A Country Doctor Writes:

As I look back over the past work week I can’t immediately recall any great diagnostic coups or clinical victories. I vaguely remember having to reboot my EMR a lot because it seemed to freeze up, and I certainly remember being locked out of its iPad app for a day and a half.

What I remember best are my trips back to the waiting room pushing wheelchairs with elderly patients at the end of their visit, and I remember the gratitude of the arthritic man, no older than myself, whose toenails I cut as a “by-the-way” after I had excised a suspicious mole on his back.

Again this week I found myself, privately quiet and not much fun, living out my other persona, the secure, reassuring, jovial, gray-templed physician, fatherly to some, a peer to others, and a kind man of the (white) cloth to some.

Sure, it’s great to nail a difficult diagnosis, but we can’t expect to do that every day. What we can and should do every day is connect with and touch every human being we run across in our role as physicians. Otherwise, the new housekeeping tasks of healthcare today will wear us down.

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That thought reminds me of a post I wrote nine years ago, six months after I started writing his blog, “A Day Without a Diagnosis”:

“Thursday I saw 29 patients*, but I didn’t make a single diagnosis. I did three physicals and saw several patients with diabetes, hypertension and high cholesterol. A migraineur came in for a shot, and we double booked a few sick people who already knew their diagnosis and what treatment they needed.

One of my physicals was a Registered Nurse, about my age, who left clinical nursing a few years ago and now does research for a group of surgeons at the hospital up the road. Her research focuses on quality of care.

That got me thinking about the differences in health care between my early days in this profession and today. The spectrum of diseases we deal with has changed, and lately also the notion of what constitutes quality in health care.

Physicians today spend more time managing chronic diseases, some of which weren’t even thought of as diseases twenty-five years ago. A cholesterol level we feel obligated to treat today was considered normal back then; Type 2 Diabetes was something our grandmothers developed in their late seventies, not a multisystem disease we looked for in children and young adults; Attention Deficit Disorder wasn’t something primary care physicians concerned themselves with. And who would ever have thought that Fibromyalgia, a term coined in 1976, would be such a common disease, along with Restless Leg Syndrome (Ekbom, 1944), obesity and toenail fungus?

My conversation with my R.N. patient moved toward the issue of what really constitutes quality in medicine. I worry that some things are measured mostly because they are easy to measure: What percentage of heart attack victims is currently taking beta-blockers? What is the average Hemoglobin A1c among a physician’s diabetic patients (as opposed to how is this value trending over time)? I never hear statistics on how often we as doctors make the right or wrong diagnosis, or how difficult it was to move a particular patient from one set of numbers to another.

The practice of medicine has become more a matter of housekeeping, if not downright bookkeeping. The days of brilliant medical mavericks that could ferret out the correct diagnosis and quickly move on to the next heroic act are history; today’s focus is on long-term management according to evidence-based guidelines (“evidence-based”, now there’s another topic for a post…).

There is no point in lamenting the shift over time in what our patients need from us; I am merely reflecting on what has happened during my years in practice. If we as doctors want to see more bad, untreated and undiagnosed diseases, we need to move to more remote places – my underserved corner of Rural America isn’t the place for that anymore.

Managing chronic illnesses can be very meaningful and satisfying, but it isn’t quite what I imagined I would be doing to this extent. But it is one of the reasons we need to hone our skills as physicians; it is no longer enough to be a good diagnostician when almost every patient we see in a given day already has a diagnosis established. Our challenge is to help them manage that diagnosis. That means we need to practice motivational interviewing for our patients with lifestyle-inflicted diseases, serve as our patients’ medical home in a fragmented health care system and be a voice of reason in an era of information overload.

In a brief moment of worry about what I would do if I didn’t get accepted to medical school I had considered teaching, and I worked as a substitute teacher for one semester between my military service and medical school. I don’t think that was a waste of time at all.

Once in a while as a physician, you’ll make a diagnosis. Most of the time you help patients manage a disease they already know they have.”

That, and dispensing a little kindness in the course of each day.

(*That was before EMR, Meaningful Use, PCMH, ACA and all that. Today, between the technology and all the mandated components of every office visit, I rarely see even 25 patients per day.)