A Country Doctor Writes:

The corpse, laid out on a gurney and covered with a white sheet, was wheeled onto the stage by two women in long, white lab coats. A middle aged man with a bow tie welcomed us, the incoming class of the spring semester, to Uppsala University and the Biomedicine Center, where we would spend the next two years in “pre-clinicals”, until we knew enough to start our three and a half clinical years at the Academy Hospital.

The Biomedicine Center was almost brand new, a glass and concrete labyrinth with a large sculpture depicting Watson and Crick’s DNA molecule by the front entrance. The vast complex lay near S-1, the Uppsala military regiment. The brick buildings diagonally across the street were very familiar to me as the place where I had met the biggest failure in all my twenty years only months before.

As I sat in the large lecture hall with the corpse on the stage, I glanced over at L., my buddy from the Swedish military’s elite division, the Interpreter School, where we had also sat next to each other on the first day, when the Captain in charge told us:

“Soldiers, you may all have been the smartest kids in your school, but it’s different here. Most of you won’t make it, and will be culled over the next two months. The Interpreter School accepts eighty recruits and graduates twenty to twenty-five. If you don’t have what it takes, don’t waste our time or yours!”

L. and I had both thought that learning Russian would be a neat way to spend our compulsory year and a half in the military, but just barely more than a month after that harsh introduction, we were both on our way back to our respective home towns to figure out what to do until we would be able to start medical school. Our military service was put on hold until we could return as medics.

The man with the bow tie went on to introduce our guest professor, on loan from the University of Bavaria. As we all knew, the Germans had been the greatest anatomists since the last century, and all of us had already been to the University book store to purchase Hafferl’s “Topografishe Anatomie”, which would be our constant companion for the next five months.

“Hopefully, most of you took several years of German in High School,” the man continued, “but those of you who chose French instead and only took one year of German are encouraged to take advantage of our German night classes, every weekday from 8 to 9 pm in Hall B next door.”

With that, he gestured to the Bavarian guest professor, who bowed and began speaking as the first slide was projected behind him. He had the most peculiar accent, and spoke in a slow drawl. I strained to get a handle on what he was saying. L. cocked his head and as I turned toward him, I saw many heads shaking.

With every new slide, the German speaker seemed to increase the tempo of his speech and as the slides behind him changed faster and faster, more and more heads were shaking in the lecture hall. Soon, all of us had given up trying to understand as the staccato voice from the stage pounded the syllables faster than a sports commentator and the rapidly changing slides became more and more filled with details. Heads were shaking, many people were talking, some stirred and rose from their seats and turned toward the exit doors.

Then, suddenly, everything turned dark, the speaker stopped talking and all the chatter in the lecture hall ceased. We sat in darkness and silence for maybe a minute. Then, a faint tune from a small flute rose from the dark stage and dim lights began to illuminate the two women in white lab coats. One was playing the flute, the other picked up a clarinet and began to play.

As the lights continued to brighten, the sheet suddenly flew off the corpse, who sat up, pulled a trumpet to his mouth and belted out a tune like something from a Mardi Gras parade.

The stage filled with upperclassmen and the “German” professor took a bow as they all applauded in his direction.

Then, from a side door, a tall man with a very straight back, white riding pants, tall black riding boots and a whip appeared. Everyone fell silent as he began to address the students in the lecture hall.

“I’d like to introduce myself. I am professor A. of the Department of Anatomy. I just came back from riding in the fields beyond here. I want to welcome you all.”

L. and I looked at each other and shrugged – was this part of the joke?

Professor A. continued:

“So, you made it to medical school. And if you really want to, all of you will make it out of here with a diploma. Just work hard, enjoy Uppsala, and don’t worry about the German classes – all lectures will be in Swedish!”

He was right, all of us who wanted to made it all the way through. My friend L. chose to leave medical school for a life as a writer, but he often writes with great insight about doctors.

I remember that first day as if it were last week, but it was forty years ago. It was the beginning of a journey of learning I can’t imagine ever reaching a final destination. In 1974 there was no HIV; we had only Hepatitis A, B and non A-non B; Sweden didn’t have a single CT scanner; mammography screening was just beginning; Tagamet, Prozac, “statin” cholesterol drugs and clot-busters weren’t invented; low-dose aspirin wasn’t known to reduce heart attack risk, and so on.

In spite of all that has changed in medicine since I started, the way I learned at Uppsala how to evaluate scientific information, to elicit a disease history, to examine patients, and to approach them as individuals, not “cases” – that has not had to change in forty years of doing the only work I could ever imagine doing.

(Originally published on The Healthcare Blog, where my friend L. read it and thought I made it sound as if we were “culled” from the elite military school. We chose to drop out. Everything else happened just the way I wrote it…)

P.S. This is my 300th post on “A Country Doctor Writes”.

Knowing what to do when faced with a sick patient is relatively straightforward. We learned a lot of it in medical school, picked more up by experience, and usually have the opportunity to look things up quickly on the Internet. Even when faced with a brand new situation, we can usually fall back on our general knowledge of science and medicine.

But in today’s practice of medicine, that’s not enough. Physicians, PAs and NPs all live in two parallel universes these days, the World of Medicine and the World of Metamedicine.

The world of Medicine was created through understanding of Life itself. It is vast and complex, and growing exponentially. Its rules tend to follow scientific principles.

The world of Metamedicine was created by humans with limited understanding of Life, but with vast experience in actuarial calculations and bookkeeping. It is growing faster than medicine itself. Its rules follow a logic not taught in medical school.

Imagine a well trained physician faced with a patient who has gained some weight and complains of swollen legs. The doctor notices that the patient seems just a little short of breath. But our patient also admits to eating more than he used to and he has been on his feet more than usually in hot weather. He wonders if that may have caused the swelling.

