Archive for the 'Progress Notes' Category

I Love Calling Patients – And I Don’t

That is, I don’t do it very much and I don’t love it with all my heart.

Talking to patients on the phone can be very efficient and quite rewarding, like when I called a worried patient today and told her that her chest CT showed an improving pneumonia and almost certainly no cancer, but a repeat scan some months down the road would still be a good idea. She told me she was feeling better, but still quite weak and that her sputum was still dark yellow. So, while still on the phone, I e-prescribed a different antibiotic, after going over her long list of allergies with her.

But as a primary care doctor with a productivity target of 24 patients per day, and absolutely no credit for phone calls, this is not something I am incentivized to do.

So instead, I am tempted to resort to the internal EMR messages:

“Mrs. Jones is looking for her CT results, please advise.”

I could have typed in what to tell he patient, but then when the medical assistant had her on the phone, she probably (hopefully) would have mentioned that she was still raising dark yellow sputum. The medical assistant would then tell her she’d check with me and get back to her.

Would I have remembered that the levofloxacin the ER gave her caused horrific nightmares if I hadn’t been engaged in conversation with her? Maybe I would have just tried to refill that?

How many back and forth messages would it take to handle something as simple as this, and how many times would the medical assistant need to call the patient back to get all the necessary information?

If all work we do was recognized as work, if Medicare and Medicaid paid our clinics for phone calls, doctors would have time in their schedules to personally return patient calls. (Medicare does, but so far only for people we sign up for chronic care management where they will incur monthly copays for this “added service”, mostly designed for nurse calls).

Some commercial insurers now do pay for phone calls, but in Federally Qualified Health Centers, where I work, private insurance is such a minor portion of our payer mix that their reimbursement policies are close to irrelevant for our bottom line.

The struggle in primary care is that right now, we get paid “per visit” with very little regard to “outcomes”, but very soon, our clinics will prosper or perish depending on how well our patients do and how much they cost “the system”. I talk with my bosses every week about how we can make this transition without losing our shirts.

Mrs. Jones, if I hadn’t called her myself, might have gone back to the emergency room several days later, in terrible shape, required admission to the hospital and incurred thousands of dollars of cost. My doxycycline prescription may have avoided that.

And, being able to personally get back to patients fosters loyalty and provides levels of reassurance that only come with the role of the physician.

Darn it, that’s what I am, and that is what I need to provide as much as I can of.

Ask the Professor

After publishing the post about my first day of medical school, I felt a bit nostalgic. I googled some of the names I remembered from back then and sent a few emails with a link to my post.

C., who was a junior teacher and researcher in the department where I earned my one citation in Index Medicus, was the first to reply. Eight years my senior, he was listed in the University catalog as Professor Emeritus.

There is something profound about learning that someone you know reached such a pinnacle of academia, earning his place among Linnaeus, Celsius, Ångström, Berzelius and Bárány.

It is also remarkable that the man I remember as barely older than I is already an emeritus, and officially retired, although still busy in both academics and clinical medicine, as I learned.

In a return email, I shared with C. my memory of the practical portion of my internal medicine exam, where Professor Boström sat and broke tongue depressors in a corner of the room. Ever since, I have had a slight doubt in the back of my mind whether my performance on that day really was pathetic enough to drive the professor of medicine to distraction.

One sentence in C.’s reply wiped away thirty-eight years of gnawing self-doubt: “Harry was always fiddling with something or rubbing his palms together”.

That sentence was an unexpected bonus in my delight at reconnecting with C.

Sunday morning as I with my pitch fork and a tarp-covered garden cart took on the task of cleaning out the goat yard, I thought to myself: “Professor of medicine at Uppsala University, huh – I wonder if he has the answers to some of my questions that the specialists at Cityside Hospital haven’t answered to my satisfaction.”

As I toiled, I began making my list of things to ask C. The first thing I thought of was why a normal nuclear medicine study trumps an abnormal stress-EKG. That is the answer every cardiologist I have asked gives me.

The EKG can change with potassium levels, digitalis administration, pericarditis and all kinds of things. Why are cardiologists so nonchalant about ST depressions and T-wave inversions just because a grainy picture of the heart has a relatively uniform color? Is it, perhaps, because they still view coronary artery disease as a plumbing problem rather than an inflammatory condition?

