A Country Doctor Writes:

In my mind I was debating whether the woman in front of me was my second-ever case of a brain abscess or if perhaps during one of her recent falls, she might have suffered an intracranial bleed. She was taking warfarin for atrial fibrillation and her frontal headaches and nausea with vomiting had been getting worse over a four week period. My own father almost died in his fifties from a chronic subdural hematoma. This woman looked like something between my brain abscess patient and my father just before he was diagnosed.

Gwen Garfield was congested and blamed her nausea and vomiting on her purulent post nasal drip. She was clearly not a complainer; she split her own firewood and walked with a severe limp from childhood polio. Her regular physician, Dr. Landry, is out this week, but his nurse has been helping Autumn out, and she told me that Gwen wasn’t her usual self at all. She had even asked a friend to drive her in because of how poorly she felt.

Both her maxillary sinuses were tender and she had nasal congestion and her forehead was wrinkled over lowered eyebrows in a static gesture of concern. Her neurological exam had no specific abnormalities, but she seemed just a little vague for a woman with her reputation. She fumbled with her keys and reading glasses and dropped them on the floor, but her finger-nose coordination was surprisingly normal.

I prescribed her some cefuroxime for her presumed sinusitis but also told her I felt she needed a CT scan of her brain before the three day weekend, especially since she lives alone far from town and “off the (electric power) grid”. “We have to rule out a bleed and an abscess”, I told her.

Because her insurance, Aetna, requires prior authorizations, I typed and clicked my office note and put the CT request in as quickly as possible and had Autumn call the referral coordinator to get the prior authorization request going.

I sent Gwen and her friend to the pharmacy and told them to check back with us in a little bit. By 1 pm we got word that her CT scan was denied. I felt concerned enough and it was already late enough in the day that I wasn’t going to risk wasting more time with an appeal with the long weekend coming up. Besides, I was the only doctor covering our whole clinic with an overbooked schedule and also responsible for the large nursing home in town; I know how long the insurance companies can keep you on the phone when you try to appeal a denial.

I told Gwen and her friend to drive down the road to the emergency room, because they don’t need prior authorizations for CT scans. Then I called Jim Anderson, the ER doctor on duty, and told him I hated to dump on him but my patient needed a scan that her insurance wouldn’t pay for.

“Well, they will pay for it now”, he said laconically after I painted my thumbnail sketch of Gwen’s history and exam.

Two hours later we got a fax saying that, after further review, Gwen’s CT scan was approved. By that time Autumn was able to get the results from the hospital computer – no bleed, no sign of an abscess. Jim added a steroid nasal spray to my antibiotic for her sinuses. Aetna ended up paying for my office visit, the CT scan and an emergency room visit I would have wanted to avoid.

The afternoon flew by. Everybody was patient with me for running behind. The nursing home did call a few times to make sure we had received the faxes they had sent us between 2 and 4 pm. As I worked my way through lab results and requests for decisions about coughs, fevers, urinary tract infections, hallucinations and other odds and ends, I gasped internally when I came to the last one.

It was actually a stack of pages, all about the same thing: A dying man had been prescribed subcutaneous injections of morphine and lorazepam placed under his tongue, two staple drugs of “comfort kits” used by hospitals, Hospice agencies and nursing homes all over the world to ease the discomfort of dying patients. The patient’s Medicare D plan, WellCare, had already denied coverage for these two generic drugs. Another provider doing rounds at the nursing home yesterday had filed an appeal, and this appeal, too, had been denied.

The nursing home asked me to write a note to WellCare to appeal.

I usually manage to retain a fair amount of what Sir William Osler referred to as aquanamitas, the seasoned physician’s unflappability, but at 4:30 this afternoon I had already had enough of arbitrary and insensitive insurance companies lacking common sense and human decency. I wrote:

“In my thirty years as a family physician, I have never seen such cruelty as denying a dying man the relief of his final agony with basic, generic drugs like morphine and lorazepam.”

I don’t know yet if that did any good. The nursing home has a supply of these drugs on hand, so for now the patient has been getting what he needs, but to me, this struck at the core of what we all have the right to expect our insurance companies to cover.

