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Friday’s Lessons

My colleague, Dr. L.T. Kim, was off this week and I covered for him.

Friday afternoon I dealt with two of his patients and learned, or relearned, two important lessons.

I saw a man with thoracolumbar back pain. He had fallen off a ladder a few years earlier and suffered from recurring bouts of back pain, sometimes with tingling in both legs. He had been to the emergency room after a particularly bad episode. Dr. Kim saw him in followup and ordered an MRI of his thoracic spine.

I saw him to review the results. The MRI showed more or less garden variety degenerative changes, but nothing that would explain all his symptoms.

“I’m feeling much better, but this very sore spot is still here”, he said and asked if he could point to the corresponding place on my back.

I asked him to remove his shirt and palpated my way down his spine.

“Right there. You got it”, he said.

I marked the spot with an X, using my green ink rollerball pen, sat down at the computer and ordered PA and lateral lumbar spine films. My tech taped a metallic marker over my X and a few minutes later I saw on the screen that his pain centered on his second lumbar vertebra, just below where his expensive MRI had ended.

A call to Cityside hospital’s MRI department verified that they couldn’t just go back and look a little lower on their images, which only included a small fraction of L2. Our patient needed a whole new, lumbar, MRI.

In case I had any temptation to feel a little smug that I had realized something Dr. Kim hadn’t, I learned another lesson at 4:55 pm.

“I’ve got a sodium of 123 on one of Dr. Kim’s patients”, our lab manager said as she entered my office with a lab printout in her hand. “If he saw this he’d probably have the patient go to the ER by ambulance”, she continued.

“Well I don’t usually worry quite that much about sodium levels”, I said. “I’ll take care of it.”

I saw that this older woman had been discharged from the hospital a week earlier and she did run low sodiums there, about 130.

Dr. Kim is an internist by training, and he spent most of his residency years in a tertiary acute care hospital, where only the sickest patients went. In that setting, even small changes in lab values could be harbingers of deterioration, disaster and death. I spent most of my training in small town hospitals and outpatient clinics, where most people got better more or less on their own, and where small laboratory abnormalities often didn’t matter much at all.

I dialed the number.

“Hello, is this Mrs. Weld? This is Dr. D. calling from the clinic with your lab results. Dr. Kim is away this week.

“No, this is her daughter.”

“Her sodium is low so I’m calling to see how she is doing.”

There were several voices in the background.

“Guys, I’ve got the doctor on the phone”, she said and the voices went silent. She continued: “The ambulance is here, I’ll put you on speakerphone so you can talk with them.”

“Hey, Doc, what’s up”, the familiar voice of one of our local EMTs greeted me.

“Mrs. Weld has a sodium of 123, it was 130 a week ago when she left the hospital”, I said.

“What are the symptoms of that?”

“Weakness, lethargy, confusion…” I started.

“That would be it, Doc.”

“So she needs to go back to the hospital. I’ll call the ER”, I said.

“Thanks a lot for calling, Doc. Good timing!”

Indeed. And I thought this would turn out to be just an insignificant laboratory abnormality.

Not On Call

“I am not on call”, Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know”, I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54 year old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see an optometrist for glasses. I’ve called every hospital within 50 miles and there is no ophthalmologist on call over the long weekend. You helped me once before with a case of dendritic keratitis when you were on call.”

I also remembered Memorial Day weekend last year, I was in the same situation during my Saturday clinic. A young boy, whose mother had just joined the board of our health center, came in with eye irritation. He had a small rust ring very close to the center of his cornea. I had dug out plenty of them, with a special spatula or even with the tip of an 18 gauge needle, but this was a child, who might not have beeven fully cooperative, and the location was critical for his future near vision.

Cityside Hospital had no ophthalmologist on call for that long weekend either, and all my calls to ophthalmologists in the surrounding area were fruitless. He got in to see an eye doctor the Wednesday after the Monday holiday and it turned out that he actually also had a small metallic corneal foreign body. Everything turned out okay, but the wait was uncomfortable and at least a little risky.

A corneal rust ring, even a foreign body, can usually wait a few days, but if this woman had what I thought, acute angle closure glaucoma, I wouldn’t want her to wait that long to see an eye doctor.

“I think she’s got acute glaucoma”, I said.

He was silent. I continued:

“She’s got mixed injection, no foreign body, no fluorescein uptake and I can see her left fundus clearly but I can’t get a focus on her right fundus no matter what lens I dial in on the ophthalmoscope.”

