A Country Doctor Writes:

I had a medical dream last night. I was in a clinic of some sort and the nurses pointed me in the direction of a talkative woman and a silent man in her company. They weren’t in an exam room, more like a pergola of some sort. I was given a tray with syringes and other medical paraphernalia. There was neither a paper chart nor any kind of computer medical record.

The woman spoke about having Graves’ disease but also a host of symptoms that she connected with it that I knew were likely unrelated and instead signs of florid psychosis. She had seen many doctors before and none of them had understood her or offered to help her. She had her own expectations of what that treatment would look like and it was all endocrionological, but made little sense to me.

The man in her company was deferential, soft spoken, as if afraid to upset her. I couldn’t tell what their relationship was. At one point, I think I heard her refer to him as her driver.

With no medical record and a tray of museum-like medical equipment I felt a little helpless. This woman needed an antipsychotic, that was clear, but I didn’t know where we were, what was available or how to reach her in her delusional state.

I told her I thought that not only did she have Graves’ disease, but she was also suffering from exhaustion trying to figure all her symptoms out on her own. I said that I wanted to help her, even though I didn’t really know how and with what.

I started to become aware that this was probably a dream, but I hesitated rising to full consciousness. It was as if I didn’t want to give up on my patient, my improbable clinical challenge.

The dogs’ rhythmic breathing, the cool morning air through the window and the sputtering noise from the coffee maker in the kitchen drew me away from my imaginary duty and into my Saturday morning reality.

How familiar, I thought to myself. A sort of parallel to the experience I had in the psychiatric ER in late 1980 back in Norrköping.

That time, I admitted a psychotic patient for observation. He was the only one who knew that very soon, earth was going to switch places with another planet and our lives would be switched, too. I got him to accept a sedative so he could get a few winks of sleep while things were still quiet, to gain strength and prepare for the next day; a back door to a first dose of treatment.

I had spent great effort aligning myself with his suffering, not challenging his delusion, but instead focusing on his distress. It didn’t work badly.

A few hours later, he tried to escape through a skylight.

Ever since then, I have used the same non-confrontational, low key frame of mind to try to form a therapeutic alliance for very small or incremental goals when treating patients – psychotic, disbelieving, hostile or otherwise unreachable.

But that time my overnight clinical experience provoked a dream after my shift where his powerful delusion suddenly played out in my own mind. All of a sudden I became him and in my dream I was convinced the planets were actually going to switch places.

Switching Places

Brian Johnson is a janitor at the nursing home in town. He’d been wearing a regular mask at work, but last week he and all the other staff were told to wear N 95 masks.

Today he was in my schedule. I had never met him before, but he had requested a same-day appointment in hopes of being excused from wearing this type of mask because it bothered his breathing.

A smoker, he had never been on any inhalers and the only chest X-ray I could find on him was a normal study from 2016.

Autumn said she got his oxygen saturation at 87% when he walked in from the parking lot with his N 95 on. When I saw him, I recorded 95% with the paper mask the front desk had given him at his request. I asked him to put the N 95 back on and took him for a walk down the clinic halls, but I couldn’t get his saturation below 92%.

His lungs were clear. I excused myself and got my Wright peak flow meter from my top right desk drawer. He removed his mask and blew into the device, twice: 230 each time.

“That’s half of what you would expect a man your size and age to be able to do”, I told him. “It looks like you’ve got COPD. So even that mask is pushing you over the edge to where you feel acutely short of breath. I’d like to give you a sample inhaler. It’ll last you two weeks – so if you see your regular doctor before it runs out, we can see what it does for you by testing your breathing again.

The sample I gave him was Stiolto, a once-a-day, long acting anticholinergic-beta2 agonist combination. I think he’ll be able to work with that N 95 if he stays with the inhaler – unless he has another agenda.

The other day I happened to talk with a colleague about our respective electronic inboxes. Office workers in other trades often spend their entire workday at their computers and sometimes the bulk of that time reading and answering emails that arrive in their inboxes. They do that because that is what they are getting paid to do.

Doctors and their employers basically get paid only when there is an encounter – face to face or via telemedicine, hardly ever when the exchange happens over the phone. Consequently, doctors, PAs and NPs are scheduled to see patients (generate revenue) all day long. Unlike office workers, we have no time set aside for managing our inboxes. Except for past payment models like HMOs and future reiterations of capitated care not yet in place, inbox management occurs at the expense of the employer or the medical provider. The general tendency is the latter – “between patients” (a post where I suggest the opposite – protected time for the inbox and then two MAs, more exam rooms and more efficient visits to make up for that computer time) or after hours without overtime or even regular pay because we are salaried.

