Archive for the 'Progress Notes' Category

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.

Progress in Weekly Increments

I’m prescribing Suboxone again, not in a half empty strip mall in town, where I filled in for a number of years, but in my own office.

My clinic received a grant that helped us hire an additional social worker, a part time medical assistant with recovery experience and a part time substance abuse counselor.

For a couple of months now I have met once a week with each one of a dozen patients with widely different stories and circumstances. Unlike the last time I worked with opioid addicted patients, I am not just one of several prescribers rotating through the clinic. I am the only doctor for this, our first group.

I have followed this group of a dozen fellow human beings every single week through the cold of winter and the snowstorms outside and through the outer and inner tumult of their own lives. Our encounters are brief, pulling each member out from a group session to review how the Suboxone is changing their bodies and their lives, check the rapid drug screen results and send the electronic prescriptions to the pharmacy.

In those brief encounters, I get deep glimpses into the many lives that are starting to move away from the brink: A young woman has moved out of an abusive relationship. A young man has made a plea bargain with the District Attorney. A heroin addict is enjoying her children without the Department of Health and Human Services watching her every move. A depressed young man smiled at me for the first time two weeks ago, and someone else has stopped drinking.

Other participants have transferred in from other clinics. One was already my patient, but I couldn’t prescribe Suboxone for him without the full structure of a substance abuse program. He has a visible career in our community, and he is like a mentor or older brother to those that have just started on their own road to recovery.

My last tour of duty in substance abuse care was all individual appointments; this time, I hear everyone saying that the group is more effective in bringing out honesty and accountability in its members than one or two clinicians have been able to do before.

In my previous setting, I had to be careful not to assume the role of primary care provider and give detailed advice or prescriptions for general medical matters. Here, in my own office, I can adjust antidepressants, prescribe for insomnia and restless legs as I would any time filling in for one of my colleagues. In the same way, the staff counselor who attends the group can give advice and refer seamlessly to clients’ individual therapists here.

This time for me, the care for opioid addiction is integrated with both the provision of primary care and behavioral health. This is as it should be. It requires a certain structure and a certain level of expertise, but it is by now a basic kind of care for a very common chronic condition with, if untreated, potentially devastating consequences.

Last time I wrote about treating opioid addiction, “I don’t hate coming here”. This time, I feel good about having helped bring this service home, under our own roof, in our own community.

On a Personal Note

In the ten years since I first clicked “Publish” and posted my first piece on “A Country Doctor Writes”, I have published roughly the quantitative equivalent of Moby Dick and War and Peace combined. Not that I claim to be quite in their league, but have written quite a lot.

During this decade I have recertified twice as a Family Physician. I have buried both of my parents and several cats, dogs and horses. I have grayed significantly at the temples and I have gained and lost two pants sizes.

This week I received news that I passed my Board examination, 34 years after my first one, and I got an email that “A Country Doctor Writes” is one of the top 25 doctor blogs in the country.

On the day of my ten year anniversary I will be in Boston at a Harvard course for medical writers. Such a coincidental symbol of my milestone as a writer.

Listening to Audio Digest’s Family Medicine Review course on my way to and from work gave me a sense of renewal, and the other events this month make me feel that I am preparing for a professional growth spurt at an age when some of my contemporaries are retiring.

One of my purposes when I started this blog was to inspire the next generation of doctors and counterbalance some of the negativity I see among my colleagues today. I have seen that my writing has been republished and commented on in student doctor circles, and I have had some of them comment here, first as students and later as new doctors.

I have also tried to paint a picture of how rural medicine today is a soulful endeavor, allowing you intimate access into the lives of people in a way that is not very different from how doctoring was a generation ago.

I have created a fictional version of my community, its citizens, my colleagues, the nearby hospitals and the specialists in the city. But the essence of all of what I have written is pure truth. “Only the names have been changed”, as they say.

Thanks very much for reading.

(P.S. Because my senior colleague did retire, and because one of my contemporaries is planning to do so, I’m looking for one or two new partners. My email is in the sidebar on the right.)

From EMR to Paper to EMR

I can’t help myself from telling patients how things really work in health care. But I feel they have a right to know.

When I see new patients their jaw usually drops when I sit down with them next to the computer with a stack of papers held together with a rubber band or a gigantic clamp and with yellow sticky notes protruding here and there with words like LAB, ER and X-RAY.

Patients always assume that medical records transfer seamlessly between practices. They don’t, even between clinics that use the same EMR vendor. The stack of papers gets scanned in, as images or PDFs, but they don’t appear in searchable, tabular or report-compatible form. Often, they don’t each get labeled, but are clumped together under headings like “Radiology 2010-2017”.

In one of the clinics I work in, a Registered Nurse enters patients’ medical history in the EMR before each new patient’s first appointment. In the other, it is my job.

