A Country Doctor Writes:

After several years of ER visits with normal bloodwork and negative CT scans, Fred Hooper ended up in my schedule a few weeks ago.

“I’ve had stomach pains for 20 years and it’s gotten worse since my colonoscopy 7 years ago”, he said.

Fred had seen an emergency room doctor more times than any of the primary care physicians he tried over the years. He described severe lower abdominal pain and bloating soon after eating, followed by small, hard bowel movements. Each episode lasted a few hours or even less.

“Do I need a colonoscopy”, he asked.

“Maybe, maybe not, but you’re almost 80 years old and you’ve had this problem for 20 years. I’d like to try something first”, I said.

“Could this be Crohn’s disease”, he asked.

“Not likely, the episodes are quite short and in 20 years, nothing bad has ever happened because of them”, I answered. Instead, I went in a different direction.

I asked, “has anybody ever talked to you about trying a milk free or gluten free diet, like avoiding bread, crackers and pasta?”

“No, but now that you mention it, I’ve noticed that dumplings and pasta tend to bother me, and I do drink milk with my meals quite often.

“Let’s do this”, I suggested, “get some bloodwork to look for inflammation and full blown celiac disease, then stop milk products for one week. If you don’t feel better, go gluten free. Avoid anything made with flour, like boxed cereals, bread, pasta, crackers and so on. And see me one week into that. I’ll let you know if there are any surprises in your bloodwork as it trickles in.”

The emergency room has a different purpose from the primary care physician. They are geared up to identify acute problems that require immediate treatment. Fred got the bloodwork and the CT scan every time to make sure he didn’t have a surgical, infectious or vascular emergency. Once he was cleared from those things, their job was always done.

The primary care doctor’s job is to listen to the patient and, in Fred’s case, consider the chronic and often functional diseases that might explain the symptoms. But Fred is a somewhat impatient man who never seemed to invest in a primary care relationship.

Primary care doctors don’t necessarily dig deep into a new patient’s chronic but not so dangerous sounding symptoms until after they have done all the mandated new patient intake items like immunizations, routine lab work, screening for depression, alcohol abuse, smoking, food insecurity and more. In Fred’s case, he says he got the impression his doctors weren’t all that interested in his symptoms.

I was interested, because I had a gut feeling his problem was probably quite simple.

The other day, a few weeks into his dietary experiment, Fred came back to see me. Guess what he told me…

I am happy to report that my gut feeling was right on, and his gut is doing much better than it has been for the past few decades.

So, does Fred have low level gluten sensitivity? Maybe, maybe not. This is still not a completely understood phenomenon, but it has definitely moved from the fringes into mainstream medicine.

The Harvard Health Blog writes “The expression ‘leaky gut’ is getting a lot of attention in Medical blogs and social media lately, but don’t be surprised if your doctor does not recognize this term.”

This phenomenon has in fact become better understood and accepted and earned endorsement by the medical establishment, gaining the more scientific name increased intestinal permeability.”

The Celiac Disease Foundation reports that people with non-celiac gluten or wheat sensitivity who don’t test positive for celiac disease sometimes in fact have a systemic immune reaction with intestinal cell damage, really blurring the line between celiac disease and non-celiac gluten sensitivity, NCGS.

Canadian Society of Intestinal Research writes that since “wheat is a complex structure with an estimated 95,000 genes”, more than humans have, many other compounds besides gluten could be the culprit in wheat sensitivity.

Empiric elimination of wheat is an easy thing patients with unexplained gastrointestinal symptoms can do on their own. We owe them that suggestion.

The medication and allergy lists seem like they would be the most important parts of a health record to keep current and accurate. But we all see errors too often.

I think it shouldn’t be possible to enter an allergy without describing the reaction. Because without that information the list becomes completely useless.

The other day I saw a patient who needed an urgent CT angiogram. The allergy list said “All Contrast Materials”, which isn’t even “structured data entry”, and thus not recognized by the computer if my EMR (Me again, Greenway!) would have been clever enough to check for allergies when I order a CT scan.

After a lot of probing, the “allergy” in this case turned out to be a host of nonspecific, chronic symptoms after several lumbar CT myelograms in a short period of time many years ago.

Some people claim to be penicillin allergic because “it never works”. Others list ciprofloxacin or sulfa antibiotics because they get a yeast infection after taking them. Others were slightly nauseous after their first dose of an SSRI like fluoxetine or fatigued after starting gabapentin.

