A Country Doctor Writes:

Everybody is a stakeholder these days in what we broadly call Medicine, or healthcare. But there is little agreement on what Medicine is and what the priorities of the healthcare “industry” should be.

I propose this breakdown of Medicine into 3 separate phenomena.

1) Micromedicine

2) Macromedicine

3) Metamedicine

Let me explain:

Micromedicine: One On One, Real Doctoring

Doctors from antiquity have served their patients one on one, as individuals. Osler, the father of modern medicine said “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”.

My generation of physicians has seen the individualized care of patients fall from grace in favor of seeking the lowest common denominator for a particular medical problem. Hypertension treatment, for example was tailored to the “phenotype” of each patient: A high strung or Type A patient would get put on a beta blocker when I started out in Sweden, even though my American pharmacology text, Goodman & Gilman, pretty much dismissed beta blockers for hypertension. We knew better. A patient with overweight and edema would get a diuretic. When ACE inhibitors came along and did well in some randomized control studies, everybody suddenly ended up on them, regardless of what else was going on with them. That is still the party line, at least in the United States.

Micromedicine is concerned with accurate diagnosis, individualized treatment and patients’ values and priorities. It doesn’t matter to the individual patient if one type of blood pressure medication generally performs better than another if that patient’s blood pressure is elevated because of undiagnosed hyperthyroidism, alcoholism, coarctation of the aorta or a pheochromocytoma.

Micromedicine considers the average but never assumes that averages dictate action in individual patient encounters.

Macromedicine: Population Management

At the risk of offending some of my colleagues, I hereby declare that Population Management is reductive, simplistic and beneath physicians to spend their career on. It is a skeleton framework best handled by paraprofessionals. It is the broad strokes view from 30,000 feet, useful for policy makers and actuaries, but useless for individual doctors and patients in the exam room.

Macromedicine is all about averages. It is JNC blood pressure targets, Hemoglobin A1c targets, use of aspirin and statins, immunizations and bone density screenings.

In case anybody needs me to justify myself, a very low blood sugar in an eighty year old patient can result in a fall with a hip fracture. Aspirin use was recently a good thing and now it isn’t a good idea for most people. That’s how fickle the mistress of Quality Population Management can be. And don’t get me started on Lipid targets, the bane of our existence until the revised 2013 Lipid guidelines, and still a thorn in our sides because old habits die hard, especially among the less educated in our field.

Unfortunately, much of our time and effort in the office, those precious fifteen minutes with our patients, is spent on public health issues that even a nursing degree is superfluous for: If everyone should be offered a flu shot in the fall, you don’t need medical professionals to offer it. We can answer questions and reinforce the message, but it is a waste of our time to make us the primary promoters of such things.

Macromedicine is concerned with the masses, not infrequently at the expense of individuals that don’t seem average.

Metamedicine: The Parallel Universe of Non-Clinicians

Pharmacy Benefit Managers, Prior Authorizations, ICD-10 codes, EMR vendors, Meaningful Use, Maintenance of Certification – sometimes it seems that these non-clinical entities and considerations rule our lives, drain our energy, instigate burnout and overpower the fundamental motivations of physicians to help their patients.

I call all these things Metamedicine. The word is analogous to the Metadata that is recorded on websites and on our computers, like tracking codes, cookies, and even (invisibly) parallel to the music we listen to in the form of Gracenotes.

Metadata is necessary, but it shouldn’t overshadow real data; no amount of metadata can replace the value or experience of actually looking at a Da Vinci or listening to Beethoven.

Metamedicine means money unrelated to the patient visit. It means profit for middlemen. It means clutter in the diagnostic and therapeutic encounter. It is not the heart of the matter. It means measuring that which is easy to measure. It means satisfaction surveys and cycle times, it means cherry picking the easier cases to achieve better statistics; it means viewing patients as mere numbers.

Metamedicine is less concerned with patients and more with the data itself.

Saturday clinic. No lab. Just me and a medical assistant.

A fifty year old woman comes in with a fever a couple of days after a dental cleaning. Her gums are sore and she has some bodyaches. I’ve never seen her before. She used to see Dr. Wilford Brown and transferred to Dr. Kim.

The inflammation in her mouth is mild. She has a Grade 1 holosystolic murmur. Nobody has documented that before, but a Grade 1 is usually insignificant and barely worth documenting.

