A Country Doctor Writes:

Today I saw another patient who struggles with her pharmacist’s instructions to take her thyroid replacement by itself long before breakfast and her other medications.

“I keep forgetting to do it that way, so then I go without it for that day”, she told me.

“Then I think you should just take it with breakfast and your morning medications”, I answered.

“Really?” Her eyes widened as I continued.

“Well, I’m just a country doctor, but it seems to me that if you take levothyroxine with all your other pills at breakfast and you get a little less into your system, two things happen. First, you’re more likely to get the medication on board every day. And, second, if you really get a little less than you need because of interference from food and other medicines, don’t we check your TSH every so often to make sure your pituitary is happy with that amount?”

“Yes, we do”, she agreed.

“So maybe we just have to give you a slightly higher dose if you take it that way, so what’s the big deal?” I asked.

“That makes sense”, she agreed.

“I think this morning routine thing is kind of like saying never open any windows in the winter because you’ll freeze to death”, I suggested. “But we both know that if you open some windows, the thermostat will make your furnace crank out more heat until the house is exactly the temperature you set it at.”

“That seems so straightforward”, she concluded.

As we wrapped up our visit, I finished my speech:

“I think a lot of doctors get hung up on theoretical fine points that don’t matter a whole lot in real, clinical, practice. There are drugs we can’t easily measure levels or effects of, so then we probably should dose them according to what works best. Like, old statin drugs, like simvastatin, don’t stay in your system for 24 hours. So we dose them before bed, which is when we make the most cholesterol. But modern ones, like atorvastatin, work for 24 hours so when you take them doesn’t matter. But so many pharmacists still slap a label on these newer drugs saying to take them at night. And I hear too many people say they have a hard time remembering to take medications at night.”

A medicine taken at the “wrong” time is usually a whole lot more effective than one you completely forget to take.

(You can quote me on that.)

When this country needed to immunize a few hundred million citizens, primary care clinics were generally the last institutions that got invited to participate.

Instead, hospital systems held clinics in huge venues like stadiums and conference centers and retail pharmacies expanded their vaccination offerings to include in-store and drive through Covid immunizations.

Why were primary care clinics the last resort for the vaccine rollout?

The sad reality is that we are too inefficient to be part of a fast moving mass immunization. We are not designed to be fast. We are designed, or shall we say redesigned -away from the way things used to be- to be comprehensive and geared up for at least the possibility that whoever walks through our doors will be a long term user of our services. This is why new patients get inundated with questionnaires that have nothing to do with their presenting concern (which we used to call complaint) and which nobody in their right mind would expect completely truthful answers to at the first encounter, like “do you need a drink first thing in the morning to feeel okay?”

My pet peeve is that primary care offices are ill suited for being the primary source of public health. We are very good at working one-on-one when patients are ready for it or seek us out. But there are just too many public health messages out there to cram them into what patients expect to be problem solving visits when they have chest pain, shortness of breath or unexplained weight loss, and even if they want a “complete physical”. How could you possibly be “complete” in 30 minutes, which is all the time you have for it if you’re lucky?

Let the pandemic teach us that public health is a mass market kind of thing. We’re happy to reinforce its messages, but please abandon the illusion that we can or should shoulder the responsibility for it.

And use existing resources to their fullest, like immunizations at pharmacies. Then, if those get recorded so primary care clinics can follow up (provided we get paid for such work) when our patients didn’t get their shot, we would have more comprehensiveness. And we would be working more one-on one, the way we were designed.

Looking at my EMR patient schedule in its usual display, I can’t see quickly if I have appointment slots open. I would have to think 8:00, 8:30, 9:30 – so 9:00 must be open. There is a grid display, too, which lets me quickly see the unfilled slots. But the grid view gives no indication of why the patient is coming to see me. The standard version prominently displays 15 minute or 30 minute “visit type” but I am at the mercy of the scheduler as to whether there is a freetexted comment about the purpose of the visit.

For a busy clinician, it is crucially important to know why the patient is coming in. A wound check is not like a “doesn’t feel well” visit. When you’re always asked “where can we squeeze somebody in”, you need to know “why” in order to guess “how much time”.

I actually have no tolerance for “not feeling well” visits. Come on, use some common sense: Does the person have the sniffles or are they desperately ill with shortness of breath, chest pain or something equally dramatic? In my opinion, even offices that don’t have an automated phone system that says “if this is a life threatening emergency, please hang up and call 911” should have that triage step first and foremost in the mind of whoever answers the phone.

“Why” is also crucial when it comes to planning what needs to happen. If someone is coming in to have a wart frozen, the cryo equipment from down the hall needs to be available. A “3 month diabetes” visit needs a glycosylated hemoglobin, either a result from the lab or a fingerstick done in the office, whereas “followup blood sugars” is an interim visit to just review the blood sugar log.

