A Country Doctor Writes:

“I hate to leave you with such an unfinished workup”, my senior colleague, Dr. Wilford Brown, said three Thursdays ago. He was going on vacation and Norman Sprague had just been in to see him with a one day history of a strange pain near his right shoulder blade.

Mr. Sprague is a 68 year old retired accountant with rheumatism and diabetes. Dr. Brown ordered some bloodwork and a chest X-ray and told the patient to stay in touch with me about his symptoms.

“I wonder if it’s early shingles”, Dr. Brown told me.

The next day I got the negative wet read of the chest X-ray and a bunch of normal blood tests and a phone message from Mr. Sprague that he was getting some nausea. I told Autumn to have him come in to get reexamined.

Norman didn’t have a fever, and he didn’t have a rash or any alteration of skin sensation on his torso. His lymph nodes and breath sounds were normal and his abdomen was soft. But if I pressed hard enough over his gallbladder, he did hurt – that was obvious from his facial expression. He told me the pain was also I the lower front of his chest now, to the right of his sternum just by his lowest rib. It was relentlessly steady and unaffected by movements or deep breathing. He denied any shortness of breath. He told me was nauseous but still able to eat a little, and he had not vomited. His ribs weren’t tender. His bowels were normal and his urine had normal color.

I ordered a gallbladder ultrasound. There were no gallstones, but the radiologist said there was a suggestion of sludge in the gallbladder and the common bile duct was at the upper limit of normal size.

I called one of our local surgeons. He suggested doing a plain HIDA scan. Because of the national shortage of cholecystokinine, that is the only type of biliary scan we can get right now. The test showed that the gallbladder filled normally, but the tracer was slow to travel down the bile ducts and into the duodenum.

Last Monday, Norman met with the surgeon, who called and said he was pretty sure the pain was biliary, but also told me that over the weekend before the consultation, Norman had developed shortness of breath and dizzines. I asked him to send Norman over so I could reassess him.

He was not all that short of breath and did not have a cough, but his breathing had changed since I saw him last. He admitted that he had had some difficulty shopping at Walmart since last winter because he felt “out of shape” pushing a cart up and down the aisles. He also described his right-sided chest pain as more severe, but still unrelated to movement and breathing.

He had dizziness and a hint of nystagmus only when turning his head to the left in a supine position with an otherwise normal ENT and neuro exam, so I was comfortable ascribing his dizziness to Benign Positional Vertigo.

His oxygen saturation was normal and his EKG was unchanged from three years ago.

I ordered a PE protocol contrast chest CT, which did not show any pulmonary emboli, but it did show mildly enlarged mediastinal lymph nodes and three nodules peripherally in the right lung, the largest one just over an inch. I had also ordered an abdominal CT, which was perfectly normal. The nuclear stress test I also ordered that day came back normal. By that time I had called Cityside Pulmonary Associates. They promised to look over the images and get back to us with an appointment.

Norman Sprague called back two days later. He had received a call from the pulmonary office, telling him he was on a cancellation list, but only had a firm appointment for the first week in October.

I called the thoracic surgery group at Cityside and got to talk with Dan Grossman. He looked at the images and when I asked him if a video assisted thoracoscopy was an option for getting a tissue diagnosis, he said, yes, but bronchoscopy would be better. I told him about the long want to see a pulmonologist.

“Either we or they will see him sooner”, Dan said. I’ll get back to you. Twenty minutes later he called me back. “It’s all set, Roger White will see him on Friday and do a scope then.”

Norman had his bronchoscopy. The needle aspirates were benign and the washings and cultures negative. Dr. White’s note listed sarcoidosis and methotrexate related lung disease as the top differential diagnoses, and he thought a PET CT would be the next step, and maybe a percutaneous needle biopsy of the distal lesions.

Today I met with Norman and his wife to go over the results that had come in after the bronchoscopy. As I reexamined his abdomen, he was more tender in the right upper quadrant than before, and when I lifted up the back of his shirt there was a red spot with a small, raised center, not a blister but more of a papule.

“Ouch, that’s sore”, he said.

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.

“Prior Authorizations, Mrs. Kafka. May I have your name and the patient’s policy number.”

“My name is Country Doctor, and I don’t have the patient’s number but I have her husband’s – it is 123456789”.

