A Country Doctor Writes:

Treating Symptoms

Back when Prozac (fluoxetine) and Zoloft (sertraline) were new, I remember the mental acrobatics doctors made to justify giving these drugs to anxious patients. The drugs were approved for treating depression, but we knew they often seemed to help anxiety. The reason, we were told, was that some anxious patients were actually depressed, deep down, and we had just failed to recognize their depression.

Now, with studies to support their use in anxiety, we are pressured to prescribe them, since they, unlike benzodiazepines, are said to “get to the root of the problem”. But do they get to the causes of either anxiety or depression?

Even before Prozac, my medical school courses in psychiatry, back in Sweden, taught the distinction between endogenous depression, treatable with the tricyclic antidepressants of that era, and exogenous depression, which only the Americans chose to treat with drugs. The Swedish opinion was that depression due to external factors should be treated by addressing those external forces or the patient’s cognitive-behavioral reaction to them.

Depression, along with other mood disorders, has earned the alternate name of “chemical imbalance”, even though we really don’t know all that much about the chemistry inside the blood-brain barrier. The new moniker does help justify choosing medication over exploring the psychological reasons behind the symptoms, though. Never mind that the efficacy of medication alone is only marginally better than placebo. And never mind that therapy along with medication has a much better success rate than medication alone. We truly are just treating symptoms empirically with these drugs. Worse still, our understanding of how our current medications work is very incomplete. For example, fluoxetine and sertraline are said to treat depression by inhibiting re-uptake of serotonin in synapses of the brain. Yet, in Europe there is a drug that instead enhances serotonin re-uptake, and it also helps depression, so two opposite drug mechanisms seem to bring about the same clinical result.

Psychiatrist Steven Reidbord blogs about how more and more diseases have been snatched away from the psychiatrists’ realm as science pinpoints their causes. He concludes that there will probably always be conditions with unknown or uncertain neurobiological mechanisms that only psychiatrists, with their tolerance for uncertainty, have the patience to treat.

Today, in primary care, urology and many other specialties, symptoms are what we treat all day long, it seems. From overactive bladder and erectile dysfunction to myofascial syndrome, restless legs, neurodermatitis and insomnia, we have the drugs but not quite the understanding of how and why they work. In many cases, several possible mechanisms seem to lie behind each symptom.

The old-fashioned notion of “syndrome” applies here; we recognize clinical constellations of symptoms, but we often don’t have a straightforward cause isolated. We have empirically established treatments that work at least some of the time, but we often don’t know why. In many cases, clinical syndromes are relegated to the sidelines, even when there are available treatments, unless those treatments are brand-name drugs. More than once, pharmaceutical companies have made obscure syndromes, such as Restless Leg Syndrome, famous in order to promote a new drug, even if the drug is not always effective, as it doesn’t quite seem to address the root cause of the disease.

This reminds me of the medical school professor, who during morning rounds on his top floor ward at Uppsala Academy Hospital dismissed many patient concerns with the words “I treat diseases, not ailments”.

Times sure have changed.

Today, ailments are honorable to treat. We talk about improving or enhancing quality of life. Ailments are also now big business. Myrbetriq, for overactive bladder, costs $250 per month; Viagra, for erectile dysfunction, $28 per pill; Lunesta, for insomnia, $280 per month, to name just a few examples.

In this era of genetic and neurobiological advances, we are sometimes naively optimistic about the depth of our understanding. We like to think that we have moved beyond treating symptoms, but even when we prescribe statin drugs or stent blocked coronary arteries, we are not even attempting to address the causes of coronary artery disease, for example.

So, maybe only a select few subspecialists among us can say that they only treat diseases and not ailments, or symptoms; most of us do a lot of it. For every new scientific breakthrough, there seems to be a handful of empirical discoveries of something that sometimes works, even though we don’t know why.

Dr Reidbord is not alone in living with the uncertainty of treating symptoms of unknown cause; welcome to the world of primary care.

Laura Schwartz could have hour-long spells of squeezing chest pressure, but she was pretty sure it wasn’t her heart. After all, she was trim, athletic and by her own admission also a “health nut”.

A few years ago she had a stress test with with an abnormal EKG response to exercise but normal nuclear images. The cardiologist we consulted, as most in the cardiac community, felt the normal imaging trumped the abnormal EKG and declared her pain non-cardiac.