In both cases, only a fraction of he information is usually carried over from one EMR to the other, and the patient’s life story risks getting diluted, even distorted.

It doesn’t take much imagination to understand why things work this way:

Once upon a time, the Rulers of a great country handed out money to all the medicine men so they could start using computers to document what they did (and what they charged for, which was the real reason the Rulers handed out money the way they did).

This was a gift, not only to the medicine men but also to a lot of computer companies, who quickly geared up and made EMRs that the medicine men needed to buy before the deadline the Rulers had imposed.

Soon the medicine men gave all their newfound money to the computer makers. One of the things they thought they remembered hearing about was “interoperability”, but the computer makers were no fools. By making it just about impossible to transfer data between EMRs, the computer companies figured they could keep their respective customers hostage, because no matter how much they hated the slapped-together systems, it would be too costly to start over with another system.

Eventually, each vendor secretly hoped they would end up with the most users and thereby becoming the industry standard when the medicine men and the Rulers caught on to the lack of interoperability.

That, I explain to those of my patients who were around for it, is like the early days of VCRs – Betamax or VHS – more than 100 times over or, think about it, 100 times worse.

(I wrote this on April 1, but I’m not fooling…)

Triage at the Front Desk

It happened again the other morning.

As I left the conference area and crossed the main lobby I saw a young woman approaching the front desk, leaning on an older woman. I didn’t think much of it, and unlocked the clinic door. I did what I had to do, and as I returned to the lobby, I heard an overhead page “Triage at the front desk”. As I reentered the lobby, the young woman was on the floor and a lab tech was just leaning down over her. A medical assistant almost pushed her way through the door with me, emergency box in hand.

“What’s happening with you?” I asked the woman, who is my patient and has several chronic health problems.

“I need my blood pressure checked”, she answered.

“We’ll do that”, I said as we opened the box. “Why do you need your blood pressure checked?”

“I just need my blood pressure checked.”

“She passed out in the kitchen”, the older woman said.

“She’s a diabetic, check her blood sugar”, I said to the medical assistant as I placed the blood pressure cuff on the woman’s arm.

“Your blood pressure is fine”, I said. “Now, did you just pass out again?”

“160”, the medical assistant announced. Normal for a diabetic. Her pulse rate and oxygen saturation were also normal.

“I don’t think I passed out.”

“Do you hurt anywhere?”

“My behind is sore and my chest hurts.”

“She had chest pain this morning when she walked across the kitchen and fell to the floor”, said the older woman, who turned out to be her mother.

“Call the ambulance”, I called out.

“No, I want to go home”, the young woman mumbled.

“Listen, we don’t know why you passed out, and we don’t know yet what this chest pain is from. You need more testing.” I held my hand on her pulse for a while to make sure it was regular.

As the ambulance crew entered the lobby with their stretcher, she sat up and protested. The crew listened to my rapid fire description of her medical background and today’s events.

“You need to be checked out further”, one of the attendants pronounced.

They were in charge now, and I returned to my office and called the hospital to let them know what was coming.

Over the years I have seen countless patients who in a medical emergency have a specific idea of just what they need and whose medical care is delayed because of that.

When I first started practicing in this area, we didn’t have advanced EMTs on our volunteer ambulance corps. It was the on-call doctor’s duty to fill that role, which meant I would sometimes get paged after hours to meet the ambulance at somebody’s house or at one of the local motels.

Later, even when the ambulance service was upgraded, I would get calls from patients in the middle of the night, demanding that I open up the office, singlehanded, and do an EKG because the person figured that was the full extent of a medical assessment for chest pain. A few times my refusal to do so caused complaints to the management and the board of directors.

Ten years ago, we ended our longstanding free blood pressure checks. Until then, when we were titrating blood pressure medications, we would simply tell patients to drop in and have their blood pressure documented. We would then look over the numbers to make sure we got the medications right. But what started to happen more and more was that people who felt poorly and couldn’t get an appointment soon enough or were offered a time that was inconvenient for them would simply show up for a “free blood pressure check”.

Once in a room with the medical assistant, they would say, “I’m having chest pain”, or “I think I’m going to faint”, forcing the doctors to interrupt their schedules. Some patients event went so far as to threatening on the phone “if you can’t give me an appointment this morning, I’ll just come in for a blood pressure check and then you’ll have to see me”.

We are not the only practice that has to balance access with medical appropriateness. Most clinics and pharmacies, even Cityside Cardiology start their automated telephone attendant system with “If this is a medical emergency, please hang up and call 911…”

I’m grateful I’m not expected to meet the ambulance in the middle of the night or open up the office alone for someone who could collapse in front of me. I’m not complaining that people think we can do more than we are equipped to do. I am only puzzling about why, in this era of ever increasing sophistication in emergency care, so many people think they know exactly what they need.

Like the woman in the lobby – she had passed out and had chest pain, but her blood pressure was okay, so she wanted to go home.

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