A Country Doctor Writes:

We all have 168 hours a week to spend.

For some time now, I have been working well over 60 hours a week and spending 15 hours in the car traveling the more than 200 miles between my two homes and clinics.

As of this July, the month of my 66th birthday, I am staking out a new life for myself. I’ll be spending 30 hours a week in my Van Buren clinic, only 3 hours commuting, 30 on horse related things and 30 on my writing. Add the 63 hours I figure I need just to survive, and I will still have 12 hours to do something else. I admit some of that time, probably 5 hours a week on average, will be remote chart work, which can be done while looking out at the horse pasture. That still leaves an hour a day on average to do something new.

I’m calling this a semiretirement although it is really just slowing down to a more normal pace.

That means I’m giving up the medical directorship and work in my other clinic. But it also means I’ll be a more well balanced human being, I hope, as I consolidate my life in northern Maine, in a Swedish looking little red farmhouse not far from the village of New Sweden.

Aerial view of SOLTORP, which means “Sunny Little Farm” in Swedish

I have written about this before: During my internship in Sweden, I read an article in a Stockholm newspaper about the Swedish colony near Caribou. I was in the process of applying for my Family Practice residency in Maine, so I wrote to one of the people featured in the article. He forwarded my letter to the presidents of both the Caribou and Presque Isle hospitals and they both invited me to come and take a look. The rest is part of my career history and apparent ultimate destiny.

First trip to New Sweden, 1983

As I now reach what the American Social Security Administration calls my full retirement age, I hope to be able to continue the work I love for many more years, but at a pace that allows me to smell the roses along the way. I look forward to having more horse time and more time for my writing.

Another change, sadly, is that I have exchanged my wedding ring for a newly purchased caduceus signet ring. Not that my dedication to medicine and long hours caused this to come about, but this change certainly did make me think hard about how I want to spend whatever time I have left on this planet.

Raking the roof at Soltorp

Look for much more writing in the future, at least after I get settled into my new routine.

Thanks for listening (I mean, reading).

Hans

If my hypertensive patient develops orthostatism and falls and breaks her hip, I fully expect the orthopedic surgeon on call to treat her. I may kick myself that this happened but I’m not qualified to treat a broken hip.

If my anticoagulated patient hits his head and suffers a subdural hematoma, I expect the local neurosurgeon to graciously treat him even though it was my decision and not his to start the patient on his blood thinner. After all, brain surgery is tricky stuff.

Why is it then that primary care docs, sometimes myself included, feel a little annoyed when we have to deal with the consequences of psychiatric medication prescribing?

My psychiatry colleagues diligently order the blood work that is more or less required when prescribing atypical antipsychotics, for example. But when the results are abnormal I get a fax with a scribble indicating that the PCP needs to handle this.

We need to just deal with that and appreciate that there has been communication between treating providers. Because that doesn’t always happen. Particularly with medication prescribing, we don’t always get a notification from our psychiatry colleagues when a patient is started on something new because their records are so much more secret than ours.

The other day I sat in my monthly conference with staff from the Behavioral Health Home that I serve as the medical director for. I consult on clinical and policy matters.

I heard of a couple of examples like the one in the headline and thought that we need to have a Clinical Collaboration Contract in place between providers who see these patients.

This would require notification when medications are started or changed and an expressed understanding that the participating clinician who is best qualified to treat a complication of either a psychiatric or somatic medication should do so.

If a prescribing provider notices that their prescription has a side effect, but the medicine is clearly the best choice for the patient, I can’t just expect them to stop what may be a major therapeutic breakthrough for the patient.

Here are some ideas for what a Clinical Collaboration Contract might include:

I will tell my colleagues if I start, stop or change any medication.

I will share lab work I have done in order to avoid duplication.

I will update my colleagues on major changes in the patient’s health or circumstances.

I will collaborate with my colleagues for the benefit of the patient even if it’s inconvenient.

I will not criticize my colleagues in front of my patient but raise my concerns provider-to-provider in a professional and open-minded manner.

Maybe this is too obvious and self evident to formalize, but judging from the stories I heard the other day, it probably isn’t.

When I use Dragon and say “PRN”, the words “as needed” appear on the screen.

