A Country Doctor Writes:

Christmas always makes me think of my childhood in Sweden, but it also makes me think a lot about my place in time and in people’s lives. This year, as I alluded to in my post “Don’t Do Chronic Care in December”, I’m spending extra time with our opiate addiction recovery groups because of the obvious stress we have seen in those patients around the holidays.

My Swedish upbringing put me in more contact with the Old Testament than perhaps many American Protestants, and my High School exchange student year in this country placed me in the only Jewish Family in a small Massachusetts town (Hi, Bob!). My Swedish High School German prepared me well for speaking some Yiddish with my host mother.

I am of the Old World, and I find comfort in ancient traditions. The Mezuzah is one I learned about only in the last decade. This led to my 2012 Christmas reflection, quoted in its entirety below. This year I am not taking a mini vacation. I work half a day with my Suboxone groups Christmas Eve, and some time Christmas Day I’m heading 200+ miles north to our Caribou house in order to work at the Van Buren clinic December 26 and 27.

Merry Christmas, happy belated Hanukkah 2018 and thanks for reading…

Hans Duvefelt, MD

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TOUCHING THE MEZUZAH (12/24/2012)

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A mezuzah (Hebrew: מְזוּזָה‎ “doorpost“; plural: מְזוּזוֹת mezuzot) is a piece of parchment (often contained in a decorative case) inscribed with specified Hebrew verses from the Torah.

And thou shalt write them upon the door-posts of thy house, and upon thy gates. Deuteronomy 6:9

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It’s almost 4:30 and I have three more patients to see before my Christmas mini-vacation can begin. Snow and sleet are beginning to fall outside. Our lab tech, who leaves between 3 and 3:30, just called from home to warn the rest of us that she had seen nine moose on Route 1, probably attracted by the road salt.

“Three encounters in thirty minutes”, I think to myself, “and neither of them completely straightforward”. I used to shudder when healthcare administrators called medical office visits “encounters” , but the more I have thought about it, the truer the word rings to me. Two people meet briefly and try their best to communicate in spite of sometimes very different viewpoints and agendas. I remember the phrase “Marriage Encounter” from my first visit to this country in the early 1970’s – an event where couples learn to see each other with new eyes and communicate more effectively.

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

4:35 – In Room 1 sits Bill Boland, the fellow who always sasses me for my habit of knocking on the exam room door before I enter. He had been in with pneumonia and his x-ray came back suspicious for a tumor. The purpose of today’s follow-up visit is to make sure he is feeling better and to tell Bill he will need more testing. I raise my hand in an automatic door knocking gesture, but catch myself and instead touch the doorframe briefly and take a slow breath before entering the exam room, ready to deliver the disturbing news.

4: 50 – In Room 2 sits Wally Parker, here to talk about his blood sugars. His wife is in the hospital with a lower GI bleed, and her colonoscopy showed an ulcerated tumor that is almost certainly malignant. “Why is he here tonight instead of at Mary’s bedside?” I ask myself as my hand reaches for the doorframe. At the same time I try to clear my mind of my own clutter and my guesses why he has chosen to keep this appointment under these circumstances.

5 o’clock – The child in Room 3 is an 11-month-old with a fever. He belongs to the pediatric group in town, but probably the slick roads and the late hour are the reasons he is here. A new patient, and a sick child at that, requires me to be unhurried and receptive. I must be aware of how well we connect, so neither this child’s young mother nor I miss something important in our encounter. In this case, the child has an ear infection and the mother is a registered nurse with an older child at home who has recurrent ear infections.

At 5:15 I wish Autumn and the new receptionist a Merry Christmas before I leave through the back door.

Route 1 is covered with snow and the large flakes coming right at me make it impossible to see with high beams. I drive slowly with only my low beams, and don’t see a single moose.

Our house is all lit up for Christmas. In one of the sunroom windows shines the metal star-shaped lamp that hung in my bedroom window when I was a child. I remember coming home from school in the dark, looking up at my star on the third floor of our Swedish apartment building, even closer to the Arctic Circle than where I live now.

