Archive for the 'The Art Of…' Category

The Art of the Message

Sometimes I wonder if I am wired differently from other doctors, in terms of what I remember on my own and what I need some help with.

The other day I got a “medical call” that simply said, “Mr Brown called to report his blood pressure is 120/80”.

With more than fifty calls in my inbox and no memory of what the issue was with Mr Brown’s current blood pressure, I replied “seems like a random fact, is there a back story?” I never heard back.

Seeing up to thirty patients a day and receiving at least fifty each of EMR “documents”, messages and lab results, my mind doesn’t retain the details of each clinical plate swerving in the air above my head. Mr. Brown could have stopped his blood pressure pill because he was lightheaded with a low blood pressure, or he might have stopped his valsartan because he was caught up in the fears of cancer causing ingredients in Chinese generics, or he could have had an abnormal potassium and stopped the medicine that could influence potassium levels. Or, perhaps he got a home blood pressure cuff to prove that he has white coat hypertension.

In my world view, in light of the productivity requirements in primary care, messages need to be anchored in a clinical scenario so that the provider can make a decision without doing several minutes of research during time stolen from scheduled patient visits, lunch, bathroom breaks or life in general.

“Tell me why you were asked to call in your readings” would have been the way to handle that call, but I have a vague suspicion that the medical assistant who took the call felt pressured by the list of other calls that needed attention, for example the mandatory ER Followup calls that are a quality indicator for us. The quality of clinical calls doesn’t count, so they might be a lower priority. Everyone in the medical office has their own hoops to jump through and sometimes we are tempted or have no choice but to do the minimum and pass the buck just to get through our day.

I had hoped, naively as many readers commented back then, that the Patient Centered Medical Home concept would foster a reengineering and a clearer focus on what really matters. Like so many other quality enhancements in medicine, it has created another layer of superficial check-offs that has made it harder to see the patient and the clinical issues at hand.

I still wonder what the deal was with Mr. Brown, which is not his real name; I forgot the name the instant I hit “reply” and got the incoherent message off my already full plate.

The Art of Covering

I was a little taken aback when Dr. C. changed my patient from warfarin to one of the “Novel Anticoagulants”, and one I seldom use, at that.

I have only worked with her for about three years, and we seem to come from the same mold, seasoned family docs with a penchant for teaching and patient empowerment. I had not imagined she would step in and completely change my treatment plan when she was just covering for one day.

As far as which is safer, warfarin with variable therapeutic effect and fluctuating INRs or Novel Anticoagulants, which have hardly been studied at all in patients on dialysis, you won’t see test results that may worry you, but the unknowns are still there.

It was a judgment call, and she took it upon herself to change my treatment. She may never see that particular patient again, but that brief doctor-patient relationship has changed my patient’s risk of stroke, to the better or to the worse, I don’t know which way.

As we are now adding a couple of new providers to our clinic, I think back to discussions we had 20-25 years ago, when we had another major influx of providers.

We met back then to talk about what we all wanted from each other when “covering”, and we were all pretty clear that, even though we might feel tempted to tweak blood pressure medications, diabetic regimens or other things while treating an acute problem, we wouldn’t necessarily appreciate if someone did that to our patient and our treatment plan.

So we had a truce: We would deal with the problem at hand and suggest that the patient talk to their PCP about adjusting their treatment. As far as the acute situation, we agreed to emulate each other’s style a little. Dr. Z often gave very explicit advise on over the counter and alternative treatments for more or less self limited illnesses, while I have always been inclined to say, “those things won’t make this go away any faster, they just keep you busy while you wait”. I did a lot more handholding when I covered for Dr. Z. and I think she was less adamant about my patients spending money at the health food store.

Doctors aren’t all the same, and patients usually gravitate to providers who meet their needs. And, I hope this doesn’t surprise anybody, there are many different ways to treat the same problem. Trained “abroad” and old enough to have seen medical “facts” come and go, it has been obvious to me for a long time.

I think there is a balance here. A patient who seems dissatisfied with the status of their condition or its treatment deserves to hear that there are options, and a covering provider can point that out, but to offer such advise unsolicited can do more harm than good. We shouldn’t try to look smart at the expense of our colleagues. It may be better to approach that colleague privately and say, “do you still prefer warfarin over Xarelto in dialysis patients?”

