Archive for the 'Progress Notes' Category



The Elfins Return

I have known him for over thirty years. He has been legally blind for the past five.

He tends to be a practical, no nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said:

“I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things…” he began, “I’m seeing children with elfin faces…”

His large, thin hands were in his lap. I put mine on his and said “I know what that is. You’re not crazy. This is something that often happens to people with very poor eyesight. It’s called Charles Bonnet Syndrome, and it was actually described in 1760 by a Swiss philosopher who observed it in his grandfather who was going blind. It’s like the brain fills in the empty spaces, and for reasons we don’t understand, much of the time it tends to be with elfin like children. They’re usually friendly and jovial and there’s nothing threatening about them.”

“Right, these are. I’m so glad to hear this is not some psychosis.”

“It’s a hallucination, but not a psychosis”, I reassured him. I printed up an article and gave it to him to show his friends and the staff at the Senior Citizens Home.

A few days later I heard how appreciated the article was.

This was only the second time in my career I have seen this condition. The first time I had no idea what it was but a family member of that patient brought in a printout of an article they had googled. That was ten years ago and I wrote about it in my first year of blogging.

Apparently up to 10% of people with visual acuity under 20/60 have this syndrome, and it tends to go away when vision is completely lost.

This little incident evoked two distinct feelings for me. The first one was the comfort, confidence and gratitude that I could instantly reassure my longtime patient that what he was experiencing has happened to other people and has a name and a long history. The other feeling was equally profound and mixed with all kinds of emotions:

My patient was once my neighbor, and my soon to be 35 year old son was often hanging around his yard, checking out his motorcycle, convertible Mustang and garden tractor. My son did look like a little elfin at that time. Maybe it was him that he was “seeing”.

Teflon Doctors and Velcro Patients

I guess I should take it as a compliment when patients come to see me after visiting a specialist and ask me a bunch of difficult specialty-related questions.

“Did you ask the specialist that?” I typically ask, and the the answer will be a plain “no”.

I’ve seen it in action. Some doctors speak quickly, say a lot, and exude so much authority that it’s hard to stop and question them. There is also the fact that on a first visit there isn’t yet much of a doctor patient relationship.

As a long term family doctor, I’m probably viewed as more approachable and less intimidating and therefore end up getting the questions that didn’t get asked in the consultation.

I think a lot about this balance of ours – when and how to engage deeply and with a large “contact area” and when to appear close without engaging or attaching too much. Still remembering when the Teflon frying pan technology, first patented in 1954, took Sweden by storm in the sixties, I use the metaphor “Teflon doctors”.

I consciously move back and forth along this spectrum. In line with my effort to be the kind of doctor my patient needs in a particular situation, I think there are times when I should “stick” and times when I need to be like Teflon.

When a patient hesitates tackling an important issue or feels desperately depressed or disconnected, it is my role to “stick” tight and help them stay with their task or avoid drifting emotionally. But on the other hand, there are times when I don’t let anything stick to me.

The other day when a patient started listing all the minor to moderate aches and pains he’d been saving up for his once a year routine physical, I mentally took a step back and, sensing he was looking for pain medications, said:

“If you have specific pains or orthopedic issues, I or an orthopedist can look into them, but my first duty in a physical is to go over the big health risks you may be facing at your age. Today I will focus on if all your pains are part of a bigger picture, some underlying disease, or if your body just has a lot of wear and tear.”

When patients are suffering in large or small ways, doctors risk feeling like they “own” the patient’s problem. We never do. We are guides, supports, experts and even friends, but we should never shoulder a patient’s problems for them, no matter how much love and empathy we feel for our patients as fellow human beings. Taking over their problem weakens them and creates an unhealthy dependence.

Being “Teflon Doctor” and still helping the patient is an art to cultivate. It involves putting the patient at the center, by saying things like, “how do you feel when…” and “what have you found to be helpful when…”

Sometimes we come across patients who are like Velcro, another product of my childhood, patented in Switzerland in 1955. Perhaps a more common word doctors use for such patients is “sticky”. Fancy talking doctors call them “Frontal lobey“. This is because people with frontal lobe lesions can exhibit symptoms like inability to make decisions and lack of the ability to interact, feel joy and express spontaneity.

One review of the function of the frontal lobe puts it this way:

“The evolution of the human frontal lobes lies at the very essence of the characteristic behavior of humans. Everyday traits that define our existence, both socially and as individuals, have important substrates in the frontal lobes: humor, intuition and insight, deception and truthfulness, optimism and skepticism, affection and hatred, and inspiration. One of the great tragedies for patients and their families is a disease of the frontal lobes that destroys the distinctive personality around which a whole life has been built.”

