A Country Doctor Writes:

This weeks New England Journal of Medicine has an article titled Physical examination for asymptomatic adults.

It describes a clinical scenario where a 60-year-old male presents for a routine visit with normal vital signs, up-to-date screening history and no concerns or symptoms. I think we all know that the evidence favoring in depth routine physical exams in people with a negative review of symptoms is by now fairly nonexistent. But the article includes opinions from two different doctors about the overall benefit, including which approach Fosters the best Doctor, patient relationship.

Allan Goroll, MD writes in favor of doing an exam. He summarizes:

Time is in short supply in modern clinical practice, particularly in primary care. Reducing low-value administrative tasks to free up time for a 10-minute thoughtfully directed physical examination that generates trust, addresses concerns, and picks up potentially important findings warrants serious consideration. The payoff in terms of relationship building, patient satisfaction, and risk reduction represents an excellent investment in time.

My eminent fellow substacker, Adam Cifu, MD, writes in favor of not doing an exam. He says

Forsaking the routine physical examination will be difficult because it has become a standard part of an annual visit and is expected by patients. There is, however, precedence for abandoning common practices when their clinical value is deemed to be marginal. Routine prostate examinations, pelvic examinations when Papanicolaou (Pap) smears are not warranted, and testicular examinations have been abandoned. We should focus on providing patient care that is necessary, evidence-based, and value-based, instead of care that is expected but potentially harmful.

I am a stickler for not doing a physical exam during a Medicare Annual Wellness Visit, because it was never meant to include an exam. If a patient raises concerns that require attention during that visit, which normally is free, they will have a bill for what amounts to an additional service.

During routine visits for a medical problem or with a new patient I have to confess I do at least a limited exam. My personal belief and opinion, as well as experience, is that patients more or less expect it and I do believe it helps establish rapport. It also adds to the perceived value of the visit. The literature now less and less supports doing much of a physical exam during routine visits, but the literature also has established very clearly that the patient’s trust in the physician greatly impacts the success of any prescribed treatment.

Here are a couple of pieces I have published before about doing an exam on your patient, in large part to establish the clinical scenario and the trust it can build. I have also included a piece about a life-saving auscultation of the carotid arteries on a high risk person.

How Much Should Physicians Touch?

A Quick Listen

On my birthday six years ago I had this piece published on a now defunct medical blog and I put a teaser here with a link to that site but never the whole thing. I think it deserves a place here because I really believe that there is a spectrum between health and disease. It’s seldom black and white, or binary as people say these days.

The other day I saw a new patient who used to be on Lamictal, a mood stabilizer. The young man explained that he had gone through a difficult time in his life a few years ago and his primary care doctor put him on Prozac, which, as he put it “hijacked” his brain and made him “ugly, hyper and careless”. The man immediately stopped the Prozac and his doctor prescribed Lamictal, which he stayed with for about a year.

He decided to stop the new medication, because he reasoned that he didn’t have any psychiatric issues. It was just a side effect of the Prozac, which he in retrospect probable hadn’t needed at all.

Since then, he admitted, he had felt sad or unsettled in the spring and fall, but it always passed and he didn’t think his wife or anybody else noticed his seasonal mood changes.

“So, did anybody actually use the word “bipolar” in talking about what you went through?” I asked.

He winced and almost seemed teary eyed. “Yeah, but I don’t think that’s right. How can you put a label on somebody that will follow them for the rest of their life because of what their brain did when, basically and literally, they were on drugs?”

I nodded.

“Who knows how many people might react the same way if you give them Prozac”, he continued.

“I think labels can hurt sometimes, but they can also be a way of understanding how our minds and bodies work”, I began. “I don’t believe diagnoses are as cut in stone as some people like to think.”

He looked quizzical as I continued:

“Take diabetes – this country and Canada have slightly different cutoffs for what a normal blood sugar is. Or blood pressure – every few years the experts pick a different number for what’s good enough and what’s ideal. I believe most things we call diseases are points at the extremes of a spectrum that we all fall somewhere on.”

Now he was the one nodding.

“Take mood”, I continued. “At one end of the mood spectrum there is depression and at the other there is what we call mania. Sometimes that looks like exaggerated happiness and confidence, but sometimes it is more like irritability and agitation. We can all experience any one of those moods, but usually we are somewhere in the middle. So, people are making up disease definitions depending on how far and for how long we deviate from the middle. But if we never move an inch from neutral, that’s not necessarily being healthy – I think of that as definitely abnormal.”

