A Country Doctor Writes:

Today, I had a medical assistant covering for Autumn. Near the end of the day, she handed me one report from our emergency room and one from the competing healthcare system’s walk-in clinic.

A patient of mine had gone to the walk-in clinic for a toothache.

“I wonder why he went to the walk-in clinic for a toothache”, I said.

“I sent you a Task about it this morning”, she said.

That’s the workflow In Greenway’s Intergy. In eClinicalWorks, my other clinic’s EMR, “task” is called “Jellybean”, because the icon with the number of messages is one of several different color ovals on top of the computer screen. But it’s the same flawed idea: Pass messages to the clinician in the order they came in instead of according to urgency.

“Oh well”, I said. “I saw the task about a note for the landlord about a cat and the one about wanting a backdated referral and a hundred other non-urgent messages. Listen, I’m drowning in messages while I’m busy seeing patients. What Autumn does is put a stickie on my computer monitor about important or time sensitive messages. I would have sent in an antibiotic for that guy.”

“No problem, I can do that”, she answered.

I can think of lots of posts I have written about this before, but it needs to be said again:

There is a real danger that providers and patients will waste time doing the wrong thing at the wrong time when nobody directs and prioritizes the inflow of information.

Computer people, who sit at their screens all day, don’t acknowledge that providers are looking into patients eyes, ears and other orifices, listening to convoluted histories and solving clinical problems in the exam room most of our working day. The patients in the office are our priority unless someone with the appropriate triage savvy declares that a not-present patient’s issue should be prioritized.

Where else is the decision maker for a million-plus-dollar-revenue operation surrounded by helpers who dump everything on the boss’s desk without even trying to sort it?

I’m not the president, would not want to be – or even compared with one – but think about how ridiculous my workflow would be if applied to other arenas besides primary care (posted in 2015):

All the President’s Mail

Yesterday I wrote about Sphincter of Oddi dysfunction, SOD, a problem where bile accumulates temporarily in the common bile duct.

Burt’s case reminded me of how often I’ve hit the nail on the head suspecting a bile problem to be the cause of a patient’s symptoms.

We certainly have an epidemic of gastroesophageal reflux, in part related to our dietary habits and obesity. So many fast foods can aggravate it, like pizza with red sauce, sweetened and carbonated beverages. Eating late at night and going to bed on a full stomach can also trigger reflux. A big belly, whether from pregnancy or obesity, is also a major trigger.

We have developed more and more acid blockers, yet I see more and more people with reflux symptoms not controlled by these fancy drugs. Surgeons seem to be looking for even small hiatal hernias to operate, and I see many patients who don’t feel much better after their Nissen fundoplications.

So consider this: Endoscopies often show bile reflux. Bile is alkaline, but locally irritating just the way acid is. If we suppress production of stomach acid, is unopposed alkaline bile then more important than if it is present in the stomach along with stomach acid – in a way neutralizing each other? I don’t know, but I wonder.

Following up on my recent case of giardia in the stomach of a patient with stubborn reflux symptoms (skip the inserted post if you read and remember it), this is what happened after the antiparasitic treatment:

When I Escalated His GERD Treatment, My Patient Got Worse. Now I Know Why

Pierre Patenaud was heartburn free when I saw him in followup. Killing the giardia seemed to have done that. But he had developed another problem: Yellow, loose stools that caused him anal pain. He seemed like he had a case of post cholecystectomy bilious diarrhea, except he didn’t just have a cholecystectomy. I prescribed my usual treatment, colestipol. One tablet per day took care of his problem.

My second quiet consideration is: If you bind the bile with colestipol (wherever the two might meet, in the stomach, duodenum, jejunum, ileum or colon), can you control bile reflux, bile gastritis and bilious diarrhea as well as what Pierre called his “burning butt”?

Before statins became available, we used colestipol pills or powder to lower serum cholesterol; by binding to our bile, colestipol prevents reabsorption of cholesterol, a major component of bile, thereby lowering serum cholesterol. So there is plenty of experience giving it to patients even if they don’t have post cholecystectomy diarrhea, its major remaining indication.

