Archive for the 'Progress Notes' Category



Chronic Disease Drugs are Big Business, Antibiotics are Not

(A New Year’s Reflection)

I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.

Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.

Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.

Suddenly it’s perfectly clear: There is endless profit potential for countless corporations in America’s chronic disease epidemic and it is in their interest that people with chronic disease stay as sick as possible without dying from their disease. Why risk research money on acute disease when there is no continuing revenue stream to look forward to?

If people did all the things we know could improve their health, pharmaceutical companies, insurance companies, pharmacy benefit managers and many others would go out of business, just like shopping malls and print media companies.

Where are the disrupters in healthcare? Will the perverse motives of the sick care industry create a public uproar? Will the old system someday finally crumble?

Now, I’m just a country doctor but I’m starting to wonder if a system like the one we have can really continue to function much longer.

Happy New Year, American Healthcare.

Tell Me Again Why We Should Screen for Early Alzheimer’s?

Happiness is widely thought of as being present in and enjoying every moment of our lives. The whole mindfulness and meditation movement is built on this premise, as are some of the major religions of the world.

But how possible is it to enjoy every ordinary day if our thoughts are elsewhere, ruminating about a future that may not even happen?

Let’s be honest and admit that there are no good treatments for Alzheimer’s disease. Let’s also admit that the things we know can delay its onset are the same things that to some degree can ward off diabetes, heart disease and many other chronic diseases that afflict us westerners.

So, I don’t buy into the strategy of using genetic or other predictors in singling out individuals for scare tactics in promoting healthy lifestyles that we should all be adopting anyway.

It doesn’t work very well with diabetes, now does it? We can and do talk about blindness, kidney failure and toe amputations, but people still get those things, even though diabetes is a whole lot more reversible than Alzheimer’s.

If scare tactics can delay the inevitable outcome of this terrible disease only to a small degree, what impact can an early diagnosis have on people? Depression? Suicide? Self-neglect? Risk taking? I think those negatives are a whole lot more frightening than poor estate planning, which is one argument for early diagnosis I have heard again and again.

Would you tell a school child they’ll never get the life or career they hope for? Would you tell a pregnant woman that her baby will die from SIDS a few months after birth? Would you tell a bride that ten years from now she’ll be a widow or divorcee? Would you tell a grandmother that her first grandchild will die from an overdose before age 15?

All we have is today. We should live it to the fullest, not in a hedonistic way, but with respect for our bodies, our fellow humans and our planet. And we should lead healthy lives because it is the right thing to do, and because that can help us enjoy the future more – if we should happen to get there.

I watched my father die at 86 from Alzheimer’s, which is how his mother had died. He seemed puzzled sometimes, but he didn’t seem aware or concerned about his declining cognition or his ultimate diagnosis by the time it had become obvious to the rest of us.

Curiously, the common word for it in Sweden when my grandmother died was åderförkalkning, hardening of the arteries, which actually better approximates the pathophysiology than the mumbo jumbo amyloid theory that made this disease seem quite random. When it was called hardening of the arteries, the commonsense implication was that unhealthy eating habits accelerated the disease in predisposed individuals, which is where we have now ended up again.

We should promote healthy lifestyles with the carrot – as a way to feel better in the short term and possibly into the future, but spare us from the stick. Reward is a better motivator than punishment.

Doctoring at Christmas

I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.

This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.

As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.

Many people in this country routinely say things like, “have a good weekend”. I’m not sure that is such a universal high point in life. For some, it is a time for dreaded chores, for others a time to muster enough energy for that second job to help pay the bills.

Christmas is a more universal time of feeling celebratory and unselfish, and for me it marks the passage of time as well as the consistency of it. It was my time of awe and delight when I was a child, and now it is that for my grandchildren. As Christmas week culminates in the New Year celebration, it also helps me think about what’s next – for me and everyone in my family.

During the coming weeks, I will make sure to share some of the joy and peace I feel in my own heart with my patients and I will be more than usually sensitive to signals of holiday blues or distress in them.

