A Country Doctor Writes:

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.”

I had seen him now and then, but he didn’t come in very often. He was on the thin side, a hard core smoker with chronic bronchitis. But he was still running some borderline blood sugars, a quick chart review revealed.

One day, he came in with a few months of increased “arthritis” in his shoulders, neck, back, knees and hips. There was no sign of small joint synovitis, but the range of motion in his shoulders was poor, and he had a little trouble getting up from his chair without using his arms.

“Polymyalgia Rheumatica?”, I thought, but also remembered how people with lung cancer can develop all kinds of musculoskeletal pain. He had had a screening chest CT not too long ago. So I ordered a sedimentation rate and prescribed some low dose prednisone and asked him to come back in a week.

A week later he was only a little more limber, and his sed rate was only 28, not exactly diagnostic.

As I sat there and looked at him, thinking about what to do next, I made the observation that his skin was a little dark for the time of the year and his ethnic background. Then I looked at his fingernails, brown. Not just the ones that held his cigarette, but all of hem, even his pinkies.

I quickly clicked to his lab section in the EMR to check what kinds of lab tests had been done over the past year or so. His CBCs had not changed much over the past few years, and I had just checked one when I did his sed rate. His chemistry profiles had been okay except for those borderline blood sugars. Nothing more had been checked.

“What?” I thought to myself.

“Hyperpigmentation, Addison? No symptoms, and the nails…”

“Iron”, was my next thought. “Could he have hemochromatosis?”

I’ve never diagnosed a case of it before.

“It is possible that all these pains could have something to do with your iron levels”, I told him. “I hate to do this, but would you mind giving us some more blood for some extra testing?”

Sure enough, his iron level was elevated. I made a referral to hematology.

I was away for a little while and my first day back he was in my schedule for “Followup blood sugars”. He had seen a colleague for urinary frequency and turned out to have a very high random glucose and a glycosylated hemoglobin of 8. He had fallen into the trap of quenching his thirst, which was caused by spilling sugar in his urine, with juice and soda.

Scanning further in the EMR, I saw than the hematology report was back. It spelled out all the possible complications of hereditary hemochromatosis: Joint pain, fatigue, unexplained weight loss, abnormal bronze or gray skin color, abdominal pain, cirrhosis, diabetes, heart disease…

The lesson for me was the nail discoloration, which isn’t often mentioned in the medical texts; I remember noticing it before, but always assumed it was just nicotine staining. I never looked at all his nails. And I should have.

I pay $500 per year for UpToDate, the online reference that helps me stay current on diagnostic criteria and best treatment options for most diseases I might run into in my practice. They also have a rich library of patient information, which I often print out during office visits.

I don’t get any “credit” for doing that, but I do if I print the, often paltry, patient handouts built into my EMR. That was how the rules governing meaningful use of subsidized computer technology for medical offices were written.

If I describe in great detail in my office note how I motivated a patient to quit smoking but forgot to also check the box that smoking cessation education was provided, I look like a negligent doctor. My expensive EMR can’t extract that information from the text. Google, from my mobile device, can translate between languages and manages to send me ads based on words in my web searches.

When I do a diabetic foot exam, it doesn’t count for my quality metrics if I freetext it; I must use the right boxes. If I do it diligently on my iPad in eClinicalWorks, one of my EMRs, even if I use the clickboxes, it doesn’t carry over to the flowsheet or my report card.

Not only are these things annoying and part of the mounting overall frustrations of being a doctor, or PA/Nurse Practitioner, today. They are also misguided; I may document a foot exam or provide a disease specific handout, but then what?

Our primitive technology can’t automatically do anything more. Did the printed information change my patient’s behavior? Did the foot exam reveal diabetic complications, and did I do anything about that? Did my smoking cessation advice (CPT code 99406) produce results? Or did the patient quit on her own because her sister got lung cancer?

More and more, I am thinking we, as providers, are measured too much for the wrong things.

I also think that, more and more, we are expected to do the wrong things.

My diabetic patient may see a well qualified podiatrist, who spends a great deal of time examining and treating my patient’s feet, but I am the only one who can prescribe the diabetic shoes. How detailed does my foot exam have to be for that prescription to count? Not very, mostly clicking the designated box.

