Archive for the 'Progress Notes' Category

Unavailable Antidotes

Last week I had a patient with mild kidney disease and a high potassium. I thought that would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast and nobody had Kayexalate, the time-tested antidote, in stock.

It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4, his labs were available by 4:30.

It was 4:45 and we were almost done calling around to pharmacies. I had Autumn, my medical assistant, make some of the calls. 15 minutes left before clinic with 14 patients to see in 90 minutes (we pull them out from group therapy to check in and renew their scripts). And I had a new patient, an internal transfer but still new to me, with multiple medical problems to see before clinic.

I did what I hardly ever do: I asked Autumn to call the emergency room on my behalf and tell them that we had no choice but to send the patient over. We faxed records and lab reports and I moved on.

The ER doctor’s report was scathing. He clearly thought I had dumped on him. He didn’t do what I had thought he might do:

I hadn’t done it since I stopped doing hospital medicine a generation ago but I know you could hydrate him to help his mild acute kidney injury and coadminister glucose and insulin to lower the potassium at the same time.

Instead, the emergency room doctor gave him Kayexalate, because the hospital had it in stock. He probably didn’t know that wasn’t an option for us. I looked like an idiot to him, but that often happens in primary care.

I had gotten over my frustration and embarrassment when, this week, I had a patient on warfarin with a supratherapeutic INR and no active bleeding. I’ve never been terribly nervous about those situations but this was a high number and Up-To-Date suggested vitamin K, orally because it works faster than injectable, while obviously holding the warfarin. So, guess what, we called every pharmacy from Bangor to Ellsworth to Belfast and nobody had vitamin K in stock. The Natural Living Center in Bangor had a very low potency supplement where maybe 50 pills would be enough of a dose to make a difference.

Oune of the hospital pharmacists was available to talk to me and explained that a small bottle of vitamin K in the potency required to reverse warfarin costs about $1,000 and neither hospitals nor pharmacies want to stock them because they will lose so much money if the drug expires. What the hospitals do instead is compound an oral form from the injectable that is still expensive but less so. But a hospital can’t sell or administer to an outpatient whose primary care physician does not have privileges at that hospital. I technically have privileges at Cary Medical Center in Caribou, but that’s 200 miles north.

So this was a judgment call: Send the patient to the emergency room so she can incur the emergency room fee and have them give her an oral medication that may or may not make a difference since she had no active bleeding. Or I could bubble wrap her for a couple of days while the warfarin effect wore off.

Today, in Van Buren, I called the small local Rexall (a historical U.S. pharmacy name) and chatted with the owner, John Hebert. He has Kayexalate in stock. This is in a town of 2,000 people. From Bangor to Ellsworth to Belfast I imagine there are 100,000 people. They don’t have outpatient access to this drug.

It’s a sad situation when potentially life-saving medications are unavailable because pharmacies don’t want to risk having them expire and go on unsold. We have automatic defibrillators in schools and shopping malls, why not some basic antidotes available, maybe even subsidized, in strategically located pharmacies?

P.S. Hebert’s is about to open a pharmacy in Bangor within the next few weeks and John has promised to stock Kayexalate there, too. And he delivers to a large geographic area…

A Spot-On Analogy

The young woman was only slightly overweight, with a BMI of 28, but she seemed really wound up about her need for me to continue the phentermine her previous doctor out of state had started her on. She volunteered that her BMI was only 29 when she started.

She was a walk-in patient, not a regular, and we didn’t have any records on her, except I was able to verify her prescriptions on the multi-state Prescription Monitoring Program website. I told her it was incredibly easy to lose weight if you really want to, “just don’t eat any refined carbs”, and cited my own example as a recovering vegetarian.

She almost broke into tears.

“With your weight, you don’t even have to be all that radical to get your BMI down under 25”, I tried to reassure her. She did not seem reassured.

I decided to try some analogies.

“Taking diet pills with a BMI of 28 or 29 is like asking for ADHD medication just so you can stay up all night and study for a final exam; it’s not a case of a lifelong, debilitating problem.”

She burst into tears.

“They do help me keep track of my life, I’m so disorganized and so distracted. I flunked out of college, I can’t keep a job…”

“So you think you have ADHD?”

