A Country Doctor Writes:

I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

For those who don’t know:

A “precancerous“ adenomatous polyp has only a 2% risk of actually turning into a cancer. So screening colonoscopies, while they make some sense on the population level, are less obviously a statistically good deal for the majority of people who have them if you consider the out of pocket cost when something is found.

Cologuard, the noninvasive screening test, sounds like a good deal but a positive test result represents no disease at all 50% of the time and non-cancerous conditions about 45% of the time. And if you have a positive Cologuard, the subsequent colonoscopy is technically definitely a diagnostic colonoscopy subject to all the financial penalties people are so upset about.

So, my 40-year-old woman with colon cancer until proven otherwise keeps calling me, saying she won’t have the colonoscopy unless I can make sure it’s billed as a screening colonoscopy.

Well, traditional guidelines have been to start screening at age 50, and now there is a movement to start screening at age 45 because colon cancer is seen in many younger people now. You can also qualify for a screening colonoscopy 10 years before a first-degree relative developed colon cancer.

Those are the rules. I didn’t make them up. Somebody working for Obama did.

In the area where I practice, there are no gastroenterologists. General surgeons are the ones who do colonoscopies. And unlike big city gastroenterologists (Bangor, Maine) our local surgeons meet with the patients first to take their history and establish the need for and classification of the colonoscopy.

We have urged my patient to at least go and talk with the surgeon. That will not cost $5,000 but will hopefully make her understand her situation better.

This is what I call Metamedicine. I know what my patient needs, but how do I get her there? What are all the bureaucratic and financial obstacles standing between me and my patient on one hand, and what we both agree she needs to have done on the other?

Doctors predictably get themselves into trouble when they prescribe controlled substances for themselves.

In an earlier era that was a common practice, partly perhaps because doctors were solo practitioners far apart from each other, and perhaps also because doctors were thought to be able to handle the conflict of interest of being their own providers.

The Latin “Sig” “Ad Usum Proprium” means “for personal use”, but it is often confused with “as directed”. In the EMRs I have seen, that is not in the drop down choices for electronic prescriptions.

These days any self prescribing is discouraged, but I think we should promote some kinds of it: I think doctors should treat themselves more often when it comes to diet and exercise prescriptions.

We are witnessing an epic shift in the health of our nation. Overall life expectancy and healthy life expectancy are decreasing in my generation, the baby boomer cohort.

This deterioration of our nation’s health status is fueled in part by the food and snack industry and the comfort and convenience concepts of the postindustrial sedentary American lifestyle.

The misinformation about what constitutes healthy living, in particular when it comes to food choices, is colossal, and few people have the insight and wherewithal to navigate through this. This is where well educated health professionals may offer a glimmer of hope for a shift for the rest of the population.

I think healthcare providers need to use all the influence we have left in the fight against junk food and physical inactivity, not only in what we say but also what we do.

We need to speak out against consumption of high fructose corn syrup, boxed breakfast cereals and instant oatmeal, snack crackers, pretzels, Pringles, Cheetos, Little Debbies, Twinkies, Pop Tarts, breakfast bars, milkshakes, chicken nuggets, French Fries and a whole host of restaurant and fast food favorite meals.

The list goes on, and the literature is out there. As I used to tell my mother when I was a picky young eater who didn’t like complicated dishes: “I want straight food” (Jag vill ha rak mat). It is almost axiomatic that food that is prepared with minimal processing and without unnatural ingredients is the healthiest and probably best suited choice given our genetic makeup.

Are we talking enough about this with our patients? Do we buy into the fact that such conversations can make more difference in our patients’ health than our medication prescriptions? And to what degree are we really paying attention to this in our personal lives? Are we walking the walk, not just talking the talk?

Resources:

High Fructose Corn Syrup exposes humans to unnatural quantities of fructose:

https://www.healthline.com/nutrition/why-high-fructose-corn-syrup-is-bad

Palm oil’s health risks are a bit controversial but environmental impact of its production is clearly negative:

https://www.who.int/bulletin/volumes/97/2/18-220434/en/

Mounting evidence against ultraprocessed foods:

New evidence links ultra-processed foods with a range of health risks

What are ultra-processed foods and are they bad for our health?

Worry about breakfast cereals:

https://www.healthline.com/nutrition/are-breakfast-cereals-healthy

The 28 Worst Breakfast Cereals—Ranked!

Many patients make this or similar requests, especially in January it seems.

This phenomenon has its roots in two things. The first is the common misconception that random blood test abnormalities are more likely early warning signs of disease than statistical or biochemical aberrances and false alarms. The other is the perverse policy of many insurance companies to cover physicals and screening tests with zero copay but to apply deductibles and copays for people who need tests or services because they are sick.