I cringe every time. My medical record needs to be a tool for me and my peers, and most non-medical people have watched enough medical dramas on TV growing up to be thoroughly familiar with that particular abbreviation.

Why is it that almost everybody on the planet eagerly adopts the acronyms, abbreviations and technical terms of smartphones and other modern inventions without whining that the words are too difficult?

We have all had to add SIM card, SMS, jpg, mp3, LTE, RAM and a host of other abbreviations to our vocabulary in the last few years.

The language of everyday technology is advancing naturally and organically with the times while the language of medicine is continually being dumbed down and held back by political forces that assume people are unable to learn even the simplest words of any technical jargon.

But the US isn’t the worst in this regard. I just came across a listing by the British National Health Service, NHS, that strives to tell doctors how to speak with patients.

The Brits always did have a quirky sense of humor, and it seems to me that this list has sprung from that tradition:

passing wind

We don’t use “passing wind”. People understand “fart” better.

pee

We use the nouns “pee” and “urine”. We know that everyone can understand “pee”, including people who find reading difficult. Most people also understand and search for “urine”, for example in phrases like “blood in urine”.

We don’t use “wee” because it can confuse people who use voice technologies or screen readers.

We use “pee” for the verb, not “urinate” or “pass urine”. We know that the people who use NHS digital services talk about and search for “peeing more often” and “peeing at night”.

persist

We use “carry on” or “keep going”.

poo

We mostly use “poo”, rather than “stool”. We know that everyone can understand “poo”, including people who find reading difficult.

rectum

We prefer “bottom” or “anus”. Only use “rectum” when the other alternatives aren’t clear enough, for example when talking about surgery to remove part of the rectum.

We found that people don’t search for “rectum” in Google as much as other terms.

sick

We use “feeling sick” instead of “nausea”, but you may want to put “nausea” in brackets afterwards: feeling sick (nausea).

We use “being sick” instead of “vomiting”. Again, you may want to put “vomiting” in brackets afterwards: being sick (vomiting).

https://beta.nhs.uk/service-manual/content/a-to-z-of-NHS-health-writing#P

I think much of that list is a bunch of poo…

Most Saturdays I join a therapy session down the hall from where I do my walk-in clinic. A patient of mine has a weekly session just before the Alcoholics Anonymous meeting at noon in our big conference room.

Last weekend he told my behavioral health colleague that the people in the AA group who have the most solid recovery seemed to be the ones who claimed to really carry a lot of hatred for alcohol.

Later that day as David and I wrapped up our week, we talked about this. Generally, we don’t think of hatred as particularly healthy or therapeutic. Hatred for others is thought to always eventually create negative feelings towards oneself and even illness. “Depression is anger turned inward” is a common saying attributed to Sigmund Freud. He used the word “ambivalence” for the coexistence of love and hate, which many others have also written about.

(Freud’s linkage of love and hate now have a Functional MRI correlate: According to a ten year old article, “The Origin of Hatred” in Scientific American, the areas of the putamen and insula that are activated by individual hate are the same as those for romantic love. “This linkage may account for why love and hate are so closely linked to each other in life,” neurobiologist Semir Zeki, of University College London’s Laboratory of Neurobiology wrote in 2008.)

https://www.scientificamerican.com/article/the-origin-of-hatred/?redirect=1

But is there a place for pure, single-focused hatred? Freud, again, “defined hate as an ego state that wishes to destroy the source of its unhappiness, stressing that it was linked to the question of self-preservation” (Wikipedia, referencing ‘The instincts and their vicissitudes’ (1915) in On Metapsychology (PFL 11) p. 135).

David had already asked our patient to write down for next week if there was anything about alcohol that he hated, and he asked me as the primary care physician to list each of my patient’s health problems that could be related to alcohol. Of course, we can’t be sure, but it’s like the question on Maine death certificates whether smoking contributed to the death: There is a “probably” answer option. Before next Saturday I’ll have to go through the chart and make my list. I know it won’t be short.

Will our respective lists bring this patient to hatred of alcohol according to Freud’s definition?

But will such hatred, if not coexisting with its opposite, eventually cause this man to be depressed because of anger turned inward? In fact, he is already on medication for depression and it seems to be working well.

