Archive for the 'Progress Notes' Category

Patients Are the Real Healers

The Swedish word for physician is läkare, which literally means healer. That seems a lot more glamorous than the American word physician, which is derived from physic, the old fashioned laxatives that were thought to rid the body of poisons and impurities. But we are actually the healers a lot less often than we think.

The more we learn about how the body works, the more we have to admit that rather than us doctors, it is each patient that heals themself with at most some guidance from us.

We may recommend a change in diet, but we aren’t there to watch what our patients make of the advice we give them. We may prescribe a medication, but we know that many of the standard treatments in our armamentarium are only marginally better than placebo, and we now understand a little bit about psychoneuroimmunology, so we have to admit that patient expectations greatly influence the efficacy of treatments, even surgical procedures. We have learned this from sham knee operations for meniscal problems, for example. Imagine that, placebo surgery, not just pills.

This goes all the way back to the words of Hippocrates: “Let food be thy medicine and medicine be thy food”, “Walking is man’s best medicine” and “The natural healing force within each of us is the greatest force in getting well”. These quotes seem especially relevant in our struggle with the chronic diseases of the times we now live and practice in – heart disease, diabetes, arthritis; all of them at least in part autoimmune in their pathophysiology. If he body can attack and destroy itself, it also has the potential to do the opposite, to heal.

Our job, then, is to provide basic medical care AND to inspire, empower or whatever one calls awakening the self healing potential that a good diet, physical activity, good sleep, healthy relationships, care of one’s emotional needs and a good measure of faith, trust and optimism can ultimately bring about.

Ordering Tests Without Using Words: Are ICD-10 and CPT Codes Bringing Precision or Dumbing Us Down?

The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.

So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).

So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.

Patients are waiting, I’m behind, the usual time pressure in healthcare.

Can’t find a previously used diagnosis. Search for “nonspecific finding on chest X-ray” and multiple variations thereof.

I see R93.89 – “abnormal finding on diagnostic imaging of other body structures”. Close enough, use it, type in exactly what the chief of radiology had said in his report. Move on. Next patient.

Several days later I get a printout of that order in my inbox with a memo that the diagnosis doesn’t justify payment for a PET scan. Attached to that is a multi page list of diagnoses that would work.

Frustrated, I go through the list. It’s another day, other patients are waiting. Eventually I come across R91.8 “other nonspecific finding of lung field” – not exactly pleura, but what the heck, close enough, let’s use that one.

Why is this – me hurriedly choosing the next best thing on a multipage printout, while my other patients are waiting – any more practical, accurate or fraud proof than having me describe in appropriate CLINICAL language what the patient needs and letting SOMEONE ELSE look for the darn code?

Here I am, trying to order what a radiologist told me to order, without having the tools to do it.

Next thing you know, Henry’s insurance will probably have some third party radiologist deny coverage because he disagrees with my radiologist, and I’ll be stuck in the middle…

Not quite what I thought I’d be doing. Who works for whom in healthcare?

A Country Doctor Reads: September 14, 2019 – Life Forms Inside Us are Controlling Our Behavior

Several news media (I first saw it on BBC’s website) recently published the picture of an insect, invaded by a fungus, compelled to climb high, then killed off only to become a means for airborne spread of fungal spores.

I had also read in The New York Times about how massospora live inside cicadas and spread between them like an STD and stimulate mating behaviors to promote its spread, even though the cicadas become grotesquely altered by the fungus (see the yellow fungal “plug” in its rear). This behavior is caused by the release of Psilocybin, a mind altering controlled substance that eases depression and anxiety in cancer patients, and cathinone, a powerful stimulant.

Interesting that one life form can alter another’s behavior, but does anything like this apply to mammals, or humans? Certainly – maybe not for fungi, but definitely other parasitic (or symbiotic) organisms and viruses. Just consider the behaviors caused by rabies infection:

This seemingly improbable concept that specific microbes influence the behavior and neurological function of their hosts had, in fact, already been established. One prime example of “microbial mind control” is the development of aggression and hydrophobia in mammals infected with the rabies virus (Driver, 2014). Another well-known example of behavior modification occurs by Toxoplasma gondii, which alters the host rodents’ fear response. Infected rodents lose their defensive behavior in the presence of feline predators, and instead actually become sexually attracted to feline odors (House et al., 2011). This results in infected rodents being preyed upon more readily by cats, and allows Toxoplasma to continue its lifecycle in the feline host (House et al., 2011). Further, a variety of parasitic microbes are capable of altering the locomotive behavior and environmental preferences of their hosts to the benefit of the microbe. For instance, the Spinochordodes tellinii parasite causes infected grasshopper hosts to not only jump more frequently, but also seek an aquatic environment where the parasite emerges to mate and produce eggs (Biron et al., 2005). Temperature preference of the host can even be altered, such as observed during infection of stickleback fish by Schistocephalus solidus, which changes the hosts’ preference from cooler waters to warmer waters where the parasite can grow more readily (Macnab and Barber, 2012). Other microbes can even alter host behavior to seek higher elevations, believed to allow the infected host to be noticed more easily by predators or to eventually fall and disperse onto susceptible hosts below (Maitland, 1994). More coercively still, microbes can influence the social behavior of their hosts, causing insects, such as ants, to become more or less social to the benefit of the parasite (Hughes, 2005). In fact, the sexually transmitted virus IIV-6/CrIV causes its cricket host (Gryllus texensis) to increase its desire to mate, causing its rate of mating to be significantly elevated and allowing for transmission between individual hosts (Adamo et al., 2014).
— Read on

There is, of course, now more and more interest in the role our microbiome plays in seemingly every aspect of our lives – from mood to metabolism to immunity. The more I read about this, the more humblingly (is that a word?) fascinated I become.

The well referenced review article quoted above illustrates several already known ways our microbiome affects us, and I highly recommend reading it. I’ll zero in on how our behaviors are influenced, leaving cancer, allergies and other aspects of their influence for another post. Here are some highlights:

Germ Feee (GF) mice tend to be anxious and socially impaired. These behaviors normalize when normal gut flora is introduced.

GF mice have an increased permeability of the blood brain barrier both during fetal development and in adulthood. Some strains of clostridium and bacteroides and also the short chain fatty acid butyrate can restore normal blood brain barrier function.

Probiotics (L. Helveticus and B.longum) caused decreased self reported anxiety and decreased urine cortisol levels in humans.

Microbiota metabolize fermentable complex carbohydrate/fiber into short chain fatty acids (SCFAs) such as acetate, butyrate and propionate, which cross the blood brain barrier. Acetate influences the hypothalamus’ regulation of glutamate, glutamine and GABA. It also increases anorectic neuropeptide, which suppresses appetite.

Probiotics from fermented dairy do not alter the composition of gut microbiome, but they alter the transcriptional state and metabolic activity of the microbiota.

Autism spectrum disorder (ASD) patients have an increased incidence of constipation, increased intestinal permeability and altered intestinal microbiome. Mice with ASD like behaviors have a similar overrepresentation of gastrointestinal abnormalities. Introduction of B. fragilis has normalized intestinal permeability and reduced stereotypical behaviors, communication deficits and anxiety behaviors.

“It is becoming increasingly recognized that other psychiatric and neurological illnesses are also often co-morbid with gastrointestinal (GI) pathology (Vandvik et al., 2004), including schizophrenia, neurodegenerative diseases and depression.

“The enteric nervous system (ENS) is directly connected to the central nervous system (CNS) through the vagus nerve, providing a direct neurochemical pathway for microbial-promoted signaling in the GI tract to be propagated to the brain on mood and behavior, including depression, anxiety, social behavior, and mate choice.

Bifidiobacterium infantis can normalize depression-like behavior in mice to a degree similar to the antidepressant citalopram.

Finally, I got the impression in medical school that the vagus nerve was unidirectional. Now I understand that it is very much bidirectional, as quoted above. Here is a quote from another article I ran into about that:

The bidirectional communication between the brain and the gastrointestinal tract, the so-called “brain–gut axis,” is based on a complex system, including the vagus nerve, but also sympathetic (e.g., via the prevertebral ganglia), endocrine, immune, and humoral links as well as the influence of gut microbiota in order to regulate gastrointestinal homeostasis and to connect emotional and cognitive areas of the brain with gut functions (1). The ENS produces more than 30 neurotransmitters and has more neurons than the spine. Hormones and peptides that the ENS releases into the blood circulation cross the blood–brain barrier (e.g., ghrelin) and can act synergistically with the vagus nerve, for example to regulate food intake and appetite (2). The brain–gut axis is becoming increasingly important as a therapeutic target for gastrointestinal and psychiatric disorders, such as inflammatory bowel disease (IBD) (3), depression (4), and posttraumatic stress disorder (PTSD) (5). The gut is an important control center of the immune system and the vagus nerve has immunomodulatory properties (6). As a result, this nerve plays important roles in the relationship between the gut, the brain, and inflammation. There are new treatment options for modulating the brain–gut axis, for example, vagus nerve stimulation (VNS) and meditation techniques. These treatments have been shown to be beneficial in mood and anxiety disorders (7–9), but also in other conditions associated with increased inflammation (10). In particular, gut-directed hypnotherapy was shown to be effective in both, irritable bowel syndrome and IBD (11, 12). Finally, the vagus nerve also represents an important link between nutrition and psychiatric, neurological and inflammatory diseases.
— Read on

I Have a Strong Relationship with my Bank but I Almost Never Go There. How Could this Translate to Primary Care?

