A Country Doctor Writes:

We all learned about type 1 diabetes in medical school. That is a disease where the bodies ability to produce insulin vanishes very quickly. Type 2 diabetes, which only affected 2% of Swedes when I went to medical school, is more a problem of insulin resistance. It used to be called a disease of old age, but it is now common in Children with overweight. Lately, Alzheimer’s disease has been nicknamed type 3 diabetes. We are also screening our patients for Prediabetes in order to offer early intervention. With recent drug development and expanded indications for various medications, we suddenly have an entirely new class of people who take diabetes medicines because they have been proven to at least to some degree improve cardiovascular outcomes. Voilà, welcome to the bizarre phenomenon of Pseudodiabetes.

Let me explain:

A recently developed class of antidiabetic medications, the SGLT2 inhibitors (Jardiance and Farxiga) can lower blood sugar by inhibiting the body’s ability to reabsorb glucose that is about to be excreted in the urine. These medications can help improve or preserve kidney function in people with type 2 diabetes. They have also been shown to reduce cardiovascular event risk. I don’t know exactly how that works but I sure know how it has affected my daily work as a primary care doctor.

Primary care physicians are held to many treatment standards for our quality ratings and in many cases our insurance reimbursement. For example, if we have patients who refuse colon cancer screening, we get dinged for it. If we have diabetics with normal cholesterol, who don’t believe us when we say that cholesterol pills can reduce the heart attack risk even for people with normal cholesterol, we risk getting bad report cards and less money coming into our practices. In the case of this new class of anti-diabetic drugs, the SGLT2 inhibitors, even if somebody gets put on them purely for cardiovascular risk reduction, they are now in the eyes of the insurance companies, full-blown diabetics. We are obligated to check their urine for microalbumin and send them to the eye doctor for annual eye exams to look for diabetic eye disease.

This makes no medical sense and it is downright stupid. I would think a clever high school student or a simple AI program could find a way for the actuarial people to see whether this class of drug was started to reduce heart risk or control blood sugar, but so far that has not happened.

We can transplant hearts and do surgeries on fetuses, but we can’t eliminate the unnecessary Pseudodiabetes silliness.

A patient appointment for a physical could yield a cancer suspicion or diagnosis. An appointment for chest pain could lead to an intervention for domestic violence. A quick visit for a skin rash could land a high school senior in the hospital for a leukemia workup.

In this business we can never assume that a visit will be about what we somewhat callously have been calling the “Chief Complaint”. You have to be prepared to shift gears, sometimes because the patient drops a hint or a bombshell revelation they didn’t tell the scheduler, front staff or medical assistant. And sometimes because you hear, see or palpate something suspicious.

In some ways, we always have to be triaging, before we settle into a “routine” visit. Triage comes from the French word “trier”, which means “to sort” or “to select”.

Primary care is messy. We have to sort who needs something done quickly for a high risk symptom or finding, who needs a different level of care, who needs simple reassurance and who needs a long term plan.

All of this without forgetting the screening and preventive health agendas, which is what we are graded on. There is no formal tool to evaluate our diagnostic acumen. So we are measured for what is easy to measure, the so called “street light effect”.

An Innocent Looking Rash

The Art of Listening: Beyond the Chief Complaint

Primary Care is Messy

I posted this on my Substack in February 2023 and realized I never posted it here.

The trending post right now on Acountrydoctorwrites.Blog is about the unending stream of calls for medical advice we get in my office and, I’m sure, others like it. We get calls asking how to treat a cold. My suggestion is that we hire some grandmothers. Our own staff, even though most are wise grandmothers and mothers, are not allowed to give “medical” advice in the litigious climate we live in. And the medical providers don’t have a lot (read any) of wiggle room in their schedules to handle non-urgent calls in a timely fashion.

I also recently posted about what I recommend in treating the symptoms of a cold(note that there is no treatment for the cold itself; it’s going to run its course). I don’t know if that will make a difference in our call volume, but it’s worth a try.

All medical bloggers touch on or delve deeply into the pandemic of physician burnout. My 1/22 post, The Future of Doctoring is Already Here: Do More, Give Less or Burn Out,   is the most read in my blog’s almost 15 year history – well over 13,000 views and counting.  On 2/14, The New York Times picked up on broadly the same unsolvable equation (not to say they were inspired by my piece) in their article According to Medical Guidelines, Your Doctor Needs a 27-Hour Workday.

So, how do I, or any of us, stay sane in this crazy system?