He was silent again for what seemed a very long time. Then he said:

“I live an hour away, but I happen to be in town. If you have her walk out your door right now, I’ll meet her at my office in, what, 25 minutes?”

“She’ll be there. Thank you so much.”

I haven’t heard yet what he found, and I haven’t wanted to bug him, but I am anxious to hear what the final diagnosis was. I do know that an urgent slit lamp exam was necessary.

One postscript:

When I sent my emergency eye patient off with her office note and insurance information to see Dr. Stoltz, her husband said:

“You’ve done well by us. I came in and saw you once with a cauda equina syndrome.”

I didn’t remember him, but he must have had a critical enough pressure on his lower spinal nerves to also have warranted an urgent referral to a specialist.

Disease strikes at inopportune times.

Diagnoses Right Under My Nose

When I read a case report in a journal or whenever a patient comes in to see me about a new symptom, all my senses are tuned in and I know there is a diagnosis to be made.

But on regular clinic days with “routine” follow ups, I find myself not being as tuned in as I would like to be. I know my patients well; we are all growing older together. They change gradually over the years, just as I do. A couple of times last year I have found myself surprised and ashamed that someone else made a new diagnosis in a patient I was seeing on a regular basis.

Stella Sanders world had shrunk since her boisterous husband died a couple of years ago. She had never learned to drive, so without Roy to take her places, she had become virtually housebound. Her spinal stenosis had gone from moderate to severe, and she couldn’t take care of her home in the way she had always prided herself in. She admitted she was depressed, but didn’t want to take an antidepressant and wouldn’t hear of seeing a counselor. Her whole demeanor had changed. She never smiled, and she was less animated in all her facial expressions and body movements.

It was her neurosurgeon who saw it. He had nothing to offer for her spinal stenosis, but he suggested she talk to me about the possibility of her having Parkinson’s Disease.

I saw her again the other day, and on Sinemet she looks almost like her old self again.

Fred Nystrom’s health had been declining for years, and after going through both an operation for a fractured hip and emergency bowel surgery for perforated diverticulitis last year, he never recovered his old level of functioning. He came back from rehab the second time using a walker. Two months later he was still using it. His affect was flat and he couldn’t keep track of his medications the way he had a year earlier. His enlarged prostate seemed to bother him more and more, and he moved too slowly to always make it to the bathroom.

It was my partner, Dr. Wilford Brown, who made the observation that Fred had dementia, gait disturbance and urinary incontinence – the classic triad of normal pressure hydrocephalus. Fred is going in to have a shunt placed to drain his ventricles at the end of this month.

Our challenge is, in the hustle and bustle of everyday practice, to look beyond the issue at hand often enough to “see the big picture” in each patient, and at the same time keep a constant vigil for small changes that could mean a new disease is evolving.

Doctors Should Be Paid Like Athletes

Think about it, athletes aren’t the ones who document their performance. It’s other people that keep the score. That’s a whole science in itself. People talk for hours after the game or tournament is over about how each athlete did this or that in whatever way they did it and the numbers are in many cases captured by extremely sophisticated electronic equipment.

Physicians work hard to diagnose and treat their patients, and on top of that, we have to do all the work of documenting what we did and how we did it. It isn’t enough that we make a correct diagnosis or provide an incredibly effective treatment. We have to code and document so that accountants, lawyers and the general public can understand what we did.

Our medical charts are now instruments for billing and, sadly, less and less of a tool for us. I suppose it is a bit like if a baseball coach in America had to speak to his/her team so that any Swedes or Martians accidentally present could also understand what was going on. (Baseball is not big in Sweden, or on Mars.)

Now, you might think doctors aren’t worth the millions we pay our professional athletes. I’m not going to argue with you on that one, but I will point out that the medical spending controlled by your average family doctor, through direct care, tests and consultations ordered, emergency room visits and hospitalizations – per capita spending multiplied by the number of patients cared for – is in the ten million dollar ballpark, to borrow a term from America’s favorite sport.

My point is, why do we have to input the data with our own, in my case, two typing fingers, when professional sports doesn’t make athletes keep their own score? The technology is there in other arenas (sorry, the sports terminology keeps popping up), so why not in ours?