The only other thing I notice on her exam is that she has two thin brown lines under one of her fingernails. Like splinter hemorrhages. But there are only two.

“I banged that finger by accident a month ago, I’m pretty sure those lines have been there since way before my dental cleaning”, she said.

“Hmm, how bad are your bodyaches?”

“I’m not a complainer, I guess you could call them pretty bad.”

Time to make a decision. A judgement call: Hospital for blood cultures, possibly IV antibiotics, or blame the whole thing on a sore mouth and a virus and an incidental fingertip injury. One explanation or three?

Logic seemed to dictate one explanation for three clinical signs: mouth, fever, fingernail. But then there are bodyaches, bad bodyaches.

I made my decision, explained it carefully, and she concurred.

“So, stop in first thing Monday morning for some bloodwork, pick up the prescription I’m sending to the pharmacy, and call us if you don’t hear back from me by 10 am”, I said.

I slept well for two nights and did my Sunday farm chores without thinking much about it.

Monday, 9 am:

Lowish white blood cell count, close to 50% each of lymphocytes and neutrophils.

“I got your bloodwork. How are you feeling?”

“Fine, my mouth feels great and the fever is gone.”

“The blood count looks very typical for a virus.”

Minor mouth infection, viral illness and a banged fingertip. Bingo.

I saw two patients with a chief complaint of bubbles in their urine this month.

One middle aged woman had eaten some wild mushrooms she was pretty sure she had identified correctly, but once her urine turned bubbly a few days later, she came in to make sure her kidneys were okay.

Even though she was feeling quite well they were not and she ended up going straight to Cityside hospital for IV fluids, a kidney biopsy and dialysis. We don’t know yet how much her kidney function will recover and we still don’t know if the mushrooms had anything to do with it.

I saw her in followup the other day and she was taking everything in stride, showing more curiosity than fear and despair.

The other, a woman in her thirties, came in for sudden swelling of her ankles. She mentioned her urine had been bubbly for months. She had googled her symptoms and was convinced she had either acute kidney or heart failure. She felt weak.

Her review of systems had several positives, including joint pain. Specifically, one knee had been swollen and painful for a while.

“Have you taken any ibuprofen or naproxen for your knee?” I asked.

“Yes, why?”

“Nonsteroidals can cause sodium and fluid retention”, I explained.

Her cardiovascular exam was normal.

Because of her obvious anxiety, I minimized the EMR on my computer screen and googled “leg edema NSAIDs” and showed her that Dr. Google agreed with me that this was a plausible explanation.

“The problem with Google is that it displays possible diagnoses without ranking their probability. Exotic things may rank higher because more people look them up”, I explained.

She understood but was visibly not reassured. She did agree to hold the ibuprofen for a while to see if her swelling resolved and to get some labwork to check her kidney function.

So far, I know that her kidney function is perfectly normal. We’ll see if her swelling goes away and stays away.

I didn’t tell her that I once had a woman about her age come in one December day with just a little ankle swelling and, ten years later, ended up with a heart transplant.

As I told another patient the other day, it is my job and not the patient’s to think of the worst case scenarios.

It’s been said in the world of business that people only buy two things: Good feelings and solutions to problems. In medicine, the single most important factor that brings patients through our doors isn’t a “toward” kind of desire, but an “away” one – away from feeling bad.

More specifically, it is pain and fear that most often cause patients to call and ask for an appointment. They hopefully leave with good feelings and solutions to their problems, but that only happens when we have the knowledge, resources and, perhaps most important, the time to give them the relief they seek from us.

I am not considering the purely administrative functions we perform, but even some of them are more “away” desires, like patients needing a work excuse due to illness out of fear of otherwise losing their jobs. Even getting a flu shot or a physical is often rooted in pure fear of illness.

So, how often do we have the knowledge, resources and time to help our patients escape their torments?

And also, forbid the thought, how often is this relief of suffering in the broadest sense the overarching principle that guides each doctor and each healthcare organization?

In my random readings the other night I came across an article, almost a manifesto, by the British National Health Service from 2011. The document was titled “A Better NHS” and I am quoting the part about patients’ pain and the profound responsibility of the treating physician:

“The commonest reason for visiting a GP is ‘fear’.

