A Country Doctor Writes:

We are used to seeing time as a forward movement when it comes to infectious diseases. This has been due to improved socioeconomics and public health, including vaccinations. As of this year with vaccine skeptics leading our public health system, measles is back as a threat we had started to not even worry about. There are now also early indications that tuberculosis is becoming more common again and it is widely anticipated that HIV will become more common in this country and definitely in other countries that had relied on US aid for treatment and prevention. With the newly declared return to fossil fuels, away from clean energy initiatives, many worry that chronic respiratory illnesses will be more common and more severe.

I don’t think we know yet if our chronic lifestyle diseases like obesity, diabetes and heart disease will increase, decrease or stay the same. But it is certainly bewildering to see us step back in time when it comes to infectious diseases.

If large numbers of Americans lose their health insurance, their food stamps or even their jobs, more bad things will happen to the state of health in this country. For example, how can people eat healthier on a smaller food budget?

With cutbacks and eliminations by Executive Order of the institutions that monitor disease trends and guide interventions, will we even know what’s going on? Will we have competing/alternate views of the reality we live in? That trend started before our regime change. Did the mRNA vaccines ultimately help lessen the severity and mortality of Covid, or would the virus have mutated in a benign direction anyway? I, for one, believe they helped, but that’s not what everyone believes.

And whatever one thinks of abortion, gender identity and the other LGBTQ societal trends that have evolved over many years, I find it almost mind blowing that the clock has been turned back to such a degree in so little time, not by consensus but by small voter margins and politically appointed Supreme Court Judges in today’s extremely polarized political climate.

As a physician, I have always avoided talking politics in my patient encounters, but that is becoming harder and more and more ethically problematic right now.

Happy New Year 2026 – or is it?

Once a voracious reader, I now find myself listening to Blinkist or audiobooks

Joy is a Skill that We Can Develop by Neuroplasticity

-Max Lucado

“We have neuroplasticity on our side. In other words, your brain can rewire itself at any age, creating new pathways that override old patterns. When you deliberately interrupt a negative thought spiral and choose a different mental direction, you’re not just changing your mood – you’re physically reshaping your brain, one thought at a time.”

From the ancients to Jung to modern science, we understand that our thoughts can change how our brains work. 

Maybe a thought to consider as a possible New Year’s resolution?

There’s an incredible confusion in some medical practices about which outgoing orders are referrals and which are not.

According to healthcare.gov, a referral is:

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

As a primary care physician, I can refer a patient to an individual specialist, to a specialty practice without naming the doctor, or to the hospital – often to the emergency room because immediate testing or treatment is needed, sometimes directly to the hosptalist service for admission.

If I order lab work or imaging, those are not referrals, they are orders. The results come back to me and I have to decide what to do with them. Even if a radiologist who interprets an X-ray makes a diagnosis, it is still up to me to make a medical decision as to what to do for my patient. Neither lab or X-ray orders are technically referrals.

Why is this distinction important? Let me tell you a story.

John McCall is a 76-year old man who just had a triple bypass. Almost a year ago I saw him for exertional chest pain that he had had for over a year and it wasn’t getting worse. I put in an order for a nuclear stress test in his electronic chart. It seemed to take an awful long time to get that test results back, but that’s not entirely unusual in a shortage area like where I practice. Resources are few and weights can be long. I wasn’t all that worried because his angina seemed stable, I just wanted to see, roughly, what the extent of his coronary disease was.

I was surprised when I got a fax from the cardiology office. It was a consultation note from a part-time cardiologist in the two doctor office. The conclusion was that Mr. McCall needed a nuclear stress test.

I scratched my head and looked back in his chart. This is what happened. In some hospitals, the X-ray department schedules nuclear stress test because it’s an imaging procedure. In the hospital, John wanted to have the test at, the cardiology office schedules such tests.

In our medical record, we have the option to initiate a referral or the option to initiate an imaging order. The referral template automatically includes patient demographics like address and insurance information. An imaging order does not automatically include that. The referral order also has a text box that states referral for treatment, including consultation visit. The imaging order template has no such phrasing in it. Somebody in my office sent my imaging order to the cardiology department using the template for referral rather than what in my record is called just “provider letter”.