It is crazy to financially penalize a person with chest pain for going to the emergency room and having it end up being acid reflux and not a heart attack while at the same time providing free blood counts, chemistry profiles and lipid tests every year for people without health problems or previous laboratory abnormalities.

A lot of people don’t know or remember that what we call normal is the range that 95% of healthy people fall within, and that goes for thyroid or blood sugar values, white blood cell counts, height and weight – anything you can measure. If a number falls outside the “normal” range you need to see if other parameters hint at the same possible diagnosis, because 5% of perfectly healthy people will have an abnormal result for any given test we order. So on a 20 item blood panel, you can pretty much expect to have one abnormal result even if you are perfectly healthy.

One way I explain this to my patients is that if you say that every person under a certain height is a dwarf, you will misdiagnose many people. You need to look at, in this case, other parameters such as head size, length of the fingers and so on. An isolated number doesn’t mean very much.

In some cases normal or abnormal values do not represent health versus disease. For example, a fasting blood sugar of 120 mg/dL is considered non-diabetic in the United States but a diabetic level in Canada. You have to draw the line somewhere and where you draw it is a judgment call or a matter of consensus. For example, we are not entirely clear on the clinical significance of a slightly low vitamin D level, which is being studied and debated right now. And in the case of magnesium, you can have a normal level in the blood and be severely deficient in the rest of your body because we are designed to maintain a certain blood level more or less at all cost. Serum sodium doesn’t correlate completely with the level in our cerebrospinal fluid and brain, so it is possible that of two people with low sodium levels, one can be healthy and the other one desperately ill.

On top of all the vagaries of test interpretation, can anybody imagine how many things we can now test for, how much that can cost and what insurance company would consider footing the bill for such blanket requests?

So I try to not order any bloodwork before annual physicals. I want to know what’s going on, what my patient’s priorities are and make a shared, informed decision about what to test for. I can still use the physical exam diagnosis code to get many tests that patients want covered, but it would be preposterous and presumptuous for me to order hepatitis C, HIV or urine chlamydia and gonorrhea tests without asking patients if they want to be tested.

A new decade and a new EMR are making me think about what the best use of my time and medical knowledge really is. The thing that stands out more and more for me is the tension between what my patients are asking me for and what the medical bureaucracy is mandating me to do. This is, to be blunt, an untenable, crazy-making situation to be in.

Many of my patients with chronic diseases don’t, deep down, want better blood sugars, BMIs or blood pressures – nor do they want better diets or exercise habits. People often hope they can feel better without fundamentally changing their comfortable, familiar and ingrained habits – that’s just human nature.

I went to medical school to learn how to heal, treat and guide patients through illness, away from un-health and toward health. I didn’t go to school to become a babysitter or code enforcement officer.

“So, it’s been three months. I can see you haven’t lost any weight, actually, you gained some. Your blood sugars are up a hair and your blood pressure is staying about the same. I think it’s time we add a couple more medications…” I might say as I imagine my quality scores continuing to lag for 2020.

My patient has dutifully showed up for a potential shaming or embarrassment session due to his lack of motivation to give up some of his comforting vices. But if you don’t show up, you might in the end lose your entry point to the primary care system – you may become an “inactive” patient.

What he really wants is some answers, explanations and reassurance about common symptoms he’s been having and maybe some shortcuts to better health without turning his routines upside down too much.

“I work for you”, I often tell my patients. “I’ll help you move toward your own health goals for yourself.”

How crazy is it that Medicare decides the best use for each of my fifteen minute encounters with my patients? That is a dystopian, totalitarian, nightmarish concept that makes me think of clanking iron gates, media censorship and surveillance cameras.

For 2020 I will record more health information videos and find more ways to communicate positive health messages in my clinic and community.

I will automate the way I meet the Medicare mandates as much as I can by mastering my new technology and I will work hard to make sure every patient feels heard and valued during our visits.

I will continue to see myself as an example for my patients. If I don’t take care of myself, how could I possibly help my patients help themselves? Many have seen me lose weight, so I tell them what I eat. They ask about my little farm and I tell them I have no power equipment and do a lot of walking, carrying and shoveling.

I will be on the lookout for natural opportunities to nudge my patients toward making lifestyle changes without preaching or criticizing past behaviors.

But most of all, I will make sure to ask everyone soon after walking through the exam door what they hope to get out of that particular visit.

Darn it, it is my patient’s visit. May I never lose sight of that.

Since medicine is such a relationship based vocation, I find myself very often looking at my patients as people and not as clinical subjects. I have to keep reminding myself to do both.

