Archive for the 'Progress Notes' Category



The Stages of a Man’s Life

Moving always involves pondering book titles as you pack and relocate your library. This weekend I did my last walk-in Saturday in Bucksport and back in Caribou sixteen hours after starting out I randomly opened a box that contained my prized Osler biography, signed by Cushing, and came across the 80-some page monograph “He” by Jungian psychologist Robert A. Johnson. I wrote about this book here six years ago.

I have a couple of copies of this little book and I keep coming back to it. First published in 1989, just before I started a four and a half year stint at Cutler Health Center at the University of Maine during my first exile from Bucksport, it describes the archetypical journey most men must undertake as they move through the stages of life, referencing literary names like the Fisher King, Parcifal, Don Quixote, Garamond, King Arthur and the knights around his table, the Holy Grail and the Grail Castle.

The essence of Johnson’s book is that males during adolescence have a profound (Holy) Grail experience, too powerful for them to remain in but then spend the bulk of their manhood hoping to find again. They finally learn that they were never that far from it; it is just a short way down the road and to the left, and this time, if they have learned their life lessons, they can enter the castle and remain there.

Central to the legend is that a simple man, a fool, needs to ask the simple question “whom does the Grail serve” in order for the wounded Fisher King to be healed. But Parsifal, who is such a person, heeded his mother’s advise “don’t ask too many questions” and missed his opportunity.

As I reread the book this time, a sunny Sunday morning over several mugs of coffee, I reflected on how much I have changed in the thirty years since I first read it.

One of the themes throughout the book, woven through the Grail legends, which exist in several cultures and languages, is man’s relationship to his inner feminine, one of the strong elements of Jungian psychology.

Johnson lists six basic relationships a man shares with the female world. All are useful, but they must not be confused with each other: His human mother, his mother complex, his mother archetype, his fair maiden (Jungian speak for inspiration), his flesh and blood wife or partner and Sofia, the goddess of wisdom.

Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reigning in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

Medicare PSA Screening Reversal: Yesterday’s Quality Measure is Today’s Rejected Claim

(So much for “The Conversation”)

There are two versions of “The Conversation” we have with men: One is for teenage boys and it is about wet dreams, sexually transmitted disease, unwanted pregnancy and at one point also about testicular self-examinations. Those have now been edited out of the script, which makes sense to me since I have seen only three cases of that in forty years of practice, all but a couple of them diligently preaching that particular gospel.

The other one is with men of the age I now am, explaining, a few years ago, the benefits of blood tests (and, remember the rubber glove exam?) for prostate cancer screening and more lately the confusing intricacies of PSA blood tests.

For several years I’ve been spending a lot of time during physicals and wellness visits talking about the pros and cons of prostate cancer screening. I tell people you have to treat maybe 36 patients with prostate cancer to save one life. I tell patients that a recent long term study of men with early prostate cancer showed that 10 years into it only half of them had needed to do anything about the cancer. Still, many people want to be screened and I just encourage them not to panic if the result is abnormal.

A few weeks ago I got my first rejection of a Medicare PSA test for cancer screening purposes (ICD-10 diagnosis Z12.5, screening for prostate cancer).

My first, primitive, reaction was “here I have to spend all this time soft pedaling the news that PSA testing, which men (and doctors) were brainwashed into performing, is a general waste of time” and Medicare simply stops paying for it overnight without even telling me to save my breath.

Medicare will now only pay for PSA testing if you have the dribbles or something like that, not for screening for prostate cancer. On my iPhone I get notifications of all kinds of stupid things that don’t bother me a whole lot. Why couldn’t somebody tell me that Medicare no longer covers PSA for screening? Or maybe there’s an App or social network I’m not on?

Medical Quality is a fickle mistress, reminding me of the mythical Swedish “älva” (fairy), or is she just one of those random formations in the foggy mist I drove through on my way up from Bucksport to Caribou last night?

I Wish My Clinical Hunches Were Wrong More Often

He did a double take as we passed on our small town sidewalk the other day.