I have found my curiosity to be my biggest defense against burnout. Asking why, looking for connections, not settling for I don’t know, but doing a quick google search instead, is my recipe.

This week, for example, I saw a new patient, 27 years old, with foot pain that had been diagnosed in the ER as plantar fasciitis, heel spur. But his pain wasn’t just under the heel, it went partway up toward his knee. And he couldn’t feel light touch there. I asked if he had back pain. “All my life”, he answered. So I tested the strength in his legs, definitely weaker than in a healthy 27 year old. Next I asked him to get off the exam table and sit in the chair with arm rests next to it. “Try to get up from the chair without using your arms”, I said. “I know I can’t”, he answered. He grunted and tilted to no avail.

I don’t have an answer yet to what ails him, but I ordered a bunch of tests. How could I not think my job is interesting and meaningful?

Another patient has low calcium from hypoparathyroidism. The only endocrinologist in northern Maine has been gone for a couple of years, so I am monitoring her lab values. She was running a little lower than the endo or I would want, but she said her calcitrol was so expensive that she skimped on the dose. The other day she told me that when she had Covid last month, she had two strange spells where her body seemed to stiffen up and get a little shaky. Seizure, critical hypocalcemia, I thought. A quick search revealed that the inflammatory response to Covid has triggered hypocalcemia in many cases. I told her she had been on the brink of a grand meal seizure, and she said, “I’ll take them the way I’m supposed to”.

And there were others, not as exotic, but in a handful of cases I was able to connect the dots.

A woman with low sodium was borderline  before and normal years ago. Her first drop happened when she started taking Prozac some time ago, and when her dose was increased recently, her sodium level tanked. That is a known side effect from the SSRI class of drugs. So we reduced her dose as a first step – some people don’t do well stopping medications like that cold turkey, although Prozac’s long half-life makes it less likely that she would have severe withdrawal symptoms.

To be honest, there are many such little pearls, or mental challenges, some of which I can’t even remember when the week is over. So far I’m still very happy to be a somewhat overworked primary care doctor in this underserved corner of our country.

Acetylcysteine is an old drug with two major uses. Orally it can lessen liver toxicity from acetaminophen (paracetamol) overdose. Inhaled, it is a powerful mucolytic (loosens phlegm for people with lung disease).

I have a patient with severe lung disease who is on oxygen 24/7. She had been using high doses of guaifenesin, but still couldn’t raise her phlegm. I haven’t used it in many years but remembered from the early days of my career that acetylcysteine is a powerful mucolytic.

It’s used in the hospital more often than in outpatient care. So I called the patient’s pharmacy and they don’t have it in stock, but they can get it and my insurance would require a prior authorization. So I sent in a prior auth request with the diagnosis of chronic respiratory failure with hypoxemia. My application was denied. It said that the diagnosis I gave them was not a qualifying diagnosis. They were kind enough to reference a website I could go to to see what might qualify. So I did. There, I saw that emphysema qualifies. Well, darn it, She has had a CAT scan of her lungs showing severe emphysema, but in my book respiratory failure with low oxygen is a more severe diagnosis than emphysema. This is one instance where I sort of wish that AI would be used. The insurance companies deny requests because there’s no common sense in the process. They have check boxes. Emphysema would be a check and respiratory failure with low oxygen would not be a check.

So I appealed the denial and we will see what happens.

Soon after graduating from medical school, I stopped checking the sense of smell in my neurologic exam, just like most of my colleagues. It’s inconvenient to carry different smelly objects around on the hospital ward or in the clinic. So, “Cranial Nerves I-XII normal” turned into “Cranial Nerves II-XII normal”. There was a brief period during the Covid epidemic where we at least asked about our patients sense of smell.

Researchers at Sweden’s Karolinska institute did a 12 year longitudinal study of the sense of smell and the mortality data of more than 2500 participants with an initial average age of 72. The researchers used a 16 item odor identification test and classified the participants into three groups: Anosmic (0-6 correct answers), Hyposmic (7-10 correct answers) and Normosmic (11-16 correct answers).

At both their 6 and 12 year follow-ups the anosmic group had almost 70% higher relative risk of mortality than the normosmic group. For each wrong answer, the mortality increased 5-6%.

Interestingly, the only causes of mortality involved were neurodegenerative deaths (mostly Alzheimer’s disease), respiratory and cardiovascular diseases. There was no association with cancer mortality.

So, maybe it’s time to reintroduce the first item in the neuro exam we all learned in school…

https://jamanetwork.com/journals/jama/fullarticle/2833992