I’m still thinking about that one.

The Art of Asking

Most people know from experience or through intuition that there is a right time and a right way to ask important or sensitive questions. You don’t usually just blurt out requests for raises or marriage proposals, for example.

In many areas of life, knowing when and how to ask difficult questions is viewed as an extremely valuable skill, for example in criminal investigations and in journalism.

In some cases this kind of skill can even make you a media star: Interviewers like Barbara Sawyer, Oprah Winfrey and Howard Stern are more famous and better paid than most of the celebrities they engage in intimate conversations in front of their national or world-wide audiences.

This year, the US presidential debates have been said to require unusual savvy from their moderators and their performance may even affect the outcome of the election.

Why is it, then, that in health care so little value is placed on when and how you ask sensitive or important questions?

In healthcare, we are constantly told that we must ask the most personal and intrusive questions of anyone who walks through our doors before we even ask what brings them to the doctor in the first place. And, unlike other interviewers, we must use “standardized” and “validated” questionnaires, because our work isn’t like other forms of fact or truth finding; our purpose is to collect data and to apply statistically proven interventions. No room for tact or finesse here.

When Autumn, my nurse, checks in a new patient, each one has already answered questions about gender identity and gender at birth. Autumn, along with doing the usual vital signs, has to administer a depression screening, inquire about alcohol habits and smoking, along with readiness to quit. For people with a BMI over 30, she has to ask what they are planning to do about it.

In many practices, the patient’s “History of Present Illness” and “Review of Systems” are asked and documented into obtrusive computers by freshly graduated medical assistants with limited medical and psychological training or experience. But that’s okay, because we use validated instruments and people always open right up and tell us the truth, and they always present their most important symptoms to us on a silver platter, the thinking goes. So, therefore, professional skill and experience may be valuable in rare cases, but there is just too much variability in that.

So, let’s imagine that our mandates applied in other areas of life:

What if criminal investigations were conducted by administration of nationally established “Criminology Assessment Protocols”?

What if lawyers could only use validated questionnaires and weren’t allowed to cross examine witnesses?

What if all celebrity interviewers could only ask the same set of questions?

What if the presidential election was determined by having our citizens vote for candidates based on their answers to a standardized and validated “Presidential Fitness Inventory”?

No, that would seem ridiculous, most people would say. So why is that the way we have to ask questions in medicine?

Unlike detectives, journalists, lawyers, bureaucrats and politicians, doctors just don’t know how to ask the right questions to figure things out.

The Art of Antibiotic Selection

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.

“If you get worse instead of better on this”, I explained, “you’ll need intravenous antibiotics. So, by Saturday, 48 hours from now, you’ll know if you need to go to the hospital or not.”

Monday morning came. There were two ER reports with accounts of late Friday and Saturday visits with intravenous administration of ceftriaxone, a third generation cephalosporin. There was also a CT scan report with a hedged opinion that there was no frank parotid abscess. The third ER note, from late Sunday night, described how the doctor on duty had selected clindamycin and instructed Jacques to see me Monday morning for a referral to an otolaryngologist.

Monday morning Jacques definitely looked worse than the week before. His cheek was bigger and firmer, although not red. It seemed warm, but he didn’t have a fever. He had trismus; his mouth opened very little.

“Wait right here”, I said. “I’m going to call Dr. Ritz, the ENT specialist over at the hospital.”

I logged on to UpToDate and quickly looked at half a dozen treatment regimens for parotitis, and all were multi-drug intravenous protocols with oral step down alternatives.

“He’s in Danderville today, seeing patients at the Outpatient Clinic and tomorrow he’s in surgery all day”, his nurse said. She agreed to double book Jacques for Wednesday morning.

I called the Danderville clinic and asked to talk to Dr. Ritz.

After reassuring me that he never minded taking calls from a colleague, he listened to my story, and said “you’re old enough to remember Duricef, cefadroxil, right?”

“Sure”, I said. “I haven’t used it for years, though.” I remember we used to think of it as having better tissue penetration than other first generation cephalosporins.

