A Country Doctor Writes:

(A tedious topic)

“Then it’s me and my machine
For the rest of the morning,
For the rest of the afternoon
And the rest of my life.”

“Millworker”, James Taylor

It’s Friday afternoon, 4:30. I am sitting in front of my computer. My last patient is gone, my prescriptions are done, my messages answered, my office charges submitted and my office notes completed. Now it’s time to tackle the incoming laboratory results.

Opening up the list of completed comprehensive chemistry profiles, my heart sinks. As usual, out of 20 or so CMPs, every single listed patient name is red, which means they all have abnormal results.

My EMR displays results in three colors. Unreviewed normal results are blue, abnormal ones red and anything already signed off is black.

But abnormal is only statistical; there is no distinction between clinically insignificant results and clinically critical ones.

A high creatinine means kidney failure, but a low one is good news. A high CPK means muscle damage, but an extremely low one means nothing. My million dollar system doesn’t make any distinction. Because laboratory normals are defined as the statistical mean value plus-minus two standard deviations, the average patient has one abnormal result in each 20-item chemistry profile or complete blood count. That means a red alert is the rule, rather than the exception on every provider’s computer desktop.

As I and every other doctor click through all the meaningless red alerts in our “orders to sign off”, our senses are sometimes dulled by all the false alarms and we run the risk of missing clinically significant abnormal results.

A peculiarity with my EMR is that the color coding of test results only works in a window that displays three values at a time (only one if I log in remotely from home), so I am forced to scroll my way through each profile to find the abnormal values.

There is a full-screen result window, but it is several clicks away from and back to the Sign-off button, and comes only in black on white. It takes even longer to use.

As I glance at the numbers and the patient’s name, my right index finger is ready to move the trackball and my right thumb clicks the scroll down and Sign-off buttons again, again, again. But, as I click away, I suddenly register that a patient’s calcium level was way off – who was that? There is no “back” button. The moment, and the abnormal value, are both irretrievably lost.

I wish there was a way to go back and double check items I just signed off, a work list made up from what I just did. I wish there was a color only for clinically important results. I wish there was a way my nurse could place more important results near the top of my list.

I wish my EMR had a more clinical feel and less of an accounting one.

I wish my system made it faster and safer to review results, instead of slower and more hazardous.

I guess I just got a touch of the blues, seeing all those meaningless red numbers.

James Taylor, further along in his song, “Millworker” continues to paint the picture of alienation:

“I’m waiting for a daydream
To take me through the morning.”

Well, here is my own daydream about the machine at my work station:

I imagine a better machine, one that shows me the information I need in order to best use my skills to care for my patients. I imagine a machine that shows me results with clinical significance before it shows me the statistically abnormal ones with unlikely significance. If a patient usually has a creatinine of 1.6 and suddenly it is 3.5, that means a lot more than if it goes from 1.6 to 1.5, even though it is still abnormal. Simpler computer programs than an EMR can handle such logic, so why not EMRs?

I imagine seeing a whole chemistry profile in one screen shot, and I imagine the patient’s next appointment displayed right next to the results panel, so I don’t have to click my way over to the next appointment screen. I imagine when I open up a patient’s “chart”, that all new and pending information is visible in the same screen as my office note. I imagine a system that makes my job easier every step of the way. I imagine a system as intuitive as a smartphone.

Interesting thought….I imagine Apple and Google entered the EMR business. Now that’s a daydream with potential.

It is a trade secret among patients of many practices: If you’d like to be seen by your personal physician with no waiting and without an appointment, just ask for a free blood pressure check and then mention to the medical assistant that you are not feeling well at all. They can’t send you home without being seen and they don’t have enough to go on to call an ambulance – you are 99% assured to get seen quickly by the doctor.

Today’s free blood pressure-turned-extensive-visit was a diabetic with a history of a heart attack a dozen years ago. She just didn’t feel right, but otherwise had no specific symptoms. She had no chest pain, heart palpitations, shortness of breath, headache, dizziness, cough, fever, chills, indigestion, belly pain or anything else to report; she just didn’t feel right.

Her exam was normal, except the mildly elevated blood pressure, which was high enough that the first staff member she saw summoned me.

“I’d like to get an EKG to see if it shows any sign of trouble”, I said.

“I knew you would do that”, Mary Anderson said. “I told my son on the phone this morning “I bet it’s my heart. That’s exactly what I said, but I don’t know why I thought that.”

Her EKG showed new Q-waves in leads III and aVF with T-wave inversions, signs of a heart attack in the lower portion of her heart.

“Mary”, I lectured my patient while we waited for the ambulance, “if you don’t feel right, ask to see me or one of the other doctors. Don’t assume that your blood pressure is the reason you don’t feel well. What if your blood pressure had been normal? Would you just have gone home without getting any help?

Mary is not one to work the system for quicker access to me. In fact, as much as she may like me, she hates having to come to the clinic for her health issues. She would rather be doing her Senior Volunteer work than worry about her own health. She asked for a free blood pressure check because she hoped her blood pressure was off and that this was the simple reason why she wasn’t feeling well. Even though she had worried about her heart, as she told Donald, her son fifty miles away, she admitted she had tried to rationalize her deepest fear away.

The lesson for all of us in health care, beginners as well as seasoned health care workers, is to never assume that the chief complaint is the same as the ultimate diagnosis. This is especially true when the patient’s stated concern is high or low blood pressure, blood sugar, potassium or some other quantifiable parameter. People try to help us narrow our search for the explanation to their symptoms. We must never start our search in the middle, but always from the beginning.

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.