Osler, the father of modern medicine, said: “To prevent disease, relieve suffering and to heal the sick – this is our work.”

This is unfortunately not quite the work of the insurance companies.

I introduced myself and continued “and you are Annika LeBrun?”

“Ja, det stämmer”, she answered in perfect Swedish.

I had suspected from her first name that she might be Swedish. She continued in an accent that suggested roots near Stockholm, the area where I was born:

“With a last name like that and a license plate in Swedish, I knew where you were from.”

We continued the visit in our mutual mother tongue. I had to think fast to find the right Swedish medical terms after working as a physician for thirty-three years in this country and not having spoken Swedish for a couple of years except a few phone calls to a couple of aunts in Sweden.

My new patient had also been away from Sweden for several years, and she ended up asking me how to describe a few of her medical concerns in Swedish.

The word “cataract” came up, and it took me a few seconds to retrieve “grå starr”, and I couldn’t help myself but went on to also talk about “grön starr”, glaucoma.

Swedish has two medical nomenclatures, one newer internationalized one, where “cataract” is “katarakt”, and an older one with Swedish or Germanic words.

The word “starr” dates back to the 1600’s and derives from ancient Germanic words for “stiff”, and indirectly also to “stirra”, which means “stare”.

A cataract affected eye has a gray pupil due to clouding of the lens, whereas glaucoma, a term derived from the Greek “glaucos”, which means “blue-green”, may have a greenish hue, but sometimes may look normal or cloudy.

We finished our visit, and I struggled for a split second to find the right words for “stop at the reception desk and make a follow-up appointment”.

I mused silently about all the quaint Swedish medical words I haven’t heard or used for thirty years: “bukspottkörtel” (belly spit gland) for pancreas, “ros” (derived from Dutch and German words for red), for erysipelas, “bältros” for shingles. The English word “shingles” is derived from the Latin cingulus, which is a straight translation of the Greek “zoster”, meaning “girdle” (from the way the shingles rash can encircle half the body; the Swedish prefix “bält-” means “belt”, just like it sounds).

Later, on my way home, I thought about how you can use your second language so much that your first language, even though you may have a deeper understanding of it, can seem harder to use in some situations. But, to be perfectly honest, sometimes it is still my first choice, for example when counting.

I arrived home feeling as if I had traveled far today – 3,000 miles to Stockholm and thirty-odd years to my early days in medicine. It’s been a long but interesting day.

In these virtual pages I have written about medical mysteries, the frustrations of today’s healthcare, and the human dramas we encounter in the practice of medicine.

Below are updates to three previous posts, one from each of these three categories: “The Great Imposter”, “Calling Mrs. Kafka”, and “Invisible Ties”. Readers who don't remember these posts may want to follow the links to catch up on the beginning of each story.

A TALE OF RED HERRINGS

“The Great Imposter” ended in clinical uncertainty:

“And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.”

The other day I saw Dr. Brown walk Norman Sprague down the hall. Afterward, I asked whatever happened with his possible shingles, gallbladder pain, lung nodules and mediastinal lymph nodes.

“The PET CT looked pretty benign”, said my octogenarian colleague, “and nothing came of that pimple you saw on his back. He still has his gallbladder and Roger White is pretty sure it's sarcoidosis. Interesting, though, that the Lyrica samples you gave him when you thought it was shingles cut his pain at least in half, but the pain is on both sides of the midline…”

“I don't know why it's working, then”, I said.

“Neither do I, but I kept him on it. He's meeting with Roger next week to discuss treatment options, probably steroids.”

“Pretty sure, huh”, I muttered to myself.

A PYRRHIC VICTORY

In “Calling Mrs. Kafka”, I went to bat against the insurance company for Harriet Black. She really did have a terrible case of shingles, and Lyrica was the only thing that really helped her pain; the gabapentin and her regular pain medication had not been enough.

After my call to the surreal Mrs. Kafka in the Prior Authorization department, I asked Autumn to call Harriet and tell her the drug was approved. She was very grateful on the phone. Some time later she came in for her follow-up appointment.