“Yes, and PTSD and anxiety.”

“Well, then, let’s deal with that! I’ve got Behavioral Health Staff right here. On Saturdays, too.”

She stopped crying. I looked at the clinic schedule. My psychologist had a no-show.

“I can introduce you to my psychologist, who can help figure out your diagnosis. Would you like to meet him?

“Sure”, she said and straightened up in her chair.

“You wait right here and I’ll be back in a few minutes.”

I made the introduction, mentioned that I have collaborated with Dr. Brandt for 25 years, and said:

“I’ll refill the phentermine for one month only, and you guys figure out what’s the real problem with your attention. Then, when you see your new primary care provider, you’ll be able to go over what you and Dr. Brandt have found out and go from there. Deal?”

“Deal”, she said, and added “Thank you. I was almost ready to walk out.”

“Just be straight with us. We’ll work with you”, I said and excused myself.

There were three more walk-ins waiting to be seen.

I love my job. And I love working in an integrated practice.

Outlook and EMRs: Culture Clash in the Medical Office

I have many equally important administrative and clinical duties, but I miss many more meetings than patient appointments. The reason for this is simple: Non-clinical activities are scheduled by non-clinical people in Microsoft Outlook and patient appointments are scheduled in our EMR.

No-showing for a patient appointment is extremely bad patient care, and I go where the EMR tells me to go.

Outlook can send instantaneous, simultaneous invites to hoards of people, who with one screen tap or click can accept and populate their schedules years in advance.

The EMR requires specially trained and authorized people to custom create blocks of various types which may show up in one (grid) view but not in another (list) view.

This is a small, but telling example of how an activity that even the most basically computer literate person handles automatically in the business world requires special skill and privileges in a modern EMR.

Non-clinical coworkers are still puzzled by my seemingly erratic meeting attendance, and they give me blank stares when I suggest they stop using Outlook and make the EMR their appointment book and message hub. They’re no fools; they know how clunky my technology is.

And (I’m on a roll now), compare EMR messages with email: If a clinical message in my EMR has various new timestamps and comments added to it, it doesn’t move to the top the way emails do; it stays in the order it was created, so while I never miss a patient appointment, I do miss new information in patient communications.

Why does my EMR not work like modern office computer programs? It’s a rhetorical question we all know the answer to: Proprietary functionalities of their software with lack of interoperability is a cornerstone of the business strategy of EMR vendors; profits to be made as long as customers stay with the product. And the more expensive and complex it would be to migrate data and retrain people, the surer those ongoing profits are.

Inhaler Cures GERD?(!)

His heartburn was way out of control, even on maximum doses of pantoprazole and ranitidine. It burned all the way up behind his breastbone and he could feel the choking quality of the sticky acidity deep in his throat. He hurt and coughed after eating, so hard that he would vomit and lose his breath. What he vomited was mostly mucous. “It’s like my esophagus is bubbling over”, he described it.

If he missed a dose of either medication, his symptoms worsened within an hour. “So the medications must be doing something, but nowhere near enough”, he told me.

A couple of years ago he had been turned down for an upper endoscopy because he also happened to have severe angina, and the gastroenterologist was concerned about his anesthesia risk.

“So I keep suffering”, he sighed.

He had the head of his bed elevated, and he didn’t eat spicy food or drink alcohol, but he did smoke. And he admitted to a “smokers cough”, every morning with some light colored phlegm.

I listened. Something didn’t fit. He talked too much about mucous.

“Would you be willing to try something?” I asked.

“Anything”, he answered.

I listened to his lungs and recorded his Peak Expiratory Flow, 300, moderately below normal.

“You have COPD”, I explained.

He raised his eyebrows.

“Chronic Bronchitis, one form of COPD, is defined as cough with phlegm more than two months out of the year. I’d like you to try an inhaler that reduces your phlegm production and improves your breathing.”

I left the room and went to get an inhaler from the sample closet. I logged it in the EMR and showed him how the device works and said, “use this once a day and see me back in two weeks. It will help your ’smokers cough’, but it may also do something for your heartburn. If not, we’ll really have to put our thinking caps on”.

