A Country Doctor Writes:

“I am not on call”, Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know”, I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54 year old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see an optometrist for glasses. I’ve called every hospital within 50 miles and there is no ophthalmologist on call over the long weekend. You helped me once before with a case of dendritic keratitis when you were on call.”

I also remembered Memorial Day weekend last year, I was in the same situation during my Saturday clinic. A young boy, whose mother had just joined the board of our health center, came in with eye irritation. He had a small rust ring very close to the center of his cornea. I had dug out plenty of them, with a special spatula or even with the tip of an 18 gauge needle, but this was a child, who might not have beeven fully cooperative, and the location was critical for his future near vision.

Cityside Hospital had no ophthalmologist on call for that long weekend either, and all my calls to ophthalmologists in the surrounding area were fruitless. He got in to see an eye doctor the Wednesday after the Monday holiday and it turned out that he actually also had a small metallic corneal foreign body. Everything turned out okay, but the wait was uncomfortable and at least a little risky.

A corneal rust ring, even a foreign body, can usually wait a few days, but if this woman had what I thought, acute angle closure glaucoma, I wouldn’t want her to wait that long to see an eye doctor.

“I think she’s got acute glaucoma”, I said.

He was silent. I continued:

“She’s got mixed injection, no foreign body, no fluorescein uptake and I can see her left fundus clearly but I can’t get a focus on her right fundus no matter what lens I dial in on the ophthalmoscope.”

He was silent again for what seemed a very long time. Then he said:

“I live an hour away, but I happen to be in town. If you have her walk out your door right now, I’ll meet her at my office in, what, 25 minutes?”

“She’ll be there. Thank you so much.”

I haven’t heard yet what he found, and I haven’t wanted to bug him, but I am anxious to hear what the final diagnosis was. I do know that an urgent slit lamp exam was necessary.

One postscript:

When I sent my emergency eye patient off with her office note and insurance information to see Dr. Stoltz, her husband said:

“You’ve done well by us. I came in and saw you once with a cauda equina syndrome.”

I didn’t remember him, but he must have had a critical enough pressure on his lower spinal nerves to also have warranted an urgent referral to a specialist.

Disease strikes at inopportune times.

Friday was unusually hazy, hot and humid for our northern location. My last patient before lunch was a “double book”. Nat Bruehl, an infrequent visitor to our clinic, had called about congestion and an irritated eye. Probably a case of conjunctivitis, everyone involved had concluded, and he was given an appointment within an already filled time slot for a “quick look”.

“I brought my daughter to her high-risk obstetrician’s appointment in Capital City Monday, and she made us drive with the blasted air conditioner on the whole way there and back. Ever since then my eyes seemed irritated”, Nat explained. “I figured I got a cold in them. I took some cold pills that didn’t do any good. Then, last night my right eye started to hurt like a son of a gun and now everything is a little blurry. I even had a hard time driving myself here in this rain storm.”

I looked at his face. His right eye was red, and as I looked closer, I noticed his pupil was enlarged. As I directed my wall mounted light at his eye, the pupil remained dilated and I could see that the fluid behind his cornea was gray and cloudy, barely letting the light through.

I brought him out in the hallway to look at the vision chart.

“Start with your good eye”, I asked him. Outside, lightning struck not far from the office. The earth shook and the fluorescent lights blinked.

He squinted and strained, and missed two letters on the 20/40 line. With his right eye, he couldn’t even do 20/100.

“You’ve got a true emergency”, I explained. “I think you’ve got a dangerous buildup of pressure in your eye because of an internal blockage – a case of acute glaucoma, and I want you to see an ophthalmologist today.

“But I couldn’t drive to the city”, Nat protested. “Not in this weather.”

“I wouldn’t want you to”, I warned him. “You need to find somebody else to drive you.” I also asked for his permission to bring in our head nurse and my own nurse, Autumn, to look at his eye. “I would like everyone here to see what you’ve got”, I explained.

He agreed, and I showed his abnormal eye to our nurses.

I made a call to the nearest ophthalmologist, Mike Dube, but he was off and had signed out to Jeremy Sweet over at Cityside Hospital. After hearing my case description, Dr. Sweet’s assistant gave Nate a 3 o’clock appointment.

“Now, don’t try to drive all the way there yourself”, I warned him. He agreed to find someone to drive him. I gave him directions and went back to my office to catch up on charts and grab a bite of my sandwich. Outside, the sky darkened as if night had already fallen.

The afternoon was a whirlwind. Other places may wind down on Friday afternoons, but not our clinic. Just before 5 o’clock there was a call from Dr. Sweet’s assistant.

“You were right”, she said. “He has a bad case of angle closure glaucoma and we are having a hard time getting his pressures down. It’s 50 even in his good eye. That antihistamine-decongestant he took for three days is probably what did it. Good thing you caught this – we often see people like this bounce around a bit before getting diagnosed.”

I thanked her and made sure to let the staff know about the callback. Flashes of lightning lit up the darkness outside, the thunder roared almost continuously, the floor vibrated and the rain beat hard against my office window as I finished my charts for the week.

I have made the argument that being the first contact for patients with new symptoms requires skill and experience. That is not something everybody agrees on.

One commenter on my blog expressed the opinion that it is easy to recognize the abnormal or serious and then it is just a matter of making a specialist referral.

That is a terribly inefficient model for health care delivery. It also exposes patients to the risks of delays in treatment, increased cost and inconvenience and the sometimes irreversible and disastrous consequences of knowledge gaps in the frontline provider.

UNNECESSARY SPECIALIST REFERRALS ARE COSTLY

Seeing a high charging, high earning specialist when the primary care provider can’t diagnose and manage the condition involves higher cost and, in many cases, a comprehensiveness that is based on the fact that the patient traveled 200 miles for their appointment. In such cases patents aren’t likely to come back for a two week recheck. Consequently, specialists tend to do more in what may be the only visit they have with a patient.

UNNECESSARY SPECIALIST REFERRALS CREATE TREATMENT DELAYS

For my patients, seeing a neurologist involves a one year wait for the out of state neurologist who does consultations almost 100 miles from my clinic, or a three to four month wait for an appointment more than 200 miles away in Bangor. The situation for rheumatology or dermatology is about the same.

Even if a primary care provider makes a correct referral, patients risk getting sicker and suffering needlessly because of these delays or, for them, nearly insurmountable barriers to travel.

And the days are gone when a rural medical provider could call city specialists several times a month and get free curbside consultations about tricky cases.

Rural America is almost like a different country in terms of the availability of specialist physicians, so less knowledge on the frontlines of medicine is a big deal here. Distance is an overlooked health disparity. I even have patients who hesitate traveling 20 miles to Caribou for an x-ray.

THE DANGER OF NOT KNOWING WHAT YOU DONT KNOW

The biggest concern with the you-can-always-refer mentality is that it actually takes good training and real life experience to know what constitutes an emergency when the clinical signs are subtle and similar to more trivial conditions.

In my own writing I have described the inexplicable phenomenon of clinical instinct and the newbie hubris of the Dunning-Kruger effect and also illustrated many common primary care triage situations:

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Why are so many people systematically belittling the skills that are needed to be a safe and effective primary care provider? In many other countries, primary care physicians are the backbone of their health care system.

Oh, I almost forgot, our system was never actually designed. It looks the way it does because of market forces, corporate strategies and all those kinds of things.