Everything Goes Through Me

On an ordinary day last month, I saw patients for eight and a half hours. I addressed a dozen computer messages, took four or five calls from outside providers and held innumerable curbside conversations with medical assistants, case managers and colleagues.

I didn’t get to any of the 100+ lab results or 50+ documents in my electronic inboxes. Consequently, the care for several dozen of my patients didn’t move forward.

Many of them didn’t get the news that their blood tests, mammograms or CT scans were normal; some never got scheduled for follow up visits to discuss options based on their mildly abnormal studies; a few didn’t get their highly abnormal tests acted on. Others didn’t get their annual eye exams logged in their diabetic flow sheet.

This happened because I am the official bottleneck by virtue of the “work flow” dictated by our electronic medical record.

My last office note might say “Follow up to review results”, but if I am late getting through my inbox, the clerical task of scheduling that appointment doesn’t happen.

It’s a little bit like having me answer our clinic’s telephone, or, a presumptuous analogy, the President opening the Government’s mail and then forwarding each item to the proper cabinet secretary.

Because every piece of data in a medical office has an ordering provider or a provider of record, it seemed like an EMR no-brainer to send everything to that person. But I think someone forgot that the current primary care business model is based on each medical provider cranking out as many visits per day as is humanly possible. That makes desk work a money losing activity.

With all the talk about having everyone in the medical office work to the top of their license, I think it is high time we turn the virtual mail sorting work flow on its head:

Have non-providers check incoming reports and lab test against existing treatment plans with cut-offs for when to interrupt providers, and give the provides more time to provide care and make medical judgements. A lot of information comes in to the primary care office just so we can maintain a record of patients’ care. It isn’t necessarily imperative to have the physician read a seven page specialist report to find one relevant medication change that needs to be updated in a patient’s record. That is what we used to call secretarial work in the old days, but that word and concept, dear Health Care Industry Comrades, seems to be taboo these days.

So, back to my reality: Last night, after cleaning the horse stalls, I spent almost two hours going through my backlog of reports. At least I was able to do my work from home, in the company of my horses, but I keep feeling that on a daily basis I am making up for a system that isn’t all that well designed.

The Illusion of “Other People’s Money”

The problem with healthcare, and drug prices, in America isn’t that we spend too much money. The real problem is that we believe we are spending “other people’s money”.

Yes, I was raised in Sweden, but no, I’m not a Socialist. But the irony is that “free” healthcare there is more clearly understood to be directly financed by local(!) taxes that can go up if people in that region consume more healthcare. Here, nobody really knows what anything healthcare related actually costs, or who pays how much, so how can we really care about the cost of healthcare?

Here, most health insurance is financed by employers, and I don’t believe the average American worker is lying awake at night worrying that his family’s medical bills will eat into the corporate profits of his employer. And even if American workers bear some of the costs of their health insurance, the relationship between how much healthcare they consume and how much their portion of the insurance premium will go up is less than obvious, depending on who else is insured in the same risk pool as each particular worker’s employer sponsored insurance.

The Swedes have, in spite of their minimal churchgoing, a set of ethics that relates their personal choices to the impact they have on society as a whole. They recycle batteries instead of throwing them away, they worry about air pollution – so much that it is illegal to idle your car for more than 60 seconds, for example when the bridge over the canal in my home town opens to let a tall ship through. My former countrymen also care deeply about how waste in the healthcare system can affect the availability of healthcare for vulnerable people.

Another thing they are more sensitive about than we are over here is corporate greed. The examples on this side of the Atlantic are so many, and occur so frequently that we soon forget each individual case. What we do retain is the regrettable sense that healthcare is a dirty business where someone is always taking advantage of someone; providers cheat Medicare, insurers cheat patients, drug companies cheat them all.

What we need in this country is a moral wake up call, whether that comes as a crisis or a disruptive innovation. It is obvious that Government regulation and oversight has done relatively little to reduce the “Wild West” behavior and mentality of the big players in our “industry”.

The first thing we need to do is scrap the concept of health insurance, because insurance is when something expensive but unusual and infrequent is paid from a pool of money that a lot more people pay into than withdraw from. In America today, everybody draws from that pool of money, even for things that are completely predictable, like having a baby or even an annual physical (except if you have Medicare, and then you get a Wellness Visit, but that’s another story). That means every single transaction of healthcare in this country becomes a profit center for one or more types of middleman, who most of the time adds little value but draws handsome revenue from what they do.

