A Country Doctor Reads: August 17, 2019

I Learned a New Word Today: RECRUDESCENCE – NEJM

The New England Journal of Medicine’s question of the week was about an elderly man with a prior stroke history, who during a febrile illness had a temporary recurrence of his original stroke symptoms.

“Patients who have had neurologic deficits as a result of stroke or multiple sclerosis sometimes experience reemergence or recrudescence of those deficits in the setting of an intercurrent illness. The most common triggers include infection, hypotension, hyponatremia, hypoglycemia, insomnia, stress, and benzodiazepine use. Recrudescence occurs most commonly with middle cerebral-artery infarcts and can lead to language, sensory, and motor deficits. Gaze preference, hemianopsia, and neglect are not typically observed.

— Read on knowledgeplus.nejm.org/question-of-week/1860/

Diabetes Related Hospitalizations Not Necessarily Caused by Poor Outpatient Management – JAMA

Quality is an elusive thing: JAMA Network Open has a piece about what kind of correlation there is between the diabetes quality indicators we all deal with in primary care and what really happens to patients. Any guesses?

In this study, the associations among different types of diabetes quality measures were weak, and much variation in the rates of utilization-based outcomes was unexplained by clinical practice group performance on traditional process and disease control measures. This outcome may be due in part to the topped-out nature of process measures, but the weak association between clinically robust disease control measures and hospitalization rates, the modest difference in hospitalization rates based on process and disease control performance, and the small amount of variation between clinical practice group hospitalization rates explained by process and disease control performance all raise concern about the validity of utilization-based outcomes as a measure of quality in chronic diseases. In chronic diseases such as diabetes, more hospitalizations may not necessarily be evidence of poor outpatient care, which has significant implications for quality-based reimbursement in chronic disease management.

— Read on jamanetwork.com/journals/jamanetworkopen/fullarticle/2747756

Family health history: underused for actionable risk assessment – The Lancet

I’m making a plug again for The Lancet, which has lots of free material, available just by registering.

Here’s something so basic we should be ashamed for not making better use of: The FAMILY HISTORY. Now that there are genetic markers and all, why don’t we pay more attention to obtaining a proper Family History?

If applied across the general population, systematic FHH-based risk assessment has the potential to have a substantial effect on population health management. Up to 44% of people meet criteria for increased risk for at least one hereditary condition based on current guidelines, so the potential for impact on health is huge.40 Scaled to a population, FHH becomes a means of assessing the true risk and potential costs that a health system might use to better manage its financial risk. When multiplied to potentially affected family members, the effect becomes even greater.
— Read on www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31275-9/fulltext

Whom Does the EMR Serve? Who Owns and Who Needs THE STORY?

I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find THE STORY. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them in my opinion.

The way I approach reading a note is with the two questions “What happened in the last visit?” and “Why was that the clinical decision?” In more and more of my office notes I answer these two questions for future readers, which would include me, in temporal, typographical and spatial connection with each other, right on top.

Let’s face it, how often would it be more useful to try to scan a lengthy Review of Systems and a Comprehensive Exam to find the pertinent positives than to read in the top paragraph that the patient who was placed on a potassium sparing diuretic two months ago and kept rescheduling their followup appointment is now hypotensive and nauseous with an unusually pale complexion and putting out less than normal amounts of urine. Consequently we stopped the medication, sent the patient for STAT labs or to the ER. Seriously, I don’t need to read anything more in that office note: You and I both know this person is in acute kidney failure, caused by the spironolactone. DONT WASTE MY TIME AS A FUTURE READER by mixing those crucial elements with other, less pertinent information. Put it in there, away from the story in case somebody needs to check if we screened for depression or smoking status, but those are filler materials and side plots in this riveting STORY of iatrogenicity.

I admit that in today’s healthcare environment, the office note serves many “stakeholders” (I’m not sure I like that word…), but since I am the clinician who sees the patient, makes treatment plans and then has to follow up on what parts of the treatment plan worked and what parts didn’t, I can’t accomplish anything without the thread of the chain of events I am ending up calling THE STORY. It belongs to the patient, but I’m the one that needs it, desperately sometimes, as even small nuances in the narrative of a life or a disease can change my assessment and the trajectory of care I provide.

And, here’s a confession, if I don’t have time to finish my note in real time, or if (ahem) I’m catching up on a backlog of chart notes, it’s the “a for abstract” segment I focus on; the number of “bullets” and 99213 versus 99214 is not my priority when I’m in survival mode (mine AND possibly the patient’s).

