A Country Doctor Reads: April 20, 2019

Suppressing The Inward Eye Roll

The Canadian RuralMed listserv, which I was invited to join, had a comment today, inspired by my post “If You Are a Doctor, Act Like One“, Dr. Yogi Sehgal reflected on how seemingly trivial concerns can be very appropriate if you try to understand the context:

“[Dr. Duvefelt’s] post reminds of one of my little practice tips that I have learned over the years to reduce frustration in the ER.

When a patient presents to the ER or the office with a very minor complaint, and the nurse says to you, “OMG, I can’t believe they came to the ER/office with this,” followed by an eyeroll, it’s easy to get jaded or cynical. I find the simple question, “Was there something specific you were worried about?” or “What was it about this that worried you?” is the gist of the “FIFE” questions that we were taught in medical school and do so poorly except on exams. It opens up the discussion about what the real issue is and gives you a chance to educate (doctor, from the Latin “docere”, meaning “to teach”) and feel less cynical or jaded.

Real cases recently:

Patient with a tiny little scratch on their finger which probably doesn’t need a bandaid. “I have a cut I’d like to get checked out.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient: “My grandmother died of tetanus from a minor cut like this, my mother died of sepsis from blood infection from a wound like this, I’m worried I’m going to die of this too.”

You: (Aha, now I get it!) “Ok, it sounds like the issue is not your finger so much but your family history. When was your last Td? Screen for anxiety… etc.”

Teenage patient comes to ER (with Mom) with a sore foot that comes and goes for the past week, not an athlete, pain-free now: “I sometimes have a sore foot.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient and Mom: “We were worried it had something to do with her congenital hip dysplasia.”

You (Aha, now I get it!): “Ok, sounds like we need to know a bit more about the hip and mechanics of what’s going on.” (Turns out that indeed it likely was partly related to her hip in this case, and she needed to do some PT at home which she had not been doing.)”

(yogi sehgal)

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Sore knee? Maybe You Have a Fabella

The BBC has an interesting little piece about a small extra (sesamoid) bone that seems to be more common now than even just a hundred years ago, even though other sesamoid bones elsewhere in the body are not becoming more common.

The fabella (“little bean” in Latin) can be the cause of knee pain and perineal nerve palsy.

“Between 1918 and 2018, reports of the fabella bone’s existence in the knee increased to the extent that it is now thought to be three times as common as 100 years ago.
The scientists’ analysis showed that in 1918, fabellae were present in 11% of the world population, and by 2018, they were present in 39%.”

https://www.bbc.co.uk/news/health-47950258

The BBC originally picked this item up from a Wiley publication

“Hou (2016) recently investigated the effects of the fabella on posterolateral pain and palsy of common peroneal nerve following total knee arthroplasty. During trials, fabellae were excised from some patients but left in others. Post‐surgery, posterolateral pain and palsy of common peroneal nerve were only observed in patients who still had fabellae. Accordingly, Hou recommended removing the fabella when knee replacement surgery is performed.”

https://onlinelibrary.wiley.com/doi/full/10.1111/joa.12994

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Vaccination is Not Really Just a Personal Decision: People Don’t Understand Herd Immunity -NEJM

I may survive an infectious disease just fine, but what about vulnerable people I come in contact with? The less of it there is going around, the less risk for morbidity and mortality for everyone.

The New England Journal of Medicine editorialized about this:

Exposure to measles in the community certainly represents a danger to high-risk persons during a local outbreak; however, nosocomial transmission may pose an even greater threat and has been reported throughout the world. For example, during a measles outbreak in Shanghai in 2015, a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%.5 When the umbrella of herd immunity is compromised, such populations are highly vulnerable.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1905099

If You Are a Doctor, Act Like One

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 – Yours Truly

It cannot be said enough: Ours is a relationship based vocation. Unless you are doing autopsies for a living, you need to establish rapport with real, live human beings in need of something, with fears or suffering, with past experiences and future hopes.

As a doctor, I play some sort of role, small or big, in the life of every patient I see, for a single visit or over the course of many years.

I am only one person, but I have a vast repertoire of demeanors and vocal inflections, a rich vocabulary of medical and non-medical words and a well honed body language I can put to use in each patient encounter depending on what my patient needs in that moment.

One obvious role is to be the one who correctly diagnoses and treats each medical problem. But medicine is more complicated than that. We know that a physician’s behavior greatly influences medical outcomes, even for conditions that don’t appear to be psychosomatic.

