Somebody Stole My Inhaler Idea. Finally!

Years ago, I remember telling people I had this brilliant idea to improve asthma control. Slip some steroid into the rescue inhaler, so that the more often patients use it, the more steroid they inhale. This month, decades later the New England Journal of Medicine has an article about just this idea. No surprise, it works. This type of combination reduces risk for future severe attacks without increasing the risk for adverse effects.

I am not at all upset that somebody else finally had the same idea; I’m just a country doctor, not a researcher or statistician. I’m just happy that asthmatics who resist getting one more inhaler can have a sort of autotitration in a single prescription device.

And if anybody out there is looking for more ideas, I have often wondered why there isn’t a combination condiment for hot dogs like mutchup – half mustard and half ketchup. Go ahead and create it, I won’t sue for a share of the profits!

There Are Too Many Back Seat Drivers in Medicine Today

“Your patient may benefit from X”, “Your patient may be due for Y”, “Your patient may be non-compliant with taking their Z”.

“Care Considerations” is one of the many names for a phenomenon that seems to be exploding. Insurance companies are more and more acting like back seat drivers, hoping that such communications will improve “quality”, “compliance or “conformity” – whatever you want to call it. They are trying to tell us what to do.

Most of the time, there is some sort of admission that we are the doctors and that we may know something about our patient that they don’t. But the underlying idea is that we are not doing our jobs. Ironically, the more reminders we get, the more distracted and ineffective we might actually become.

There are two problems with what these middlemen are doing: They spew out generic data that may or may not be relevant for our patient’s unique circumstances and they try to steal our attention away from the patient’s we are actually scheduled to see today.

These back seat drivers are essentially babbling about which way to turn on a different road trip from where we are driving in the moment and saying things like “you might be out of gas” because they must have been napping when we stopped to fill up a little while ago – trying to be helpful, but ultimately doing the opposite.

This is because today’s primary care doctors are essentially working in synchronous mode, scheduled to see one patient at a time. The dirty little secret in primary care is that anything to do with patients who are not present in our clinics, physically or in a telemedicine appointment, happens “between patients” even though there are no breaks between patient appointments in our schedules. Not infrequently such tasks are done after hours, during what is quaintly called “pajama time”. (Can you spell burnout?)

Clinic driven messages are generally fairly specific and appear in our electronic records linked to each patient’s “chart”: If I get a question if a patient could increase their dose or get a refill or get a referral to go back to their specialist, all their information is there, linked to the request.

But the “Care Considerations”, arrive on paper, sometimes even in a format with several patients’ information on the same page. In order to consider any of them, we have to locate the patient’s electronic file and spend more or less time searching for their relevant information. This is time consuming and basically interrupts the workday of busy primary care doctors whose working conditions make no allowance for asynchronous communication or considerations.

In a different world, if clinics become reimbursed for managing patients and populations, maybe we could look at these kinds of letters, but in today’s reality they are essentially junk mail, trying to interrupt our clinic flow.

Most of us just toss them in our shred basket. Can you blame us?

Between Patients: The Myth of Multitasking

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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