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

As we are now starting to think of how to make the transition to a system that pays medical offices not for the number of visits but for the overall health of our patients (as defined by our quality metrics), we should ideally free up doctors’ time to review and act on health data that comes to us in more ways than face to face visits – but there’s a catch: We don’t think we can afford to have our docs see fewer face to face visits, because right now there is no money in what in the future will compare to the bank’s cash flow that their customers generate when they use online banking, ATMs and so on.

If a patient sends me a list of blood pressures or blood sugars, there is a cost for us to review and act on them – lost lunch breaks, unreimbursed overtime (”provider pajama time”) OR lowered productivity targets (for face to face work in an organizational leap of faith that these efforts will actually result in incentive payments some time down the road).

Most medical offices are quaintly or hopelessly old fashioned in our approach to the changing demands and desires of our payers and our patients. It is hard to make the transition to something new: We are being asked to start working differently and potentially making less or spending more without knowing for sure if it will pay off.

(The Banking business analogy can only go so far. After all, healthcare is still a humanitarian endeavor: More and more payers want us to “take risk”. I bet. Your patients cost more to care for, not just in the office but in hospitals you have no control over. Result: You lose money. But when the bank takes risk, they charge accordingly and if you’re a terrible credit risk, they’ll turn you down. Doctors can’t turn away patients because they are too sick and a bad financial risk. We can only view what we do as a business up to a point. Banks and insurance companies have actuaries and people like that whose entire careers involve projecting costs and calculating risk. Even big medical practices don’t have that. So while I think we can emulate banks in our interactions with patients, I don’t think it’s fair to ask us to behave like banks in every aspect of what we do.)

When Was the Last Time You Saved Somebody’s Life?

I got an email Saturday from Laurence Bauer of the Family Medicine Education Consortium. 

Larry said that when he talks to doctors and residents about saving lives they usually think of their preventive medicine efforts and few people have stories about the short term impact they have on people’s lives. Larry asked me if I had anything to say or write about that.

The first thing that comes to my mind is my work with substance abuse, our medication assisted treatment, which I still do for Bucksport via telemedicine even though I live and otherwise work 200 miles north of there. Statistics show that immediately upon entering a Suboxone program participants risk of dying from an opioid overdose is reduced by 50%. So it’s possible I’ve saved a life or two there. At the annual staff appreciation day in August patients from the Suboxone program had written greetings to me on the whiteboard and a couple of them had written that I saved their lives.

The other thing I think of is the triage type of decisions we make. Somebody comes in with chest pain and we have to decide whether or not to send them to the emergency room or order tests for heart disease or blood clots in their lungs. We’re supposed to make the right decision and when we do we don’t necessarily get a thank you card or anything. Perhaps if we don’t, there would be all kinds of repercussions. Very often in our line of work our reward is the absence of negative feedback.

In less dramatic cases, we make choices all the time that could be life altering or life saving. When we order an x-ray or CT scan rather than say, “let me know if it doesn’t get better”, we could be in a lifesaving situation, but once you have been practicing for a few years you don’t reflect on that as much as when you first start out. 

In my post “Primary Care is Messy” I wrote about this five years ago, although I didn’t even remember the incident until I searched my own blog for “saved my life”. For non-physicians it may seem incredible that one might not remember a story like this one, but when you see sixteen to thirty patients day in and day out for forty years, you can only make so many personal notes and still keep up the pace. 

“Knowing what constitutes success in frontline medicine is not easy. Let me illustrate:

A middle aged smoker comes in for a follow up on his blood pressure treatment and mentions that he would like to try Chantix (varenicline) to help him quit. My nurse has already secured our practice credit for documenting his smoking status. I can use certain billing codes to document my counseling on the subject, and I can get credit for printing out the drug information, even though the pharmacy also provides a printout. This is a successful visit, it might seem.