Exactly two weeks later, after I knocked on the exam room door and entered, he rose from his chair with a big grin and stretched out his right hand.

“With that inhaler just once a day, my heartburn is completely gone.”

I checked his Peak Flow, 420.

“And your breathing is better, too”, I added.

“Yes, and my smokers cough.”

I sat down.

“All these years, all the doctors I’ve seen, and you just listened for a few minutes and…gave me an inhaler. Was it not GERD?”

I told him what I thought.

“You’ve got bad acid reflux, no question, but you also, obviously, have chronic bronchitis. So we’ve helped your breathing and dried up your bronchial secretions, which were very significant and very bothersome. Some of them probably went down your esophagus, even if you weren’t consciously swallowing them, and maybe caused some irritation.”

I took a deep breath and continued:

“But the inhaler I gave you is called an anticholinergic. It doesn’t just reduce secretions in your lungs. It is absorbed into the blood stream and can have anticholinergic effects elsewhere in the body. I once had a patient, an older man with an enlarged prostate, become unable to urinate and need his bladder catheterized because the inhaler affected his bladder’s ability to contract. We use anticholinergic pills to help the problems many women have with frequent urination. Medications with anticholinergic side effects, like amitriptyline, can also affect bowel contractions and cause constipation. But I’ve never seen that from an inhaler like the one I gave you.”

He seemed almost spellbound, and I continued:

“I really didn’t know if the inhaler would do much for your acid reflux, and I’ve never heard of it being used for that, but when I was young I had terrible heartburn from the hiatal hernia I didn’t even know I had back then. This was before the kinds of medicines you take were invented, before omeprazole, the Swedish forerunner to pantoprazole, and before ranitidine. The only medicine that existed for stomach acid was – an anticholinergic. I still remember, it was called “ULCOBAN” [probably for ’ulcer banned’?], and I also still remember how dry my mouth used to be when I took it. But it worked.

So, it was just a gut feeling, no pun intended, that there might be a double effect from the anticholinergic inhaler, less mucous in your lungs and less acid in your stomach. And we lucked out.”

I thought he’d never let go of my hand as he shook it on his way out.


The Perfect Office Note? SOAP, APSO or aSOAP?

I’ve been toying with this dilemma for a while: SOAP notes (Subjective, Objective, Assessment, Plan) are too long; APSO just jumbles the order, but the core items are still too far apart, with too much fluff in between. We need something better – aSOAP!

Electronic medical record notes are simply way too cumbersome, no matter in what order the segments are displayed, to be of much use if we quickly want to check what happened in the last few office visits before entering the exam room.

It is time we do something different, and I believe the solution is under our noses every day, at least if we read the medical journals:

I can be aware of what’s going on in the medical literature without reading every article. How? Think about it…

A patient note, like a scientific article, should not present the information in reversed or scrambled order. It should follow logic. But, just like any long research paper worth considering, we should simply create an ABSTRACT and put it up top. Enter the aSOAP; abstract, Subjective, Objective, Assessment, Plan.

In many ways, EMR office notes are created so automatically and by more than one individual, that the author’s (clinician’s) logic can be elusive when you read the note. There are also click boxes that could be used to document the “story” but which many of us avoid because they don’t offer enough variety to distinguish one scenario from another. A free-form “abstract” can be a perfect complement to a more consistent use of this kind of structured data entry.

The abstract is not the same as putting the assessment and plan up top. It mixes all the elements of the progress note in concise form: Past history, new symptoms, Objective findings, immediate and next-step plans. It reveals how the clinician thinks.

I believe the slight amount of time it takes to Dragon or Siri (are those verbs yet?) an “abstract” is regained in multiples every time we later have to look back in our own or a colleague’s progress note.

Here are some imaginary examples:

“Former smoker with 3 week history of cough, recent weight loss. Azithromycin, inhaler, lab, x-ray when available and FU 2 weeks, CT prn at Cityside if creatinine still ok.”

“DM, HBP, migraine, psoriasis fu, all stable. Foot exam wnl. Offered Shingrix and colonoscopy, wants to wait. Refill all meds. FU 3 mo.”

How many more seconds would we need to spend on reading the rest of such notes? Probably zero.