All doctors have known patients who have difficulty moving forward or away from a minute topic or medical history item, who keep coming back to a thought, often kept on a list of concerns, and who seem unable to grasp a bigger picture.

What I tend to do in order to move forward with patients like that is to “chunk it down”. I try to create smaller steps, descriptions, decisions and interventions. But it is hard work and it almost always takes more than fifteen minutes.

Unless you’re a better Teflon Doc than I am…

Suboxone for Pain? Not in Maine

Many patients who end up in Suboxone treatment have chronic pain. They were originally prescribed other opiates and ended up addicted to them.

Skeptics argue that his is just substituting one opiate for another. But that isn’t quite accurate. More on that in a bit.

In my seven years of prescribing Suboxone for opiate addiction, I have often observed how potent a pain reliever this medication is, even in fairly low doses. More on why in a bit, too.

Now and then I hear about patients who are prescribed Suboxone for pain and not for addiction. I’m not sure exactly how that is done, since Maine law requires prescribers not only to include our Suboxone license number, but also the ICD-10 diagnosis code (F11.20, opiate use disorder) on the electronic prescription.

We also, in the case of some national pharmacy chains (Walmart) who don’t understand the Maine law, have to add “Chronic”, which is only of relevance as opposed to “Acute” when it comes to pain. Medication Assisted Treatment is always chronic. Also, they require us to put “Code D”, which is indeed a Maine Exemption Code for Medication Assisted Treatment, but only relevant when the Suboxone (or methadone) treatment exceeds 100 Morphine Milligram Equivalents (MME).

Anyway, even though you have to indicate the diagnosis of addiction on scripts, I hear there are several Maine doctors who prescribe Suboxone for pain. The more I think about it, and the more I read up on it, the more sense it makes. But I’m not going to break any laws just because it makes sense.

This is what I know:

Buprenorphine, the opiate ingredient in Suboxone, is a partial (opiate) mu-agonist, which is the most obvious explanation why it has any analgesic properties at all. But it is also an ORL1 (nociceptin) agonist, which is another pain relieving mechanism. This one is among several proposed mechanisms for why buprenorphine has been shown to reduce Opioid Induced Hyperalgesia, a Fibromyalgia-like state of generalized increased pain perception that paradoxically can make patients with, say, opioid treated back pain start to hurt absolutely everywhere.

In fact, it has been observed that there is analgesic effect at lower doses than usually required for management of opiate cravings.

Buprenorphine is superior to traditional opioids for nerve pain and, because it also is a Kappa-opioid antagonist, it has antidepressant and anxiolytics properties.

Buprenorphine has fewer side effects than straightforward opiates, specifically less constipation, less sedation, less immunosuppressant effect, less induction of gallbladder spasm (morphine is a bad choice for gallbladder attacks), less or even no decrease in sex hormones, less risk for heart rhythm problems (QT abnormalities) and it is even safe to use in older patients with chronic kidney disease.

But the law is the law. Suboxone is for addiction only. How soon will that change?

Follow link (here) for in-depth background reading about buprenorphine.

Flirting With Functional Medicine

“I used to brag that I was taking all those medications so I could keep eating anything I wanted. I guess that isn’t working anymore”, said the rotund sixtysomething man in front of me.

I had never met him before, but I have seen plenty of people like him. His Hemoglobin A1c had been rising steadily over several years, and now his diabetes was way out of control and his copays for all the newfangled pills and shots he was taking were crippling his retirement lifestyle just as much as his obesity and neuropathy were.

I delivered my usual, miniature plain talk monologue, aided by my personal iPad. I have a table of what happened to another patient’s numbers in one year following such an intervention.

.

I call this person my “flex fuel man”, because, just like many cars, our bodies can run on different kinds of fuel, but most people are hesitant to switch fuel even though what they’re using now clearly isn’t working anymore.

I tell my diabetic patients that I agree with the notion that a balanced diet is generally best, but that their diet so far has probably been unbalanced enough to completely stress their carbohydrate burning system. It is as if they have already had their lifetime supply of carbohydrates and they now need to correct that imbalance.

The man in front of me became enthusiastic and said he would stop eating processed, carbohydrate rich foods and eat more like our ancestors, more similar to my own post-vegetarian diet (more on that here).

Thinking more deeply about these conversations that I am having more and more often, I guess I am steadily moving closer to what has had many names and permutations but has now become known as Functional Medicine.