“These are all staph. And Duricef works better than any other oral antibiotic. In thirty seven years, I’ve never had to operate on one of these.”

I thanked him and mentioned that I had scheduled Jacques to see him two days later, just to be safe.

“Oh, I’m happy to see him, but he’ll be fine”, the old otolaryngologist told me.

I related my phone conversation to Jacques and told him about his Wednesday appointment with Dr. Ritz at his office, thirty five miles away.

“If I can make it there. It’s going to storm, you know.”

Jacques’ usual drugstore didn’t have any cefadroxil in stock, but the other pharmacy in town did, so I e-prescribed it there.

“I’ll see you back here if the roads are too bad, but if you spike a fever or feel worse, go back to the hospital”, I concluded our visit.

I had a vague, uneasy feeling about just switching from one cephalosporin to another, but Ritz has a lot of experience and he’s the only ENT within a hundred miles.

Wednesday morning brought eight inches of snow with a thin layer of ice. After a slow commute in four wheel drive, I stomped the snow off my boots inside the clinic back door and hung my thick leather coat on the back of Autumn’s and my office door. I changed to my indoor shoes and booted up my desktop and tablet computers.

“Jacques Johndreau is coming in at nine”, Autumn told me, “he didn’t dare driving down to Dr. Ritz’ office.”

At nine o’clock I knocked on the door to room 2 and entered. Jacques stood up from his chair and greeted me with a handshake.

“I wanted you to confirm”, he said, and paused to show me how far he could open his mouth. “But I am definitely better.”

There was no question. His gland was half the size it had been 48 hours earlier.

“You didn’t need me to tell you that, even. This is very good news, that such an old drug worked better than two newer ones that I and the ER tried, even intravenously. I’ll call Dr. Ritz to let him know just how dramatic the difference is”, I said and patted Jacques on his broad shoulder.

The experience of an almost seventy year old solo doc beat the Boston medical Brahmins this time. I was fortunate to have my senior consultant to back me up.

And as for antibiotics, too, sometimes newer isn’t better.

The Art of Diagnosis

Arthur and Tom both had low testosterone and were prescribed testosterone by their doctors.

In Arthur’s case, it later turned out his low testosterone was just the tip of the iceberg; he was eventually diagnosed and treated by a Boston neurosurgeon for a pituitary tumor.

Tom’s low testosterone, he found out too late to save his life, developed because his pituitary and almost every organ of his body was poisoned by iron due to hemochromatosis.

Early in my career I diagnosed Fran Dennison with hypertension and put her on lisinopril. She asked me to write her a 90-day prescription to save her money. As I always did, I ordered a creatinine and potassium level to be done the following week, and I asked her to come back in two weeks for a followup visit.

Three months later, I saw Fran again. She had never gone for the blood tests I had ordered. Her blood pressure was normal, 130/80, but she looked gravely ill. She was tired and nauseous, complained of leg cramps, had lost weight, and her skin had a peculiar yellow color. Unlike the last time she was in, her arterial pulses at the ankles seemed weak. I put my blood pressure cuff around her right calf and with my fingers on her posterior tibial artery I pumped the cuff up. When the sphygmomanometer reached 120, she winced, but I kept pumping, as the ankle pressure is usually significantly higher than the brachial pressure. In Fran’s case, the ankle systolic pressure was 90 at best. As I listened with my stethoscope on her abdomen I heard a faint bruit over the aorta. I couldn’t remember if I had listened the first time; there was no documentation of it in her chart.

Fran was in kidney failure from having a low blood pressure in the entire lower half of her body due to atherosclerotic narrowing of the aorta above the renal arteries. Before my blood pressure prescription, her leg muscles and kidneys had been adequately supplied with blood. If she had come in for her blood test, there would likely have been signs of early kidney stress, and she would have been spared months of suffering, but we did not track overdue lab results back then.

I stopped Fran’s lisinopril, sent her for some STAT labwork and called the vascular surgery office at Cityside Hospital. They operated on her the next week, and her blood pressure normalized without treatment. I have been more diligent about listening for abdominal bruits and checking blood pressures at the ankles since then. I even got a Doppler soon after that in order to get the most accurate ankle blood pressure readings. I also never prescribe 90 days of lisinopril until the followup visit when I have seen the labwork.