Time saved. Move on. Here’s my marketing slogan: aSOAP makes ASAP!

(For those of you who weren’t there…this is what entire office notes used to look like. I’m proposing that the future lies in the past.)

How I Will Work Smarter in 2019

Last year I put down ten things I intended to do better in my role as a doctor, and as I look back at that post, I think I made headway in most of those areas.

This year, I don’t really feel up to making a long, detailed list. I’m more thinking about “the big picture”.

There are two kinds of philosophies, two diametrically opposed ways of looking at the world, expansive and reductive.

We move back and forth along that spectrum. Many forces are at work to push us to one of the extremes: Touch as many aspects of a patient’s medical situation as possible. This is manifested in our mandated and self imposed checklists. We screen for depression, smoking, alcohol use, cancers and a host of preventive care gaps every time we see a patient.

The expansive approach has been viewed as desirable while “reductive” has become something negative, even described as “crude” by several dictionaries.

I think, and I will cultivate this in the coming year, that medicine has brought us too far in the expansive direction and that we aren’t seeing the forest for all the trees.

We aren’t seeing the patient behind the multitude of measurements; we aren’t seeing the connection between their various ailments; we aren’t seeing the connection between their emotions and their bodies.

I believe that whatever success I have had in filling my appointment schedule through four decades with loyal patients who travel great distances or wait longer than I’d like to see me isn’t from me covering a million things in each visit. I believe, and many tell me, that it is because I dig deep into their concern of the day, and because I zero in on who they really are.

In order to get to know somebody, do you step back for some kind of “birds eye view” and ask many wide ranging questions, or do you lean in, look them in the eyes, lower your own voice and invite them to speak freely?

Ours is a vocation founded in relationship. I aim to strengthen my patient relationships, and I aim to use my available technology and my team members to help with the laundry lists of today’s health care duties so that I can know my patients even better and be the glue that connects my patients to the clinics I work for.

Stop Trying to Hijack Medical Huddles! Haven’t You Heard of Constant Contact?

I’ve huddled since before we used the word for it: You want to be prepared for the patients coming in that day. “Followup MRI” – did they have it and what did it show? “Ankle pain” – do we have X-ray today? “Eye pain” – be sure to check her acuity and put her in a windowless room, and did the new fluorescein strips come in? All fast paced, to the point and here-and-now items.

I’m no sports fan, but I think I know that when sports teams have a brief huddle on the playing field, they speak rapid-fire about the most necessary aspects of play that will help them advance in the game.

I don’t think sports teams huddle about new colors on team uniforms or need for extra practice on how to dribble. So why should medical teams?

But in healthcare these days, quality jocks and others are trying to also fit health maintenance issues into our fast paced huddles. Does the woman with acute grief need a Pap smear? Is the man with high fever and splitting headaches overdue for his colonoscopy? Is the diabetic with an appointment for chest pains due for tetanus and pneumonia shots, eye and foot exams?

I’m sorry, but we’ve only got fifteen minutes. People come in for a reason and expect us to handle that issue. The unsolicited, often time-insensitive health maintenance agenda items are ill suited for the hustle and bustle of primary care visits and their daily huddles.

I have kvetched about this before, but today I have a better argument and a better analogy for how to get the quality work done without slowing down the clinic flow or offending patients any more than we have to:

There is a different way to do this besides putting more and more on harried provider teams’ shoulders.

Hasn’t anybody in healthcare ever heard of Constant Contact? Mailchimp? Auto Responders? We live in a new era of connectivity, and everybody else is trickling information, tips and reminders to their customers or communities via email.

My chocolatier sister-in-law doesn’t wait for her customers to drop in to her shop or tasting rooms to tell them about her Valentines Day or Easter chocolates. She sends automated, season-appropriate emails every so often.

It is time for us in primary care to seriously reconsider how we interact with our patients. It’s no longer all about the brief provider visit. It’s about an ongoing partnership for better health. We can send season specific general reminders via regular emails, and we can post patient specific reminders on our patient portals. Most of us have hardly begun looking into the potential of this secure form of communication.

Let’s get with the times, automate that which can be automated and make the face-to-face visits count for dealing with the personal stuff!

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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