Maybe a positive EKG stress test with a negative nuclear image should be viewed as evidence of heart disease with not-yet-critical blockages, but still cause for aggressive action, particularly to reduce inflammation and thrombosis risk?

That is probably enough to ask the professor; I wouldn’t want to bombard him with all the random everyday musings of a country doctor.

P.S. I first drafted this post in 2014 and never came back to it until now. Shortly after writing it, I realized that C.’s successor as Professor of Medicine at Uppsala University was S., a classmate of mine. He always had, like Columbo, one more question. I settled for “what do I do if I run into a [Blank]? That’s why S. became a professor and I a Country Doctor. But I wouldn’t trade my job(s) for any other career in the world.

Sometimes You Just Gotta Treat It

“Red” McDougall had terrible leg pains soon after going to bed. He did have a bad back, and some mild spinal stenosis, but I hadn’t heard much about that in the past few years. He was just dealing with the ache in his legs when he was on his feet too long.

A few months ago he saw his vascular surgeon for a routine followup. He’d had a femoral-popliteal bypass to restore circulation to his right leg a few years ago. The vascular surgeon was intrigued by the fact that both legs hurt when elevated. That is usually a sign of severe ischemia, but Red’s pulses were palpable. To play it safe, the surgeon ordered formal pulse volume recordings and a CT angiogram.

The studies were normal and the surgeon speculated that the pain could be related to Red’s bad back.

I saw him for a diabetes followup a few weeks ago. He had ever so slightly decreased monofilament sensation in both feet and his legs had normal strength, normal reflexes and no atrophy.

“Does it feel like cramps?” I asked.

“Not really, they just hurt”, Red answered. “It’s so bad I have to sit on the edge of my bed and dangle my legs or walk around a bit before it goes away. But it’s driving me crazy. I hardly get any sleep anymore.”

“Well, we know it’s not your circulation”, I began. “It could be just a form of leg cramps, even though you can’t tell if there is spasm in the muscles. Or it could be a strange way for your spinal stenosis to act up in the opposite position from the way it usually behaves. So I have an idea.”

“Anything”, he was quick to answer.

“Cyclobenzaprine. A muscle relaxer that is related to the antidepressant amitriptyline. In addition to preventing muscle spasms, it has pain relieving properties and it usually helps people sleep.”

“Gimme some”, Red held out his hand.

“I’ll send in a script. Let me see you back in two weeks, because if this doesn’t work, I’ll need to do some serious thinking.”

I thought to myself about how often specialists are in a position where they can simply declare “Not my department”, but primary care docs are then more or less obligated to pick up the ball again and do something.

Two weeks later, Red was a new man.

I’m sleeping through the night, and no pain”, he grinned.

I still don’t know exactly what this was, but it’s gone.

Sometimes you just gotta treat it.

Reruns

I have published well over 500 posts on A Country Doctor Writes since I started blogging over ten years ago. Right now I am pretty much posting something new twice a week. But I thought I’d put a “rerun” of an older post up every day (or almost every day) for the next year to allow frequent visitors to see older posts that would take lots of WordPress Infinite Scrolling or scrolling down the “Archive” to get to. The one I am pinning to the front page today is called “The Power of Words“.

HELP ME!

He seemed like his usual self, strong willed and irreverent, with his gravelly voice and nicotine stained fingers, and as always tied with clear plastic tubing to the oxygen concentrator on the back of his wheelchair.

He is a DNR, Do Not Resuscitate. But during his last hospitalization he ended up intubated and on a ventilator for several days.

His daughter gave her version of what happened and the discharge summary was less clear cut. So I turned to him and asked:

“So what happened? How did you end up on a respirator as a DNR?”

He answered “I said HELP ME, and that’s what they did”.

“I think the doctors panicked when he said that”, his daughter concluded.

“And would you want that to happen if you say HELP ME again?”

“No.”

“So when somebody can’t breathe, there are sometimes only two options, sticking a tube down their throat and hooking them up to a respirator or giving them morphine to treat the agony and anxiety of the process.”

I glanced over at his daughter and then looked him straight in his eyes.

“So, let me make sure I hear you right. If you can’t breathe and say HELP ME, does it mean machine or morphine?”

“Morphine”, he said, emphatically.

I’m glad we had this talk. This very plain talk.

