Archive for the 'Progress Notes' Category

A Country Doctor Reads: March 23, 2019

Health Insurer Profits From Your Death, Life Insurer Profits From Your Survival – WSJ

If you get sick and die quickly your health insurance doesn’t have to pay out a lot of money. They lose money by providing you expensive cancer treatment for example. Your life insurance on the other hand wants you to stay alive long as possible so they don’t have to pay out the death benefit. In a thought-provoking article the Wall Street Journal points out that this opens doors to access to expensive treatments for cancer and other serious illnesses.


From Ancient Greece to Yours Truly to NYT: Is Pain a Sensation or an Emotion?

We seem to be catching up with the old Greek philosophers in acknowledging that pain isn’t an objective sensation, but more of a subjective, emotional experience. Here’s a nice piece from The New York Times:

Looks like NYT has been reading my blog; I pointed this out March 9 😎:

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

.. and I wrote about it in 2013:


Priests, Providers, and Protectors: The Three Faces of the Physician – Psychiatric Times

I have a soft spot for the comparison of physicians and priests (See my 2009 post “Thank You, Father“). And, like many doctors, I’m not crazy about the term “provider”.

Psychiatric Times has a very nice essay on the topic by their Emeritus editor, Ronald W. Pies, MD, where he proposes a role between the extremes of Priest and Provider:


I believe there is a “third way” of viewing the role of the physician—one that neither elevates the physician to the exalted (grandiose?) position of “priest” nor demotes us to the level of mere “providers.” In the role I call the Protector, the physician’s chief obligation is the safeguarding of the patient’s physical, emotional, and spiritual well-being.

Between the extremes of priest and provider lies the healing heart of the physician.
— Read on

The Power of Focus

I keep thinking about the dichotomy between covering a lot of ground and getting to the point.

The other day I saw my bosses at one of my clinics stop in their tracks when I suggested that a lot of the things we are measured on as physicians could be turned into standing orders and simply get shifted off my plate. I have just created a letter that anybody can send on my behalf to any patient of mine who hasn’t been screened for colon cancer; it’ll look like I sent it, which is fine, because I support it, but I shouldn’t have to crowd my glorious fifteen minutes with that too in addition to the diabetes and depression and whatever else I need to address.

I seriously believe that doctors have somehow been excluded from the theory of working to the top of your license. And that’s a shame; I’ll gladly lend my name to colon cancer screening, immunizations, diet and exercise and other public health programs.

But, and I’ll probably insult some folks (again): You don’t need a medical degree and decades of experience to carry out no-brainers like that.

I want my training and experience put to a different use: Seeng what matters in a tangled mess of symptoms or data, making interconnected value and probability judgements and disregarding a patient’s formal response if their demeanor or body language suggests that their answers are incongruent. (What percentage of suicidal patients answer that question truthfully?)

I often find myself abdicating from deciding if a late patient can still be seen or if one person needs to go ahead of another: I’m too focused on something else.

It is my ability to hyperfocus that lets me deal with a diagnostic dilemma in short order. Don’t ask me to also direct traffic or upsell with unrelated health maintenance gaps in care.

When my patients say “he really listens”, it means “he focuses” and “he’s not all over the place”.

I don’t think you can have it both ways.

Pay me to focus and pay somebody else to do he housekeeping.

I’m an artist, a problem solver, not an accountant.

No Information Exchange, Major Diagnostic Delay

I’ve known Pat McCann for many years. He carries a diagnosis of COPD and has a preventative and a rescue inhaler, but he has never really had any serious flare-ups.

He fell and broke his hip. Then he went to skilled rehab, one of a half dozen near Cityside Hospital. His stay turned longer than expected because he fell, luckily didn’t break anything, but had to go back to the hospital because he hit his head and needed to be observed for a small subdural hematoma.

I saw him late Friday afternoon for a Hospital Followup visit. Medicare pays us handsomely for such Transition of Care visits (CPT 99495 or 99496) when a Care coordinator reaches out by phone, does a medication reconciliation, makes sure what followup tests are needed, if the patients understand their instructions and so on.

In this case, we had reams of printouts from the two hospitalizations, but we only had a medication list from the rehab facility. Pat’s regular boarding home had all kinds of questions about all his nebulizers, his oxygen orders and so on. We never did get anything from the nursing home, so “Continue the nursing home orders until we see him”, was all we could tell them, as we had nothing to go on.

So, 4 pm Friday Pat shows up, in a wheelchair, tied to an oxygen tank set at 3 liters per minute. He is coughing. He tells me he is raising phlegm, green and brown. His lungs have crackles and wheezes on both sides. I get a normal blood count and a chest X-ray that shows double pneumonia.

I know what happened. I used to be Medical Director at a rehab facility.

Because he carried a diagnosis of COPD and was on a maintenance inhaler, and because he ended up coughing and desaturating, it is safe to assume a nurse acted on standing orders to administer oxygen to COPD patients to keep levels above 90%. It is also likely that the inhalers were switched to nebulizers because his symptoms weren’t controlled.

