Archive for the 'Progress Notes' Category

The Art of Tinkering: The Man With Cold Fingers

Recently I solved a medical dilemma by changing the medication that seemed to have nothing to do with my patient’s problem.

Ethan Blake is a thin-boned, soft-spoken man with atrial fibrillation and a history of high blood pressure. He lives alone and prefers to shovel his own driveway. He also loves to walk his springer spaniel in the woods behind his house. He is in great physical shape.

At his routine followup early last month, he lamented how his fingers were always cold and painful when he goes outside in the winter.

He takes a blood thinner because of his atrial fibrillation and metoprolol to control his heart rate. He has also been on lisinopril for blood pressure since before he developed his arrhythmia.

We know that some people get cold extremities because of an underlying autoimmune condition. We then call his problem Raynaud’s syndrome. When it is an isolated phenomenon, we call it just that – Raynaud’s phenomenon.

His metoprolol could cause cold fingers all by itself, or it was at least likely to aggravate Ethan’s symptom because it constricts blood vessels. A different rate controlling medication, the calcium channel blocker diltiazem, does not constrict blood vessels but would not in itself do much to improve Raynaud’s phenomenon. The calcium channel blocker nifedipine is routinely used in Raynaud’s but does little for heart rate and could drop his blood pressure too much in combination with his other medications.

Switching from metoprolol to diltiazem could be tricky. Theoretically, during the transition, his heart could either start racing or slow down too much. You would have to do it gradually, because stopping metoprolol suddenly could cause a rebound surge in heart rate, like if you were to release the emergency brake on a moving car while flooring the gas pedal.

It seemed like a tricky situation.

I looked at Ethan’s historical vital signs. He has lost weight slowly over the last few years and his blood pressure lately has been on the low side, often 110/60.

A thought struck me: What if I had him back off on his lisinopril to get a blood pressure in the 130s? Would that increase the perfusion of blood to his long, thin fingers? Then I wouldn’t have to fuss with a switch from metoprolol to diltiazem or the addition of nifedipine.

I explained my theory. He was eager to try it.

Over the month of December, Ethan tapered his lisinopril from 40 to 10 mg while he kept track of his blood pressure. When I saw him the other day, his fingers were warm and he told me they felt quite all right outside most of the time. His blood pressure was 134/68.

We decided he could try stopping lisinopril completely and let me know what happened.

I wasn’t sure when we started out that my plan would work. It seemed a bit tangential to just let his blood pressure rise a bit when the seemingly obvious problem was constricted blood vessels. But as an amateur plumber I also knew that the main water pressure and the pipe size can conspire to cause poor flow in the faucet.

Quality in Healthcare: Cultural Competence, Diagnostic Accuracy or Patronizing Insensitivity?

I sometimes tell patients “I work for the government”, but sometimes I say the opposite, “I work for you”.

Herein lies a dichotomy that is eating away at primary care in this country, like a slow growing cancer. I suspect everybody is aware of it, but it seems nobody has the inclination to deal with it.

2020 exposed how differently Americans view and prioritize things like personal freedom and public safety. We have also seen how vastly different perceptions of reality suddenly exist about what constitutes medical facts. Alternative facts and fake news are suddenly household concepts.

For years, American healthcare has paid lip service to ethnic and cultural sensitivity, as long as minority opinions or practices don’t clash too badly with the holy cows of western society. We tolerate circumcision in men, but not genital mutilation in women, for example. But we don’t even pay lip service to the majority’s right to direct their own healthcare.

Some people want to be screened for everything and some don’t. How heavy-handed should the healthcare system or individual providers be? If you buy a car and never bring it in for routine maintenance, isn’t that your personal choice, your personal freedom? Why should healthcare be completely different?

In bread and butter primary care, we are squeezed every day between patients’ requests for healthcare and the American quasi-religious medical quality dogma. The possibly well-meaning principles were set forth by CMS, the Center for Medicare and Medicaid Services, and turned into business opportunities for private health insurers and the many middlemen of the healthcare industry.

We disagree on whether mask wearing decreases the spread of the coronavirus and whether, even if it does, you can legally mandate it.

Yet medical providers have been routinely measured and financially rewarded for things like recommending aspirin use in middle aged people until it turned out that was faulty science. We have been mandated to do all kinds of things that have nothing to do with why people come to see us, because Uncle Sam (in the broadest sense of America’s paternalistic healthcare system) knows best what people need.

A patient smokes, feels depressed, has an elevated blood pressure and hasn’t had a screening colonoscopy. They also have this gnawing pain in the belly that six months later will turn out to be an inoperable pancreatic cancer. I can get 4 quality brownie points for clicking EMR boxes for smoking cessation counseling, scoring degree of depression and suggesting a behavioral health referral, advising salt and alcohol restriction and arranging for a blood pressure followup as well as referring my patient for a screening colonoscopy.

But there are no quality parameters or incentives for paying attention to this patient’s main concern, “Chief Complaint”, for making an early and correct diagnosis and saving the patient’s life.

Medical providers are disincentivized from listening to their patients because the screening opportunities have become the dominating purpose of primary care in the eyes of those in power.

People with new symptoms may have long waits to see their primary care providers, who are overburdened with screening and housekeeping duties. Doctors went to medical school, residencies and fellowships to learn how to diagnose and treat disease. We were never selected for or trained for the bookkeeping duties that are becoming the bulk of our work.

So much of what we do could be done by others, even digitally and remotely. It’s a new year in a shaken-up healthcare system in a shaken-up nation. It’s time to think about what we really need doctors to do.

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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