Even the word followup means something. For me, a “followup blood pressure” visit is a predictable visit at my request, not something urgent. Theoretically such a visit could be “bumped” in a pinch to make room for an urgent hospital followup or something similar. But a patient’s own request to be seen because their blood pressure is skyrocketing must be labeled as “BP high”. Such a visit should obviously not be bumped and should not be labeled the same as a routine visit.

This may seem picky, but think of hailing a ride or making a dinner reservation. The driver might benefit from knowing how far and how many passengers, just like the restaurant might want to know how many guests and a regular meal or a birthday party and so on.

Another scheduling issue in my opinion is the “physical”. I hear family members worry about someone being ill and saying “he needs a complete physical”. First of all, there is no such thing as a complete anything in medicine. Second, billing for a physical implies that you did a lot of preventative things that would be inappropriate when somebody is very ill. I sometimes actually say “you are too sick to have a random physical, tell me what’s going on instead”.

Doctoring in 2020: Why is the Patient Here? Whose Visit is it Anyway?

Almost two years into this new age of varying degrees of self quarantine, I am registering that my own social interactions through technology have been an important part of my life.

I text with my son, 175 miles away, morning and night and often in between. I talk and text with my daughter and watch the videos she and my grandchildren create.

I not only treat patients via Zoom; I also participate, as one of the facilitators, in a virtual support group for family members of patients in recovery.

I have reconnected with cousins in Sweden I used to go years without seeing; now I get likes and comments almost daily on things that I post. I have also video chatted with some of them and with my brother from my exchange student year in Massachusetts 50 years ago.

I have stayed in touch with people who moved away. And I have made new friends through the same powerful little eye on the world I use for all these things, my 2016 iPhone SE.

Members of my addiction recovery group stay in touch with each other via phone or text between clinics. They constantly point out the value of the social network they have formed, even though they only meet, many of them via Zoom, once a week. The literature has supported this notion for many years and is very robust: Social isolation is a driver of addiction.

It is also a driver of cardiovascular risk and is thought to be a risk factor of the same magnitude as smoking.

But, do new, online friendships mean as much for our health? This is probably a question that is too new to be answered. How many of these relationships can transition and deepen over time and through different stages of life? Suzanne Degges-White, PhD, writes cautiously about this in Psychology Today.

In 2017, pre-pandemic, Frontiers in Psychology reported that people who spent a lot of time on the Internet were more lonely than people who used the Internet less. But that was in a different era, when in-person relationships were a more practical and safe option than they are today. Back then, the heavy users of the Internet were possibly a self selected group for entirely different reasons than today’s high utilization demographic.

But with the fragile state of affairs, exemplified by the revolving door of new coronavirus mutations – of which Omicron is unlikely the last one – we probably need to make the most of whatever means we have to stay in touch with family and friends. Not so much that we neglect the necessary solitude we all need for introspection and self care, but enough to feel connected in some way to the human race.

It is human nature to name things. Even babies do it. They point at or grab a new object and say “Da” or some other one syllable word as they discover and claim the world around them.

People who don’t feel well search for answers. It is bewildering for them to hear “We don’t know what’s wrong with you”.

Nobody wants to be dizzy. It feels more substantial to have vertigo, even though in reality both terms are equally specific.

Every era has its diagnostic terminology, influenced by larger trends in science and sociology. People who are searching to name their symptoms tend to latch on to the diseases that get publicity and there are usually practitioners who feed into that. Many times diagnostic criteria are undeveloped or controversial. We call these entities syndromes, just like clinicians have done over the centuries before us. We describe constellations of symptoms and speculate about their cause. Only much later do we understand their pathophysiology and become able to sharpen their definitions. This tends to exclude some people who self diagnosed their way into something nameable.

Right now, there is the emerging concept of “Long Covid”. Before that it was chronic Lyme. It was neurasthenia in the early 1900’s. In between, we saw the emergence of fibromyalgia, chronic fatigue syndrome and many others.

Different cultures have different diagnostic frameworks. In Sweden there are 300,000 people with nonspecific symptoms who are diagnosed with sensitivity to electromagnetic fields. They move into super insulated homes off the power grid. I never hear of that here.

Wikipedia and many other sources, including Science Direct, list such “Culture-Bound Syndromes”. For example, Premenstrual Syndrome, Anorexia Nervosa and Morgellons aren’t universally recognized conditions, but fairly specific to Western cultures.

I am torn about using labels that may not fit exactly. They can help as concepts, but can also predispose patients to magnifying their illness experience and thus be self-fulfilling prophecies. I tend toward the concept of shadow syndromes and disease spectrums.

For example, I’m not hung up on how many fibromyalgia tender points a patient has. As long as they don’t meet the criteria for inflammatory rheumatic diseases, I often introduce the concept early on by saying “you have many features of what we call fibromyalgia, so these are some things that may help you feel better, even if you don’t have the full-blown condition…” (See more on my thoughts on the spectrum of disease here.)