It is equally likely that no medical provider assessed him at that time, and only responded to incoming faxes from the rehab facility. There’s only so much time for sick visits when you round at the nursing home, which is not every day.

It is also absolutely certain that the rehab facility had no access to my records, and even if they did, would not have had the available time to go through them to see that he he’d never ever had a serious COPD exacerbation before.

It is also a cold hard fact that it is easier and less expensive for the rehab facility to administer oxygen and nebulizers than to put him in a wheelchair van and send him, with staff, across town to the hospital for a chest X-ray to check for pneumonia.

I sent Pat home with prescriptions for prednisone and antibiotics and a few words of encouragement about hopefully getting him off the oxygen soon.

I think we could do better…

An Accidental Cure

I have one patient in each of my clinics with a long history of relentless abdominal pain, mild constipation, poor appetite and general malaise. Neither one has any abnormality on any of the testing I or my colleagues at the clinic or in the nearest hospital have done: An alphabet soup of blood tests, CT scans, ultrasounds, endoscopies, gastric emptying studies and I don’t know what.

Each one of these older gentlemen usually comes in looking pale and gaunt, saying “I just don’t feel good, Doc”.

Now, one of them seems to be cured, within three days of starting a new prescription, intended to treat something else.

Hector Dunn happened to come in with a COPD exacerbation within a couple of months of his last one. I prescribed the usual steroid, but, because it hadn’t been too long since he had taken the usual Bactrim, I put him on doxycycline.

When I saw him in followup, my medical assistant warned me: “You’re not going to believe this, but Hector looks and feels like a million bucks”.

I knocked on the door of his exam room and entered.

He jumped out of his seat, grinned and gave me a strong, firm handshake.

“I feel better than I’ve felt in years after that last prescription. My breathing got better right away, but my stomach feels great, I don’t hurt anywhere and I have all kinds of energy. I’d say I feel the best I have felt in twenty years.”

His wife nodded and chimed in:

“The day after he started the doxycycline, he got rid of all kinds of gas over about 48 hours, and then he was like a new man.”

I sat quietly and took in the scene before my eyes and, just like with the patient I once had hat developed Parkinson’s disease under my nose and was diagnosed and treated by someone else, I suddenly saw Hector move his face while he talked, shift forward in his chair, make gestures with his hands, arms and shoulders as he provided more vivid and extraneous details about his colonic gas elimination. I had never seen him that lively; before that, he had always carried himself as if any extra effort or movement might cause him to crump.

“Could that antibiotic have gotten rid of some intestinal infection he had been carrying for years”, his wife asked, astutely.

“Absolutely”, I answered. “It’s called SIBO, or Small Intestine Bacterial Overgrowth. While we are supposed to have billions of bacteria in our large intestine, the small intestine should not have bacteria in it. Sometimes it does, and that can cause anything from diarrhea to chronic abdominal pain and bloating, and I now have to admit that may have been what Mr. Dunn has had for a long time now. There’s no handy test for it so sometimes we just guess and treat, but it had not occurred to me. Doxycycline isn’t the typical treatment for it, but it can work, and doxycycline also has some antiinflammatory properties, and SIBO may have elements of inflammation linked to it.”

“I don’t know what any of that really means, but I do know I feel good”, Hector concluded, rose from his chair and patted me on the shoulder. He seemed eager to get out of there, unlike other times when I was probably the one who wanted the visit to end because of my own helplessness.

“Now, I’ll need to hear if the belly pain comes back”, I said. If it does, we’ll have to decide if we’re going to use doxycycline again, or the stuff the books say might work even better. Let me know how you’re doing, okay?”

Later that day, I thought about my other patient, Percy Barr. What if he might respond to doxycycline, too? But he’s on warfarin, and there’s an interaction between those two drugs. I’d probably give him rifaximin. But he’s in Florida, as every other winter.

So in a twist of fate, I’m starting to look forward to him coming back, now that I have something different, new and promising to offer him.

The Cruelty of Managed Medicare

Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying”, she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that”, I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

I scrolled around in her chart. She was up to date on her mammogram and colonoscopy.

She was clearly worried.

“We’ll put in requests for the Prior Authorizations for these scans and let you know when they’re approved”, I said.

She looked puzzled.

“I have Martin’s Point Generations Advantage, that’s good insurance”, she said.

I sighed. “Well, it’s managed Medicare by a for profit company, like an HMO, and on the one hand they pay for physicals, unnecessary screening tests like carotid ultrasounds on people without bruits or symptoms, gym memberships and whatever, but on the other hand they don’t automatically pay for things like CT scans for weight loss.”

She looked incredulous.

“We’ll keep you posted”, I promised her.

Sure enough, a day or two later my referral coordinator came and told me:

I’ve just spent 45 minutes on the phone with these people and they’ve denied the CT scans.”

“Here we go again”, I answered her and thanked her.

I called Jeanette up and told her. “You’re due for your liver ultrasound pretty soon anyway, so we’ll do that, and we can get an x-ray of your lungs right here if we stress that you have a smoker’s cough. And, even though your thyroid test was normal six months ago, we can repeat that, plus I can run a test to make sure you’re still making your own insulin and not turning into a Type 1 diabetic.”