Another role I often think, speak and write about is that of guide. In that role, we need to carefully balance our own authority with deference to our patient’s need to develop and maintain their own. Project too much confidence in your knowledge and experience and hold the patient back; project too little and be of no help at all.

When it comes to the lifestyle related epidemics of our time, we need to be the bellwether for our patients, not by preaching from a pedestal but from a position of a near equal, just one small step ahead. Never obese, I still carried more weight than I should, and I use my own fifteen pound weight loss journey as a peer-to-peer example.

When our patients face the end of life or tragedies of any kind, like it or not, we need to shoulder the priestly mantles many modern people need us to wear as they lack religious connection or foundation. In such cases, we need to seem a little bit above the trivialities of this world, which often makes no sense to those who suffer.

Oftentimes, in the maze of the healthcare bureaucracy that our patients find themselves lost within, we as doctors need to fill the role of advocates. We cannot ever give the impression, or think to ourselves, that we aren’t working for them. Without patients who believe we are on their side, where would we be? This one is probably the most important role we play in 2019.

Choosing how to behave in any given patient encounter is not “acting” in the sense of not being yourself. It is being tuned in to each patient in each instance and filling the need each one has. It is about not barging into the exam room with our own agenda all set. It is approaching each patient with an open mind, ready to listen:

“How can I help you today?”

I Am Not an InstaDoc*; This Is Not InstaMedicine*

* (I know these words are used for Instagram pictures of beautiful medical professionals and gory surgical procedures, but I choose to use them as words of instancy in the practice of medicine.)

The other day a patient called every hour to inquire about the status of her elective cardiology referral. She had been thoroughly evaluated twice at the hospital for chest pain and wanted a consultation.

Another patient called three times the same day because she had seen “Ambulance Chaser” legal firm advertisements about lawsuits against manufacturers of generic valsartan, which may have traces of Chinese cancer causing chemicals.

It has been said that new medical information takes 17 years to alter the way we practice medicine. Contrast that with the immediacy of today’s electronic media…

A certain delay before acting is not a terrible thing in every instance. Overcorrection can be just as risky as undercorrection when you’re steering a big ocean liner approaching a harbor or a fast moving car on icy Maine winter roads. Or when you’re juggling the multifaceted responsibilities of caring for hundreds of patients’ lives.

We live an era of instant fulfillment. We have become impulsive and impatient. Fewer and fewer things are considered better when taking the time they used to take: Faster is viewed as inherently better.

Speed reading and speed dating, same day surgery, curing lifelong depression with a single infusion – we strive to defeat time and the forces of nature. There is no respect for the rhythms of life.

And yet, there is also the mindfulness movement, but it is largely linked to the alternative practices of medicine. Mainstream medicine is paying some lip service to such things, but it is becoming more and more firmly pigeonholed in the whirlwind of consumerism and electronic immediacy.

The practice of medicine used to be, and should return to being, a more contemplative pursuit. When we constantly go for the quick fixes, we risk overlooking or not even understanding the big picture.

In the case of the drug recalls, it wasn’t too long ago that some of my patients insisted on being switched from one angiotensin receptor blocker to another and then another and then yet another as the news about their impurities trickled in.

And, remember Vioxx, Merck’s stomach-friendly arthritis pill? Sales were booming, then reports of high blood pressure and heart attacks started to make the news. Merck panicked and took the drug off the market. Pfizer had steadier nerves and kept making their sister drug, Celebrex. Not long after, the data came out that Celebrex also increased heart attack risk, so doctors started to avoid it and switched patients back to the older NSAIDs. However, they, too, turned out to increase heart attack risk. Not as much, but still enough to make us reconsider our use of all of them.

In this case, instead of panicking and switching patients back and forth in desperation, we would have been better off doing nothing while stepping back and assessing the situation.

We’re supposed to be professionals, not robots…

A Country Doctor Reads: April 13, 2019

Vitamin D as Cancer Therapy? Insights From 2 New Trials – JAMA Network

All right, I’ve been less than enthusiastic, even downright acerbic, about the widespread interest in Vitamin D. I’ve written many times about it. Then I started taking Functional Medicine courses….

This is from this week’s JAMA:

It may be tempting to interpret the preliminary findings regarding recurrence- and progression-free survival as specific antineoplastic effects of vitamin D3 supplementation. However, higher vitamin D levels have been associated with substantially decreased mortality and morbidity among hospitalized patients with a range of nonneoplastic diseases as well as with cancer.14-16 Thus, the findings of the 2 trials may reflect relatively broad biological effects of vitamin D.