I don’t double check the retina specialist’s work examining and injecting my diabetic patient’s eyes, now, do I? I am only charged with documenting that my diabetic patient sees the eye doctor. I wonder why Medicare needs me to tell hem that when they are presumably paying big money for that to happen?

In our fifteen minute world, wouldn’t it be better if I had time to read the podiatrist and eye doctor reports and use them to help motivate my patient to eat differently and exercise more? Instead of:

Have you seen the eye doctor? Check.

Have you seen the podiatrist? Good, let me check your feet real quick so I can say I did it and get you the shoes he wanted you to have…Check.

And do you know smoking is bad for you? Check.

Do you know too many carb calories raise blood sugars and cause weight gain? Check.

You don’t drink too much, do you? Check.

Not too depressed this time of year? Check.

Did you get your flu shot, colonoscopy and Pap smear? Check.

And what about hepatitis C, domestic violence and making out those Advance Directives? Check.

Makes me feel I’m a great doctor. Or does it?

There is another dimension of Medicine, invisible to those who measure us, but it is the only one our patients see.

Last week I had a patient with mild kidney disease and a high potassium. I thought that would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast and nobody had Kayexalate, the time-tested antidote, in stock.

It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4, his labs were available by 4:30.

It was 4:45 and we were almost done calling around to pharmacies. I had Autumn, my medical assistant, make some of the calls. 15 minutes left before clinic with 14 patients to see in 90 minutes (we pull them out from group therapy to check in and renew their scripts). And I had a new patient, an internal transfer but still new to me, with multiple medical problems to see before clinic.

I did what I hardly ever do: I asked Autumn to call the emergency room on my behalf and tell them that we had no choice but to send the patient over. We faxed records and lab reports and I moved on.

The ER doctor’s report was scathing. He clearly thought I had dumped on him. He didn’t do what I had thought he might do:

I hadn’t done it since I stopped doing hospital medicine a generation ago but I know you could hydrate him to help his mild acute kidney injury and coadminister glucose and insulin to lower the potassium at the same time.

Instead, the emergency room doctor gave him Kayexalate, because the hospital had it in stock. He probably didn’t know that wasn’t an option for us. I looked like an idiot to him, but that often happens in primary care.

I had gotten over my frustration and embarrassment when, this week, I had a patient on warfarin with a supratherapeutic INR and no active bleeding. I’ve never been terribly nervous about those situations but this was a high number and Up-To-Date suggested vitamin K, orally because it works faster than injectable, while obviously holding the warfarin. So, guess what, we called every pharmacy from Bangor to Ellsworth to Belfast and nobody had vitamin K in stock. The Natural Living Center in Bangor had a very low potency supplement where maybe 50 pills would be enough of a dose to make a difference.

Oune of the hospital pharmacists was available to talk to me and explained that a small bottle of vitamin K in the potency required to reverse warfarin costs about $1,000 and neither hospitals nor pharmacies want to stock them because they will lose so much money if the drug expires. What the hospitals do instead is compound an oral form from the injectable that is still expensive but less so. But a hospital can’t sell or administer to an outpatient whose primary care physician does not have privileges at that hospital. I technically have privileges at Cary Medical Center in Caribou, but that’s 200 miles north.

So this was a judgment call: Send the patient to the emergency room so she can incur the emergency room fee and have them give her an oral medication that may or may not make a difference since she had no active bleeding. Or I could bubble wrap her for a couple of days while the warfarin effect wore off.

Today, in Van Buren, I called the small local Rexall (a historical U.S. pharmacy name) and chatted with the owner, John Hebert. He has Kayexalate in stock. This is in a town of 2,000 people. From Bangor to Ellsworth to Belfast I imagine there are 100,000 people. They don’t have outpatient access to this drug.

It’s a sad situation when potentially life-saving medications are unavailable because pharmacies don’t want to risk having them expire and go on unsold. We have automatic defibrillators in schools and shopping malls, why not some basic antidotes available, maybe even subsidized, in strategically located pharmacies?

P.S. Hebert’s is about to open a pharmacy in Bangor within the next few weeks and John has promised to stock Kayexalate there, too. And he delivers to a large geographic area…