The chest film and extra bloodwork came back normal. But the liver ultrasound suggested a problem in the pancreas. A “pancreatic protocol CT” was suggested by the radiologist.

Martin’s Point approved the CT this time.

It showed calcifications in the pancreatic duct and an irregular appearance of the texture of the distal pancreas. Now the radiologist recommended an MRI evaluation of the pancreas and its ductwork.

Martin’s Point denied the MRI. After 45 minutes on the phone with my referral coordinator.

Medicare for all? That’s coming up a lot in the american health care debate these days.

Which kind, would be my question. The Lyndon Johnson kind or the Martin’s Point, Aetna, WellCare, Cigna, United Health kind?

I know the difference. I have a brand new red white and blue card in my own wallet.

And I’m probably breaking some obscure insurance gag rule right now. But this story happens every week in clinics like mine and it’s got to stop.

A Country Doctor Reads: March 9, 2019

Ketamine, first synthesized in 1962, is in the news this week both for its antidepressant and its analgesic effects, again demonstrating the blurry line between Pain and Suffering.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

“Moreover, based on the available preliminary evidence, the magnitude of the antidepressant effects of ketamine appears to be more than double that of conventional antidepressants.[10]On the basis of these findings, a 2017 review described ketamine as the single most important advance in the treatment of depression in over 50 years.”

FDA Approves Ketamine Nasal Spray for Depression

The U.S. Food and Drug Administration today approved Spravato (esketamine) nasal spray, in conjunction with an oral antidepressant, for the treatment of depression in adults who have tried other antidepressant medicines but have not benefited from them (treatment-resistant depression). Because of the risk of serious adverse outcomes resulting from sedation and dissociation caused by Spravato administration, and the potential for abuse and misuse of the drug, it is only available through a restricted distribution system, under a Risk Evaluation and Mitigation Strategy (REMS).

Ketamine Reduces Opioid Need in Severely Injured Patients – Pain Medicine News

San Diego—The first randomized, double-blind, placebo-controlled trial of ketamine in patients with rib fractures has shown that low-dose ketamine infusions are a safe adjunct in the setting of treatment of acute traumatic pain

Weight Loss Cures Diabetes. Is Anybody Surprised? – The Lancet Diabetes & Endocrinology

I keep writing about my small victories in sometimes motivating overweight Type 2 Diabetics to give up particularly processed carbohydrates and thereby reversing and curing diabetes.

But if you read the manual, it is actually a flex fuel body. It isn’t metabolizing carbs properly, but it can still run on fat and protein, and believe it or not, we now know that diets that are low in carbs and higher in protein and at least what we call good fats, are good for weight loss, diabetes control, lipid lowering and heart risk reduction.

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 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.

Now The Lancet is saying he same thing…

The DiRECT programme sustained emissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss.

It’s Not Burnout, It’s Moral Injury

All medical bloggers write about BURNOUT and I am no exception:

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

The Counterintuitive Concept of Burnout Skills

Here’s a video I saw via a Canadian Rural Medicine Listserv, renaming “Burnout” as “Moral Injury” and calling it “Victim Shaming

A Science of Uncertainty and an Art of Probability

There is a lot of talk about team based care nowadays, and I have seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.

But at the same time, there are so many decisions – judgement calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.

I talk to patients all the time who ruminate, often at night, about the choices they made every day, and replay their conversations, reasoning and actions to the point of losing sleep and experiencing distresss.

I also know of a few clinicians who do the same thing.

I think there are a few fundamental tolerances clinicians must have:

One is tolerance of uncertainty. The other is a tolerance of being where the buck stops.

“Medicine is a science of uncertainty and an art of probability” is a famous quote by my hero, Sir William Osler, the “Father of Modern Medicine” and of bedside teaching.

This is a dichotomy: On one hand, the diagnostic possibilities in most cases are nearly endless, thus uncertainty, but at the same time, the major probabilities are usually pretty clear cut.

Our mission, should we chose to accept it (Mission: Impossible – in my case, the original series; I assume that quote is still relevant) is to embrace both the uncertainty and the need not to accept indecision.

In that moment, we are often alone.

The only way to balance these seemingly opposite notions is to acknowledge that no one can know for sure but the probability is…that is, being human and being fallible, but also possessing a certain amount of knowledge based confidence.

In my Swedish training, it was considered appropriate to consider and make a clinical decision based on “the odds”. In America, that isn’t always recognized. I agree you cannot completely skip over considering the probability of the esoteric, but how much weight do you give it?. If we don’t reign in the temptation to overestimate the odds of the esoteric, our health care will bankrupt us even faster than I imagined.

The kinds of decisions we usually need to make on our own are ones we have to live with and ones we cannot let ruin our sleep or our sanity:

Antibiotics or not? Hospital admission or not? Imaging or clinical diagnosis?

You do your best. It is all you can do. Without obsessing. Osler called that Aequanimity.

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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