Archive for the 'Progress Notes' Category

N 95 Mask As Screening For COPD?

Brian Johnson is a janitor at the nursing home in town. He’d been wearing a regular mask at work, but last week he and all the other staff were told to wear N 95 masks.

Today he was in my schedule. I had never met him before, but he had requested a same-day appointment in hopes of being excused from wearing this type of mask because it bothered his breathing.

A smoker, he had never been on any inhalers and the only chest X-ray I could find on him was a normal study from 2016.

Autumn said she got his oxygen saturation at 87% when he walked in from the parking lot with his N 95 on. When I saw him, I recorded 95% with the paper mask the front desk had given him at his request. I asked him to put the N 95 back on and took him for a walk down the clinic halls, but I couldn’t get his saturation below 92%.

His lungs were clear. I excused myself and got my Wright peak flow meter from my top right desk drawer. He removed his mask and blew into the device, twice: 230 each time.

“That’s half of what you would expect a man your size and age to be able to do”, I told him. “It looks like you’ve got COPD. So even that mask is pushing you over the edge to where you feel acutely short of breath. I’d like to give you a sample inhaler. It’ll last you two weeks – so if you see your regular doctor before it runs out, we can see what it does for you by testing your breathing again.

The sample I gave him was Stiolto, a once-a-day, long acting anticholinergic-beta2 agonist combination. I think he’ll be able to work with that N 95 if he stays with the inhaler – unless he has another agenda.

“Has a Bad Cold, Please Call”

The other day I happened to talk with a colleague about our respective electronic inboxes. Office workers in other trades often spend their entire workday at their computers and sometimes the bulk of that time reading and answering emails that arrive in their inboxes. They do that because that is what they are getting paid to do.

Doctors and their employers basically get paid only when there is an encounter – face to face or via telemedicine, hardly ever when the exchange happens over the phone. Consequently, doctors, PAs and NPs are scheduled to see patients (generate revenue) all day long. Unlike office workers, we have no time set aside for managing our inboxes. Except for past payment models like HMOs and future reiterations of capitated care not yet in place, inbox management occurs at the expense of the employer or the medical provider. The general tendency is the latter – “between patients” (a post where I suggest the opposite – protected time for the inbox and then two MAs, more exam rooms and more efficient visits to make up for that computer time) or after hours without overtime or even regular pay because we are salaried.

Electronic inboxes are definitely burnout factors. I have found that medical organizations don’t have systems in place to manage this aspect of healthcare delivery. So it is typically up to each of us to figure out how we would want the flow to go. And we must then work with our support staff, whom we don’t supervise, to meet our patients needs without causing undue stress, interruptions, delays and confusion in our respective workdays.

A natural support staff response is to simply pass on questions and messages to the provider, like the title message. As a physician who generates the revenue that pays both me and my support staff, plus my bosses, I try to create a sense that my time on the phone or in the inbox needs to be as efficient as it possibly can, not because I am lazy but because I want to be efficient.

A lot of people in management are nervous about having unlicensed staff give medical advice. These are my thoughts on this: We need our staff to ask common sense questions and we need them to know when it is an obvious emergency. We can’t bottleneck everything by passing every request unfiltered to the provider – or we would have them answer every incoming call themselves already. (Or imagine a president with no admin support opening his own mail.)

We must allow and encourage all staff to use common sense. A person who has made it to adulthood, raised children or cared for a sick family member should and does know pretty well what basic self care is and what the doctor might need to know when you need advice. In the example above, why should the doctor be the first one to ask how long, what symptoms, getting worse or dragging on, what self care measures have you tried etc. See my post THE ART OF THE MESSAGE and the PowerPoint staff talk about common sense telephone triage I created a decade ago (where these slides are from).

When it comes to the most common requests, we have options: Websites, recorded messages on common topics, hyperlinks and things like that with generic advice on colds, sprains, allergies, child rearing and so on. The days are over when the family doctor was the ONLY source of medical information. 

My philosophy is that I need to mentor and support the people I work with to make them more than robot message takers. I explain what I need in order to make good decisions. If I get a good message I can give a simple answer that makes their job easier. If I get a sloppy or vague message, it will just be returned with my request for common sense information.

But I also encourage bypassing the back and forth messaging by having a running conversation: In my Van Buren clinic, my medical assistant/LPN and I share an office. This is a mixed blessing, but it allows exchanges like “Mrs. X left a message asking…” and I can say “If she says this, we’ll tell her to do A but if she says that, she needs to go to the ER”. I may still get a message about the outcome of that callback, but that is just to sign off, not to tie me up on the phone.

My support staff knows I don’t want to end up conducting visits on the phone that belong in the exam room or at least in a telemedicine session. If someone has an upcoming appointment and calls with requests for a new referral or a random blood test they’ve read about, I don’t even get a message – the patient is advised to bring it up in the next visit, or they can come in sooner.

Phone medicine isn’t just bad for the practice’s bottom line. It can also be bad medicine. A patient’s medical history is definitely the most important factor in making a diagnosis. But, very often, even the briefest of clinical exams can alert the physician to a patient’s over- or underestimation of the cause or significance of their symptoms.

It can be false economy for both the clinic and the patient.

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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