Electronic inboxes are definitely burnout factors. I have found that medical organizations don’t have systems in place to manage this aspect of healthcare delivery. So it is typically up to each of us to figure out how we would want the flow to go. And we must then work with our support staff, whom we don’t supervise, to meet our patients needs without causing undue stress, interruptions, delays and confusion in our respective workdays.

A natural support staff response is to simply pass on questions and messages to the provider, like the title message. As a physician who generates the revenue that pays both me and my support staff, plus my bosses, I try to create a sense that my time on the phone or in the inbox needs to be as efficient as it possibly can, not because I am lazy but because I want to be efficient.

A lot of people in management are nervous about having unlicensed staff give medical advice. These are my thoughts on this: We need our staff to ask common sense questions and we need them to know when it is an obvious emergency. We can’t bottleneck everything by passing every request unfiltered to the provider – or we would have them answer every incoming call themselves already. (Or imagine a president with no admin support opening his own mail.)

We must allow and encourage all staff to use common sense. A person who has made it to adulthood, raised children or cared for a sick family member should and does know pretty well what basic self care is and what the doctor might need to know when you need advice. In the example above, why should the doctor be the first one to ask how long, what symptoms, getting worse or dragging on, what self care measures have you tried etc. See my post THE ART OF THE MESSAGE and the PowerPoint staff talk about common sense telephone triage I created a decade ago (where these slides are from).

When it comes to the most common requests, we have options: Websites, recorded messages on common topics, hyperlinks and things like that with generic advice on colds, sprains, allergies, child rearing and so on. The days are over when the family doctor was the ONLY source of medical information. 

My philosophy is that I need to mentor and support the people I work with to make them more than robot message takers. I explain what I need in order to make good decisions. If I get a good message I can give a simple answer that makes their job easier. If I get a sloppy or vague message, it will just be returned with my request for common sense information.

But I also encourage bypassing the back and forth messaging by having a running conversation: In my Van Buren clinic, my medical assistant/LPN and I share an office. This is a mixed blessing, but it allows exchanges like “Mrs. X left a message asking…” and I can say “If she says this, we’ll tell her to do A but if she says that, she needs to go to the ER”. I may still get a message about the outcome of that callback, but that is just to sign off, not to tie me up on the phone.

My support staff knows I don’t want to end up conducting visits on the phone that belong in the exam room or at least in a telemedicine session. If someone has an upcoming appointment and calls with requests for a new referral or a random blood test they’ve read about, I don’t even get a message – the patient is advised to bring it up in the next visit, or they can come in sooner.

Phone medicine isn’t just bad for the practice’s bottom line. It can also be bad medicine. A patient’s medical history is definitely the most important factor in making a diagnosis. But, very often, even the briefest of clinical exams can alert the physician to a patient’s over- or underestimation of the cause or significance of their symptoms.

It can be false economy for both the clinic and the patient.

John Roe has plaque but no symptoms. He ended up getting an angiogram a few years ago for chest pain that ultimately turned out to be acid reflux. But somebody put him on 80 mg of atorvastatin.

He had wanted to know what his lipid numbers were, so we checked them. They were quite low. His LDL was 42. For people who believe in target numbers, under 70 is the desired target for patients with known heart disease. Would John qualify as a member of that population?

“My daughter thinks that’s too high a dose for me”, he said. Amanda, his forty something daughter, is a psychiatric nurse practitioner. “I’m worried about my liver and my kidney numbers were off last year and what if they get worse again?”

This is a conversation I find myself in very often.

“It’s all a question of how much risk you tolerate, how worried you are about having a heart attack. How much insurance, or assurance, you want. The more you take, the more protected you are. And atorvastatin does more than lower cholesterol – I’m sure we have talked about that before. It stabilizes plaque and prevents plaque rupture. And 85% of all heart attacks happen not because of plaque growth but because of plaque rupture – sometimes of plaque that are too small to make you flunk a stress test.”

“I remember you saying that”, he admitted.