“How’s your shingles pain”, I asked.

“Still pretty bad”, she answered.

“I thought the Lyrica was working pretty well”, I said, confused.

“I can't afford it. The copay is too high”, Harriet said, her voice trailing.

So much for getting a medication approved by the insurance company…

MOTHER AND CHILD

Four years ago, in “Invisible Ties”, I described how Kirk Donner, adopted at birth, went to the State Capital to look for his birth mother after he turned eighteen. He knew she had an unusual name, Suann:

“Kirk took the elevator to the fourth floor. He was alone. As the door slid open, he stepped forward and almost collided with a tall, dark-haired woman with designer jeans and a plain, white blouse. Her eyes met his as he stopped and apologized. They were large and kind. She flashed a smile as he swerved around her, embarrassed and eager to get to the registry.

He walked up to the receptionist and stated his errand with words he had practiced in his mind the whole trip.The clerk handed him a form and as he reached for a pen he saw a stack of similar forms in front of her. Reading the top one upside-down he saw the name: Suann Walker.”

Mother and child made contact soon after that day, and each found peace in knowing what had become of the other. Kirk met his half-sister, also raised by an adoptive family.

Suann and her fiancé attended Kirk’s college graduation in May, and this summer Kirk spent a lot of time at their house while he took a summer course in the southern part of the state.

“Finding her and learning what she is like has helped me understand myself better, it makes me feel more whole”, Kirk has told me.

Many of my vignettes on this blog end with unanswered questions or unstated uncertainties, just like any typical physician’s patient encounters. These updates moved the plot forward in just three cases, but even these are not the final installments in the history of each patient’s own journey. Medicine, even practiced over many years of physician-patient continuity, is but a glimpse into the lives of a few fellow humans.

This week I suddenly felt transported back to my earliest years in medicine back in Sweden. In the last few days I have seen almost a dozen children with rashes. We have a Hand, Foot and Mouth epidemic in our little town, hitting the second and fourth grade children hardest.

One eleven year old boy had looked like an early strep throat a few days ago, but he came back today with subtle red spots on the palms of his hands. He was in the room across the hall from his two-year old cousin, who had a full blown case of HFMD, the worst I have seen all week. His aunt had sore, itchy palms with no rash. I don’t know if it’s a sympathy reaction or if she is next to come down with it.

Mixed in with the rest of them was a two year old from out of town with a sketchy immunization history and a bad case of chickenpox, and a handful of children with colds and worried parents. One little boy with a runny nose had one single macular lesion on his thumb – too soon to tell whether he is coming down with Hand, Foot and Mouth disease or not.

Working acute care in Sweden, I saw a lot of rashes, and in those days we did not have all the immunizations we have now. I remember feeling pretty confident with my differential diagnosis of rashes – measles, German Measels, scarlet fever, things we don’t see much of anymore. Scarlet fever, associated with streptococcus infections, was common then but is rare these days. We also saw enough post-streptococcal nephritis that I routinely brought strep patients back for a urinalysis after their sore throat had resolved.

I remember the varied reactions among parents during the small epidemics I witnessed in those early days. Most parents took things in stride, expressing gratitude that their children got their “normal childhood diseases” over and done with. Some parents even sought out chickenpox cases in their neighborhoods and had chicken pox parties in order to have some control over when their children got the disease. I just read somewhere that the Swedes still aren’t immunizing children against chickenpox, apparently for cost reasons.

When I worked in student health here in the U.S. in the late 1980’s, we had a measles epidemic at the university. Because the students had been immunized as children, they tended to get milder and atypical forms of the disease. I remember being called in to see my colleagues’ cases all the time as the local expert on the rashes of “childhood diseases”.

Hand, Foot and Mouth disease was first described in New Zealand (or Australia by some accounts) in the 1950’s. I don’t remember running into it often back when I used to see measles and German measles. I remember just calling it a coxsackie virus rash. Recently I have read that the Swedes call the disease “höstblåsor”, or “autumn blisters”. I do remember seeing more “herpangina”, which looks the same and is also caused by a coxsackie virus, but is limited to the mouth.