So I am again making the case for a narrative abstract at the top of each office note, an executive summary if you will, just like the world of academic journals has decided to present complex information.

If it’s good enough for The New England Journal of Medicine, it should be good enough for this Country Doctor.

Passed a Stress Test With Flying Colors and Had a Heart Attack on the Way Home, How Could That Happen?

Tomorrow I’ll have another “Medical Monday” talk taped for our local TV station.

It’s set up more like an interview but I still have to prepare it like a talk. It’s a little speech I give to patients several times per week, but it still causes some raised eyebrows, so I think it’ll be useful for a bigger, more general, audience.

I think I’ll say something like this:

The reason you can have a heart attack even after a normal stress test is that it isn’t necessarily the biggest blockages that cause heart attacks.

Big blockages, or plaques, don’t develop overnight. They take a while, and are more likely to either be silent (if other blood vessels take over the blood flow, like when commuters start to choose the side streets because the highway gets too congested) or to cause what we call stable angina.

Stable angina is chest pain after a certain work load, say two flights of stairs but not one.

Big blockages don’t always cause people to have chest pain if they push themselves too hard; diabetics, for example, often don’t feel pain when the heart is suffering lack of oxygen from its diminishing blood supply, because diabetics can have all kinds of nerve damage, not just in their feet.

Medium sized blockages, say 30-50 percent ones, are the scariest ones, because they may not limit blood flow enough to cause EKG changes or any visible decrease in the radioactive glow we measure in a nuclear stress test.

But 85% of all heart attacks happen as a result of plaque rupture. The wall of the plaque breaks and the “gooey stuff”, cholesterol and other lipid particles, oozes out into the blood stream and a clot forms around it. That’s why we give “clot busters”, fast acting blood thinners, to people who are teeter-tottering on a heart attack. This is what we call Acute Coronary Syndrome.

A couple of decades ago, doctors first gave Lipitor to people with Acute Coronary Syndrome and their pain went away. Lowering cholesterol doesn’t happen that quickly, so what was that all about? More on that in a bit.

Of course, big blockages can rupture, but they are more likely to cause warning symptoms before that happens, while the smaller ones are undetectable unless you do a heart catheterization on everybody.

(CT scans can be used to look for calcified plaque, but the non-calcified, softer plaque might actually be more dangerous.)

So, let me come back to he smaller blockages.

The first thing to make clear is that our arteries are not metal pipes, or even plastic tubes. they are living tissue. And just like our skin renews itself every thirty days or so, our arteries are undergoing all kinds of repair and renewal.

One important aspect of how healthy our arteries are is whether there is inflammation, and we are talking coronary arteries here, but the same thing holds true for the blood vessels to our feet and our brains, too.

When there is inflammation in, say a knee or on the skin, there is redness and swelling and all kinds of chemical reactions that work great if you need to heal broken bones or open wounds. But that kind of reaction can also lead to unwanted bone spurs, thick and peeling skin or, in our arteries, plaque formation.

And sure enough, people with inflammation, be it rheumatoid arthritis or chronic gum infections, on average have more plaque and more heart attacks than you would expect from looking at just the classic list of risk factors, like blood pressure and cholesterol.

Another alarming tidbit here is that some foods cause inflammation, like sugars and refined carbohydrates, while other foods like fish and olive oil reduce it.

In addition to lipid blood testing for determining heart attack risk, we sometimes use blood tests we call “inflammatory markers” (one of them is CRP, or C-Reactive Protein) to decide who should take drugs to lower their heart attack risk.

And this is where Lipitor, now generic atorvastatin, comes in.

It was one of many “statin” drugs developed for lowering harmful LDL cholesterol. It also lowers inflammatory markers in the blood, and as we found out after years of study, it decreases, and in high doses it can even reverse, plaque buildup in the neck arteries as measured by ultrasound, and it can reduce heart attack and stroke risk by 30-50%.

There are other, non-statin drugs (like Zetia), that lower cholesterol and inflammatory markers, but have nowhere near the impact on heart attack risk that the statins have.

So what’s going on?

We now know that Lipitor and the other statins actually do five things:

1) THEY LOWER CHOLESTEROL AND LDL, and that means something but is probably not their main action.

2) THEY MAKE THE PLAQUE WALL LESS BRITTLE, LESS LIKELY TO RUPTURE.

3) THEY PREVENT PLAQUE BUILDUP AND CAN SHRINK EXISTING PLAQUE.

4) THEY HAVE ANTI-CLOTTING PROPERTIES THAT ARE DIFFERENT FROM THE WAY ASPIRIN WORKS.