In summary, the SUNSHINE and AMATERASU clinical trials reported in this issue of JAMA provide new information regarding the potential use of vitamin D among patients with colorectal cancer and other luminal gastrointestinal malignancies. Confirmatory trials are needed to evaluate these preliminary findings, ideally with longer follow-up to obtain better estimates of effects on survival as well as biological measurements to clarify underlying mechanisms.

— Read on jamanetwork.com/journals/jama/fullarticle/2730095

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Billion dollar Medicare Fraud depends on doctors signing papers without reading – The New York Times

In this day of electronic medical records, we still get a lot of paper to sign, and we really never have time to read much of it. Home Health nursing orders require a signature on every single spaced page, for example.

This week, the New York Times wrote about the billion dollar market for fraudulent prescriptions for a back braces etc. I get these often, always return faxed with the comment “MEDICARE FRAUD!”, and I also get prescriptions “needing” my signature for compounded enormously expensive pain creams.

www.nytimes.com/2019/04/09/us/billion-dollar-medicare-scam.html

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Leonardo da Vinci – The Lancet

We may laugh or shrug at the Brits, but when it comes to their medical journals, I am always impressed by their depth, from both a humanistic and historical perspective. Last week’s The Lancet has a nice article about Leonardo da Vinci:

“It is a sobering thought”, said the satirist Tom Lehrer, “that when Mozart was my age he had been dead for 2 years”. Leonardo di ser Piero da Vinci lived almost twice as long as Wolfgang Amadeus Mozart, but his life and work provoke an even deeper sense of hopeless awe. Leonardo made three of the most influential and most parodied artworks in history—the Mona Lisa, The Last Supper, and his sketch of Vitruvian Man. Throughout his life, he kept notebooks, works of art in themselves, crammed with crisp observations and lists of questions from every field of life. No-one, wrote Giorgio Vasari in his gossipy biography of the Renaissance masters, was ever his peer in “vivacity, excellence, beauty and grace”. What can we do but throw up our hands and call him a genius?

More snippets from this wonderful article:

“the four universal conditions of man”—joy, weeping, fighting, and labour..

… he began the Mona Lisa and the Salvator Mundi, and became the subject of intense jealousy from the young Michelangelo…

True to form, he left behind a mess: unfinished paintings, flaking murals, and a heap of manuscripts that took centuries to sort—a fitting memorial for what the art historian Kenneth Clark called “the most relentlessly curious man in history”. But the “disciple of experience”, as he once signed himself, also left a humanist paradise in paint and ink, revealing the world as it might have wished to depict itself.

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Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study – The BMJ

This population based, sibling controlled analysis showed a clear association between clinically confirmed stress related disorders and a higher subsequent risk of cardiovascular disease, particularly during the months after diagnosis of a stress related disorder, in the Swedish population. This association applies equally to men and women and is independent of familial factors, history of somatic/psychiatric diseases, and psychiatric comorbidities. These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.
— Read on www.bmj.com/content/365/bmj.l1255

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Writing the body – The Lancet

The Lancet offers free access to some of its articles by just signing up. This week has an interesting book review:

Ned Beauman argues for the utility of the appendix, arguing in favour of the theory that in less hygienic times it served as a reservoir for helpful bacteria, ready to repopulate our insides after infection had purged us. Appendicitis, he says, is the mark of an immune system “deranged by tedium”.
— Read on www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30801-3/fulltext

Treatment of Peritendinitis Crepitans: Heparin or Prednisone?

In Sweden, my treatment would have been IV Heparin. But a single dose prednisone also worked.

My trusted SUV, now with 266,000 miles on it, needed a new transfer case so I couldn’t trailer my monthly hay purchase last weekend as I usually do. Instead I rented a U-Haul with an incredibly awkward driving position. Afterward, the front of my right lower leg started hurting and Saturday morning, almost a week later there was the characteristic crunching feeling of peritendinitis crepitans whenever I dorsiflexed my ankle.

In a sudden blast from the past I remembered how we used to treat it in Sweden: A little heparin IV push. I’ve been gone long enough that I don’t know if they even do that now but I certainly have never heard of it in this country.

I demonstrated my clinical findings to Autumn, my Medical Assistant, and to a colleague, and told them about the heparin. Obviously, we don’t stock any in my clinic, and, besides, it wouldn’t look good if I injected myself with anything intravenously in this day and age. (I have previously quoted the famous 1800’s Parisian Swedish physician and writer Axel Munthe, who shamelessly reported shooting up some “Morphia” after a hard day at the office).