Martin Brandt almost lost his leg one night in a small emergency room on the opposite side of Cityside Hospital. He was in the area visiting his sister when his left leg started hurting. The emergency room doctor ran many tests and gave Martin intravenous morphine, but even that barely controlled the pain. The surgeon on call finally made the diagnosis of an arterial embolus and almost six hours after his leg pain started, Martin had surgery at Downstate Hospital to remove the clot. He followed up with the vascular surgeons at Downstate and seemed to do well.

Four months later, when I saw him for a scheduled visit, I asked him if he was trying to lose weight. He had lost 20 lb. and admitted to feeling run down. He also had a possible hint of jaundice. His lab work confirmed that his bilirubin was elevated and after a CT scan showed dilated bile ducts and a possible pancreatic mass, I referred him to Cityside Gastroenterology for an ERCP. The stenting done during his procedure relieved the bile obstruction, but the biopsy showed pancreatic cancer. It isn’t likely his prognosis would have been different if his tumor had been diagnosed along with his blood clot, but it is possible that it would have. Both arterial and venous blood clots can be paramalignant phenomena, but not every doctor thinks of that possibility.

There is an intense focus on the technical aspects of treatment in today’s healthcare. The art of diagnosis is viewed as a quaint historical vestige in this era of advanced imaging and treatment protocols, and there seems to be less discussion about differential diagnosis than in years past.

We get caught up in the traps of self diagnosis or single dimension “diseases”, like “low T” and irritable bladder. Even such common “diseases” as hypertension are really groups of diseases with similar symptoms but frighteningly different treatments and prognosis.

In today’s fast paced medical office environment, how do we find the time and the mental space to step back and consider what might seem temptingly obvious with fresh and critical eyes – how do we manage to still practice and hone the Art of Diagnosis?

The chronicler of the vignette about Tom, the “low T” patient who died from his hemochromatosis, David A. Shaywitz, M.D., put it as well as anyone I have heard:

“The need to look beyond a patient’s immediate clinical symptoms and to search intensively for deeper meaning has been and must always remain a defining quality of the medical profession.”

The Art of Prognosis

“It appears to me a most excellent thing for the physician to cultivate Prognosis: for by foreseeing and foretelling … the present, the past and the future, he will be more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.”

Hippocrates: “The Book of Prognostics”, 400 B.C.

This time of year, many of my patients make public announcements, at least to me, of their intentions to quit smoking, eat less of certain kinds of food, exercise more and so on. In many cases, this year’s New Year’s resolutions are the same as last year’s.

Physicians sometimes also walk around making promises that are more optimistic than realistic. Sometimes we do it as a way to invoke the placebo effect, for example when we prescribe a new antidepressant for someone who has “failed” on several others. Other times we do it because neither the patient nor the doctor is ready to admit that the disease seems to have the upper hand.

We need to be careful with our promises. Those of us who treat children know that “This won’t hurt a bit” makes for unhappy and mistrusting patients for years to come. Honest predictions like “This will hurt for just a couple of seconds, and then you won’t feel any pain at all” makes young patients more trusting and courageous the next time.

Promising recovery in a case that proves fatal is a far more serious error than to be proven wrong when predicting a patient’s death from their disease. Still, many doctors make vague promises in the name of hope and encouragement.

Little Amy Ruggles’ family doctor and consultant pediatrician more or less promised she would catch up in her development when she, in fact, had Rett syndrome (“Amy Laughs with The Angels”).

William Sykes’ pulmonologist predicted his alpha-1-antitrypsin deficiency would claim his life within 18 months (“Adverse Effects”), but Bill lived another ten years, haunted by his carelessly delivered death sentence.

One physician I know has made an art form of preparing his patients and their families for the worst possible outcome. Andy Spoerri is a brilliant infectious disease specialist, who was one of my teachers in residency. Every time he admitted or consulted on a patient with pneumonia, he called a meeting with the family. In his animated style of speaking as if time was running out, he would explain the mortality rate of pneumonia. Even in the most routine case, Andy would explain that the patient had a one-in-ten chance of dying from their condition. When the patient recovered without complications, the family would praise Andy as a genius and a lifesaver.