But I also ask, “Ron, what makes you want to quit at this particular point in time?”

“Well, I’ve had this funny cough, like a dry hack, for the last two weeks whenever I take a deep breath”, he answers. 

Ron turns out to have a very small, resectable lung cancer. My question about the reason for his request probably saved his life, and catapulted us from shallow administrative success to probable or at least possible clinical victory, without making any further difference in my own quality metrics.”

So, Larry, I think there is a lot of focus on doctors supporting each other when they feel burned out or inadequate, but I’m not hearing much about taking notice and stopping to celebrate the small and large clinical and relationship progress or downright victories we have in our everyday work. With no doctors lounge to visit anymore (another blogpost of mine from just four months ago), how do we do that?

Magnesium Deficiency: An Undiagnosed Epidemic Behind the Epidemics of Heart Disease and Diabetes

A patient who hadn’t felt good for many years came in the other day and told me an osteopathic physician she had gone to for OMT, manipulative treatment, had suggested she take a basic 400 mg magnesium supplement and it had been life changing for her.

She handed me a xeroxed little essay the osteopath had written about the many functions of magnesium in the human body and the symptoms of deficiency.

All her vague gastrointestinal symptoms were gone, her skin had cleared, her energy level had improved and she felt more clearheaded.

“What was your level?” I asked.

“He didn’t check it” was her answer.

I didn’t know what to think, I mean it’s probably harmless to take, but without knowing the level…

I started looking into this and the more I read, the more intrigued I became.

I found several articles from the last century (the 1990’s) all the way up to last week (news that excess vitamin D can lead to osteoporosis, apparently through lowering bone magnesium levels), all saying mostly the same things:

Even though magnesium is abundant on this planet, many people (for example 80% of postmenopausal women with osteoporosis) have low intracellular magnesium. Almost half the US population consume less than the recommended daily amount of magnesium.

Serum levels of magnesium tell us nothing about total body magnesium, because we are programmed to pull magnesium from our tissues to keep blood levels in range. Only 1% of our body’s normal 25 grams of magnesium is found outside our cells, and about 90% is found in bone and muscle cells.

Magnesium is essential for the function of 300 enzymes, mitochondrial ATP production and activation (cellular energy), synthesis of DNA, RNA and protein and regulation of ionic gradients (keeping sodium and potassium levels normal).

Magnesium deficiency is linked to inflammation (as measured by C-Reactive Protein, CRP), atherosclerosis, vasospasm, insulin resistance and metabolic syndrome as well as isolated hypertension.

Magnesium deficiency has been linked to sudden cardiac death.

The magnesium content of ur modern diet is decreasing, because of more and more processing of food as well as modern farming practices and soil depletion; we are also consuming things like phosphorus (in soft drinks) that lower body magnesium levels.

According to the NIH:

“Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur. Severe magnesium deficiency can result in hypocalcemia or hypokalemia (low serum calcium or potassium levels, respectively) because mineral homeostasis is disrupted.”

Not only can low magnesium contribute to the development of diabetes, but there are indications that magnesium supplementation may improve blood sugar control in diabetics. Magnesium supplementation has been shown to improve lipid profiles. Other not yet certain possible benefits of magnesium supplementation are migraine prevention and asthma control.

People at risk for magnesium deficiency, besides diabetics, include the elderly, patients taking diuretics or Proton Pump Inhibitors, those with inflammatory bowel disease or chronic diarrhea from other conditions, patients who have had small bowel surgery, people with gluten sensitivity and patients with alcohol or soft drink dependence. Perhaps surprisingly, people who exercise vigorously can also become magnesium deficient.

Foods that supply good amounts of magnesium include almonds (check), spinach (check), black and kidney beans (check) and avocado (check), and also some things that aren’t on my meal plan: Peanuts, soy milk, shredded wheat, bread (presumably whole grain) and yogurt.

So, this is from someone who usually doesn’t think much of vitamins and supplements: Because I’ve been taking PPIs for my hiatal hernia since they first came out and because my blood pressure is higher than I’d like in spite of being pretty ideal weight – I picked up a bottle of magnesium capsules the other day.

And the more I read, the more I worry about the decreasing nutrient value of much of our mass produced foods. The BMJ article cited below points out:

“The loss of magnesium during food refining/processing is significant: white flour (−82%), polished rice (−83%), starch (−97%) and white sugar (−99%). Since 1968 the magnesium content in wheat has dropped almost 20%, which may be due to acidic soil, yield dilution and unbalanced crop fertilisation (high levels of nitrogen, phosphorus and potassium, the latter of which antagonises the absorption of magnesium in plants).”

