Archive for the 'Progress Notes' Category

If You Are a Doctor, Act Like One

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 – Yours Truly

It cannot be said enough: Ours is a relationship based vocation. Unless you are doing autopsies for a living, you need to establish rapport with real, live human beings in need of something, with fears or suffering, with past experiences and future hopes.

As a doctor, I play some sort of role, small or big, in the life of every patient I see, for a single visit or over the course of many years.

I am only one person, but I have a vast repertoire of demeanors and vocal inflections, a rich vocabulary of medical and non-medical words and a well honed body language I can put to use in each patient encounter depending on what my patient needs in that moment.

One obvious role is to be the one who correctly diagnoses and treats each medical problem. But medicine is more complicated than that. We know that a physician’s behavior greatly influences medical outcomes, even for conditions that don’t appear to be psychosomatic.

Another role I often think, speak and write about is that of guide. In that role, we need to carefully balance our own authority with deference to our patient’s need to develop and maintain their own. Project too much confidence in your knowledge and experience and hold the patient back; project too little and be of no help at all.

When it comes to the lifestyle related epidemics of our time, we need to be the bellwether for our patients, not by preaching from a pedestal but from a position of a near equal, just one small step ahead. Never obese, I still carried more weight than I should, and I use my own fifteen pound weight loss journey as a peer-to-peer example.

When our patients face the end of life or tragedies of any kind, like it or not, we need to shoulder the priestly mantles many modern people need us to wear as they lack religious connection or foundation. In such cases, we need to seem a little bit above the trivialities of this world, which often makes no sense to those who suffer.

Oftentimes, in the maze of the healthcare bureaucracy that our patients find themselves lost within, we as doctors need to fill the role of advocates. We cannot ever give the impression, or think to ourselves, that we aren’t working for them. Without patients who believe we are on their side, where would we be? This one is probably the most important role we play in 2019.

Choosing how to behave in any given patient encounter is not “acting” in the sense of not being yourself. It is being tuned in to each patient in each instance and filling the need each one has. It is about not barging into the exam room with our own agenda all set. It is approaching each patient with an open mind, ready to listen:

“How can I help you today?”

I Am Not an InstaDoc*; This Is Not InstaMedicine*

* (I know these words are used for Instagram pictures of beautiful medical professionals and gory surgical procedures, but I choose to use them as words of instancy in the practice of medicine.)

The other day a patient called every hour to inquire about the status of her elective cardiology referral. She had been thoroughly evaluated twice at the hospital for chest pain and wanted a consultation.

Another patient called three times the same day because she had seen “Ambulance Chaser” legal firm advertisements about lawsuits against manufacturers of generic valsartan, which may have traces of Chinese cancer causing chemicals.

It has been said that new medical information takes 17 years to alter the way we practice medicine. Contrast that with the immediacy of today’s electronic media…

A certain delay before acting is not a terrible thing in every instance. Overcorrection can be just as risky as undercorrection when you’re steering a big ocean liner approaching a harbor or a fast moving car on icy Maine winter roads. Or when you’re juggling the multifaceted responsibilities of caring for hundreds of patients’ lives.

We live an era of instant fulfillment. We have become impulsive and impatient. Fewer and fewer things are considered better when taking the time they used to take: Faster is viewed as inherently better.

Speed reading and speed dating, same day surgery, curing lifelong depression with a single infusion – we strive to defeat time and the forces of nature. There is no respect for the rhythms of life.

And yet, there is also the mindfulness movement, but it is largely linked to the alternative practices of medicine. Mainstream medicine is paying some lip service to such things, but it is becoming more and more firmly pigeonholed in the whirlwind of consumerism and electronic immediacy.

The practice of medicine used to be, and should return to being, a more contemplative pursuit. When we constantly go for the quick fixes, we risk overlooking or not even understanding the big picture.

In the case of the drug recalls, it wasn’t too long ago that some of my patients insisted on being switched from one angiotensin receptor blocker to another and then another and then yet another as the news about their impurities trickled in.

And, remember Vioxx, Merck’s stomach-friendly arthritis pill? Sales were booming, then reports of high blood pressure and heart attacks started to make the news. Merck panicked and took the drug off the market. Pfizer had steadier nerves and kept making their sister drug, Celebrex. Not long after, the data came out that Celebrex also increased heart attack risk, so doctors started to avoid it and switched patients back to the older NSAIDs. However, they, too, turned out to increase heart attack risk. Not as much, but still enough to make us reconsider our use of all of them.

In this case, instead of panicking and switching patients back and forth in desperation, we would have been better off doing nothing while stepping back and assessing the situation.

We’re supposed to be professionals, not robots…

Treatment of Peritendinitis Crepitans: Heparin or Prednisone?

In Sweden, my treatment would have been IV Heparin. But a single dose prednisone also worked.