Maybe hatred of an inanimate object is different from hatred of any of our fellow humans, like hatred of plastic, pesticides or pollution. Maybe hatred for alcohol, once the spreadsheet we’ll create together makes its many negative effects on this person’s life and health undeniably and objectively evident, will make ambivalence impossible?

But maybe alcohol has more than two dimensions in my patient’s life. In his current ambivalent state of seemingly equal parts love and hate there is a tiebreaker, or maybe this one is a third and equal part of a complicated triangle: Habit. It isn’t for nothing we speak of someone’s alcohol habit. Alcohol is a strong one, linked to food, celebration, socialization and relaxation. It is for many people a strong conditioned response to all kinds of external and internal triggers.

I believe anger and hatred could have a catalytic effect, because few of us make purely logical decisions from lists of pros and cons. Rather, we use logic to justify the emotional split-second decisions we have already, at least almost, made.

I believe in the possibility that something emotional uncovered or triggered through this exercise might become the seed of hatred we are hoping for. Maybe it will be the sheer size of the list; maybe a health issue he never realized alcohol’s connection to; maybe a single item on the list will trigger a flashback to some childhood impression related to alcohol.

The more I think of it, I believe hatred is necessary because we are fighting both “love” and a very strong habit in this case. And I do think you can hate a thing without hurting yourself.

Some drugs are used for indications beyond their original FDA approved ones that make complete sense. I mean, if old seizure medications help nerve pain, it might be reasonable to try new ones for the same purpose if everything else fails.

Sometimes the broader use of a medication leads to additional FDA approved indications. One good example is bupropion, Wellbutrin, for smoking cessation. It even got a new name for that indication, Zyban, presumably to remove the stigma of taking an antidepressant.

The story behind Viagra is interesting:

Sildenafil, eventually marketed as Revatio, at 20 mg three times daily, was studied for angina and hypertension. At the end of the trial, many male patients refused to return their unused medication. Researchers asked why in the world these middle aged men wanted to keep their leftover experimental heart medication. The rest is history.

Sildenafil had little effect on heart disease, did work for pulmonary hypertension, and wasn’t a major blockbuster as a drug for that indication. But it certainly was when two years later, in 1998, it was re-marketed under the name Viagra, (a word play on virility and Niagara, I am told).

Now, even shortly after Viagra went generic, the 25, 50 and 100 mg tablets are quite expensive. But the generic version of Revatio, same compound in a 20 mg dose, costs about $1 per pill. Two or three of them on a PRN basis is the same, right? No, actually not. The 20 mg pill strength has only been approved for pulmonary hypertension. So at the moment, this may very well be one of the more prevalent forms of off-label prescribing in the US.

Today, beyond the FDA approved indications of pulmonary hypertension and erectile dysfunction, sildenafil is used off-label for Rayneaud’s phenomenon, female sexual arousal disorder and, non-prescribed, for athletic performance enhancement (placebo or not?)

Any FDA approved medication can be prescribed for other indications. Sometimes insurance companies and pharmacy benefit managers (PBMs) save money by only paying for “approved” use of expensive drugs (See my post “Calling Mrs. Kafka“).

Some “unapproved” drugs from my personal tool bag are:

Cyproheptadine is an antihistamine with anticholinergic and antiserotonergic properties. I have used this very successfully to treat SSRI induced delayed ejaculation. I have also tried it many years ago, based on the literature, for migraine prevention and cyclic vomiting syndrome with dubious efficacy. Reading up on it today, I also see that it has been used off-label for psychogenic itch and drug induced akathisia and hyperhidrosis. It is also used as an appetite stimulant.

Doxepin is an antidepressant with anticholinergic properties. I use it occasionally as a sleep aid and for chronic urticaria, because the modern nonsedating antihistamines are less effective for itching. It is the anticholinergic effect that relieves itching and the more famous diphenhydramine (Benadryl) is too short acting to be very practical for chronic itching.

Misoprostol is one of the few medications that can help tinnitus. The use of benzodiazepines for this condition, which is what I was thought in medical school, has largely fallen out of fashion. Misoprostol is only approved as a stomach protectant for people who take NSAIDs like ibuprofen, and to induce abortions, start labor or control postpartum hemorrhage. Why it sometimes works for tinnitus is a mystery to me.