Chronic disease is crippling our people and our healthcare system. Like the man said, many medications, blockbuster drugs, are developed and promoted so people can keep doing what is obviously hurting them. This is true for diabetes, hypertension and countless chronic disease processes we know to be linked to inflammation, gut bacterial imbalance and more or less subtle nutritional deficiencies and toxin buildups.

Functional Medicine is about addressing these root causes of disease.

I, for one, am starting to devote a few of my precious fifteen minutes with patients to the conversation starter “There is another way to handle this”.

Monday night, I registered for some free classes with the Institute of Functional Medicine and on my way up to Van Buren Tuesday night I finished Chris Kressler’s audiobook “Unconventional Medicine”.

My experiences with curing diabetes have nudged me toward a new journey.

How Often Should Doctors Check Labwork?

Back when cholesterol target numbers ruled unopposed (before 2013), we all checked fasting lipids every three months. Before 2012, we also checked liver function quarterly in hapless riders on the cholesterol pill merry-go-round. That year the FDA announced there had not been enough reports of statin induced liver problems to recommend routine monitoring.

I have many colleagues who still do this, and who also routinely monitor routine labs quarterly or even more often on patients on blood pressure pills and sometimes even in the absence of high risk medications, “just in case”.

For patients on the traditional blood thinner, warfarin, many colleagues monitor blood work on an almost weekly basis, and home-testing requires weekly testing in order to be reimbursed.

There is a problem with 1) doing blood tests often and 2) paying close attention to those numbers.

I liken this to driving your car in a snow storm with your high beams on. When you do this, you see way too many distracting snowflakes immediately ahead of you, and not enough of the road further ahead, to see where you are going.

This myopic arrangement tempts you to overcorrect your steering wheel angle; the road suddenly appears to curve in either direction and you assume you are entering a major curve, but it is just a slight wiggle in an essentially straight roadway. This could make you drive into the ditch.

The healthy way to drive in a snowstorm is to turn off the high beams and paradoxically see further ahead by not emphasizing all the snowflakes just ahead of the car hood. There is less detail in this view but a better sense of the general direction of the road.

Doctors overcorrect too often. Warfarin dosing is a common and frightening example. Over the years I have often seen the practice of ordering based on only the current dose and the current PT/INR value.

Say the INR is 1.5 (should be 2-3) on 5 mg of warfarin. The doctor orders 7.5 mg daily without seeing that two months ago when the patient was given that dose, the INR shot up to 3.9. Even electronic medical records sometimes display the current value (and/or the place to order and “sign off” on it) in a whole different area from where we see historical values and dosing (Any reference to Greenway or eClinicalWorks here is purely coincidental). This causes a risk for overcorrection very much like my winter driving example.

The same thing happens with all kinds of laboratory parameters. Recently I saw a man who periodically had to take a diarrhea inducing drug to treat high serum potassium. His kidney function is mildly reduced. After a lot of detective work, going back over bloodwork and medication orders two years back, I saw that a colleague had stopped the patient’s fluid/blood pressure medication, hydrochlorothiazide, one day when the kidney number jumped up a little. That medicine wastes potassium. Ever since, there had been incidents of high potassium, causing physician worry and subsequent emergency prescriptions for the diarrhea causing rescue medication.

Looking back and forth in time, I realized that the patient’s kidney numbers had fluctuated in the same range two years before and two years after the stopping of the fluid pill. I restarted it and don’t expect to have to fuss with high potassiums again. I believe this was another case of myopic laboratory analysis.

Some amount of testing is necessary, for example after starting a new medication like lisinopril, to make sure the kidneys tolerate it (people with poor blood flow to the kidneys don’t handle this medication well), but there has to be limits to how paranoid we continue to be about the medicines we prescribe for bread and butter medical problems; if ordinary drugs are that scary, should we even be using them?

What is a Dose of Psychotherapy?

I don’t know how many times a patient has told me “I was in therapy once, and it didn’t help”.

My response is always: “That’s like saying ’I saw a movie once and I didn’t like it’”.

That usually breaks the ice just a little.

In primary care we certainly run into a few patients with chronic mental health problems that could use some long term, in depth counseling. But usually patients in my practice have a specific problem they need help with.

So I went to my Director of Behavioral Health and asked: “Would you be able to offer a couple of sessions for people with insomnia, retirement quandaries, illness in he family…you know, typical life change stuff”.

He got inspired and came back to me a few weeks later with rough outlines for more than two dozen structured interventions for common psychological scenarios.

A month later, he mused about the concept of “a dose of behavioral health treatment”, like a treatment plan for any medical condition where cure or remission is anticipated: Ten days of penicillin, five weeks of radiation, several courses of chemotherapy or whatever.

