A Country Doctor Writes:

The title of this post is a quote from Hippocrates, the father of Medicine. In my own life, practice and forays into Functional Medicine, I am increasingly convinced about the wisdom behind those words.

And, both foods and medications are best consumed in stringent moderation; less is usually more.

My 2011 post, “The Virtues of Oligopharmacy”, opens with the above Hippocrates quote, followed by Ben Franklin’s and Sir William Osler’s Words:

“I saw few die of hunger; of eating, a hundred thousand.” (Benjamin Franklin)

“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals”

(William Osler)

I think that sums up where we are today:

There’s a pill for every ill. Eat too much sugar and Farxiga makes you pee it out. But you might get urinary tract infections, kidney failure, bladder cancer or Fournier’s gangrene. And so on.

Drug companies spend unimaginable amounts of money to produce drugs that allow us to have our cakes and eat them too. Most middle aged or older people with diabetes or hypertension are on three or four drugs, but foods, with their natural ingredients and lack of processed, unnatural or artificial ones can take the place of pills in many instances, at lower cost and with lower risk.

I have sometimes fumed about hospitalists suggesting our practice’s patients are on too many medications and then sending them home on magnesium, B12 and all kinds of more or less over the counter type medications. This irks me partly because of the hassle factor of documentation and cluttering up our medication lists. These days we are obligated to list all over the counter medications and supplements our patients are taking, even if our EMRs don’t have them in their data base…

But I guess I should be grateful that they’re not usually starting dangerous medications I wouldn’t agree with. I’ve never heard of anybody dying from low (or high) magnesium, but I guess I shouldn’t worry myself silly over a relatively harmless supplement to treat a laboratory abnormality still more or less looking for a purpose (seldom critical as an isolated finding, if other electrolytes and minerals are normal).

(UpToDate states: ●Hypomagnesemia is a common entity occurring in up to 12 percent of hospitalized patients. The incidence rises to as high as 60 to 65 percent in patients in an intensive care setting.)

But I do think we all, however conventional we may want to be, need to think hard about food:

If the wrong diet can cause kidney stones, migraines, diabetes, pancreatitis or whatever, shouldn’t we be better educated and more vocal about which foods can instead help patients avoid those conditions?

I, like most doctors, didn’t learn much about nutrition in medical school, but I was a squeamish eater, esthetic former and now recovering vegetarian, who (I always shock my patients with this) gained too much weight when I didn’t eat fish, chicken or bacon (I lived on pasta, sandwiches and oatmeal). This journey lead me to read a lot and learn a lot.

I’m not mad at my medical school for not teaching me more back then. Nobody ever suggested I’d be fully prepared for a lifetime of practice the day I graduated. I knew I’d have to keep learning, and that’s what I’m doing now…

Turmeric anyone? Blueberries?

We do a lot of things in our head in this business. Once a patient reports a symptom, we mentally run down lists of related followup questions, possible diagnoses, similar cases we have seen. All this happens faster than we could ever describe in words (let alone type).

And, just like in math class, we are constantly reminded that it doesn’t matter if we have the right answer if we can’t describe how we got there.

So the ninth doctor who observes a little girl with deteriorating neurologic functioning and after less than ten minutes says “your child has Rett Syndrome” could theoretically get paid less than the previous eight doctors whose explorations meandered for over an hour before they admitted they didn’t know what was going on.

Does anybody care how Mozart or Beethoven created their music? Or do we mostly care about how it makes us feel when we listen to it?

We know that stress, meditation and Thai Chi can alter metabolism, immune response and neurotransmission. But do we endorse them based on how many minutes, elements, movements or postures they involve over what their results are?

Of course not!

We also know that physician demeanor can affect treatment efficacy a whole lot more than the number of minutes spent or boxes checked in the EMR. So why are we so fixated with proving the monetary value of our process, instead of the value of our results?

Medicine, at least in the non-procedural specialties, is a relationship based business. If a hostile stranger spends fifteen minutes trying to change your behavior, is that more effective or more valuable than if a trusted doctor, friend or admired mentor mentions the same thing almost in passing?

Of course not!

So why is medicine viewed as an easily quantifiable and standardized endeavor? The manufacturing analogy is outdated; we are more like old-house renovators or art restorers most days, and, on perhaps rare but inspiring and memorable occasions, like composers. We sometimes find ourselves creating something new in the lives we touch and interact with. In those instances we should take little credit for anything except how we were able to awaken the healing potential within our patient.

Health care professes to value outcomes, but we are a long way from doing that. We are stuck in a thick soup of surrogate endpoints and ignorant overemphasis on standardized processes in an era where we are only beginning to understand how genetically different we all are.

Or, are we really suggesting our patients are all 70 kg white males with only one, typical and standardized, medical problem?

I haven’t counted how many times this happens every month, but I find it annoying:

I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a Prior Authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) make a toll free call and spend unpredictable amounts of time pleading to have it paid for.