Fear that the lump is cancer, that the chest pain is another heart attack, the headache a stroke, like the one that tragically disabled Maureen. Fear that I may die before my children grow up, fear that I may lose my sight, my balance or my mind. Fear that I cannot cope, that I am a failure or that I will be judged unfairly and blamed for my suffering. To be a patient is to be unfamiliar with oneself, to inhabit an unfamiliar shell, barely in control and in need of help. The world and our relationships are radically altered when we are patients.

What an extraordinary job we do. Grounded in a therapeutic relationship, everything we do depends on trust. What an extraordinary responsiblity to be charged with caring for people when they are at their most vulnerable and most easily exploited.

Because of this it is absolutely vital that we are not led into temptation. Just as monks and nuns need to be protected from the distractions of the world so that they can dedicate themselves to God, so we need to be protected from mammon and the perverse incentives of the market-place, so that we can dedicate ourselves to our vocation and our patients, and be the doctor that they need, not the doctor the market makes us.”

This was a call, or a prayer, not to be led into temptation by greed. As employed physicians, which is what most of us primary care physicians now are in the US, our temptations to profit from our patients’ fear, misfortune and illness are limited. Here and now, the temptation we all face is maybe not one of the deadly sins, but it is gaining traction:

Distraction from what really matters is perhaps our biggest temptation and a poison we are constantly exposed to. We let our focus wander away from the patient and toward the clock, away from the therapeutic moment and toward the measurable quality indicators. Even when we embark on practice redesigns to become more patient focused, the certification process itself becomes a distraction from the work we set out to improve.

This week I saw two new patients, both of them with shortness of breath and heart palpitations, both fearful that something was dreadfully wrong. Each one ran over their allotted thirty minutes (my longest appointment type, reserved for new patients and hospital followups) by a good ten minutes, but each one left reassured, one with a clean bill of health, the other with reassurance that only two tests were needed to confirm my clinical assessment that there was nothing serious. Both women gave me a firm handshake, repeated by their largely silent accompanying husbands, both of whom silently mouthed the words “thank you”.

I laid it on fairly thick, I invoked what I sometimes refer to as the source of my calling, and I drew on my experience and they gray hair I have earned recently, and my ability to use simple language and everyday analogies to dispel the mystery of how our bodies work.

Instead of feeling pressured or overwhelmed by these encounters, I felt satisfied and energized. I easily caught up with my schedule and I didn’t give the daily distractions much thought.

I had done some real Doctoring. I had mitigated the fears of two fellow human beings.

Few things in primary care give patient and doctor mutual and instant gratification.

It’s been a while since I reduced a “nursemaids elbow” or a spontaneous shoulder dislocation other than my own, or a finger dislocation, but those all count.

I once wrote about curing deafness in a man with a movement disorder by flushing ear wax more or less on the run as he bobbed around the exam room. That was instantly rewarding and also both exhausting and exciting. Even more ordinary cases of cerumen impaction are rewarding to treat. I almost never let my medical assistants get the satisfaction, or the risk, associated with that procedure.

A few months ago a man came to my Saturday clinic with a plastic tip from his hearing aid lodged sideways deep inside his ear canal. With the help of my modern headlamp (I trained on the cartoonish forehead mirror ENT doctors used to sport) and a delicate long pair of forceps I was able to remove it and relieve the stranger’s suffering.

Often, I delight in asking a patient to make the shoulder movements that hurt them so much a few minutes earlier and now feeling no pain, confirming that my steroid-Xylocaine (Hurrah Sweden!) injection hit the right spot.

A few weeks ago I saw a patient for an unrelated problem, who had recently received a nerve block by a nurse practitioner to the minor occipital nerve. The patient had presented with severe pain on the side of her head and the shot gave instant relief. I had never heard of that injection, so I read up on it.

Wouldn’t you know it, the following week I saw a different woman with an excruciating pain on the left side of her head. The pain seemed to originate in the back of her head. She was tender on the scalp over her ear and even more so over the lesser occipital nerve. She agreed to an injection. It was instantly successful.

In medical school it was “see one, do one, teach one”. This time it was “read about it, then do it”. Now I’m ready to teach it, thanks to a clinician with fewer years of education, born well after I started medical school. I’ll happily learn from anyone who knows something I don’t.