Distance, an American Health Disparity

Driving north in a snowstorm Tuesday of Thanksgiving week I certainly took my time. I left after our Suboxone clinic wrap-up conference, around 7:30, and arrived at my unplowed driveway in Caribou about 1 AM.

On the way up, I saw two ambulances, one from Caribou and one from Presque Isle, on their way back home from Bangor. I’ve got a large SUV with all wheel drive and studded Finnish snow tires. They don’t, but they passed me and blew up clouds of snow behind them as they did. I also met an ambulance careening south toward Bangor down I-95 with full lights on.

I had an appointment for a telephone interview with a journalist for the next evening to talk about the challenges of rural medicine.

Distance is certainly one of them.

Not long ago I met a patient who, after a routine knee surgery, developed a lot of swelling as his hemoglobin dropped precipitously. Two hours passed before it was clear he needed emergency vascular surgery. The Presque Isle hospital has sometimes had a vascular surgeon and sometimes not. This was during a “sometimes not” time.

The Bangor vascular doctors accepted the transfer. The patient was on IV fluids, received blood and drugs to keep his blood pressure up, but it was a snowy night. Neither helicopter nor fixed wing aircraft could fly, so there was no other choice besides ground transport.

Seven hours after the original injury, he was in the OR. Circulation to his lower leg was restored, but today he still has problems with it. If Presque Isle had had a vascular surgeon on staff, if the weather or time of year had been different, he would have fared better.

There is one full time neurologist north of Bangor, no full time gastroenterologist, no neurosurgeon, no endocrinologist, no nephrologist, no dermatologist and the list goes on. Some specialty services are available as once a month or so visiting doctors to each hospital’s “Specialty Clinic”.

There is a lot of talk among my kind of primary care clinics about eliminating “Health Disparities”, and I often hear about cultural and economic differences in access to care. But here, the biggest challenges are geographic, sometimes compounded by something as uncontrollable as the weather.

When I interviewed for my 1981-1984 Family Practice residency, I really liked what I saw in Bangor, but it seemed so far north. I instead chose Lewiston, 100 miles to the south.

As life played out, I now work near Bangor part of the week and 200 miles north of there the rest of the time. And I now think of Bangor as “south”.

I told the journalist some of these things on the phone the night before Thanksgiving as I drove from Van Buren to Caribou long after dark. I also told her that practicing primary care in a remote, rural area lets me use my training and my skills more than where there are specialists on every street corner.

I canceled my plans to challenge the tail end of the snowstorm by driving back “downstate” for the holiday after just three hours of sleep the night before and a full day of clinic work. I got an early start the next day instead. You can’t make exact plans during northern Maine winters.

The Elfins Return

I have known him for over thirty years. He has been legally blind for the past five.

He tends to be a practical, no nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said:

“I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things…” he began, “I’m seeing children with elfin faces…”

His large, thin hands were in his lap. I put mine on his and said “I know what that is. You’re not crazy. This is something that often happens to people with very poor eyesight. It’s called Charles Bonnet Syndrome, and it was actually described in 1760 by a Swiss philosopher who observed it in his grandfather who was going blind. It’s like the brain fills in the empty spaces, and for reasons we don’t understand, much of the time it tends to be with elfin like children. They’re usually friendly and jovial and there’s nothing threatening about them.”

“Right, these are. I’m so glad to hear this is not some psychosis.”

“It’s a hallucination, but not a psychosis”, I reassured him. I printed up an article and gave it to him to show his friends and the staff at the Senior Citizens Home.

A few days later I heard how appreciated the article was.

This was only the second time in my career I have seen this condition. The first time I had no idea what it was but a family member of that patient brought in a printout of an article they had googled. That was ten years ago and I wrote about it in my first year of blogging.

Apparently up to 10% of people with visual acuity under 20/60 have this syndrome, and it tends to go away when vision is completely lost.

This little incident evoked two distinct feelings for me. The first one was the comfort, confidence and gratitude that I could instantly reassure my longtime patient that what he was experiencing has happened to other people and has a name and a long history. The other feeling was equally profound and mixed with all kinds of emotions:

My patient was once my neighbor, and my soon to be 35 year old son was often hanging around his yard, checking out his motorcycle, convertible Mustang and garden tractor. My son did look like a little elfin at that time. Maybe it was him that he was “seeing”.


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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”.

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