Off-label use of a whole host of medications is so common that we almost forget that the FDA hasn’t caught up yet, but of course the FDA will only “approve” an indication after it has been presented with sufficient evidence (at great cost to somebody). Who will do testing on old, generic and inexpensive drugs if there is no money to be made from the new indication?

Very rarely does a drug company bring evidence to the FDA about the safety and efficacy of an old drug. This happened some years ago with the ancient drug colchicine for gout. One manufacturer produced the required evidence and got a patent, and the new brand name Colcrys. Now that patent has expired and, ironically, now there is another indication, still off-label, we all use: It is very effective for painful pericarditis. But who will spend the money to get it “approved”?

Medicine is an art, and use of medications is one of the expressions of this. There are two ways of looking at off-label prescribing. You can be rigidly against it and deprive your patients of perhaps their only chance of relief from their suffering, or you can read the literature, remember your pharmacology and weigh the risks and benefits with your patient and make a shared, informed treatment choice.

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The man, who has traditional Medicare and thus the right to see any specialist who accepts Medicare, wanted me to get him in touch with the brilliant Boston hand surgeon. The man told me he wanted a diagnosis and a cure, and not just a bunch of pills, which is what his family doctor had offered him.

“I won’t take gabapentin, I mean, with all those side effects”, the man said emphatically.

“Did anybody suggest the diagnosis of Reflex Sympathetic Dystrophy or Regional Complex Pain Syndrome?” I asked.

“No, is that the name for what I’ve got?”

“I think so”, I told him. “And I don’t think even the most brilliant hand surgeon can help you. Around here, this is a problem that physiatrists, rehabilitation specialists, handle. I think you should see Dr. Paul DeBeck.”

“What would he do?”

“Confirm the diagnosis and probably offer you medication to start.”

The man frowned.

“The list of side effects is only a list of possibilities. It’s published for legal purposes, so you can’t sue the drug company for not warning you”, I explained. “I mean, would you drive a Jeep, or any car, on a public road if you read a document that said your gas tank could explode if you got rear ended, you could hit a moose, you could roll over if you went through a curve too fast, you could slide into a ditch on an icy road or you could get impaled if you drive too close behind a logging truck…”

“Anyway”, I continued, “I think your problem is not surgical, so going all the way to Boston would probably be a big waste of your time. I suggest you ask your doctor for a referral to Dr. DeBeck, right in Bangor. Then he could guide you from there, even if he doesn’t think it is what I think you have. He sees a lot of that type of problem, so he’ll know.”

The same day, I saw a woman with “hip pain”, which turned out to be on the lateral, outer side, of her hip and a little toward the back side. That spelled sciatica from lumbar disc disease. She had wanted an orthopedic referral. But in the northern half of Maine, almost none of the orthopedic surgeons deal with back problems, so an orthopedic referral would have been a terrible waste of time for her.

I sometimes wonder why it is that medical specialties are divided up the way they are; you need to know the diagnosis before knowing what specialist to see. I mean, why isn’t there a belly pain speciality? But, that is why it makes sense to see a generalist first. Plus, we are qualified to treat most cases of the majority of diseases people run into.

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

We also get penalized if we see an infrequent visitor only once in a given year and don’t screen and provide interventions for depression, alcohol use, smoking and a host of other conditions unrelated to what the patient came to us for.

So we can’t afford to have quick visits since anything less than comprehensive makes us look bad.

Imagine if you pull up to an ATM for $40 in cash and the machine insists on going over your annual budget with you. That’s what primary care feels like sometimes.

Of course I will look one or two steps beyond the chief complaint. If a smoker has bronchitis, I’ll talk about smoking. And if an alcoholic falls down his front steps, I will take the opportunity…

But I can’t do everything for everybody in every visit. I can be comprehensive, over time, if I am not penalized for squeezing In patients with simple problems for quick visits. I think that is more comprehensive than declining to provide rapid access and thereby forcing patients to fragment their care between multiple unrelated providers.

Here is my simple prayer:

Dear Overlords of CMS and all you other Healthcare Policymakers and Deities,

Let us judge how to best meet our patients’ needs when they come to our clinics. Admit that sometimes a sore throat is just a sore throat.