Some symptoms listed as allergies are poorly understood. For example, morphine causes itching in many patients, even skin manifestations like blushing as well as sweating. But this is not usually a histamine mediated symptom, and not an allergy. Other opioids, like hydromorphone, tend to have less risk for itching.

Cough from ACE inhibitors isn’t a true allergy, but we often note that in our allergy lists. People with this side effect can safely be switched to angiotensin receptor blockers, ARBs.

Angioedema from ACE inhibitors is an allergic and serious reaction with significant risk for cross-allergy also from ARBs. So it is essential to distinguish between the two in our allergy lists.

Medication and allergy history is one of the few things specialists look to us for. They often ignore and repeat the tests we had done, for example. But a good allergy history is something we can and should try to collect for every patient.

The big challenge is that patients often don’t remember the details of their allergies or side effects years after the fact. So, principle number one is to put down new reactions carefully when we hear about them.

My personal trick with new patients sporting long lists of proclaimed allergies is to ask: “Did you almost die from any of these medications I see listed as allergies?” That is the first step in a reality check about the real magnitude of their allergies.

The other list we could do better with is the PROBLEM LIST. Since we went electronic, it has bulked up and become much less helpful than it used to be. I just reread a post I wrote about that eleven years ago:

Problem List Problems

Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.

Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?

The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.

Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.

Primary care here is wasting time in many ways:

When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.

When we are forced to act as if we only see our patients once – ever, instead of over several visits year in and year out. We can’t see you quickly for your sore throat or UTI, because a visit without the required screenings hurts our quality ratings. Having non-physicians do the screening (the point I am making above) is not necessarily the solution because my medical assistant can’t keep me humming and at the same time do all the screening duties on even patients with the simplest of clinical problems.

When we keep thinking that the only time and place for us to interact with our patients is in the office visit. All other “businesses” are figuring out how to engage their “customers” via emails, podcasts, events and so on. Very few medical practices are doing the same. We typically only make money when patients are seen in the office, but if we could have staff interact with patients in whichever way is most appropriate between visits, the time patients spend in the office would be shorter and more effective and clinic productivity would improve – as would quality. Right now, so many of our visits are a real scramble to get through.

When we use the telephone in such inefficient ways. In an era when people generally have their personal cell phone on them, we act as if we are calling them at the phone booth on the corner of their block. They leave a message saying “please call me back”. You do and they don’t answer. You leave a message saying “please call me back”, and so it goes. A personal cell phone is as private these days as an email or a secure patient portal. I think we can leave general messages with patient permission – your tests came back normal, please double up on your new prescription and come back in two weeks, things like that.

When our administrators are too preoccupied with well-meaning but stilted and bureaucratic top-down mandates. Just like providers often can’t be as helpful as they would like to their patients because of our mandates, there is little room for innovation on the administrative side because of the regulatory burden.

We have become a terribly rigid and stuffy “industry” during my 40 years as a physician. We are not like a flea market or Saville Row (London’s bespoke tailor street) like yesterday’s private practice. We are like the postal service or the US immigration service. There will be disruptions if we don’t start moving with the times, and with our patients. They will move away from us whenever they can, to Concierge Medicine, Direct Primary Care, freestanding clinics, varyingly alternative practices or even non-medical caregivers, leaving only the most utterly sick and complex patients with us. Is that what the Fed, Medicare, Medicaid and the insurance companies want for us? And is that what is best for most patients?

Our personnel policies require all hourly staff to punch out for their lunch break. As a salaried physician, I can work my entire shift without a break. This requires some juggling with nursing staff, but it works.

The other day, Autumn came back from her break giggling.

“I was reading from your book again, and I still laugh at your story about that ear flush. I remember it so well…”, she said.

“I know, it was wild”, I answered, but I also remembered thinking with some sadness at the time about how misunderstood this patient must have been. But I, too, smile inside when I occasionally reread “A Moving Target”:

Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.

On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.

In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).

Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.

The authorization for the colonoscopy referral does require my clinical judgement: My patient may not be medically stable for their routine colonoscopy because of a recent heart attack, or they may have already had a diagnostic colonoscopy at another hospital because of a GI bleed, or they may now have a terminal illness that makes screening for colon cancer moot.

But, please – when we can land robots on Mars – give me an easier way to say “yes” or “no” in my multimillion dollar system!