5) THEY RELAX THE LITTLE MUSCLES IN THE WALLS OF OUR ARTERIES THAT CAN CAUSE “CORONARY SPASM”.

The second through fifth of these mechanisms are well known by now, but we can’t measure them, so people still spend a lot of attention on the numbers that we can measure.

And speaking of measures: In 2013 the American Heart Association and the American College of Cardiology issued a new lipid guideline, with an update added this past year.

Instead of dividing people into just high, medium or low risk for heart disease, the new guideline has a calculator that lets you figure out somebody’s ten year risk. You can then compare this to the best case scenario, and also see what the impact would be of treating blood pressure, quitting smoking or taking Lipitor.

Now, I don’t mean to be overly enthusiastic about Lipitor. It can have unwanted side effects, from brain fog to rising blood sugars to muscle aches. But I am enthusiastic about how much better we understand how heart disease develops.

And I am also excited about what other research has shown: Our diet and lifestyle can address the same five mechanisms of action that Lipitor does. There is more and more proof that avoiding junk food and soda, following a plant based OR a Paleo OR Mediterranean diet, being physically active, sleeping well, managing stress and so on, can have the same impact and reduce a person’s heart attack risk by half.

I’m sure there will be reasons to ad-lib, answer questions, go in depth or off on tangents, but this is the framework I’ll start out with.

A Country Doctor Reads: August 10, 2019 – High Blood Pressure is High Blood Pressure, No Matter Where or When

I learned in medical school (1974-79) that white coat hypertension was not clinically important and should not be treated. Somewhere along the line I was also told that people with little variability in their blood pressure fared less well than people whose blood pressure varied according to their circumstances.

As late as 2008, articles were pointing out that awareness of these phenomena could avoid misdiagnosis and unnecessary treatment.

White coat hypertension is an important clinical problem given its potential to result in misdiagnosis and possibly inappropriate drug treatment. Although ambulatory and home BP measurements are more accurate and predictive of target organ damage, physicians’ office measurements continue to be the criterion standard. That being the case, the sources of measurement error that occur in the office setting remain an impediment to the accurate diagnosis and treatment of hypertension. Data from several studies show that who takes the BP and how it is taken (ie, by a person or an automated device) have a substantial effect on the measurement.24 Our findings indicate that measurements taken by physicians appear to exacerbate the white coat effect more than other means. We suggest that one way of addressing this problem is to modify the method by which BP is measured in the office setting given the wide availability of reliable and validated automated BP monitors that are suitable for both office and home use. Similarly, home BP monitoring has been shown to predict target organ damage as well as (or better than) ambulatory monitoring25 and, thus, is superior in this regard to traditional office measurements. Thus, BP taken by an automatic device, while the patient is alone in the physician’s office, may provide the best means of avoiding a hypertension misdiagnosis.
— Read on jamanetwork.com/journals/jamainternalmedicine/fullarticle/773457

In June of this year, the Annals of Internal Medicine published a widely cited paper that demonstrated that people with white coat hypertension (WCH or WCHT) have up to twice the death rate of people who don’t have it.

“Untreated WCH, but not treated WCE, is associated with an increased risk for cardiovascular events and all-cause mortality. Out-of-office BP monitoring is critical in the diagnosis and management of hypertension.

— Read on www.acc.org/latest-in-cardiology/journal-scans/2019/06/24/13/01/cardiovascular-events-and-mortality-in-wch

An old article I found explains that white coat elevations can be transient or sustained and can happen in people with or without hypertension. So what the Annals authors mean by “treated WCE” confuses me. If a white coat elevation is sustained, isn’t that the same as white coat hypertension?

White coat hypertension (WCHT) and white coat effect (WCE) are often thought to be of the same entity. They are in fact different conditions which carry distinctive definitions and prognostic significance. WCHT is diagnosed when office blood pressure (OBP) is ≥140/90 mmHg on at least 3 occasions, while the average daytime or 24-hour blood pressure is <135/85 mmHg. It is common with 15% prevalence in the general population and may account for over 30% of individuals in whom hypertension is diagnosed. Although individuals with WCHT were reported to have a better cardiovascular (CV) prognosis when compared to those with sustained hypertension and masked hypertension; they were also shown to have a greater prevalence of target organ damage (TOD) and metabolic abnormalities than that of normotensive subjects. In contrast, WCE is defined as the transient elevation of OBP induced by the alerting response to a doctor or a nurse. WCE can occur in both normotensive and hypertensive
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC4170363/

Nevertheless, the most recent piece published on this topic reveals that not only 24 hour measures of blood pressure determine outcomes, but nighttime blood pressure does to the same degree.

