraphrases Hippocrates’ first aphorism:

“And I saw that it is equal parts suffering and joy to deal with all this as a doctor: to cure sometimes, treat more often and comfort the best you can.

It doesn’t get any better than that, does it?”

Different journeys to the same destination.


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