So somebody in the cardiology office saw, presumably, that I wanted a nuclear stress test, but the comment at the bottom of the page about treatment and consultation made them put my patient on the waiting list to see the understaffed cardiology practice for a consultation.

We lost months due to this glitch. Fortunately, his angina remained stable and he had a follow up with the cardiologist after the test was done. It was not considered a high risk scan. Medication was tried, but didn’t make much difference so he ultimately ended up with a locally done catheterization and then referral to cardiovascular surgery in the big city, where he ended up with an uneventful bypass operation.

This could have gone worse, but it is a lesson that referral is the accepted word for requesting a medical opinion, and I feel strongly that it should not be used for a test order where the ordering physician will deal with the results.

Today I had reason to review a medical chart of somebody I had never met before. They hadn’t been seen for a while. The most recent notation in the medical record was a fax from Cityside hospital’s urology practice. The fax, dated in October, stated that our clinic’s referral of this patient was rejected due to lack of information.

I had to search far back in the medical record for the referral. It was sent in January of this year, almost a year ago. The virtual fax contained about 25 pages of some brief notes and messages and a lot of laboratory reports.

Before opening that fax, I went into the lab section of the medical chart and there was a mildly elevated PSA result from January. This made me think that the reason for the referral was the elevated PSA, possibly indicating a significant prostate problem.

Quickly going through the 25 pages in that fax I did not see the PSA level. And the fax did not contain a headline to indicate the purpose of the referral.

Two things are striking about this incident. One is the lack of brevity in the referral our office sent out. The other is the lack of urgency on the part of the urology office in getting back to us questioning what the purpose of the referral was.

As far as our referral, I think it’s crucial to say what the main problem or question is. The other important thing is not to send too much information.. In our state just about every hospital laboratory uploads their results to a statewide database where any doctor can look up those results. This makes faxing lab test and x-rays almost unnecessary. Not all practices upload their office notes, though, so we have to be cognizant of that.

Everybody is pressured in today’s healthcare environment. There’s so much to do and so little time. Everywhere in our society, the attention span is dropping. I found it mind blowing that the urology office took nine or 10 months to raise the issue of what the referral was for, but I’m not completely surprised. They say that you have eight seconds to make a first impression when you meet somebody and in writing, everybody’s looking for a catchy headline. I mean, who would read a novel or even a short story with no title?

I think brevity in medical communications is a virtue. American healthcare today has all kinds of documentation requirements that don’t necessarily speed up the handling of medical issues. Unfortunately, the referral letter and the specialist response have almost gone by the wayside. They used to be valuable exchanges between colleagues, dictated, printed on fancy stationery and signed in ink. EMR’s don’t always accommodate for that type of exchange.

Let me go back and look at what I’ve written about referral letters before…

The Art of the Referral Letter

https://acdw.substack.com/p/remembering-the-specialist-referral

Somebody asked me today what Thanksgiving is like in Sweden and I answered “there is no Thanksgiving because we didn’t have the pilgrims or the Native Americans”.

I was wrong. There is a Thanksgiving Sunday in the Lutheran Swedish state church (shows you how much I attended when I was living there). It takes place in early October and is a celebration of the harvest. In the old days farmers would bring wheat, potatoes, carrots, rutabagas, apples, and other crops to share with the less fortunate in their congregation or village.

Since moving to America, I have more and more embraced Thanksgiving. This year, I even have two Thanksgiving celebrations, one with my lady friend and her large extended family in Van Buren on Thanksgiving Day and one in Bangor on Saturday, when we will join my children and grandchildren for a belated Thanksgiving because my daughter works on Thursday.

I just reread some Thanksgiving reflections that I originally published in 2016 and 2017. I’m linking to them below. Other than the chronology of how long I’ve been here and so on they still describe pretty well how I feel about my life and my choice of living in this country and doing the work I’m doing.

A Thanksgiving Reflection

Another Thanksgiving Reflection