“Hey Doc, I didn’t recognize you dressed like that, without your…”, he gestured to where my tie or stethoscope would have been. I was wearing a cafe-au-lait colored T-shirt and faded Levis.

“Did you hear about the appointment with the cardiologist yet”, I asked.

“It’s in two weeks”, he answered. “Tell me, Doc, how serious is this murmur?”

“Right now, not very, but you could end up needing a valve job some day, so you’ll need to have another echo done through your esophagus so they can get a better look at that noisy valve and then regular follow-ups”, noting silently to myself and I’ll never know how you make out now that I’m handing over your care to one of my partners.

He started thanking me for being his doctor for so many years, through so many illnesses, both life threatening final diagnoses and mere scares we had worked our way through.

Two years ago, almost to the day, I had a hunch that he might have a malignant kidney tumor, based on some nonspecific symptoms and an extremely elevated sedimentation rate.

In the end, he had something a bit less serious, and I was more relieved at him not having cancer than embarrassed about my inaccurate clinical hunch.

This time, he had been in for a routine checkup and as I listened to his heart I heard something new. He had a distinct early diastolic murmur. Soft systolic murmurs, between the first and second heart sound, are dime-a-dozen, but diastolic ones are fairly rare and his was fairly loud – what I ballparked as a 2-3/6 (more than a third of the maximum volume imaginable).

Systolic murmurs sound like Bipzzzt-Bip; diastolic ones sound like Bip-Bipzzzt. The diastolic murmur I knew the most about but haven’t diagnosed very often is mitral stenosis, usually caused by rheumatic fever. My patient had never had that as far as I knew and he had no symptoms of heart failure. I sent him for an echo and I got a call from the cardiologist who read it, praising me for my “excellent pick-up” of the murmur, which on the transthoracic echo indeed looked like at least a moderate if not severe mitral stenosis.

Being praised for my auscultation skills was nice, but I wasn’t pleased that my patient could be facing heart surgery in just a few years.

Early in our careers, doctors have a tendency to triumph over serious or rare diagnoses we make as we marvel over our newfound skills and the logical complexity of the human body.

At this stage of mine, I often feel sadness when a patient I care for, and care about, develops a symptom that signals the possibility of a serious disease.

If the diagnosis I think they might have is easily treatable with a good prognosis, I can triumph over my clinical hunches and diagnostic acumen. But if it is not, how can I feel proud about my skill at recognizing the distant footsteps of the grim reaper?

My New Life

We all have 168 hours a week to spend.

For some time now, I have been working well over 60 hours a week and spending 15 hours in the car traveling the more than 200 miles between my two homes and clinics.

As of this July, the month of my 66th birthday, I am staking out a new life for myself. I’ll be spending 30 hours a week in my Van Buren clinic, only 3 hours commuting, 30 on horse related things and 30 on my writing. Add the 63 hours I figure I need just to survive, and I will still have 12 hours to do something else. I admit some of that time, probably 5 hours a week on average, will be remote chart work, which can be done while looking out at the horse pasture. That still leaves an hour a day on average to do something new.

I’m calling this a semiretirement although it is really just slowing down to a more normal pace.

That means I’m giving up the medical directorship and work in my other clinic. But it also means I’ll be a more well balanced human being, I hope, as I consolidate my life in northern Maine, in a Swedish looking little red farmhouse not far from the village of New Sweden.

Aerial view of SOLTORP, which means “Sunny Little Farm” in Swedish

I have written about this before: During my internship in Sweden, I read an article in a Stockholm newspaper about the Swedish colony near Caribou. I was in the process of applying for my Family Practice residency in Maine, so I wrote to one of the people featured in the article. He forwarded my letter to the presidents of both the Caribou and Presque Isle hospitals and they both invited me to come and take a look. The rest is part of my career history and apparent ultimate destiny.

First trip to New Sweden, 1983

As I now reach what the American Social Security Administration calls my full retirement age, I hope to be able to continue the work I love for many more years, but at a pace that allows me to smell the roses along the way. I look forward to having more horse time and more time for my writing.