I will not hesitate trying it in people with treatment resistant heartburn. I will refer people for endoscopy, but even if there is no bile reflux during a procedure done in the morning, fasting, how do we know it doesn’t happen after pizza and a six pack shortly before bed?

High-quality primary care is vital but undersupported in the United States. In communities with more primary care resources, people live longer, health care costs are lower, and there is greater health equity than in areas with less primary care infrastructure.2 More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards.2 One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.3
— Read on www.nejm.org/doi/full/10.1056/NEJMp2109700

Burt had his gallbladder out twenty years ago. But he had these recurring attacks of pain in his right upper quadrant that built up slowly and lasted for hours and then gradually disappeared.

Other doctors had checked him out and an ultrasound showed nothing unusual, such as an abnormal diameter of his common bile duct. He had even had a normal HIDA scan. Both were done fasting, the usual way.

As I listened to his story, I felt sure this was biliary, but what? It came and went and he was fine between. One time he remembered it happened the night after a high fat meal.

I’ve had patients who needed an ERCP to remove small gallstones at the sphincter of Oddi or to dilate or stent sphincters damaged by inflammation or tumors. But his symptoms were not chronic and he couldn’t very well have a stenosis present that way.

“Sphincter of Oddi dysfunction”, I thought to myself and logged in to UpToDate. “I pay $500 per year for this database”, I started. “I think you can have a bad valve, that lets the bile through some of the time and not others. Let me check something.”

And there, on my laptop screen in front of us, I had the classic symptoms, the Rome criteria which he checked off one by one. We scrolled down to the diagnostic testing. Ultrasound or HIDA scan after a fatty meal (of course!!!), invasive manometry (ugh!). Further down, the answer I was looking for: Antispasmodics may work. (I am linking to two different, free, articles here and here.)

So Burt is sticking to his low fat diet with a new prescription for PRN hyoscyamine.

We shall see…

P.S. Am I the only family doc who didn’t have this diagnosis right at my fingertips?

Three days ago I wrote about a patient who stopped his old medicine when he started a new one, while I had intended for him to take both. That episode made me think about how I communicate medication adjustments.

Well, I saw two patients yesterday who should have called me about problems with their medications. I don’t understand why they didn’t.

Samuel, a diabetic with both neuropathy and sciatica came in to follow up on his new prescription of duloxetine two weeks earlier.

“That new medicine you prescribed – I took my first one and soon after I was on the flush with the waste basket between my knees blowing out both ends of me. Never took another one.”

“And here we are, two weeks later. I never heard that you had a problem with it. If I had known, I would have suggested something different for you earlier. There are many options. Do you dare to try something different?”

He did, and I made very sure he knew to let me know if he had any worse side effects besides the typical ones I described.

Tristan was three weeks into his topiramate titration. I always start with 25 mg at bedtime the first week, twice a day the second and one in the morning plus two at night the third. Then I follow up in person to see how effective the medication is.

“That stuff”, he said, “is giving me these terrible headaches. I can’t take any more of it.”

“Did you get it even with just the one at night in the beginning?”

“Oh, yeah, first pill, and the higher the dose, the worse it got.”

I sighed. “Okay, I wish I had known that this happened, so you wouldn’t have suffered for three weeks. Here are a couple of other options…”

Both men left with new prescriptions and repeated instructions to notify me of any problems with their medications.

Just like the man with alarming new symptoms, who delayed getting evaluated and said “I thought I’d wait until my appointment”, so many people seem locked into the thinking that their doctor only exists in the physical sphere of the office visit. When I wrote about it two weeks ago, I described it as a systems problem. I blamed our clinics for making it hard for patients to stay in touch with us.

Samuel is from the older generation that may not feel comfortable “bothering” his doctor, but Tristan is young with friends in healthcare and service industries. He calls me by my first name and isn’t viewing me as unapproachable as far as I can tell.

I still haven’t mastered the Art of explaining new medications, obviously.

The Art of Prescribing (Or Not)