I have never been totally comfortable with Andy’s approach. I sometimes struggle with finding the right level of caution, of under-promise and over-delivery, without making the situation seem more serious than it is.

As physicians, we need to be aware of the power of our words in giving hope and encouragement. We need to be judicious and never promise what we cannot deliver or predict what we cannot know. We need to cultivate the skills of clinical observation and prognostication in the tradition of the old masters. And we need to be humble.

Hippocrates also wrote:

“Medicine is of all the Arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgement of them, it is at present far behind all the other arts.”

Those words were penned over 2,000 years ago, and the body of medical knowledge has grown exponentially since then. Are we perhaps so focused on keeping up with new technical information, statistical averages and Kaplan-Meier curves that we sometimes forget the tremendous variability among individual patients? Are we sometimes neglecting the value of our own experiences as clinicians when trying to deliver a prognosis?

(An earlier version of this post was published in January 2011)

The Art of the Referral Letter

One of the journals I skimmed through this weekend had a piece about Meaningful Use, which is Newspeak for what electronic medical records need to do in order to satisfy Federal requirements.

One of the requirements we must satisfy in the next round of Meaningful Use is to “send summary of care records in certain referral and transition of care situations”.

The Archives of Internal Medicine reported a year ago that 70% of primary care physicians claimed to inform specialists of patients’ medical history and the reason for consultation, while only about 35% of specialists reported to be getting this information.

I remember the eloquent referral letters I used to dictate years ago, when the administrative burden of a rural family practitioner was a fraction of what it is now:

        “Dear Mike,

         This is to introduce Mary Calderon, a 53-year-old Gravida 3, Para 2 with a BMI of 30 and a recent onset of postmenopausal bleeding 18 months after a seemingly normal menopause. Her ultrasound shows endometrial thickening….”

 

        “Dear Ned,        

         Thanks for seeing Bella Beaupre, an otherwise healthy 68-yar-old with six months of migratory polyarthralgias and an inconsistent laboratory profile. Clinically, she appears to have new onset of Rheumatoid Arthritis, but I would appreciate your help….”

 

After each consult, there would be an elegantly worded, impeccably typed letter on deliciously thick linen stationery, blue from Mike, cream colored from Ned, running a page or possibly two, signed with flair in ink with each one’s favorite fountain pen.

Just as my referral letter would state whether I wanted my specialist colleague to see the patient for a consultation so I could take it from there or simply take over and manage the patient, the consultation report would succinctly outline their thoughts and proposed treatment plan.

A few years ago, Mike’s group adopted an EMR and the two-page reports on blue linen stationery were replaced by five-page boilerplate reports that all tended to look very similar, to the point of making it hard to see what Mike really thought of the problem I had referred to him. The reports, even though he is a specialist, had smoking status, last pneumonia vaccination and all kinds of “primary care” information. Because Mike never learned to type worth a darn, his thoughts about each case I sent him were often reduced to just a line or two somewhere in the middle of each report.

My own referral letters have also lost some of their flair over the years. Instead of thoroughly summarizing each patient’s past medical history, somewhere along the line I started to focus on the problem for which I was referring the patient. I would have a catch phrase somewhat like “please see enclosed records for additional background information”. It was less satisfying, but it seemed there was never quite enough time to dictate one of those old, delicious doctor-to-doctor notes.

Now, with my own transition to electronic records, I can’t just pick up my handheld recorder and dictate a referral letter anymore. Anything written is the product of my own point-and-click or hunt-and-peck. By necessity, I now type a brief, yet to-the-point paragraph at the end of the office note about why I am requesting a consultation for my patient. It doesn’t say “Dear Mike” or “Dear Ned” anymore, and, just like Mike’s and Ned’s office notes, it has a lot of information that looks the same from patient to patient and visit to visit. But, after all, smoking status as a vital sign and all those other items are necessary to meet our current “Meaningful Use” requirements.

I haven’t asked either one of my colleagues how they feel about my referrals these days.

I, for one, really miss Mike’s thick, blue stationery and his wisely worded reports that always taught me something new or confirmed my own thoughts, signed with that broad nib fountain pen of his.

That was Meaningful Use, too.


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