This is not a time to flaunt what we have – lavish presents, successful relatives, gourmet food, fancy decorations or invitations to fun parties. It is a time to share some simple human warmth in the darkness and bitter cold of the northern Maine winter in a time of divisiveness, strife and unrest.

It is a time of “peace, good will toward men”, of greater openness to others. It is a good time for reconciliation or rekindling of relationships we may have neglected since the last time we wished each other Merry Christmas.

The Public Health To-Do List is Choking Doctors and Jeopardizing Patients’ Lives

“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”

Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.

But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.

You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?

Public health in its broadest sense is what drove down morbidity and mortality in the last 100 years. But most of those things are, at least in many places, easily and successfully done by people without medical degrees.

I don’t mean to be uppety, it is not beneath me to promote those things – I’m doing it gladly, but since I am not a solo practitioner, I believe those things can be done just as well by other staff, if necessary with standard protocols where a physician’s order is required. Ideally I would then just support or explain these things when patients have questions.

People are sick, people are worried about symptoms, treatments need adjustments, information from outside providers could affect our patients’ health or our own assessments and treatment plans for them. This is what we need doctors for, and experienced Nurse Practitioners and PAs.

Medical professionals are trained to diagnose and treat disease. Are there so many of us and are we so underutilized that our healthcare “system” can afford to fill our time with tasks that could easily be done according to protocol by non-providers?

It’s your choice, America. If you think there just might be a doctor shortage, an aging, sicker population and a looming decline in the health of our population – who should do what in healthcare?

Thou Shalt Not Try to Outsmart Me

Medical researchers and their groupies – early adopters, thoughtleaders, those easily influenced or whatever you want to call them – never seem to learn that when you try to outsmart Mother Nature or Our Heavenly Father, whichever appeals more to your world view, you usually get your hand slapped.

When I was a resident (1981-1984), I got penalized if I didn’t offer postmenopausal women estrogen-progesterone replacement therapy because it seemed obvious that if women with endogenous estrogen didn’t get many strokes or heart attacks and women without estrogen did, all we needed to do was make up for God’s or Mother Nature’s oversight in not keeping the estrogen coming after age 50.

Then the Women’s Health Study in 2000, almost 20 years later, showed that women on Prempro had more strokes, blood clots and heart attacks, and more breast cancer on top of that, than women who accepted the natural order of things – menopause with all its symptoms and inconveniences.

The same things has happened with osteoporosis – more subtrochanteric femur fractures after five years of Fosamax than in untreated women.

A simple thing like hypertension has played out similarly: People who take certain third tier blood pressure medicines, like alpha blockers, don’t have the benefit of lowering blood pressure that you might expect; those medications actually increase risk of death from cardiovascular causes.

The typical blood sugar targets that have been drilled into our heads, hemoglobin A-1 C under 7%, have been found to be detrimental to older patients who are more sensitive to low blood sugars than younger patients, so now we have a hemoglobin A-1 C target of 8% for older folks (thank goodness, especially for those with classic late onset diabetes).

And even my own affliction, gastroesophageal reflux, has a downside when you rely entirely on medications instead of lifestyle measures for management; escalating proton pump inhibitor doses are now known to increase the risk of iron and vitamin deficiencies, osteoporosis, pneumonia and C. difficile infections.

Just like prednisone and Humira work brilliantly when you feel like you have do decrease autoimmunity, rather than say “what it is making the immune system overreact” (gluten, artificial food additives and antibiotics in the food chain), reaching for medications instead of asking “what is my body/God/Mother Nature trying to tell me” sooner or later might come back to haunt us.

We must always ask: “Is this a symptom caused by unhealthy lifestyle choices that need to change rather than medicated with more or less risky medications” or “Is this an aging manifestation normal enough to make medications unnecessary” or “Is this premature aging and possibly worthy of intervention?”