My trusted SUV, now with 266,000 miles on it, needed a new transfer case so I couldn’t trailer my monthly hay purchase last weekend as I usually do. Instead I rented a U-Haul with an incredibly awkward driving position. Afterward, the front of my right lower leg started hurting and Saturday morning, almost a week later there was the characteristic crunching feeling of peritendinitis crepitans whenever I dorsiflexed my ankle.

In a sudden blast from the past I remembered how we used to treat it in Sweden: A little heparin IV push. I’ve been gone long enough that I don’t know if they even do that now but I certainly have never heard of it in this country.

I demonstrated my clinical findings to Autumn, my Medical Assistant, and to a colleague, and told them about the heparin. Obviously, we don’t stock any in my clinic, and, besides, it wouldn’t look good if I injected myself with anything intravenously in this day and age. (I have previously quoted the famous 1800’s Parisian Swedish physician and writer Axel Munthe, who shamelessly reported shooting up some “Morphia” after a hard day at the office).

So I did he next best thing I could think of, 20 mg prednisone (the wonder drug I wrote about the other day). Saturday 7 pm, resting after a somewhat crazy Walk-in day and a nice dinner, the crunching is gone and the pain much less severe.

So now I have time to do some research. The first page or two on my Google search had articles from 1957-1961, all or most from Scandinavia.

I did find one guideline from 2017 that recommends low molecular weight heparin:

http://www.ebm-guidelines.com/ebmg/ltk.free?p_artikkeli=ebm00430

But, in my case, the prednisone seems to be working. And my old Mercedes is fixed, running like new again, so my next hay trip will be more comfortable.

A Country Doctor Reads: March 30, 2019

A No-Pain Gene Mutation – NYT

Last week I wrote about whether pain is a sensation or an emotion. This week, there was a story across multiple platforms about Jo Cameron, a 71 year old woman who has felt almost no pain in her lifetime, including from burns, arthritis and several surgeries. She also scored zero on standardized anxiety questionnaires and doesn’t recall ever feeling depressed. Her two gene mutations responsible for this have been mapped now and may open doors to new approaches to treating chronic pain. And, of course, this discovery supports the notion that physical and emotional pain are, really, all the same.

https://www.nytimes.com/2019/03/28/health/woman-pain-anxiety.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

………..

Is it a Crime to Underestimate How Long a Patient Will Live? – WSJ

The Wall Street Journal has an interesting piece about a court battle involving a hospice and home health agency whose patients seemed to live longer than the certifying doctors predicted. Was it fraud, and should the doctors get penalized? In a funny twist, the prosecution’s expert witness physician contradicted himself in some cases he happened to review twice: One time he agreed the patient qualified for hospice because they had six months or less to live, yet another time he thought they would live much longer. The article concludes:

“The antidote is not to pretend that subjective decisions in a hospital room become objective facts in a courtroom. 

Some medical judgments can be false. But the government is trying to create a standard that is far too broad. Professional disagreement should not be illegal.”

https://www.wsj.com/articles/medicares-hospice-rules-could-make-your-doctor-a-criminal-11553209261

……….

FREE: Important Articles – JAMA

So many journals, even single articles (including some of my links, I would think) are expensive to access. JAMA has one free section, called JAMA Network Open Access.

For example, the current issue has an article on how opioid prescribing has changed in each state over the past several years.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2728005

PDSA for Dummies

Clinics like mine are supposed to do lots of PDSAs, rapid quality improvement projects. It’s part of our agreement with Uncle Sam. We keep starting them, but many of them fizzle. Our Federal Project Officer told us (again) at his last inspection to do more of them.

We have gone through multiple forms and formats, one more complicated than the other. But simple folks like me can’t wrap our heads around them. It should be simple: P stands for Plan, D for Do, S for Study and A for Act. Four short words, fourteen characters and, in our case, years of confusion.

Every PDSA form creator has his or her own idea. In some iterations, Plan means a detailed description of multi step processes, without declaring the overarching idea or purpose behind the project in the first place. In some, Do is where you enter your measurements and Study is where you analyze the results, while in others Do is the experimental workflows and Study is where you put the measurements.

So, as one to often reduce complicated things to their bare essence, here’s what I’ll be presenting my boss with. I’ll call it “PDSA for Dummies, v. 1”. My secret weapon is that each word, Plan, Do, Study and Act, is followed by a sentence that spells out my interpretation of what it stands for. It may not be the best, and is certainly not the only, way to do it but at least I think it’s clear:

P – Plan: In one sentence, what will you try to do?

(Example: Decrease the number of patients who leave the clinic without making a followup appointment)

D – Do: What steps or workflows will you carry out and how will you measure what works?

(Example: Give the first ten of my patients a numbered, sealed envelope and ask them to drop it off at the reception and have me or my medical assistant give everyone else just a friendly reminder to stop there on their way out. Keep a log of who got an envelope, a nurse reminder or a doctor reminder.)

S – Study: What results did you record?

