A Country Doctor Writes:

It’s been three years. Three years of sanity, three years of road trips for house calls, instantly learning more about each patient than you could ever learn in an office visit, making friends with their dogs and having all their cats climb into my leather house call bag, three years of virtual visits from home with the dogs sleeping at my feet. But it is all coming to an end very soon. Read on and I’ll tell you…

The nitty gritty details are for my paid Substack subscribers. I need to figure out how to level the reader playing field for my WordPress subscribers.

Here’s some more from behind the Substack paywall, telling more of the story:

A couple of weeks ago, I found out that our practice lost its contract with our major (insurance) payer. Without them, we couldn’t possibly continue operating in Maine. So by the end of the year, our practice will cease to exist. My hours are, as of Monday, reduced from full time to 0.8 full time equivalents and I am slotted to go down to 0.6 FTE by November 1.

In the coming days, my quit date with Galileo and start date with two of Northern Light’s primary care offices in Caribou and Fort Fairfield will be nailed down. Each one is about 10 minutes from my house, so my driving will go from one extreme to another. My home territory with Galileo, Aroostook County, is as big as Connecticut and Rhode Island combined. And since last November I have also been serving, mostly remotely, the Bangor market which stretches 80 miles west, south and east of our Bangor office.

https://acdw.substack.com/p/no-choice-but-to-move-on?r=254ice&utm_campaign=post-expanded-share&utm_medium=web

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…