Record Breaker!

My blog just set all my previous records: Over 9,000 visits and the most views in one day of a single blog post. This one is striking a chord with my colleagues:

The Future of Doctoring is Already Here: Do More, Give Less Or Burn Out

Old school doctors like me used to give the vast majority of our time and attention to our patients. Our documentation took very little time and our support staff sorted all incoming data – lab results, x-rays, consults and hospital reports. They would prioritize things for us: courtesy copies to just sign, tests we ordered that came back normal, our tests with abnormal results and so on.

In the new world order, doctors and other medical providers are the first ones to see incoming information. It arrives in our inboxes throughout the day and night, and then it is up to us to sort and delegate everything.

This is something we are never scheduled protected time for – we are supposed to do it “between patients”. What that means is that, in order for us to stay on time, no patient visit should ever be as long as it says in our schedule – since we’re expected to do all this important work “between patients”.

I have to admit this has been hard for me to swallow and adjust to. One reason is all the health maintenance and preventive medicine we are required to pay attention to, even though as I keep saying and writing to no avail, that isn’t usually something that requires a medical degree. The other reason, of course, is that if you ever hope to get people to follow or at least consider your medical advice, you need to have a relationship with them, and that takes a little time. You can’t treat people like cattle in a roundup and expect them to follow your suggestions and prescriptions.

I work hard at delivering technically good care. I put effort into my personal relationships with patients. I don’t mind that.

I keep falling behind in monitoring my 23(!) different inboxes. I think there are too many of them and I think much of what’s in there shouldn’t even be coming my way. It’s just a liability trap, designed to make sure that if anything goes wrong, the blame will land squarely upon us.

So how do I tell my patients I’ll be shaving some more time off what they think is the contracted amount of time they have come to expect with me?

We desperately need to reimagine the primary care visit and the primary care flow of information. Bottlenecking equals burnout.

Between Patients: The Myth of Multitasking

An Unusual Case of Meralgia Paresthetica

I had a clue what this might be when Autumn asked me “can we squeeze in Sally Smith for leg numbness and a groin rash”, although I didn’t know the extent of the numbness or the specifics of the rash.

So we double booked her and I listened to her story. The numbness was only in the front of her left thigh and started somewhere around the groin. Her strength was normal and the sensation below the knee was perfectly normal. When I touched the numb area she told me it hurt, so it wasn’t just numb, it was numb and painful at the same time. Looking at the rash, it was a cluster of blisters in her left groin about the size of my fist and she also had a small patch of smaller blisters around the corner in the upper left gluteal area.

Sally had had a couple of outbreaks of painful blisters before. A couple of years ago I gave her valacyclovir for what looked like herpes simplex in her face. She became violently ill on a modest dose. She is also intolerant of gabapentin, which she had tried for sciatica in the past. She has a history of chronic back pain.

She has had the shingles vaccine, both doses of the newer one, so supposedly shingles isn’t likely to happen to her but it was clear to me that her numbness with pain qualifies her for the diagnosis of meralgia paresthetica.

This condition is usually caused by pinching of the lateral cutaneous femoral nerve as it exits the pelvis in the groin. People with large bellies are more likely to get this. Sally is a slender woman. But she was too tender and sensitive for me to feel for a hernia or lymph nodes in the groin. Even the slightest touch was unbearable for her.

So in this case I think her meralgia paresthetica isn’t caused by a big belly. Rather, I suspect the virus itself and possibly any associated swelling of lymph nodes or other soft tissues are the culprit.

So I reassured her I thought this would go away by itself. But, in the meantime, what could I do?

She is already on hydrocodone for her chronic back pain. And she confirmed when I said hydrocodone doesn’t usually do much for nerve pain. Lyrica would be too similar to gabapentin to try and duloxetine would probably take too long to help her. So I offered her low-dose amitriptyline and a burst of prednisone.

She will call me in a couple of days to report how she is doing and she already has a routine visit in a week and a half.

Previsit Planning: What, Why and For Whom?

Time is a precious commodity in today’s healthcare. Visits are short and agendas can be far reaching. The concept of previsit planning has penetrated our world in recent years, but what is it, and what should it be?

Supposedly our patients are our patients every day of the year. Why then does everything have to happen the few times they show up for an appointment?

Clinics like mine actually have staff members research “care gaps“ and save them up for us providers to deal with in each patient’s glorious 15 minutes in our presence: Depression screening, colonoscopy, immunizations and on and on and on.

There was a time when previsit planning meant making sure that we were ready to deal with the clinical issues: Are the test results and consultation reports available to discuss in tomorrow’s appointment? This task is no longer prioritized. So that means I have a long list of things that could have been done by somebody else some other time while I have to scramble to do what the patient expected and deserved to have done in our visit.

How hard would it be for those people who create our work list of care gaps to also be the ones to contact the patients, leaving us to be doctors, NPs and PAs?

We are supposed to be teams, working together for the benefit of our patients. Why do we have this crazy system that funnels, absolutely bottlenecks, everything through the medical provider?

“Hello, this is so and so from X health services, calling to remind you flu shots are out, and we noticed you haven’t had a colonoscopy since 2011…”

That would be teamwork. Having a bunch of people telling me what to do does not feel like teamwork, but more like having too many bosses.

The morning huddle has been hijacked and the role of previsit planner of what the doctor should do is becoming more and more prominent. There are better ways to provide public and preventive health in primary care offices.

Most Read Posts in 2021 (if not ever…)

I’m taking a little time off around the holidays. Meanwhile, here are the top five posts from A Country Doctor Writes in 2021.


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”.

BOOKS BY HANS DUVEFELT, MD

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