There is no widely available vaccine against Hand, Foot and Mouth disease, and antiviral drugs are ineffective against it, but it tends to be a very benign illness. Some of the eleven viruses that can cause the disease are more aggressive, and in other parts of the world, for example Vietnam, the disease can more often be associated with neurological complications, from minor twitching to convulsions.

The way our society reacts to the mild form of the disease that we usually see is interesting. People worry about second graders missing a week of school – something I have a little trouble with. The economic burden of working parents missing work is a valid concern, but with so few “childhood diseases” left to contend with, a week of reading, watching movies or playing games at home isn’t the end of the world.

Our few remaining “childhood diseases” take the time they take to get through, and we have no shortcuts. They offer us an opportunity to understand that we can’t control everything in our lives.

Hand, Foot and Mouth disease usually only strikes once, so unlike the common cold, it has not become big business for purveyors of useless remedies, and unlike influenza, we have no big-ticket disease modifying drugs, so we are left to practice good home care, humility and the ancient art of just “being sick”.

America’s favorite mid-century pediatrician, Dr. Benjamin Spock, wrote the following about the “childhood diseases”:

“There are only two things a child will share willingly — communicable diseases and his mother’s age.”

You have to think fast in medicine. Not that most doctors handle life and death emergencies all day long, but even seemingly mundane clinical situations require a lot of rapid gathering of data, processing of applicable information and attention to detail in formulating a plan.

I have always been bemused by the so called E&M (evaluation and management) coding that dictates payment by requiring documentation of how doctors think. Ironically, the AMA defines this work and thereby has been a major contributor to physicians now spending more time on documentation than on doctoring. The documentation, even with EMR templates, takes infinitely more time to complete than the thought processes that go into clinical work. Even our preliminary observation of a patient, before any history taking occurs, is something instant, that in a novel might fill a whole first chapter, or in a homeowners’ insurance inventory might go on for pages. We can take in details of a new face or a new place in the blink of an eye; this is something all of us experience. Doctors, by nature of their profession, hone this ability in Sherlock Holmes-like fashion.

Not that I follow sports, but I can imagine a pro golfer or star soccer player could go on for quite a long time describing all the millisecond judgments that go into every aspect of their game. But the difference is they don’t have to. It seems they get paid according to their results, and not by their stated mental work behind those results. In fact, most fans’ appetite for hearing all the details behind the action shots is probably rather limited.

In medicine today, unlike the worlds of Sir Arthur Conan Doyle or Sherlock Holmes, we don’t quite have the option of using the richness and nuances of our language to document our observations. Our words must be chosen from a dictionary of “findings” that correspond to numerical codes used as underpinnings of our EMRs. Our patients can’t be “uncomfortable”, “squirming”, “braced”, “forced”, “pensive” or even “vague”; we must choose between “in acute distress” or “not in acute distress”.

Our language is no longer ours; we must speak like accountants. But when we do, will accountants understand us any better than when we speak like doctors? I suspect that by speaking their language, we risk having our powers of observation, ability of analysis and skill of formulating a clinical plan reduced to something with less depth than what it is, regardless of the number of details we provide.

When we encounter patients we have seen a long time ago, our own notes can fail to give us the instant familiarity of past medical records, and when we see our colleagues’ patients, we struggle more to get to the essence of the clinical notes.

By accepting to describe our work in this foreign language, Accountanese, we have deprived ourselves of some of the tools of our trade, the shorthand that soccer teams might use to synchronize their game. We have lost the nuances of language we need to describe complex processes and multidimensional clinical scenarios involving patients of flesh and blood. So we fumble around, choosing more and more words from our pick lists, none of them quite the right one, while our notes get continually bigger and less and less precise.

We are more or less trusted to care for the lives of our patients, but we are not trusted to bill honestly for whether we just did an easy visit or a complex one.

Maybe I should ask my tax accountant for an itemized bill for his preparation of my income tax filing; all he sent me was a note, stating:

“Preparation of 2013 form 1040. $180″

I would never get away with anything that brief.