A Country Doctor Writes:

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, Meaningful Use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30 minute physical or “wellness visit” (not the same thing) visit once a year for every patient chews up 750-1,000 hours. Total “contact” hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick – less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people – blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating Chronic Diseases Leaves Little Room for Diagnosing and Treating Acute Illnesses:

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing Evidence Based Medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in-clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like RiteAid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITTP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience. Equally true, Nurse Practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called “doctor shortage”, this is what sometimes happens:

In many states, Nurse Practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.

SO, WHO SHOULD DO WHAT IN PRIMARY CARE?

I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But, “out of the box”, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950’s.

My point is that in today’s healthcare system, we are often asking the providers with the least training to see the unsorted clientele in “sick-call” while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned Nurse Practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived “doctor shortage” may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the “sick-call”, and Nurse Practitioners more of the “maintenance“ of modern healthcare.

Let’s really talk openly about who should do what in primary care today!

Andy was new to me. He told me he had seen several doctors over the past few years for various pains in his right arm.

Some months ago, he had right shoulder pain that went away on its own, but for the past few weeks, he had pain in the middle of his upper arm. Last year he had tennis elbow and forearm pain for many months.

A slender, middle aged man, he had no unusual hobbies and denied injuries or neck symptoms. He was visibly uncomfortable as we talked and kept his left hand tightly gripping his right upper arm, held close to his chest.

He had full movement of his neck and normal sensation to touch of both arms and hands. His intrinsic hand muscles were not atrophied. In fact, his grip was stronger than mine.

I asked him to abduct his shoulder forward and to the side, which he did without pain, even when I resisted his movements – a sign of an intact rotator cuff.

When I asked him to place his right arm over his head, he volunteered that he sometimes slept with his arm in that position as it offered some relief from his otherwise unrelenting pain.

I excused myself with the words “let me get my wiring diagram”. Returning with my tattered paperback copy of Mumenthaler’s pocket neurology textbook from the early seventies, I showed him its picture of the cervical dermatomes.

“You have a pinched nerve in your neck, the fifth cervical nerve, and some of the pains you’ve had before sound like they could have been from the sixth nerve also”, I told him.

His eyes widened. “You know, I did fracture my C-5 twenty seven years ago in a skiing accident, but I’ve never had any issues with my neck since that year”, he said.

We talked about what his options were. Because the pains had come and gone before and had only been severe for a relatively short time, and because his muscle strength was intact, I explained that a short course of steroids might help, at least in the short run. I also offered him pain medication.

“I’ll take the steroids but I’ll pass on the pain relievers. I hate the idea of taking those things”, he said emphatically.

I went over the dosing and side effects of the prednisone and said “if ten days of this doesn’t help, I would go ahead with an MRI”. He nodded agreement and we set up a follow up appointment eleven days later.

Day ten was a Monday. Among the weekend faxes from the hospital that landed on my desk that morning were two emergency room reports about Andy.

The first report, from late Friday night, told of how his pain had escalated steadily since he saw me. They had done plain X-Rays, which showed bone spurs and narrowed disk spaces from C-4 to C-6. They gave him some 5 milligram Percocet, which helped his pain, and sent him home with a prescription for 10 milligrams every 4-6 hours as needed and instructions to keep his follow up appointment with me.

The second ER visit, eighteen hours later, was for nausea and vomiting. The five milligram tablet Andy took in the ER Friday night was just right, but the ten milligram tablets, which he had dutifully taken every four hours, were too strong.

“Did you try breaking the pills in half?” I asked when I saw him back in the office.

“I guess I could have, but I didn’t really think of it”, Andy answered.

“I feel terrible that you ended up going to the ER twice”, I confessed, “because I should have told you that if the prednisone hadn’t done anything after three or four days, it probably wouldn’t work at all. If I had, you would have known before the weekend that you needed to let me know.”

“Ah, that’s all right”, Andy said, but I kept thinking about how the most accurate or clever diagnosis is of little use to a suffering or fearful patient if you aren’t clear enough about what seems like a straightforward plan to you, but not to a patient who never had the experience of being sick or taking medications before. As doctors we assume all patients will make the necessary judgement calls on their own.

I failed Andy and the first emergency room doctor failed him, too. We rattled off our standard instructions without making sure he understood what to do if our treatment plan didn’t work.

That’s the Art that sometimes gets lost in this business.

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.