I can see my wife in the kitchen window, but she can’t see me in the darkness outside. I quickly stomp the snow off my boots on the wooden steps outside the door. My hand touches the doorframe for balance, physical and spiritual, and as a brief gesture of love and blessing:

I am home. It is Christmas.

Too many specific theories about physician burnout can cloud the real issue and allow healthcare leaders to circle around the “elephant in the room”.

The cause of physician burnout isn’t just the EMRs, Meaningful Use, CMS regulations, the chronic disease epidemic or any other single item.

Instead, it is simply this: Healthcare today has no clear definition of what a physician is. We are more or less suddenly finding ourselves on a playing field, tackled and hollered at, without knowing what sport we are playing and what the rules are.

Historically, physicians have been viewed as professionals and also, more lately, as skilled workers. But we are more and more viewed and treated as neither. Therein lies the problem.

The way professionals are treated is this: You present them with a problem and they use their knowledge to solve that problem Since they know more than the requester, they aren’t micromanaged. They usually also set their fees and determine the time needed to realistically finish he job.

Skilled workers are asked to apply knowledge and workflows to relatively strictly defined tasks and it is the employer’s responsibility to make sure they have what they need to finish the job. If the tasks are unrealistic, the manager is held responsible: If the assembly line is moving too fast and the majority of workers end up passing on unfinished product or start pulling it off the line to finish later at home, the manager is likely to take the consequences. No one is likely to say that all workers, individually, are responsible for such chaos.

But in today’s healthcare, we have a rapidly moving assembly line. The foremen blame the workers for not attaching all the parts or not keeping up with the workload. Upper management doesn’t always take full responsibility, instead shrugging and saying: “it isn’t our problem, they’re professionals, they should be able to figure this out”.

Put simply: If anybody wants to define and manage our work for us instead of letting us do it, they become responsible for the outcomes if we aren’t given the time or the tools we, as the ones who went to school, know we need.

The cure for physician burnout is simple: Listen to us when we say what we need in order to do our best. We didn’t spend all this time and energy so we could collect our salaries and goof off.

Most of us still have a professional mindset. We want to do a good job and we know how to do it. Let us.

I am beginning to think that we should not see chronic care patients between Thanksgiving and New Year’s Day. It just makes us look bad.

Our quality metrics make the last blood pressure and the last diabetic lab test of the year for each of our patients our final report card. We should quit while we’re ahead, in mid November.

So here we are: The office has Christmas decorations up. There are trays of Christmas treats on desks and in break rooms. Patient after patient now declares that diet and exercise are on hold until after the holidays. The phrase of the month is “Next Year, I’ll Eat Better”.

I thought of this when I saw Jerry Rigg the other day.

His chest pain was a bit atypical, the stress test slightly equivocal. His belly was quite a bit bigger than last year, but the indigestion medicine seemed to work and the cardiologist was quite reassuring. He had also spoken of diet and exercise, just as I had done many times before.

This man with all the risk factors didn’t take this episode as a warning, but as a green light for stalling a little bit longer before doing something to change his trajectory.

So, instead of beating on people who really don’t want to feast less during Thanksgiving and Christmas, what is a Country Doctor to do?

It didn’t take me long to know:

My Suboxone patients, who can’t have Tuesday group on Christmas Day or New Year’s Day, had fretted about Thanksgiving, which in many families can be emotionally charged or awkward. Major holidays also often expose them to relatives who are not in recovery, who may bring drugs to the periphery of the festivities. Every single one did okay, though. But after realizing their degree of concern, we are holding groups on Christmas and New Year’s Eves and halfway between.

I also have seen a couple of patients already in tears because they can’t afford presents for their children, because they miss loved ones that won’t be there this year or because they weren’t invited to something others in their family did.

I can’t really postpone or cancel my remaining hypertension and diabetes visits on such short notice, but maybe in the future, we need to be more focused on those patients who find the holidays hard.

If by doing that our quality metrics should happen to improve, is that so bad?

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.

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.