“Thank you, Doctor. This is for Harry Black?”

“Well, no, it’s for his wife, Harriet. We asked for a PA for Lyrica for her, but it was approved for him instead, even though the forms we sent you clearly stated her name.”

“I see that Harry is approved for one year.”

“Yes, but he doesn’t need it. He has no diagnosis and no symptoms. Someone at your end reversed the names, because the application was for Harriet. I have a copy right here in front of me. So can we just get this approval switched over to her name instead?”

“I’m sorry, we can’t.”

“But why?”

“She’s a different patient.”

“But everything we sent in was on her. You were the ones who put it under his name instead. It was your mistake and I’m asking that you correct your mistake.”

“I’m sorry, but we have to process Harriet’s Prior Authorization separately. What is her diagnosis?”

(Sigh)

“Postherpetic neuralgia.”

“Is she currently taking Lyrica for this?”

“Yes.”

“I don’t see any pharmacy claims for Lyrica in her profile.”

“That’s because you don’t pay for it. That’s why you and I are talking right now, isn’t it? She’s been using samples.”

“Lyrica is not covered for that diagnosis. Studies have shown that other drugs usually control symptoms…”

“Now, wait a minute, your company already approved it for that indication when you looked at the paperwork we sent in before, all that happened was that you misread the name of the patient! And if you didn’t read her papers and still approved it for her husband with no diagnosis at all, you can’t exactly say you’re following any firm principles there at MegaScripts!”

“I’m sorry, Doctor. We have to process her request from the beginning.”

“This woman has suffered for two months and has taken several other drugs before getting any relief -amitriptyline, gabapentin, and she’s on Effexor, so there is no point in trying Cymbalta. If you can’t or won’t correct your own mistake, and if you can’t accept what I’m telling you now, I just can’t sit here and argue any longer with you. I’ve got patients waiting. Just tell me where to fax the information.”

“The number is 1-888-000-6666. Now, did you say she had tried ga-ba-pen-tin?”

“Yes, that’s what I said, and that’s what I wrote on the form we already sent you!”

“All right, hold on, Doctor. I’m getting an approval here. O.K., I have a number for you. It is 9921465. And it’s good until August 12, 2015.”

“Thank you!”

(Sigh)

“You’re welcome. Is there anything else I can do for you?”

“No, that’s all I have time for today, even if I needed anything more from you.”

“Then, you have a nice day and thanks for calling MegaScripts.”

(Click)

It is the year of Woodstock. The motorcycle accident victim lies quietly in his hospital bed. By all accounts, the surgery has gone well and Richard’s initial prognosis had been good. But his vital signs are deteriorating and he seems distant and despondent.

Marcus Welby knows the trouble isn’t physical. He calls on the parish priest, who seems slow to respond. The priest, twenty years younger than Welby, is also his patient, and has been suffering from asthma attacks. Welby believes they are due to Father Hugh’s struggles with feelings of inadequacy as a priest.

Richard turns the priest away and appears to be dying. The priest feels ready to give up the priesthood.

Marcus Welby, who had been urging the younger priest to take a break because of his asthma, now urges him to get to work. He tells Father Hugh that he has also failed many times, but failures are no excuse for quitting. The gravity of the situation mobilizes new strength in Dr. Welby, and his humanity and passion inspire Father Hugh to admit to himself and the young accident victim that, even though he is a priest, he struggles like all human beings. That honesty makes young Richard open up to Father Hugh and he begins to recover.

What neither doctor nor priest could do alone, the two men working together are accomplishing. This is what happens in a December 1969 episode of Marcus Welby, M.D., “Neither Punch nor Judy”.

The cars seemed more old-fashioned than I remember them from those days, and the 1969 medical standards of care are definitely as old-fashioned as the cars, but the struggles of the three men from three different generations are timeless.

I decided to watch this episode after rereading my post “The Apostolic Nature of our Profession” when I linked to it the other day. The video illustrates many things about medicine that we are no better at today than 45 years ago, or 2,400 years ago, for that matter:

“The cure of the part should not be attempted without treatment of the whole. No attempt should be made to cure the body without the soul. If the head and body are to be healthy you must begin by curing the mind…for this is the great error of our day in the treatment of the human body, that physicians first separate the soul from the body.”

Plato

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…