Here are two comprehensive references:

National Institute of Health Office of Dietary Supplements Fact Sheet for Health Professionals

Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis (BMJ)

Vertigo is a Symptom, Not a Diagnosis, and it’s Sometimes Caused by Loose Rocks Inside Your Head

I often hear patients speak of vertigo as if it were some brilliant diagnosis made by a genius emergency room doctor. Just because it’s a foreign word, that doesn’t make it any more clever than if they’d been told they were dizzy.

In my native Sweden there seems to be a domestic lay word for almost every disease. The runner up prize in my book goes to FÖNSTERTITTARSJUKAN, “The Window Shoppers Disease”, which we call intermittent claudication, usually caused by poor blood flow to the legs (people feeel better if they stand still for a while, for example pretending to look in a store window) but occasionally we get tricked and the symptom can be caused by pressure on the spinal cord from disc disease.

I absolutely love the number one word on my Swedish Disease Names list: The word they use for the most common cause of true vertigo, “Benign Positional Vertigo” or BPV. The Swedish word is KRISTALLSJUKAN (The Crystal Disease).

I also love explaining to patients how it works, because I think the body is a pretty clever contraption.

Vertigo is the illusion of movement, a spinning or rotatory form of dizziness. It usually originates in the balance organ, called the labyrinth, in the inner ear. Two common causes of vertigo are labyrinthitis, which is a viral infection, and Benign Positional Vertigo, which I wish we also would call the Crystal Disease.

This is how it works:

The labyrinth has two parts, the otololith organ and the semicircular canals. They are connected and filled with a sort of hydraulic fluid that we call the endolymph. Each inner ear, left and right, has this setup, and normally they provide the brain with the same, consistent information on where in space we are – but not always.

The otolith organ has one chamber, the utricle, that registers movement along a flat surface, like me rolling around the exam room on my stool (that’s how I demonstrate this). I hold my hands up with fingers pointing to the ceiling. “There are nerve cells in the otolith organ with little hairs sticking up like this”, I explain. Touching each fingertip with my other hand, I continue “and there is a weight, a little crystal, attached to the top of each of these hairs. If I move like this (stool roll..) the crystals make the little hairs bend, actually exaggerating the movement so I can register the slightest change in my position along this level path…”

The other chamber in the otolith organ, called the saccule, is set up to register movement in a vertical plane. Here I scrunch down or straighten up as I sit on my stool.

The Semicircular canals are curved tubes running in three different planes. They have a wider portion at one end with hairy nerve cells, similar to the otolith organ but without the crystals. When we turn our heads, the endolymph (fluid) movement causes the little hairs in each of the three semicircular canals to move a little differently and bend the nerve cell hairs to a different degree and maybe even in a different direction. All this information gives the brain a detailed sense of where in space we are.

Sometimes the little crystals fall off the hairs they’re sitting on top of in the otolith organ and travel with the endolymph into the semicircular canals.

Imagine what happens if the balance organ on one side tells the brain “movement to the left, thirty degrees” (here, I make the fingers on my left hand wiggle in unison just a little) and the other side, because some crystals flattened the nerve cell hairs, reports “wow, we’re upside down” (right hand and arm making a slam dunk movement). For at least a brief moment, our poor brains believe the louder, more dramatic yet inaccurate alarm report and we feel quite ill from that.

This explains why, in Benign Positional Vertigo, head movements in one direction can be much worse than movements in a different direction, depending on which angle causes the most dramatic effect from the little crystals.

This situation can go away spontaneously as the crystals can end up randomly traveling away from where the nerve cells register them.

There are also head maneuvers that can force the crystals away from the semicircular canals. Physical therapists and doctors in the specialties that deal the most with dizziness can put people through these movements, and you can even find instructions online.

Here is one of the most comprehensive explanations of all this that I have come across:

Lastly, a clinical pearl from Harvard’s neurology professor Dr. Martin Samuels. In his classic lecture on dizziness, he warns us never to suggest specific aspects of this symptom when taking a history. Most patients with dizziness will say yes to any description you suggest to them, therefore making diagnosis nearly impossible. Instead, he calls on his physician audience to repeat the word “dizzy”, maybe even a few times, scratch their chin and fix their gaze on something outside the window while rubbing their chin now and them – for however long it takes – until the patient starts to describe their symptoms themselves. Once they do, the diagnosis usually presents itself very plainly.

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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