Mental health agencies around me are struggling with how to adapt to the times we live in. Neither patients nor insurance companies want decades of psychoanalysis. Today, it’s all about solution focused therapy. My Behavioral Health guy is ahead of the curve by structuring interventions for common problems with a “curriculum” to show patients, insurers and referring clinicians.

We are doing that with chronic pain. Any patient who needs ongoing pain medication is required to attend four individual sessions to learn about what pain is, how the brain is the center of the pain experience, and how our pain experience can be altered by internal and external factors. We don’t use “pain scales” for the simple reason that pain is never objective.

We now have formalized treatment plans for a long list of common psychological symptoms, centered on one-on-one assessment and education with heavy doses of between session assignments.

Like the now so popular “coaching” modality, we explore drivers of thoughts and behaviors and challenge patients to get out of the ruts they feel so trapped inside.

The title of a 1996 book I bought around then at the Harvard COOP, skimmed through and put on a shelf, is frequently on my mind. I need to get back to it and see if it is really about what we are now doing. But even if it’s not, the title itself is beautifully inspiring:

“Doing What Works in Brief Therapy” by Ellen K Quick.

Update: The book is on Amazon and new ones are now fetching collector prices. I’m really enjoying it.

Helping Patients Accept Their “Imperfections”

Brian was in a lot of pain, I could see it. But his lumbar MRI showed only modest changes. Two back surgeons said they couldn’t help him. Physical therapy, chiropractic and osteopathy didn’t help or made him worse. Duloxetine helped only a little. After one day of a higher dose, he felt “loopy” and stopped it completely.

Then he found that marijuana helps a great deal. The only problem was that he started smoking a lot and began to act under the influence. His family didn’t support him becoming a “pothead”. His wife asked if there was anything other than duloxetine he could take.

A website that promised minimally invasive laser surgery several states away had caught Brian’s attention. He asked me what I thought.

The same day I saw a woman who cries a lot.

Holly carries a diagnosis of bipolar disease. She is on one of the newer “atypical” antipsychotics. She functions pretty well, but told me she cries very easily: Movies, songs and good news can affect her. She doesn’t feel sad, just the opposite, she cries more tears of happiness or empathy than of sadness or hopelessness.

She asked me if I knew of a medication for that.

In both cases I thought for a moment. Then I entered that mental space that gives me a sense of quiet authority and wisdom, as if I were speaking as a clergyman or a therapist.

“Brian”, I said, “I don’t think any medication will help you right now. You have your mind set on a surgical cure, and as long as you hold that vision, pills won’t work for you.”

He nodded in agreement.

“You gave up on the 60 mg dose after one single day of nonspecific side effects. You need to research the laser procedure.”

He nodded again.

“But let me point this out to you: you’ve told me that marijuana makes you less stiff and makes your legs move better. That means you’re not all rusted up. Marijuana does nothing to the bones, disks, muscles and ligaments in your body. The only thing it does is change how you experience things. If marijuana makes you limber, do you really need to have surgery, or can you change the pain experience through it and any other chemical or yoga, meditation, Reiki, prayer or whatever?”

His wife turned to him as if to ask him to answer me.

“The problem in your back can be overcome by changing how the nerves from your back and legs communicate with your brain. They are sending exaggerated signals that your back is completely broken when it really isn’t. It has some glitches, but even smoking weed makes you able to use it with less pain, and the duloxetine starting dose did the same thing.”

He looked straight at me and made a slight frown.

“But you’re not ready to work on it that way. You will only be able to do that if you know for sure surgery can’t make you “perfect”. Go see the laser folks and talk to me again afterward.”

I rose from my swivel stool and ended our visit. Brian and his wife seemed to exchange telepathic comments as they left the room.

“Holly”, I said, “I could give you some Paxil and make you cry less, but you would very likely then also feel less joy and empathy. Is it worth risking losing a really good quality that you have?”

“No. I think of myself as a very empathic person. I would give my sweater to a cold homeless person, I’m like that.”

“Right, you have bipolar disease, your mood may change quickly, but you are a very feeling person and maybe this world needs more people who can really feel things, be present in the moment.”

“I like to be called a feeling person. I wouldn’t want to not feel…I was just wondering if it is normal.”

I held my hands out, palms up.

“It is normal. It can be beautiful.”

She smiled and said “Thank you”. Her eyes moistened as she got up from her chair.

I didn’t offer any cures to these two, but I’m trying to help them see themselves as not some potentially flawless machines, but imperfect human beings, as we all are, who can still make the most of who they are and what they have.


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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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