Another change, sadly, is that I have exchanged my wedding ring for a newly purchased caduceus signet ring. Not that my dedication to medicine and long hours caused this to come about, but this change certainly did make me think hard about how I want to spend whatever time I have left on this planet.

Raking the roof at Soltorp

Look for much more writing in the future, at least after I get settled into my new routine.

Thanks for listening (I mean, reading).

Hans

Psychiatrist: My Medicine Raised Our Patient’s Blood Sugar, Can You Help? PCP: That’s a Dump!

If my hypertensive patient develops orthostatism and falls and breaks her hip, I fully expect the orthopedic surgeon on call to treat her. I may kick myself that this happened but I’m not qualified to treat a broken hip.

If my anticoagulated patient hits his head and suffers a subdural hematoma, I expect the local neurosurgeon to graciously treat him even though it was my decision and not his to start the patient on his blood thinner. After all, brain surgery is tricky stuff.

Why is it then that primary care docs, sometimes myself included, feel a little annoyed when we have to deal with the consequences of psychiatric medication prescribing?

My psychiatry colleagues diligently order the blood work that is more or less required when prescribing atypical antipsychotics, for example. But when the results are abnormal I get a fax with a scribble indicating that the PCP needs to handle this.

We need to just deal with that and appreciate that there has been communication between treating providers. Because that doesn’t always happen. Particularly with medication prescribing, we don’t always get a notification from our psychiatry colleagues when a patient is started on something new because their records are so much more secret than ours.

The other day I sat in my monthly conference with staff from the Behavioral Health Home that I serve as the medical director for. I consult on clinical and policy matters.

I heard of a couple of examples like the one in the headline and thought that we need to have a Clinical Collaboration Contract in place between providers who see these patients.

This would require notification when medications are started or changed and an expressed understanding that the participating clinician who is best qualified to treat a complication of either a psychiatric or somatic medication should do so.

If a prescribing provider notices that their prescription has a side effect, but the medicine is clearly the best choice for the patient, I can’t just expect them to stop what may be a major therapeutic breakthrough for the patient.

Here are some ideas for what a Clinical Collaboration Contract might include:

I will tell my colleagues if I start, stop or change any medication.

I will share lab work I have done in order to avoid duplication.

I will update my colleagues on major changes in the patient’s health or circumstances.

I will collaborate with my colleagues for the benefit of the patient even if it’s inconvenient.

I will not criticize my colleagues in front of my patient but raise my concerns provider-to-provider in a professional and open-minded manner.

Maybe this is too obvious and self evident to formalize, but judging from the stories I heard the other day, it probably isn’t.

Our Profession is Deprived of its Language

When I use Dragon and say “PRN”, the words “as needed” appear on the screen.

I cringe every time. My medical record needs to be a tool for me and my peers, and most non-medical people have watched enough medical dramas on TV growing up to be thoroughly familiar with that particular abbreviation.

Why is it that almost everybody on the planet eagerly adopts the acronyms, abbreviations and technical terms of smartphones and other modern inventions without whining that the words are too difficult?

We have all had to add SIM card, SMS, jpg, mp3, LTE, RAM and a host of other abbreviations to our vocabulary in the last few years.

The language of everyday technology is advancing naturally and organically with the times while the language of medicine is continually being dumbed down and held back by political forces that assume people are unable to learn even the simplest words of any technical jargon.

But the US isn’t the worst in this regard. I just came across a listing by the British National Health Service, NHS, that strives to tell doctors how to speak with patients.

The Brits always did have a quirky sense of humor, and it seems to me that this list has sprung from that tradition:

passing wind

We don’t use “passing wind”. People understand “fart” better.

pee

We use the nouns “pee” and “urine”. We know that everyone can understand “pee”, including people who find reading difficult. Most people also understand and search for “urine”, for example in phrases like “blood in urine”.

We don’t use “wee” because it can confuse people who use voice technologies or screen readers.

We use “pee” for the verb, not “urinate” or “pass urine”. We know that the people who use NHS digital services talk about and search for “peeing more often” and “peeing at night”.

persist

We use “carry on” or “keep going”.

poo

We mostly use “poo”, rather than “stool”. We know that everyone can understand “poo”, including people who find reading difficult.

rectum

We prefer “bottom” or “anus”. Only use “rectum” when the other alternatives aren’t clear enough, for example when talking about surgery to remove part of the rectum.