Her episodes of chest pressure recurred now and then. We had talked about the possibility of coronary spasm, but she wasn’t sure I was right about that. I had seen women before with “Cardiac Syndrome X”, who had classic exercise induced angina but normal coronary arteries. They tend to have only a mildly increased risk of actually having heart attacks, and sometimes get better over time on their own. In Laura’s case, the chest pain occurred sometimes with exertion like classic angina and sometimes randomly at rest the way Prinzmetal’s, or vasospastic angina usually behaves. She seemed to stand somewhere between the different types of angina, or perhaps she had esophageal spasm.

Laura wanted to leave things alone, and kept up her busy life, attending committees, exercising, gardening and maintaining her big house.

But six months ago, the intensity of Laura’s chest pressure seemed to intensify, and she was on the verge of accepting a referral for another cardiac consultation. Then she cancelled a couple of appointments and disappeared off my radar screen.

Last month Laura came back with a history of three days of on-and-off squeezing chest pressure. Her EKG was normal, but this time she was as concerned as I was. She accepted an ambulance transfer to the hospital where her first troponin blood test was normal, but the second one was dramatically elevated.

She was transferred from our community hospital to Capital Cardiac Center and underwent urgent catheterization. Bob Googan, one of their senior cardiologists, called me from the cath lab. “Hey, this patient of yours, Laura Schwartz, has normal coronaries but she has apical akinesia and must have infarcted because of spasm, so we’ll discharge her on something for spasm.

When I saw Laura in follow-up, she looked and felt great. We talked about how misunderstood women’s heart disease still is, and she sighed and said, “I know I have to pace myself. I’m not forty anymore, and I was pushing too hard”. She accepted a referral for cardiac rehab.

I am waiting to see if her calcium channel blocker will help prevent her angina, as with typical coronary spasm, or if she will need to be switched to a beta blocker, as many women with Cardiac Syndrome X.

This is the art of medicine.

Henry Halvorsen was in to see me the other day. 79 years old and usually brimming with optimism and vitality, he seemed subdued and frail. His weight loss and muscle weakness were obvious.

“Good to see you, it’s been a long haul”, I greeted him.

“Three surgeons, two CT scans, two hospital stays before they found out what was wrong with me, and then rehab and everything that happened there”, he said, exasperated.

It had started when I saw him in the office at the end of February. He had been in three weeks earlier with a flare-up of his recurring back problem. That had cleared up, but Henry was having some bowel trouble, mostly constipation but then sometimes a day of loose stools. He thought it was his muscle relaxant that caused his bowels to act up, but his bowels didn’t straighten out after he stopped his cyclobenzaprine.

He wasn’t running a temperature, but his appetite was off. He was definitely a little tender deep in his right lower quadrant, but there was no involuntary muscle guarding when I let go of the pressure with my hands. I ordered bloodwork and a CT scan and told him that even though his pain and irregular bowels had been there for a whole week, he could have a subacute appendicitis.

His white blood cell count came back mildly elevated, and his sedimentation rate was elevated at 40 mm. The wait for the CT seemed long, but he was feeling better. Then, the day before his scan was scheduled, he woke up with worse pain and severe diarrhea, so he went to the emergency room. The ER physician, Jack Morton, told him right away he was suspicious of appendicitis.

His blood count was a little higher, and his sedimentation rate was 50. His abdomen was mildly tender, as it had been in my office. The CT scan showed no definite abnormalities, but the appendix was not visible.

The surgeon who saw him didn’t feel there was quite enough reason to remove his appendix, and with intravenous fluids and bowel rest, Henry started feeling better. Another surgeon did a follow-up evaluation on the weekend and Henry was discharged home on the third day.

Two days later at one o’clock in the morning, he woke up with abdominal pain, followed by a very large, soft bowel movement. He had chills and felt nauseous. He called the ambulance and arrived at the emergency room actively vomiting.

Dr. Morton was on that night, too. He ordered the same bloodwork again and another CT scan. This time there were signs of a small bowel obstruction and free fluid in the abdomen. There were nonspecific inflammatory signs in the right lower quadrant but the appendix was not clearly identified.