If we are trying to cover everybody for everything, let’s call it what it is, Socialized medicine. But are we ready, today, for a society where we all stop and consider the common good before we ask for that MRI, “just to know what’s going on”, or where drug prices are negotiated between a “single payer” like CMS or each State Health Department and the drug companies?
I believe the citizens of my adopted homeland prefer to have more freedom of choice than a Socialist system usually offers, and I believe that by having both the ability to choose and the responsibility to pay for services, we can make the healthcare value equation come out more even.

And, I’m sorry, but if we reign in the excesses of insurers and drug companies, American patients may act more responsibly, but as long as the gauging, fraud and abuse continue to be rampant in the industry, there will be no loyalty between patients and “the system”.

Then, our only hope will be a post-apocalyptic Direct Primary Caree model, which is just as American as the corporate model. Come to think of it, maybe even more so…

Don’t Ask Me to Work for the Other Side

As a physician with a strong sense of calling, I always see myself working for each patient, regardless of who pays the bill. Following in the footsteps of role models like Hippocrates and Osler, how could I do anything else?

Ted Ross has been my patient for decades. He can’t seem to lose weight.

John Jackson has admitted he doesn’t know how long he can keep doing the kind of work that has supported his family until now.

Ted is a long distance truck driver. He needs a DOT physical. Because of the new requirements, he will probably need a sleep study to rule out sleep apnea. If he fails, he could lose his job, because we all want to feel safe on our highways.

John came in with back pain the other day. As I filled out the Workers Comp M-1 form, he sighed “this may be it for me”.

John told me his back started hurting when he lifted a washing machine at work. As long as his employer’s Workers Comp carrier doesn’t challenge the claim, he’s covered for medical costs, rehabilitation and disability income, possibly even for life. If it had happened at home, on his own time, he would not be entitled to anywhere near the same benefits.

Medicine is a very personal business. A trusted provider hears more than a stranger and his or her words have more impact. Our patients assume we are there to help them. But sometimes we are put in a position of working for someone else, against our own patients.

In Ted’s case, I won’t be the one to tell him that his job is on the line because of his obesity. When the new requirements and certifications for performing physicals for the Department of Transportation went into effect, I simply didn’t pursue them.

In John’s case, as the treating physician, I have to file regular reports with his employer’s insurance company, and every test or referral I want to make has to be approved by them. If I keep him out of work longer than they expect or prescribe more pain medication than the average situation requires, I get a call from an insurance company nurse whose job it is to bring my treatment in line with their expectations.

It is impossible to overlook the fact that his employers Comp carrier is trying to direct John’s care; they are the ones who pay me for each one of his visits.

If other life circumstances come into being while I am treating him for his back injury, I have to be very careful not to spend too much time talking about them, and I certainly can’t put any of it in his record, since every Comp visit goes to the insurance company for review. I have to constantly remind patients that a Comp visit is a legal document, to be used in what amounts to a case of litigation.

If I could help it, I wouldn’t treat Workers Compensation cases for the same reason I don’t do DOT physicals: I never want to represent an authority or institution that can be seen as the opponent of patients I need to have a therapeutic relationship with.

If John’s Comp carrier were to claim that since he went to the Cityside Hospital emergency room with low back pain after a minor car accident ten years ago, he had a preexisting back problem, his medical expenses could bankrupt him. He has a high deductible health insurance. If he can’t go back to work, he will have 26 weeks of reduced-pay short term disability benefits. After that, he’d have to apply for Social Security Disability, which could take several years.

If Ted loses his DOT certificate, how can I be effective as his personal physician with my signature on the document that cost him his career? And if he were to commit suicide, as some middle aged men who lose their jobs do, could I counsel and care for his wife and daughter?

I often think about my native Sweden in cases like these. I saw many things that frustrated me when I worked there after graduating from medical school, but they didn’t have one level of health and disability benefits for injured workers and little or no help for people who got hurt on their own time. That is a pretty arbitrary and inhumane way of stratifying health care.

If you’re hurt, you’re hurt, regardless of whose fault it is. (I’ll tell you about Sweden’s no-fault medical malpractice payments some other time.) And if you seek help from a doctor, you expect the doctor to be working with your best interest in mind. And if the society you live in doesn’t take good care of people who are sick or injured, you may have trouble accepting that your doctor is putting the good of “society” or “the system” before your most urgent needs to put food on your family’s table.

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