Our wise physician knows that right-sided heart failure predominantly causes edema, whereas left-sided heart failure more affects breathing. Suspecting heart failure, he orders a BNP, a relatively new, fancy screening test for heart failure.

The overlords of the Metamedicine universe, in their infinite and inscrutable wisdom, have determined that Medicare will pay for BNP testing in cases of shortness of breath, but not in cases of leg swelling. Our doctor orders the BNP in good faith for the diagnosis of “edema”, but the next day the lab notifies him the test was not run because there was no covering diagnosis.

Yours truly had a patient the other day with new onset of atrial fibrillation and a Left Bundle Branch Block (LBBB) on his EKG. They teach us in medical school that a new LBBB in many cases signals a blockage of a coronary artery. I ordered a stress test. The diagnosis I assumed would cover this test was my patient’s LBBB.

Wrong. Today I got a fax from the EKG department, stating this diagnosis didn’t cover the test. Presumably because of some Metamedicine Code of Ethics, they did not tell me what would, but they were kind enough to include several pages of diagnoses that would qualify my patient for a stress test.

Frustrated, I perused the list. Nothing seemed to fit, and of course you can never use “suspected” or “rule-out” as a qualifying diagnosis. That is one of the ground rules of the Metamedicine dimension. Then, there it was: The very last qualifying diagnostic option was ICD-9 code 794.31, “Nonspecific abnormal EKG”. Now, why didn’t they teach me that in medical school instead?

Also today, I had a fax from the pharmacy about a Medicaid patient with anemia and evidence of blood in the stool. She had recently undergone an upper endoscopy that showed gastritis and a duodenal ulcer. I had prescribed omeprazole, an inexpensive acid blocker. She was already on even less costly iron pills for her anemia. Medicaid required a Prior Authorization. The reason for this is that, theoretically, iron is better absorbed if the stomach environment is acidy. If you have bleeding from too much acid, this is not a worrisome drug interaction. But Medicaid has enough time and resources to micromanage everyday clinical judgements like this one. I scribbled “Aware of theoretical interaction. Will monitor”, as I always do in these cases. The PA always gets approved. I am doing my job and the folks at Medicaid are just doing theirs.

Every day has more examples like these. Unlike the laws of Medicine, the rules of Metamedicine seem arbitrary, at least to a medical mind, and there are fewer handy resources for looking things up. Besides, people like me sometimes fall into the trap of doing what makes sense to us without looking up what diagnosis covers what in the world of Metamedicine. But, how much double checking can you do in 15 minutes?

I have long thought of myself as bilingual, speaking pretty good English and even better Swedish. I’m also learning the language of Metamedicine. That is becoming more necessary in my everyday dealings than my rusty German and rudimentary French.

Here’s a quiz:

Which diagnosis covers a lipid profile?
A) Screening for lipoid disorders (V77.91)
B) Screening for other and unspecified cardiovascular disorders (V81.2)

Give up? The correct answer is B. See what I mean…

Today I got a fax that made my jaw drop and my heart sink.

A pharmacy benefits manager, the part-insurance-and-part-mail-order-pharmacy for a few of my Medicare patients, was contacting me to point out that there was a new incentive for me to consider:

For each of the diabetic patients listed on the second page of the fax, I would be paid $100 if I prescribed an ACE inhibitor or an ARB (angiotensin receptor blocker) by the end of next month.

Only one patient was listed, an extremely well controlled diabetic single gentleman in his late 70’s, Gerald Spike. Gerald has lowish blood pressure, has fallen twice in the last year, and his MCV (the size of his red blood cells) is above the normal limit. His B-12 and folic acid levels are normal, and the next likeliest explanation for this is alcohol consumption. Gerald swears he only has one glass of wine every night with his dinner.

Gerald is not a good candidate for an ACE or an ARB. I personally am not convinced that any well controlled diabetic with normal kidney function, normal urine microalbumen and normal blood pressure should be on one of those medications, especially at Gerald’s age, but that is a different story. He could ill afford to have his blood pressure lowered even a little.

Offering a cash incentive for doing something that could harm a patient, and which in one or several ways profits the pharmacy benefits manager, be it in their quality metrics, moneys paid to them by the main insurer, or copays from patients – is unethical. Call it an incentive if you wish; bribe or kickback are more accurate words for this.

If I had thought Gerald would have benefitted from an ACE or an ARB, I would have prescribed one already.

I still remember Hippocrates’ words:

“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”

Dwayne Tarlov came to see me today for pain in his right wrist and left ankle for the past month and a half.

There hadn’t been much swelling, and he had no morning stiffness to suggest rheumatism. He had not had any fever or cold symptoms, and he absolutely denied any injury or new activities that might have brought on his symptoms.

His exam revealed his usual habitus, a slender, fine-boned fifty five year old man with gray hair, a tightly cropped beard and a new stud earring in his left ear.

His right wrist had normal range of movement, but localized swelling and tenderness near the extensor tendons of his thumb. There was no clicking or catching with thumb movements and I felt no crepitations.

The ankle was puffy on the outer, lateral, side and Dwayne was a little tender. Turning his ankle outward was painful.

I ordered X-rays, prescribed ibuprofen and recommended a wrist splint. We agreed to see how he is doing in two weeks. I asked again, and Dwayne could not remember anything he could have done to cause his pains.

I went back to my office to check messages and touch base with Autumn. A few moments later I was startled by a loud motor exhaust. Looking out the window, I saw Dwayne on a large Harley-Davidson motorcycle. His right wrist revved the gas, he squeezed the clutch and with his left foot, he kicked the bike into gear and roared off across the parking lot.

I typed an addendum to his office note to remind me about my exit diagnosis of his wrist and ankle pain.