The surgeon on duty that morning didn’t hesitate. In short order Henry was on the operating table and had his ruptured appendix removed and two Jackson-Pratt drains placed. He received intravenous antibiotics and spent the next few days mostly sleeping with a Foley catheter draining his urine and a nasogastric tube draining his stomach.

At the rehab, where he was receiving intravenous antibiotics, he developed urinary retention shortly after his catheter was removed. The nurses were unable to reinsert a catheter due to his enlarged and inflamed prostate. Henry had to be transported back to the hospital where his urologist managed to get a Foley in. Then, back at the rehab, he developed diarrhea again and was diagnosed with Clostridium Difficile enteritis, resulting in more, but different, antibiotics.

As we went over everything that had happened to him, he sighed and said “I’m lucky to be alive”.

I nodded and mused out loud. “It’s such a common disease, but it can present in so many ways”. I thought about the first CT scan and the first surgeon’s decision not to perform an unnecessary operation.

I told him when I was a resident in Sweden, surgeons used to talk a lot about what percentage of innocent appendices you needed to operate on in order not to miss any guilty ones. Between 15 and 40 percent of emergency appendectomies have been reported to reveal a normal appendix, and yet 20 percent of appendicitis cases are initially misdiagnosed.

By the time I did my residency here, my hospital had just installed its first CT scanner, and the diagnosis of appendicitis was no longer a purely clinical one. In some centers, the diagnostic accuracy of CT scanning is said to be as high as 98 percent. But, when the tests are inconclusive or, worse, wrong, it is still a hard judgement call whether to operate or not.

Older patients tend to have less typical symptoms and are diagnosed later in the course of the disease than younger patients. While most cases of appendicitis fulminate within 48 hours, in 2 percent of cases the duration is more than two weeks.

“I’m just happy I pulled through”, Henry said as he rose from his chair with obvious effort.

I shook his hand and answered, “I am, too, and we should all be humbled that the great trickster almost did it again.”

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year old with track marks on her forearms. Her obstetrician and caseworker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates”, I ask with my fingers hovering over the keyboard. She tells her story, first in monosyllabic monotone, but as we move through the questions and she realizes I am not there to lecture her on anything, she warms up a little.

Because she is pregnant, she didn’t arrive here in withdrawal out of concern for the fetus. Her last use was the night before. I explain how to place the Subutex tablets under the tongue and avoid swallowing, so the medication is fully absorbed through the mucous membranes of her mouth. Then I fill out the prior authorization form for Medicaid. I make sure to put her due date on the form, so she will be approved until she delivers. Then I write the prescription, sign it and spell out my name and my special DEA number for opiate replacement prescriptions.

My next inductee is in a cold sweat. He is the same age as my own son. He snorted some Oxys and Ritalins Friday night. Today he has the shakes and the runs. He has no job, is in trouble with the law, and he has been here before, but was discharged because of repeated failed urine drug screens.

I document his COWS score, the degree of physical withdrawal he is in. He had been doing high doses, so I prescribe him 16 mg of Suboxone daily. I explain that since last time he was here, we have switched from tablets to strips that melt under your tongue the same way. He knows; he knows everything about opiates. Is he here again because of his circumstances, I wonder, more than from a deep desire to quit right now? His counselor’s notes in the computer record have a hint of skepticism in them.

“I hate coming here”, says my third patient for the morning. He is a foreman at a nearby factory, logging week number 178 in the program. He is on 2 mg per day. Going from 3 to 2 mg, he had a terrible time with both physical symptoms and cravings.

“I wish I didn’t have to be on this stuff. I want to be over this. I sit in the waiting room with these people who trade stories about what they have done, and I don’t want to hear it. I have a job, a family, and I hate having to come here for my lousy prescription, but I know I can’t keep my life together without it.”

Fourth up is a woman in her forties I haven’t seen before. She transferred in a week ago when Dr. Feiner sat in this chair. I recognize the woman’s name. She is a physician, who just lost her license a few months ago. She is stable on her dose. I write the prescription and she leaves quietly.

The next patient is a mother of two, who just had surgery for ovarian cancer. She is in obvious pain. We had talked last time about how Suboxone does help with pain, but it is not all that potent. She had told me then that she was more afraid of falling back into addiction than being in pain.