I saw a cancer survivor recently whom I have known for ten years. I had referred him to a neurologist because of an atypical tremor. The neurologist diagnosed my patient with Parkinson’s disease but also pointed out that he had Horner’s Syndrome (droopy upper eyelid, small pupil and sunken in eye as we describe it in Sweden, lack of sweating on that side of the face, the way Americans describe it).

Was I ever humbled; I had seen the droopy upper right eyelid since I first met the man, but never had reason or, rather, been medically curious enough to check his pupils – the pupil on the droopy lid side is indeed smaller.

I have seen Horner’s Syndrome a few times, twice in the context of sinus cancer. One case was a woman who ended up with surgery that exposed the back of her eye socket and the back wall of her maxillary sinus, just like the pictures in my old anatomy books, the other was my own cat, who did not go through such radical surgery. Both died from their disease.

My Parkinson’s patient must have had the syndrome for a long time and no underlying disease has been found in his case.

I remember during a Harvard endocrinology course I started looking at passing strangers in downtown Boston every afternoon between class and dinner and wondering if they had acromegaly, polycystic ovaries, Klinefelter’s Syndrome, Cushing’s Disease or some other topic discussed that day.

But to be honest, I have dragged my feet many times before ordering the tests to rule such conditions in or out, almost as if I don’t want to insult my patients by suggesting their appearance is pathological.

That just isn’t right. I need to be a keen observer of clinical signs of possibly life altering diagnoses; I need to look at each one my patients not only for any change in their appearance, which I’m pretty good at, but also against my memory files of clinical syndromes that I, as their trusted family physician, should notice before some out of town specialist makes the diagnosis in a single appointment that wasn’t even for that particular abnormality.

Maybe that can be a New Year’s resolution of sorts.

(A New Year’s Reflection)

I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.

Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.

Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.

Suddenly it’s perfectly clear: There is endless profit potential for countless corporations in America’s chronic disease epidemic and it is in their interest that people with chronic disease stay as sick as possible without dying from their disease. Why risk research money on acute disease when there is no continuing revenue stream to look forward to?

If people did all the things we know could improve their health, pharmaceutical companies, insurance companies, pharmacy benefit managers and many others would go out of business, just like shopping malls and print media companies.

Where are the disrupters in healthcare? Will the perverse motives of the sick care industry create a public uproar? Will the old system someday finally crumble?

Now, I’m just a country doctor but I’m starting to wonder if a system like the one we have can really continue to function much longer.

Happy New Year, American Healthcare.

Happiness is widely thought of as being present in and enjoying every moment of our lives. The whole mindfulness and meditation movement is built on this premise, as are some of the major religions of the world.

But how possible is it to enjoy every ordinary day if our thoughts are elsewhere, ruminating about a future that may not even happen?

Let’s be honest and admit that there are no good treatments for Alzheimer’s disease. Let’s also admit that the things we know can delay its onset are the same things that to some degree can ward off diabetes, heart disease and many other chronic diseases that afflict us westerners.

So, I don’t buy into the strategy of using genetic or other predictors in singling out individuals for scare tactics in promoting healthy lifestyles that we should all be adopting anyway.

It doesn’t work very well with diabetes, now does it? We can and do talk about blindness, kidney failure and toe amputations, but people still get those things, even though diabetes is a whole lot more reversible than Alzheimer’s.

If scare tactics can delay the inevitable outcome of this terrible disease only to a small degree, what impact can an early diagnosis have on people? Depression? Suicide? Self-neglect? Risk taking? I think those negatives are a whole lot more frightening than poor estate planning, which is one argument for early diagnosis I have heard again and again.

Would you tell a school child they’ll never get the life or career they hope for? Would you tell a pregnant woman that her baby will die from SIDS a few months after birth? Would you tell a bride that ten years from now she’ll be a widow or divorcee? Would you tell a grandmother that her first grandchild will die from an overdose before age 15?

All we have is today. We should live it to the fullest, not in a hedonistic way, but with respect for our bodies, our fellow humans and our planet. And we should lead healthy lives because it is the right thing to do, and because that can help us enjoy the future more – if we should happen to get there.

I watched my father die at 86 from Alzheimer’s, which is how his mother had died. He seemed puzzled sometimes, but he didn’t seem aware or concerned about his declining cognition or his ultimate diagnosis by the time it had become obvious to the rest of us.

Curiously, the common word for it in Sweden when my grandmother died was åderförkalkning, hardening of the arteries, which actually better approximates the pathophysiology than the mumbo jumbo amyloid theory that made this disease seem quite random. When it was called hardening of the arteries, the commonsense implication was that unhealthy eating habits accelerated the disease in predisposed individuals, which is where we have now ended up again.

We should promote healthy lifestyles with the carrot – as a way to feel better in the short term and possibly into the future, but spare us from the stick. Reward is a better motivator than punishment.