“In this population-based cohort study, higher 24-hour and nighttime BP were significantly associated with greater risks of death and a composite cardiovascular outcome, even after adjusting for other office-based or ambulatory blood pressure measurements.

— Read on jamanetwork.com/journals/jama/fullarticle/2740719

So, with the possible exception of brief elevations from pain or trauma (I think and hope that still holds true), I guess if we see it, we treat it.

And my clinic just got some ambulatory Blood Pressure monitors…

A Day of Practicing Medicine Without the Computer

It wasn’t even nine o’clock when the screen on my laptop suddenly froze. From that moment until my last patient left the building, my clinic had no Internet.

For my part, the day went pretty smoothly, mostly because of some of my own work habits. It also helped that it was a warm, sunny day and my schedule was on the light side. Others have frowned at my old-fashioned work habits, but this is what I do:

PRINTING THE LAST OFFICE NOTE

For all pre-booked visits, we print the last office note. We also print important lab results and outside reports. One reason is that I may give these to the patient. The other is that when you create an office note and need to incorporate what happened in the ER or hospital, what the MRI showed and so on, the EMRs I have worked with don’t easily allow me to read the source document and type/dictate my own note in a split screen. And since interoperability is just a theoretical concept most of the time, I cannot import or cut and paste from outside sources.

Having the last office note printout gives me a reminder of what happened, the medication and allergy lists, all kinds of information that helps me move quickly through an Internet blackout day.

MY WORK SHEET

I don’t know what life would be like without this paper, which has gone through a few renditions over the years. It lets me quickly jot down important parts of my patient’s history and exam, what tests I need to order, what referrals I need to make and all kinds of things which in theory would be super quick to do with a computer but unfortunately aren’t.

At the end of the day yesterday, I copied these sheets, left the originals with my medical assistant and brought the copies home, so that on my day off (who pays the price for a computer failure?) I can finally enter the lost visits into the system while the office schedules the followup appointments and things like that.

Ironically, I have been toying with the idea of making an update to my work sheet, inspired by old rheumatology notes I used to see; they had a drawing of a body with each joint made into a stylized box for notations about which joints were affected by disease.

My recent thought has been to put a picture of a body on my sheet with simple indicators for things like, how much edema, size of a lesion, grade of murmur and so on…

Here is my work sheet in its current form. It saved the day for me yesterday:

A Country Doctor Reads: July 28, 2019

Where Have All The Young Docs Gone? – NEJM

The New England Journal of Medicine published a sobering piece about the rapid changes in age distribution among rural physicians. They also point out that the aging and chronic disease burden of the US rural population is expected to increase demand for rural medical providers.

“Maintaining physician supply in rural areas has important equity implications, given that, as compared with more urban populations, rural residents are likely to be older and poorer, are more commonly uninsured, and have lower life expectancy.

The article by Skinner et al makes a few suggestions about what to do to forestall what they describe as an evolving crisis, from loan repayment to hiring more Nurse Practitioners.

I think these types of strategies are unlikely to reverse what is a bigger trend in our society. As a 66 year old physician moving back to Caribou, Maine, I see the challenges of my community all around me: A more than half empty shopping mall in Presque Isle, the closing of a 100 employee customer service call center in Caribou, the empty store fronts lining Main Street in Van Buren. It isn’t just the physician work force that is changing, de demographics of rural America are changing.

It’s strange in a way, when our world is increasingly well connected and distances appear to mean less and less (if only my Internet connection were better and less expensive…) why being physically located in an urban area is so attractive.

In rural New England people don’t need to lock their cars or their houses, they don’t have to stand in line, sit in traffic or feel crowded by the noise around them. But they do need jobs that pay a decent wage. That’s the problem here. Fix the economy (if you can) and the health disparities will diminish.

As the number of younger physicians entering rural practice has declined, the rural physician workforce has grayed. By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60. In contrast, the number of urban physicians under 50 grew 12% from 2000 to 2017, and in 2017 only 39% of urban physicians were 50 years of age or older and only 18% were at least 60.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1900808

————–

Switch

Moving into my new home office I constantly run into books I bought and read years ago but have thought little of since. One book I haven’t read since I first bought it but often keep referring to is “Switch” by Chip and Dan Heath. Subtitled “How to change things when change is hard”, the book has given me a lot to think about as a doctor, whose job often involves trying to cause my patients to change for the purpose of achieving better health.

The three steps to consider when asking someone, even yourself, to change are described, metaphorically as:

1.) Direct the rider. This is what we doctors usually try to do when we tell our patients to eat less, exercise more or take their pills every day.