So I did he next best thing I could think of, 20 mg prednisone (the wonder drug I wrote about the other day). Saturday 7 pm, resting after a somewhat crazy Walk-in day and a nice dinner, the crunching is gone and the pain much less severe.

So now I have time to do some research. The first page or two on my Google search had articles from 1957-1961, all or most from Scandinavia.

I did find one guideline from 2017 that recommends low molecular weight heparin:

http://www.ebm-guidelines.com/ebmg/ltk.free?p_artikkeli=ebm00430

But, in my case, the prednisone seems to be working. And my old Mercedes is fixed, running like new again, so my next hay trip will be more comfortable.

A Country Doctor Reads: March 30, 2019

A No-Pain Gene Mutation – NYT

Last week I wrote about whether pain is a sensation or an emotion. This week, there was a story across multiple platforms about Jo Cameron, a 71 year old woman who has felt almost no pain in her lifetime, including from burns, arthritis and several surgeries. She also scored zero on standardized anxiety questionnaires and doesn’t recall ever feeling depressed. Her two gene mutations responsible for this have been mapped now and may open doors to new approaches to treating chronic pain. And, of course, this discovery supports the notion that physical and emotional pain are, really, all the same.

https://www.nytimes.com/2019/03/28/health/woman-pain-anxiety.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

………..

Is it a Crime to Underestimate How Long a Patient Will Live? – WSJ

The Wall Street Journal has an interesting piece about a court battle involving a hospice and home health agency whose patients seemed to live longer than the certifying doctors predicted. Was it fraud, and should the doctors get penalized? In a funny twist, the prosecution’s expert witness physician contradicted himself in some cases he happened to review twice: One time he agreed the patient qualified for hospice because they had six months or less to live, yet another time he thought they would live much longer. The article concludes:

“The antidote is not to pretend that subjective decisions in a hospital room become objective facts in a courtroom. 

Some medical judgments can be false. But the government is trying to create a standard that is far too broad. Professional disagreement should not be illegal.”

https://www.wsj.com/articles/medicares-hospice-rules-could-make-your-doctor-a-criminal-11553209261

……….

FREE: Important Articles – JAMA

So many journals, even single articles (including some of my links, I would think) are expensive to access. JAMA has one free section, called JAMA Network Open Access.

For example, the current issue has an article on how opioid prescribing has changed in each state over the past several years.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2728005

PDSA for Dummies

Clinics like mine are supposed to do lots of PDSAs, rapid quality improvement projects. It’s part of our agreement with Uncle Sam. We keep starting them, but many of them fizzle. Our Federal Project Officer told us (again) at his last inspection to do more of them.

We have gone through multiple forms and formats, one more complicated than the other. But simple folks like me can’t wrap our heads around them. It should be simple: P stands for Plan, D for Do, S for Study and A for Act. Four short words, fourteen characters and, in our case, years of confusion.

Every PDSA form creator has his or her own idea. In some iterations, Plan means a detailed description of multi step processes, without declaring the overarching idea or purpose behind the project in the first place. In some, Do is where you enter your measurements and Study is where you analyze the results, while in others Do is the experimental workflows and Study is where you put the measurements.

So, as one to often reduce complicated things to their bare essence, here’s what I’ll be presenting my boss with. I’ll call it “PDSA for Dummies, v. 1”. My secret weapon is that each word, Plan, Do, Study and Act, is followed by a sentence that spells out my interpretation of what it stands for. It may not be the best, and is certainly not the only, way to do it but at least I think it’s clear:

P – Plan: In one sentence, what will you try to do?

(Example: Decrease the number of patients who leave the clinic without making a followup appointment)

D – Do: What steps or workflows will you carry out and how will you measure what works?

(Example: Give the first ten of my patients a numbered, sealed envelope and ask them to drop it off at the reception and have me or my medical assistant give everyone else just a friendly reminder to stop there on their way out. Keep a log of who got an envelope, a nurse reminder or a doctor reminder.)

S – Study: What results did you record?

(Example: Did more envelope carrying patients make followup appointments than reminder-only ones? Was there a difference between doctor and nurse reminders?)

A – Act: Given what we observed, should we adopt one of these new workflows or do we need to try something else?

(Example: Nothing seemed to work very well, maybe we should relocate the checkout station in another PDSA.)

Four boxes, each with a definition of exactly what we mean with Plan, Do, Study and Act and, in small print, simple examples.

That’s my opinion, we welcome yours…


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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