“It also prevents plaque buildup, and high doses can make plaque shrink – both in the carotid and coronary arteries, we have lots of proof of that. It also has a blood thinning effect that is different from aspirin, plus it relaxes the little muscles in the walls of the coronary arteries that clamp down when you get that letter from the IRS that you’re being audited (my standard joke..).”

I continued “I’ll print a couple of articles about all this for Amanda. And also, the FDA long ago stopped recommending routine checking of liver enzymes because liver damage from atorvastatin is very rare. And it has been shown to actually protect the kidneys.”

I clicked PRINT a couple of times and went back to my office for the printouts.

When I came back to the exam room, I undid everything I had said.

“But, some people have muscle aches or joint pains, some get higher blood sugars and some get brain fog or pseudo dementia. And there are other ways to avoid heart attacks. Without drugs.”

He looked up from the papers I had given him.

“I’ll print up one more thing for you. The Hale study, many years ago, showed that people aged 70-90 who followed a healthy lifestyle and a Mediterranean diet had half the heart attack and stroke rate, half the cancer rate and half the overall death rate of people with more typical western diets and habits. That’s the same reduction you can get with atorvastatin.”

John sighed. “So what am I supposed to do?”

“Only you can decide”, I answered. “It depends on how much risk you tolerate, how many hoops you are willing to jump through to avoid a heart attack. That’s a very personal choice.”

I know he wished I would tell him what to do. If he had had a heart attack, it would be simpler – there is a “party line” for that. But primary prevention isn’t that straightforward or universally agreed on. So I only provide the evidence and the options.

I don’t babysit. I want to empower.

People are asking about the latest US Public Health Service Taskforce on Prevention (USPSTF) recommendation about the use of aspirin to prevent heart disease. It has been a long-standing recommendation for people who already have heart disease.

When I turned 50, I started taking a “baby” aspirin. That was their recommendation then. I stopped taking mine because I had several nosebleeds. “It’s not worth it for me”, I told my patients. Some time later, they changed their recommendation to men over 50 but only women over 50 with diabetes (because their risk for heart disease is four times that of non-diabetic women).

The reason their recommendation keeps changing (negative view) or evolving (positive view) is that studying what happens to large groups of people who do this, that or the other over periods of many years is difficult, expensive and fraught with technical and procedural problems.

It boils down to two numbers: the number needed to treat in order to avoid one bad event, NNT, and the number needed to harm one person. When I wrote about aspirin for heart disease prevention in 2017, the number of aspirin recommendations needed to avoid one cardiac event was about 200. I didn’t know the number needed to harm then.

The harm can be a lot worse than the nosebleeds I had. Some people get bleeding ulcers or even cerebral hemorrhages that may be partly due to their aspirin use.

So last week their recommendation was revised based on more recent data. It seems the risk is greater than the benefit for people over 60 – again, we are talking about primary prevention, people who do not yet have heart disease.

Patients often worry when we change our advice because of new scientific evidence. I understand their confusion and their calls, but I don’t worry much about this change: It doesn’t keep me up at night or on the phone with patients after hours. We need to remember the NNT. It takes 200 aspirin recommendations to prevent one heart attack. That means that roughly 0.5% of people taking aspirin will be helped by it and the rest will not – but in some subgroups the benefit is greater and in some subgroups of people there will be more harm than good.

The latest recommendation includes the patient’s ten year cardiovascular risk, so the USPSTF no longer treats all men over 50 the same. The ten year risk can be calculated from a person’s sex, age, blood pressure, smoking status, presence of diabetes and diagnosis of hypertension. The American Heart Association and the American College of Cardiology created this risk calculator/smartphone app in 2013.

Here is their latest recommendation:

The USPSTF concludes with moderate certainty that aspirin use for the primary prevention of CVD events in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk has a small net benefit.

The USPSTF concludes with moderate certainty that initiating aspirin use for the primary prevention of CVD events in adults age 60 years or older has no net benefit.

So, remember that a lot of people will still be taking aspirin for nothing. But think of it like wearing your seatbelt: as long as it doesn’t hurt you, what do you have to lose – even if you never get in an accident? But the big concern with recommendations about primary prevention is that our recommendations could end up hurting people who never had a big risk of getting the disease we are trying to prevent. Then our advice could hurt innocent people. And that is what the USPSTF is now saying about seemingly healthy 60-year olds. (More people are hurt by aspirin than by seatbelts.)