My time is worth (opportunity cost) $7-14 per minute, depending on if you count only my basic (E&M) professional fees or also the ancillary revenue (lab, x-ray and additional procedure charges) I generate.

This may be for a prescription with a cash cost of $10.

Sometimes I don’t even know if the new drug I prescribe will work. In the case of self-pay, a patient can buy a few pills cash to try them, and if they work, it may make more sense for me to offer my unreimbursed time to plead for coverage.

Because, of course, the cash cost is per pill whereas the insurance copay, and the amount posted toward your total drug plan benefit, is per prescription (same cost for anything up to the allowable monthly quantity), thus counting toward deductibles and the slide toward the dreaded (Medicare D) doughnut hole.

So even if I do my patient a favor and get the new drug “covered”, they may ultimately and in reality end up paying for a month of a medicine they couldn’t use.

Even worse than my own Prior Auth faxes, sometimes a specialist prescribes something esoteric, and when they get this dreaded fax, they forward it to me.

How am I supposed to justify a drug I didn’t choose?

And my biggest gripe with Prior Authorizations is that it can be hard to figure out what is covered and what isn’t.

One of my EMRs gives me an “emoji”, green smiley, yellow quizzing or red frowney, depending on status for many insurances, but only a question mark for some. My other EMR often just claims it doesn’t know.

In the case of our biggest payer for medications, Mainecare, they avoid the Prior Auth hassles fairly well by publishing rules like:

60 days of a preferred Proton Pump Inhibitor, like omeprazole, thereafter PA if you can’t wean down to an H2 blocker, like famotidine.

Coverage for preferred stimulants only if ADHD is mentioned on the prescription.

AARP Medicare D required a phone call, with hold time, to get non-valvular atrial fibrillation to justify a prescription for Eliquis, and another Medicare D plan a similar holdup to explain Suboxone was for opiate dependence and not for pain. In both those instances, the drugs are simply only indicated for certain conditions.

There are bigger foes to contend with than the insurance companies if you break those rules…

Maybe there should just simply be a CPT code and an RVU for obtaining a Prior Authorization?

We once had a locum provider who spent a great deal of time reviewing each patient’s record before each visit. He would then enter the room and proceed to “clean up” medication and problem lists. Everything he did was done without eliciting the back story from the patient or the record. All he looked at was the data, never the narrative. Patients were often bewildered, saying “he changed my medicines without even talking to me”.

It may sound great to only act on the facts, but real medicine is a lot messier than that.

Sometimes we prescribe medications for more than one purpose: Amitriptyline may not be the theoretically best drug for neuropathy, but if the patient also has trouble sleeping and a history of migraines, it could solve three problems at once.

And propranolol could be used for migraines, tremors, palpitations and stage fright. It may not be the best beta blocker for the average 70 kg male, but there aren’t many of those around.

A high potassium could be a life threatening emergency or a simple case of hemolysis. Without seeing previous values, a provider could easily overreact.

Or, in the case of the previously stable warfarin patient I recently described, her critical INR seemed out of the blue and there was no vitamin K to be had, so I did nothing except hold the blood thinner. The next value was 1.0 and the home health nurse confessed that her device wasn’t calibrated properly.

Again and again I find that asking why before reacting has saved me and my patient all kinds of trouble, even though it takes time. But it is time well spent.

To quote myself (2014):

Context is crucial when deciding what to do with abnormal test results. But doctors are often pressed for time, and finding the story behind the results takes time. Even when all the data is in our electronic medical records, it takes time to see the patterns: The test results are usually in one place, the prescriptions in another, the office notes in a third, and the phone messages in a fourth. My own EMR (up north) can produce flowsheets with lab results, but each test is identified by the date it was ordered instead of the date it was performed, so correlating lab values with prescription dates becomes confusing, for example when following thyroid cases.

In times past, when solo practice physicians cared for their patients in the office, hospital and nursing home, they kept the threads of context and continuity together more easily. Today, with more providers sharing the care, and with other office staff also interacting with patients and their families, there is more room for errors, gaps and confusion. The tools we have right now are not always as effective as we would like, and they certainly can be cumbersome and slow to use. Reading each other’s notes can take a while, as the EMR format is primarily built for coding and not for ease of following the clinical “story”.

A few words doctor to doctor, doctor to nurse or doctor to patient can sometimes do what half an hour on the computer might not. Treatment without context is essentially just random reflex actions: Killing the innocent bacteria, lowering the falsely elevated potassium, treating the lab value and not the patient – none of it does anybody any good, and probably will cause harm to some unfortunate patients.

Our temptation to view test results as obvious facts in a predictable process instead of possibly misleading clues in a complex mystery reminds me of these words from a Sherlock Holmes novel:

“There is nothing more deceptive than an obvious fact.”