A Country Doctor Writes:

I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.

We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.

My purpose in writing about these cases is to show how disease, the enemy in clinical practice if wou will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.

Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.

A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.

When I saw her in followup, she was still coughing a little, and she wasn’t her usual happy self. Her lungs were clear. I asked her caregiver if they had done a head CT the last time she was in the ER. I saw no mention of it in the ER report.

“I’m pretty sure they did”, he said.

I retrieved it from the statewide Maine Health InfoNet site. It described that all the sinuses were infected and only slightly improved from the earlier study.

Martha is now on a much longer course of antibiotics, because a sinusitis often takes a lot longer to clear up than most pneumonias. I sometimes compare this to getting the contents of an egg out through a tiny hole in the shell (I never did learn how that is done). And, a sinusitis can sometimes cause pneumonia because of postnasal drip.

I saw another case the other day where I think I was able to piece things together.

Gretchen had seen another provider for headaches. She had migraines in her youth but they stopped after she had her first child. My colleague ordered a brain MRI to make sure there wasn’t something more malignant going on. It showed what the radiologist described as a possible migrainous angiopathy.

By the time I ended up seeing her, she had had the migraine for over a week and she had taken daily doses of over-the-counter remedies, so I figured that she now had an element of withdrawal headache. Normally I prescribe prednisone in such cases, but Gretchen told me she has had severe psychiatric side effects from steroids before.

I asked her to wean off the OTC medications and started her on topiramate. Gradually her headaches got better. Then, a few days later we got a phone call, saying her migraine had come back with a vengeance. It was late in the day and she had been vomiting. She went to the ER and they gave her IV fluids, metoclopramide and something for pain.

I saw her in followup and she was better but very worried, telling me her headache was starting to build again.

Then she told me something that jolted my brain I to action.

“Whenever I start to hurt on the side of my nose where I had the surgery, the headache comes on.”

“What kind of surgery”, I asked.

“I had a big cyst removed, se-ba-cious I think it was called.”

“Can you take your mask off”, I asked. I had not seen her uncovered face before.

She did and there was a big scar.

“What kind of pain do you have there”, I asked. Is it steady or, like, pulsating?”

“It’s like jabs and jabs, like someone is sticking needles in there.”

I pulled the monofilament from my pocket and started touching her over the three branches of the trigeminal nerve on each side of her face.

“Does this feel the same on both sides of your face?”

“No, it’s different.”

I took a deep sigh and explained:

“This looks like a nerve pain, a neuralgia, in the nerve that reaches the skin outside your sinus there, and also in the other two branches that go to the forehead and the jaw. It’s called the trigeminal nerve and it comes directly from the brain. I wonder if that is what has made your migraines come back after all these years.”

“Can you stop this from getting full blown”, she asked.

“I probably can’t stop the neuralgia very quickly. Most neuralgia medications take a while to,start working, but I’ll send in a prescription for Imitrex. Take one as soon as you get home and you can take one more later today if you have to. Then call me tomorrow and let me know how you are doing.”

The next day she told me she was headache free after just one Imitrex, and the neuralgia was barely noticeable.

I’m curious how she will do in the long run, and I’m curious if the trigeminal neuralgia is somehow related to the surgery she had there.

Like I’ve said before, curiosity is a powerful antidote to burnout.

I graduated near the top of my class from the second oldest university in the world, and one of the best medical schools on the planet. I have 44 years of post graduate experience in a part of the United States, where there is a severe lack of specialists and where a small cadre of primary care doctors see more and do more than in many other parts of this country.

If and when I look at my personal report card in my new Epic EMR I find that I am average or worse. What that means is that I’m not real quick in responding to routine messages and other such things.

I almost get the feeling that clinical competency in primary care doctors is so much taken for granted and so commoditized that the only thing that matters is how fast we are at getting patients out the door and clerical tasks completed.

Metadata, as I call the majority of items in my EMR report card, is the typically invisible information on a CD, for example: Recording date, copyright holder, maybe the album cover photo for displaying on your device. But imagine if this was all you got, if the piece of music wasn’t there. That’s what it feels like sometimes in primary care: The clinical work we do is invisible while the metadata blocks the view of what really matters.

Would you pick a brain surgeon, if you needed one, based on their speed in the operating room or at the computer? I suspect neither.

There are a few clinical measures also in these report cards, but they are set as if they are absolute, immutable laws. And do they really reflect the quality of our care?

Quality measures in medicine are basically substitutes for the real information we wish we had.

We measure surrogate outcomes, like hemoglobin A1c and blood pressures. But the person with perfect numbers could suffer a fall one day from hypoglycemia or hypotension and break a hip. The diabetic could get urosepsis from their Jardiance pill that causes them to excrete more glucose in their urine. And the perfect blood pressure person could develop kidney failure or a life threatening arrhythmia from spironolactone or valsartan, or lupus from their hydralazine. In studies, such things are tracked and judgements are made that, for a majority of patients, the benefit of a particular treatment outweighs the risk. But, in practice, we don’t know who they are. If our patient is almost “at target” and the next drug we add could be the one that will harm that particular patient, is it worth doing? Polypharmacy is a dirty word some of the time, except when patients have several medical problems and are supposed to meet several numeric targets.