This time, she is tearful. Her cancer has already metastasized, and she speaks of what will happen to her two girls if she can’t be cured. She winces with pain, and I ask her again if she is sure she wants to stay in the program. Her husband already manages the Suboxone strips for her, and he could manage pain medications for her as well. But she knows that the naloxone in her Suboxone strips keeps her from feeling the same high that other opiates give.

“I am so grateful for what this program has done for me, that I don’t want to risk that, even for this”, she says and points to her abdomen. “Whatever time I have left..” She chokes, tears streaming down her cheeks, and blows her nose with tissue from the box on the corner of my desk. “Whatever time I have left, I want to be sober, and I want to be all there for my girls and for my husband. I don’t want to be strung out.”

“I hear you”, I say. But you are in pain, I can see that.” She nods.

“I’m going to increase your dose back up to our maximum. That will make some difference. But you may be helped by something like a fentanyl patch, that stays on for three days at a time…”

“Thanks, but this is fine”, she says as she takes her new prescription and strains to rise from the visitors’ chair by the window.

I rise and open the door for her. Then I close it and sit down quietly in my black swivel chair for a few minutes as I look out over the boarded-up windows of the empty storefronts across the parking lot.

I don’t hate coming here, as some of the patients do. It is sobering to think back on the ones who are forced to come here, the ones who come here when they can’t afford their drugs of choice, the ones who fight valiantly to get their lives back in order and the ones who have lost, or are about to lose, everything.

The other day Bigtown Pharmacy sent an angry fax addressed to me. It was a printout of an electronic prescription I had sent the night before. Scribbled at the bottom were the words: “Unit field can’t say unspecified. Please correct”.

I looked at the printout, which was actually a fax they had received from the prescription clearinghouse that connects doctors and pharmacies. Even though I enter prescriptions in my Electronic Medical Record, that pharmacy receives it from the clearing house via fax.

My prescription was for lancets for a 72-year old diabetic to check her blood sugar once a day. But it didn’t say “lancet”. It said “lancer”. My first thought was that my two-fingered typing had offended the Bigtown pharmacist.

The way electronic prescribing works, at least in my EMR, is by having every medication available in this country already programmed into the prescription module, so there can’t be any misspellings or ambiguities of which drug I want my patient to have. But medical supplies like glucometer strips and lancets are not in the system, so they have to be entered manually, which means my computer program doesn’t know at all what I am prescribing; it’s just a bunch of letters to it. The same thing happens when I prescribe a Canadian medication, not available in this country, for patients who cross the river for their prescriptions; the computer can’t check for allergies or interactions because the drug had to be “manually entered” instead of picked from its list.

As I hastily had entered “lancer” instead of “lancet” in the box for “unit” in my EMR, I assumed at first that the angry pharmacist didn’t tolerate any typos, but as I looked closer at the fax, I realized that there was more to this.

The layout of the form didn’t look anything like the layout of my prescription screen. There was a field titled “unit”, and it said “unspecified”. The misspelled word appeared in a free-text window a little below, so the context seemed obvious, even if the spelling was off.

I called Bigtown. The pharmacist explained that Medicare will not pay for my patient’s strips if any of the boxes, particularly the “unit” box, is not specific enough. This is apparently a new requirement. That sounded similar to the “meaningful use” criteria medical practices have to meet in order to get paid under the new health law. One of those requirements is to reach a certain percentage of prescriptions done via the computer instead of on paper prescriptions or sent via fax.

As I was talking with the pharmacist, I pulled up my patient’s prescription log and there was my misspelled “lancer” just where it belonged in the “unit” box on my screen, even though it was missing on the pharmacy’s fax.

“Lost in translation at the middleman”, I mumbled to myself. I asked the pharmacist:

“It is entered correctly, except the spelling, at my end. What can I do?”

“You can free-text ’Unit: Lancet’ anywhere, and we can accept it.”

“Will do”, I said and typed it into the comment field. Then I moved the cursor up to my own “Unit” field and corrected “lancer” to “lancet”. I couldn’t just leave it blank, because if I did that, my EMR wouldn’t send it electronically; I, too, have to fill out all my boxes, even if the receiver can’t see them. After all, I still have to meet my own “meaningful use” requirements.