We found that people don’t search for “rectum” in Google as much as other terms.

sick

We use “feeling sick” instead of “nausea”, but you may want to put “nausea” in brackets afterwards: feeling sick (nausea).

We use “being sick” instead of “vomiting”. Again, you may want to put “vomiting” in brackets afterwards: being sick (vomiting).

https://beta.nhs.uk/service-manual/content/a-to-z-of-NHS-health-writing#P

I think much of that list is a bunch of poo…

Is Hate Ever Therapeutic?

Most Saturdays I join a therapy session down the hall from where I do my walk-in clinic. A patient of mine has a weekly session just before the Alcoholics Anonymous meeting at noon in our big conference room.

Last weekend he told my behavioral health colleague that the people in the AA group who have the most solid recovery seemed to be the ones who claimed to really carry a lot of hatred for alcohol.

Later that day as David and I wrapped up our week, we talked about this. Generally, we don’t think of hatred as particularly healthy or therapeutic. Hatred for others is thought to always eventually create negative feelings towards oneself and even illness. “Depression is anger turned inward” is a common saying attributed to Sigmund Freud. He used the word “ambivalence” for the coexistence of love and hate, which many others have also written about.

(Freud’s linkage of love and hate now have a Functional MRI correlate: According to a ten year old article, “The Origin of Hatred” in Scientific American, the areas of the putamen and insula that are activated by individual hate are the same as those for romantic love. “This linkage may account for why love and hate are so closely linked to each other in life,” neurobiologist Semir Zeki, of University College London’s Laboratory of Neurobiology wrote in 2008.)

https://www.scientificamerican.com/article/the-origin-of-hatred/?redirect=1

But is there a place for pure, single-focused hatred? Freud, again, “defined hate as an ego state that wishes to destroy the source of its unhappiness, stressing that it was linked to the question of self-preservation” (Wikipedia, referencing ‘The instincts and their vicissitudes’ (1915) in On Metapsychology (PFL 11) p. 135).

David had already asked our patient to write down for next week if there was anything about alcohol that he hated, and he asked me as the primary care physician to list each of my patient’s health problems that could be related to alcohol. Of course, we can’t be sure, but it’s like the question on Maine death certificates whether smoking contributed to the death: There is a “probably” answer option. Before next Saturday I’ll have to go through the chart and make my list. I know it won’t be short.

Will our respective lists bring this patient to hatred of alcohol according to Freud’s definition?

But will such hatred, if not coexisting with its opposite, eventually cause this man to be depressed because of anger turned inward? In fact, he is already on medication for depression and it seems to be working well.

Maybe hatred of an inanimate object is different from hatred of any of our fellow humans, like hatred of plastic, pesticides or pollution. Maybe hatred for alcohol, once the spreadsheet we’ll create together makes its many negative effects on this person’s life and health undeniably and objectively evident, will make ambivalence impossible?

But maybe alcohol has more than two dimensions in my patient’s life. In his current ambivalent state of seemingly equal parts love and hate there is a tiebreaker, or maybe this one is a third and equal part of a complicated triangle: Habit. It isn’t for nothing we speak of someone’s alcohol habit. Alcohol is a strong one, linked to food, celebration, socialization and relaxation. It is for many people a strong conditioned response to all kinds of external and internal triggers.

I believe anger and hatred could have a catalytic effect, because few of us make purely logical decisions from lists of pros and cons. Rather, we use logic to justify the emotional split-second decisions we have already, at least almost, made.

I believe in the possibility that something emotional uncovered or triggered through this exercise might become the seed of hatred we are hoping for. Maybe it will be the sheer size of the list; maybe a health issue he never realized alcohol’s connection to; maybe a single item on the list will trigger a flashback to some childhood impression related to alcohol.

The more I think of it, I believe hatred is necessary because we are fighting both “love” and a very strong habit in this case. And I do think you can hate a thing without hurting yourself.


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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