Aging phenomena that happen to everybody, such as osteoporosis, are perhaps, just possibly, better left alone, at least as far as drugs go, but certainty a subject for lifestyle exploration and intervention?

Which makes me think of all the hype about “Low T” (testosterone). Isn’t that the estrogen story all over again? I guess time will tell…

The Liability of Outside Provider Orders and What Could be Done About It

As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.

Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.

But how possible is it really to do a good job with that task?

How much time would I need to spend on this to do it well?

Is there any time at all set aside in the typical primary care provider’s schedule for this task?

I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.

10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.

But emergency room medicine is shift work, just like hospital medicine; providers may not be around when the abnormal result comes in, and the next shift worker perhaps can’t see what is in the first doctor’s inbox.

As I click through the “orders to sign off”, I end up prioritizing “my” orders, because I “own” them. The “Outside Provider” orders are in my inbox as a double check, but nobody double checks my results. I have to make them my priority if my time is limited and time, by definition, is always limited.

There is more and more data in medicine, and while I hope technology will make it easier to sort, view and prioritize data, I don’t believe artificial intelligence will do that well for frontline medical providers anytime soon.

I keep thinking that we really need to have a serious debate or examination of what we need primary care providers to do. The Patient Centered Medical Home movement (see my personal take on that here) held a promise of better care coordination by people like me in clinics like mine, but the way we do things hasn’t changed nearly as much as many of us had hoped.

I seriously believe that it would be a worthwhile investment for our whole healthcare “system” to structure and reimburse the care coordination work we primary care providers could do for our patients.

We can certainly use the help and collaboration of other professionals like nurses, but ultimately we need to know what’s going on with our patients. Otherwise their care will continue to suffer from more and more fragmentation as subspecialization brings more different doctors into many patients care “teams”, as hospital stays grow shorter with more loose ends at discharge, as options for urgent care walk-in and virtual visits increase and as more and more patients become afflicted with multiple chronic illnesses because of the declining health of people in this country.

When I started my residency in Lewiston, Maine back in 1981, family doctors were enthusiastic and idealistic. Much has dampened that enthusiasm since then, but I still believe we have a crucial role we could fill for the health of our nation.

If the “system” would only let us.

Changing EMR – Seamless Continuation, Dreaded Chore or Fresh Start?

At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.

I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.

With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.

This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.

Our old EMR will become “read-only”, and who knows how much structured data will “migrate” from the old to the new system. And some information that should have been structured isn’t, because the old system’s search function was clunky enough that if we couldn’t find the exact word for a rare diagnosis in someone’s medical history, we would give up and choose the generic “neurologic disorder” and then free text the thing we might not even be spelling correctly. That still displayed intelligibly enough while the system was live, but will that migrate to the new system – who knows? Of course, there will be opportunities to correct old mistakes and omissions, as long as there is time…

The only way to view this inevitable transition is as an opportunity to undo old beginner mistakes, bad habits and workarounds. Having worked with two systems in my two clinics, I feel this is a bit like learning a new language or instrument; I know better what functionality I am looking for and will recognize it when I see it – just like a Spanish word I don’t know might look similar to a French word I do know for the same thing.

Wise from my positive experiences of screen sharing, I will bring patients along on this journey. I will be sitting next to each one with my laptop in front of us. I will invite them to update their history and increase the transparency of how I work, because there isn’t enough time in the day to keep the EMR invisible from my patient and then do all that work outside the appointment. Also, this is an era of increasing patient centeredness and I want to embrace that as much as I can.

I am determined to become as expert as possible with the new system so that I can document everything in real time in the visit and use more of my non-patient time in front of the screen to build templates and things like that.

In a way I feel a bit like many, many years ago when, as a student or budding writer, I opened a brand new notebook and put my pen to it for the first time. I loved fountain pens, crisp paper, leather bindings and the potential of all that clean, empty space.

Instead of feeling this EMR change will be a chore, I feel like a new school year or a new writing project is just about to begin.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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