There is nothing in my report card about whether my diagnoses are correct, whether my workups are appropriate, whether my patients trust me or even like me, and what my clinical batting average is when it comes to actual outcomes.

Medicine is full of decisions, judgement calls, that should be made together by physicians and informed patients. The word patient-centered has become meaningless, because doctors who let their patients in on clinical decisions and respect their refusal to do certain tests risk getting bad quality scores.

Originally posted on my Substack.

https://open.substack.com/pub/acdw/p/practicing-at-the-top-of-your-license?r=254ice&utm_medium=ios&utm_campaign=post

You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).

You also don’t really need a medical degree to enter data into an EMR.

And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!

And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…

Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!

It is always interesting to see how old pieces suddenly show up in the stats.
Today, a 2012 piece, published around the time my clinic adopted its first EMR, suddenly got a dozen views. Rereading it, and being reminded of the old days, I felt a twang of nostalgia:

The Art of the Referral Letter

One of the journals I skimmed through this weekend had a piece about Meaningful Use, which is Newspeak for what electronic medical records need to do in order to satisfy Federal requirements.
One of the requirements we must satisfy in the next round of Meaningful Use is to “send summary of care records in certain referral and transition of care situations”.
The Archives of Internal Medicine reported a year ago that 70% of primary care physicians claimed to inform specialists of patients’ medical history and the reason for consultation, while only about 35% of specialists reported to be getting this information.
I remember the eloquent referral letters I used to dictate years ago, when the administrative burden of a rural family practitioner was a fraction of what it is now:
“Dear Mike,
This is to introduce Mary Calderon, a 53-year-old Gravida 3, Para 2 with a BMI of 30 and a recent onset of postmenopausal bleeding 18 months after a seemingly normal menopause. Her ultrasound shows endometrial thickening….”
“Dear Ned,
Thanks for seeing Bella Beaupre, an otherwise healthy 68-yar-old with six months of migratory polyarthralgias and an inconsistent laboratory profile. Clinically, she appears to have new onset of Rheumatoid Arthritis, but I would appreciate your help….”
After each consult, there would be an elegantly worded, impeccably typed letter on deliciously thick linen stationery, blue from Mike, cream colored from Ned, running a page or possibly two, signed with flair in ink with each one’s favorite fountain pen.
Just as my referral letter would state whether I wanted my specialist colleague to see the patient for a consultation so I could take it from there or simply take over and manage the patient, the consultation report would succinctly outline their thoughts and proposed treatment plan.
A few years ago, Mike’s group adopted an EMR and the two-page reports on blue linen stationery were replaced by five-page boilerplate reports that all tended to look very similar, to the point of making it hard to see what Mike really thought of the problem I had referred to him. The reports, even though he is a specialist, had smoking status, last pneumonia vaccination and all kinds of “primary care” information. Because Mike never learned to type worth a darn, his thoughts about each case I sent him were often reduced to just a line or two somewhere in the middle of each report.
My own referral letters have also lost some of their flair over the years. Instead of thoroughly summarizing each patient’s past medical history, somewhere along the line I started to focus on the problem for which I was referring the patient. I would have a catch phrase somewhat like “please see enclosed records for additional background information”. It was less satisfying, but it seemed there was never quite enough time to dictate one of those old, delicious doctor-to-doctor notes.
Now, with my own transition to electronic records, I can’t just pick up my handheld recorder and dictate a referral letter anymore. Anything written is the product of my own point-and-click or hunt-and-peck. By necessity, I now type a brief, yet to-the-point paragraph at the end of the office note about why I am requesting a consultation for my patient. It doesn’t say “Dear Mike” or “Dear Ned” anymore, and, just like Mike’s and Ned’s office notes, it has a lot of information that looks the same from patient to patient and visit to visit. But, after all, smoking status as a vital sign and all those other items are necessary to meet our current “Meaningful Use” requirements.
I haven’t asked either one of my colleagues how they feel about my referrals these days.
I, for one, really miss Mike’s thick, blue stationery and his wisely worded reports that always taught me something new or confirmed my own thoughts, signed with that broad nib fountain pen of his.
That was Meaningful Use, too.

Bucksport Regional Health Center, where I used to be Medical Director, has a “Friends and Family” support group for family members of our patients in opiate recovery. On Friday March 24, 6-8 pm, we will host a meeting for anyone interested in understanding or helping a loved one who is in or could use a Suboxone program like ours. Our remote main speaker, Dr. Paul Updike, pain and addiction specialist in Buffalo, N.Y., is an adviser to our program and helped start our “Friends and Family” group, which meets every two weeks in person and via Zoom. If you can’t attend our informational meeting in person, here’s the link:

Join Zoom Meeting 3/24 @ 6 pm

https://us02web.zoom.us/j/81788535330?pwd=MDh6dHlaSGJJVjNMSjhkRFNQWDBnQT09