2.) Motivate the elephant. This is harder, because it involves addressing the subconscious, which cares very little about things like logic or what’s best for us.

3.) Shape the path. If we make it easier somehow to do the “right” thing than the “wrong” thing, people are more likely to do it.

The book has illustrations from all walks of life, from health care to teaching to sales. And, after all, practicing medicine is part teaching and part sales, too.

The central idea for me is how necessary it is to understand and communicate with the elephant, the Heath brothers metaphor for our subconscious. I guess moving our subconscious is not only like riding an elephant, but also a lot like moving horses into a new environment.

I can’t just tell these guys what I would like them to do, I have to find ways to motivate them that are natural for them, that they might want to do in some fashion anyway.

The notion of shaping the path is something I also keep coming back to. So many times we hear that people just aren’t doing what they’re supposed to do, when in fact we are being asked to do things that seem awkward, silly or even impossible.

The recent Boeing crashes due to a software redesign that may have looked good on paper but didn’t make any sense to airline pilots comes to mind.

Similarly, in my world, the “work flows” of modern EMRs may look all right to a computer programmer, but make little sense to health care personnel.

So often in our culture, people are blamed for things that are systems problems and not people problems at all.

SWITCH feels as up to date today as it did the first time I read it.

How Much Should Physicians Touch?

Touch is a sensitive thing. No pun is intended here, but whether and how we touch our patients deserves our careful thought and deliberation.

So much interpersonal contact these days is virtual, with emojis, abbreviations and whole words thrown around as substitutes for human contact. Think :-), 💕, 😏, XOXO and “Hugs and kisses”. And when people do touch in our healthcare environment it is often with gloves, even for simple fingerstick blood sugars, immunizations or routine ambulance transports.

Shaking hands when you meet a patient for the first time is not standard procedure by any means. I wonder if it shouldn’t be in this country. There’s a lot of cultural history behind such a simple gesture.

When I examine a patient I often start by listening to their heart. I do this sitting and I almost always do this through their shirt or blouse. For my purposes, I’m able to hear what I need to hear through one thin layer of clothing; these days we tend to get an echocardiogram anyway if we hear or suspect that a murmur is present.

Listening to the heart is something so expected that almost no one is surprised, intimidated or offended by it. As I do this, I often put my left hand on the patient’s back as I press my stethoscope a little firmer against the patient’s chest with my right hand. This does give me a better chance to hear and it prevents the patient from moving away subconsciously from my stethoscope. It also creates a sort of clinical embrace as I, still fairly lightly and very clinically and professionally put their body between my two hands.

Listening to someone’s lungs, whether I do it through a thin layer of clothing, which I sometimes do, or after asking permission to pull a shirt or blouse up on the back, I don’t also touch the back with my hands while I listen to the lungs.

If, in doing a review of systems, the topic of leg swelling comes up, I often start my exam checking there by first lightly touching and then pressing with my finger for pitting edema. This is a non threatening place to start touching a patient and it feels natural as part of the history taking.

After either of those two initial exam points, I do what everyone does, although I will point out that I don’t wear gloves unless I am doing a genital or rectal exam or perhaps examining an Ebola suspect or something else that might be dreadfully contagious. I have known doctors who wear gloves for every patient visit and I think that does not help in gaining anybody’s trust or confidence in you.

Social touching I don’t do much of. I often shake hands at the end of a visit, and I only occasionally put my hand on somebody’s leg, arm or shoulder. The reason is that I’m not a very gregarious person and I wouldn’t feel that being socially touched by me would seem natural in most cases. I do make a point of “touching” people in spirit, by talking about their personal concerns and sometimes sharing my interests, joys or experiences.

The more I feel that we have a personal connection, the more likely I would be to place my hand on an arm or shoulder, and the less we connect in words or “energy”, the less likely I am to touch someone in a social way.

I find that by being “open” as a person, patients are likely to initiate social physical contact with me, and that’s easier to navigate.

But I do feel awkward if during a visit with a patient there isn’t even a brief clinical physical contact, and I have heard so many patients speak of other doctors with the words “he didn’t even touch me”. I feel strongly that even a small amount of physical contact can cement the therapeutic alliance between doctor and patient.

As I renewed my Maine medical license the other day, I had to answer questions about what is proper and improper physical contact between doctor and patient. I answered correctly the multiple choice questions about kissing and about having affairs when the patient initiates them.

It’s sad to think that someone would have to formulate questions like that for licensing adults who are supposed to be among the most trusted professionals in our society.


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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