“I see what you mean”, he nodded again.

“As a clinician, I think of labels as a type of shorthand or mental image that I keep in mind when I approach a problem. They help me choose treatments and they help me explain things. But I tend to be slow in sticking labels on patients or in their medical records. I read a book once called ‘Shadow Syndromes’ that makes the point that looking at the extremes of whatever spectrum we are on helps us understand ourselves and can be very empowering.”

“So, Doc, do you think I’m bipolar?” He leaned forward.

“You have the tendencies, yes, but a condition isn’t a problem until someone sees it as a problem. If neither you nor the people around you see your mood variability, not to use the stronger word ‘mood swings’ as a problem, then fine. But I, knowing what you’ve told me about how your brain works, would be a fool to prescribe Zoloft or Lexapro if you ever came to me feeling terribly depressed. I would then think of you as somewhere on the bipolar spectrum, needing a slightly different treatment approach if we wanted to lift your mood.”

“A mood stabilizer, like Lamictal”, I finsished, “can be like an insurance policy against ever having a manic episode in the future, and we usually recommend long term treatment if a person has had an episode out of the blue. But I’m not so sure it’s necessary if the episode was triggered by Prozac or any other antidepressant. I’m sure there are lots of opinions about that, but that’s what I think, especially since your episode was not severe from what you’ve told me.”

On my drive home that afternoon, I thought of the spectra I may have moved along during my lifetime. I remember my mother commenting on how I had turned into such a slob; “When you were little you were so neat, you used to line everybody’s shoes up in the entryway.”

That’s the OCD spectrum, and I guess I narrowly escaped that diagnosis…

Bag people, we’ve all seen them, pushing grocery store carts with what seems to be all their earthly belongings. That’s what I think of when I read some medical charts. Back when we were dictating office notes to be transcribed, I often read initial paragraphs summarizing a patient’s entire past history with smatterings of relevant information like most recent colonoscopy if they were in the office for constitutional or digestive or related conditions. That can make a certain amount of sense but often there are too many items quoted in that paragraph for readers to follow along and to grasp what the whole visit was about.

With electronic medical records , particularly written in the APSO format (which I detest, because it’s like putting the punch line before the joke, or revealing the murderer before telling the mystery plot. A better format, in my humble but well grounded opinion, is the aSOAP note.) In hospital APSO notes, I sometimes get the main diagnosis followed by all the other diagnoses the person ever had. Look at this example, for instance:

When I started practicing, clinical notes were brief and to the point. I have mused before about pediatricians with hand written sick visit notes that might read LOM. AMOX (left otitis media, amoxicillin). Before billing codes and malpractice concerns dominated our clinic days, that was all we needed. A little more information, I’ll admit, can be useful, particularly what dose you prescribed on your hand written script that wasn’t copied into the chart.

One interesting observation I have made is that emergency doctors at some hospitals create extremely malpractice defense focused notes with detailed differential diagnoses and why they appeared unlikely. And also the opposite, when somebody comes back from one of the top Boston hospitals, their discharge summary is impressively succinct.

To me the contrast between bag people and globetrotters is worth considering in our charting practices: Too much baggage bogs us down but just enough to fit in a carry-on makes us quicker and more nimble, and can still carry us through most situations we’ll encounter.

A BBC PASSWORD STORY

In all the years that I have been the primary physician for children and young families, especially as children start to become gradually more independent, I have promoted the idea of a family password.

A typical scenario would be that a teenager is with friends and starts to feel uncomfortable about what’s going on. In a telephone call to a parent, the teen would say a secret phrase like did you hear from uncle Sam? This would mean “I don’t feel comfortable with what’s going on, please come and get me“.

I just read an article on the BBC website saying that a secret password or pass phrase could be a weapon against scamming with AI voices.

The article suggests that if we get a call from what sounds like a family member saying they’re in trouble and need money or, worse, want us to talk to their kidnapper, we need to do something very quickly to verify their identity. Asking for the family password can quickly expose an AI imitation of our loved one’s voice.

https://www.bbc.com/future/article/20260804-why-your-family-needs-a-secret-codeword

Lately, in my social media scrolling, I’ve seen a lot of posts about how horses, who are animals of prey, are exquisitely sensitive to our energy and seem to be able to read our minds. There’s also more and more talk about how they synchronize our heart rates when we are together or even nearby. All this reminds me of something I wrote in 2014. I’m linking to it below.

“I Also Tame Wild Horses”