A Country Doctor Writes:

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

Nearsighted since age 6, I have a habit of holding things close to my face. I’ve had progressive everyday glasses for several years now as well as dedicated reading glasses. Before I got progressive lenses I used to take my glasses off to read the news on my small iPhone (my 13 mini may be the last iPhone I buy, because nothing bigger would fit in my left front pocket, even if I got rid of my cloth handkerchief).

My optometrist calls me an amateur, even though I have diagnosed my own vitreous detachment and many patients’ ocular emergencies, like acute angle closure glaucoma and dug out countless corneal foreign bodies with an 18 gauge needle. He said that my presbyopia shouldn’t get worse after 65. It is still getting worse in my early 70s. That means I’m now starting to take my reading glasses off and bringing my iPhone to my uncorrected focal distance, which is 5 finger breadths from my eyeballs.

But just a few moments ago, I checked the time on my Timex Expedition watch and realized that if I hold it 18” away, I see it super well and I can even read the tiny word Timex above Expedition. So technically I can still read emails, The New York Times and all my other news sites with my old reading glasses without getting new ones. I just have this one bad habit of wanting to read up close, closer than other people.

Altered Vision

Not On Call

In my first 30 days on Substack, I published a post that got eight new subscribers and broke my record of how many views it had, 195, more than twice what my budding Substack had accomplished before.

It was a call to reimagine, reinvent and reinvigorate primary care. I re-blogged this post on my original, much older WordPress blog and it got 14 comments, many more than usual. So this was a hot topic and two years later it’s still hot. In fact, personally, six months later, I started transitioning to a different job, the one I now work full-time in, doing housecalls and virtual visits for older and disabled patients.

Many of the comments were saying that Direct Primary Care is the solution to today’s primary care crisis. It’s a great alternative, for sure, but it doesn’t work for everybody. Medicare patients on a fixed income need to use their insurance if they still want to eat and heat their homes. Same thing for most people on Medicaid.

There are a few problems with primary care today. One is that our nation’s lack of a public health system has defaulted most of those tasks to the primary care practices, where we are hard wired (and usually reimbursed) for seeing patients one by one. It is hugely inefficient to do mass education and mass screenings with large populations on a one-on-one basis. This is obviously leaving less time to treat sick people one by one.

Another problem with primary care today is that managers and EMR programmers have basically no idea of what we do, the cognitive aspect of doctoring. They only see the superficial aspects of our work and they create “workflows” (a word that makes me cringe) that emphasize the scutwork aspects of our day instead of creating systems that liberate us from tasks that non-providers could do and free us up to diagnose and treat. This is a dramatic example of what it used to be like to dose the blood thinner warfarin before and after computers (note that the top image is for 4 months’ worth of test values and the bottom “workflow” is for ONE SINGLE test value).

Dosing Warfarin: From Flowsheet to Workflow. Is This Progress?

So this is my early “blockbuster” post:

Practicing at the Top of Your License is Not an Option for Primary Care Physicians

I was covering for Dr. Kim the other day. A 60-something diabetic who had started taking insulin a few months ago had left a message that she wanted to change from Novolog (insulin aspart) to Humalog (insulin lispro) because she had just had her second UTI (urinary tract infection). And she had just read that UTI is listed as a side effect of Novolog but not of Humalog.

I’d never heard of insulin causing UTIs, but if that were the case, wouldn’t all insulin do the same thing, I thought. I opened epocrates, the drug app 60% of doctors use (created by the CEO of Galileo, where I work). Sure enough, UTI is listed as number 5 of common side effects for Novolog, but it is not on the list for Humalog, where URI (upper respiratory infection) is included as number 8.

My trusted, much younger colleague, Dr. Google, quickly produced the most interesting answer to my query “UTI from insulin”.

Here are two quotes from the article Google delivered to me:

What Is Insulin’s Role in Diabetes-Related Urinary Tract Infections?

“…reduced insulin receptor activity….led to a weakened response to bacterial infections, lower antimicrobial peptide production, and compromised immunity.”

“suppressed insulin receptor signaling lowered antimicrobial peptide production and increased susceptibility to “leaky bladders” and infections caused by….Escherichia coli.”

I’ll say it again, just as I did in my story about the woman with precipitous drop in albumin:

You can’t know everything and you’re never too old to learn.

The Case of the Dropping Albumin