(Example: Did more envelope carrying patients make followup appointments than reminder-only ones? Was there a difference between doctor and nurse reminders?)

A – Act: Given what we observed, should we adopt one of these new workflows or do we need to try something else?

(Example: Nothing seemed to work very well, maybe we should relocate the checkout station in another PDSA.)

Four boxes, each with a definition of exactly what we mean with Plan, Do, Study and Act and, in small print, simple examples.

That’s my opinion, we welcome yours…

A Wonder Drug of Ill Repute

If I could only have one drug in my pharmacopeia, what would it be?

An antibiotic? A pain reliever? A happy pill? Keep guessing…

During my Saturday clinic I saw a man I had done a physical on two weeks before. He told me he had suffered from daily headaches for several years and was popping over the counter medications just about daily to no avail; he clearly had developed rebound headaches on top of his frequent migraines. In today’s appointment he announced he had been headache free for nearly a week from the ten day prescription I had given him.

I also saw a woman with hives from head to toe. I prescribed for her with absolute confidence that her symptoms would go away.

Another patient with what the rheumatologist called inflammatory polyarthritis was not doing well on methotrexate, but told me that while she was on prednisone before that, she felt normal.

A few days before I saw a sciatica patient whose leg pain had completely resolved within a week of his first visit with me.

The day before that I prescribed it for a woman with a flare up of multiple sclerosis.

Prednisone is truly a wonder drug. It treats allergies, sciatica, gout, eczema, intractable headaches, rheumatoid arthritis, inflammatory bowel disease, asthma and COPD exacerbations, chronic lymphocytic leukemia (at least when I was a medical student), cancer related hypercalcemia and a multitude of other conditions.

It is about as old as I am, and neither of us has many undiscovered secrets left.

In the case of prednisone, that is very comforting to me.

Younger doctors are more afraid of it than I am. I have seen a colleague with arthritis die from a newer medication due to pneumonia and sepsis. I worry about the way many of these newer agents can cause problems very suddenly; prednisone is a bit more predictable.

Years ago I had a British reader question my use of prednisone for acute gout. It is my go-to, better tolerated than colchicine and safer on stomach and kidneys than indomethacin.

It is amazing what steroids do, not only to rheumatological conditions but also to our pain perception. I liken their effect to the instant ability people have in times of crisis to exert more effort than any other time and never notice pain or weakness; it can give us the sudden ability to run faster than ever before, lift heavy objects that pin down an accident victim and so on.

In some arenas it has had a renaissance: I learned in school that it decreases our ability to fight acute infections, but now it improves survival in septic shock.

The problem is its side effects with long term use, but its versatility in acute care is amazing and I do think it would be the one drug, if had to pick a single one, in my extreme survival kit.

But, may I please have one or two more?

A Country Doctor Reads: March 23, 2019

Health Insurer Profits From Your Death, Life Insurer Profits From Your Survival – WSJ

If you get sick and die quickly your health insurance doesn’t have to pay out a lot of money. They lose money by providing you expensive cancer treatment for example. Your life insurance on the other hand wants you to stay alive long as possible so they don’t have to pay out the death benefit. In a thought-provoking article the Wall Street Journal points out that this opens doors to access to expensive treatments for cancer and other serious illnesses.

www.wsj.com/articles/health-cares-killer-app-life-insurance-11553122054

……..

From Ancient Greece to Yours Truly to NYT: Is Pain a Sensation or an Emotion?

We seem to be catching up with the old Greek philosophers in acknowledging that pain isn’t an objective sensation, but more of a subjective, emotional experience. Here’s a nice piece from The New York Times:

www.nytimes.com/2019/03/16/opinion/sunday/pain-opioids.html

Looks like NYT has been reading my blog; I pointed this out March 9 😎:

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

https://acountrydoctorwrites.blog/2019/03/09/a-country-doctor-reads-march-9-2019/

.. and I wrote about it in 2013:

https://acountrydoctorwrites.blog/2013/12/09/pain-and-suffering/

…………

Priests, Providers, and Protectors: The Three Faces of the Physician – Psychiatric Times

I have a soft spot for the comparison of physicians and priests (See my 2009 post “Thank You, Father“). And, like many doctors, I’m not crazy about the term “provider”.

Psychiatric Times has a very nice essay on the topic by their Emeritus editor, Ronald W. Pies, MD, where he proposes a role between the extremes of Priest and Provider:

..

I believe there is a “third way” of viewing the role of the physician—one that neither elevates the physician to the exalted (grandiose?) position of “priest” nor demotes us to the level of mere “providers.” In the role I call the Protector, the physician’s chief obligation is the safeguarding of the patient’s physical, emotional, and spiritual well-being.

Between the extremes of priest and provider lies the healing heart of the physician.
— Read on www.psychiatrictimes.com/couch-crisis/priests-providers-and-protectors-three-faces-physician


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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