A Country Doctor Writes:

Hélène described her chest pains as a pressure across her entire upper torso with shortness of breath. It happened with exertion and got better if she sat down. It also made her a little sweaty, even in her air conditioned home.

Her chemical, nuclear stress test report revealed no EKG changes, but “imaging suggested a small inferior and apical reversible perfusion defect not verified by the software” and “mild apical dyskinesia, probably artifactual”.

Stress testing is not as precise as people imagine, just like many other tests. In this case, what percentage of medical providers would trust Hélène’s reassuring report that stated in its summary that her risk of a cardiac event was average?

In many other radiology reports I read caveats like “depending on the clinical presentation, this could…”. But in the stress test reports there is no mention of pre-test probability. Perhaps there should be!

Particularly in women, where a stress echo may be a better test – but only available hundreds of miles away from where I practice – we need to avoid minimizing test abnormalities if our clinical index of suspicion is high.

I prescribed isosorbide and sublingual nitroglycerin the day I saw Hélène for her angina (that’s the diagnosis I used for the stress test order, not “atypical chest pain”) and after the stress test she told me her symptoms were greatly reduced. But she did have some side effects from her isosorbide mononitrate.

She appears to have at least significant microvascular disease, but I often see cardiologists showing little interest in this disease. I told her I wanted to adjust her medications and that we would involve cardiology but that her major coronary arteries were probably okay. She reminds me so much of a handful of other women with angina, like Doris Delaney, whose story I posted 11 years ago:

“But I Still Have Chest Pain!”

Medicare sets the tone for other insurance companies about which symptom justifies what test. Some of these coverage rules are hopelessly outdated and downright silly. Most patients have no idea how nitpicking this maze of rules really is. Most people probably believe that their doctor determines medical necessity.

I have such a hard time accepting that a healthy person with no symptoms is entitled to several free test panels per year as long as they are billed under the diagnosis Z00.00 – routine physical. (It’s almost ironic that the letter Z followed by four zeros spells out an exaggerated “zoo”.) At the same time I have to warn patients that tests to evaluate symptoms and diagnose disease have copays and may not be covered at all, because Medicare doesn’t know or acknowledge everything most doctors learned in medical school.

A classic example is BNP, brain natriuretic peptide. This is a screening test for heart failure, the symptoms of which are usually shortness of breath and leg edema. Only shortness of breath covers the test, not swollen legs. Go figure. These bureaucratic rules constitute what I call the parallel universe of Metamedicine.

I question the cost savings of these restrictions for essentially routine testing. Doctors waste time wading through the Byzantine rules, laboratories waste time chasing silly numeric codes, and sometimes middlemen eek out profit from overseeing our work. I can understand that we need stringency about big ticket genetics panels (like in the fraudulent faxes I get for Medicare patients whose data must have been stolen), but an iron level? In a system that spends twice as much on healthcare as any other country on earth? Look at this:

Restless Leg Syndrome is sometimes caused by iron deficiency, even if there is not yet significant anemia. This was shown by Professor Ekbom at Uppsala, my alma mater. But G25.81 (RLS, Ekbom’s Syndrome) won’t buy you an iron level. I have a fax on my desk right now from the lab, asking me to find another diagnosis? Do I just pretend my patient has anemia?

Imaging is even trickier than blood tests when it comes to “medical necessity”. My 2019 post The Cruelty of Managed Medicare illustrates the frustrating, torturous, heartbreaking challenge of getting patients with nearly obvious cancer the proper imaging to make their diagnosis. There should be an ICD-10 code for “looks like cancer, need to figure out where”!

The Cruelty of Managed Medicare

It happened again. A patient was on bumetanide for heart failure. It worked well in the beginning but seemed to be losing its punch over time. Plus we were concerned about lowish potassium levels.

So, I thought I went over my logic pretty well: Add spironolactone, which works differently and is potassium sparing.

A few days later my patient reported minimal weight loss and no improvement in his leg swelling or shortness of breath.

I started thinking out loud:

“Okay, so you’re taking one spironolactone and two Bumex now, right?”

“Oh no, I stopped the Bumex, because you said it wasn’t working.”

“Well, I think it was doing something, but it wasn’t working like it did in the beginning, and your potassium was starting to drop. So I thought the combination would probably work better for you.”

“Okay, I can do that.”

“Yeah, why don’t you, and call me after the weekend with your weight and an update on your swelling and your breathing.”

“Roger that”, he said. As I hung up, I thought to myself: “Why do people always assume I stop instead of add?”

The way my brain works, if you have a partial response with one drug, you keep that and add something else. If that works like a charm, you can taper or stop the first drug and maybe titrate the effective new one upward. But it can be a risky gamble to stop a partially effective drug and start sumething unproven – I mean, things could get worse in a hurry with that kind of strategy.

The only time I stop one drug completely and start another is if the patient doesn’t tolerate the first drug or if there is absolutely no benefit from the first one. Of course, I know that hypertension, heart failure and many other conditions usually require several drugs in order to achieve good control.

Hypertension patients in particular are often disappointed when they end up on three or more drugs. I tell them there are three drug combination pills out there just because it is so common to need several drugs to treat a stubborn medical condition.

So, anyway, I need to do a better job describing how my thinking goes: Keep the partially effective drug until the new one proves to be effective, then consider a full switch.

You’d think after 42 years in this business I wouldn’t have patients musinderstand me like that.

I need to do a PDSA on that one – I’ll need to do one for my Board recertification process anyway.

https://acountrydoctorwrites.blog/2019.03.29/pdsa-for-dummies

I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.

His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.

I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.

The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.

That patient and many others think that health insurance is such a complete package deal that everything should be covered. They feel moral indignation if they have to pay out of pocket.

Even Sweden’s socialized medicine system has copays. Why do some Americans balk at a one-time cash cost of $14 for a non-covered drug when monthly, lifelong copays for modern COPD inhalers that many fixed-income seniors depend on can be over $100?

People are confused when clinics don’t want to see them for their medical problems. All their lives they have been told to get their symptoms evaluated before they turn more serious. Now, with the raging pandemic, the message is the opposite: If you have Covid and feel you are getting sicker, we will talk to you on the phone or via telemedicine, but we don’t want you in our building. If you have milder symptoms that might be Covid, stay home, take care of yourself and good luck. You can’t even get past the receptionist, as the saying goes.

I am always a little bemused when people act either helpless or overly treatment fixated with common colds, for example. Body aches, fever, congestion and cough require no treatment as a rule. That’s a little bit like trying to stop the rain. It is what it is and it will pass. Pharmaceutical companies offer branded products with false claims that the disease process can be altered if you pick the right remedy.

Many people lack the ability to gage how sick they are. Under normal circumstances we, as medical providers, see our role as providing triage and reassurance for those who worry. Now, without the in-person dimension, our ability to do so is hampered. But in this state of emergency, doing what we are used to doing would endanger ourselves, our staff and other patients inside our clinics.

We are in a strange survival mode most of us never anticipated to find ourselves in. And just when we thought the vaccines would open the door to life as it used to be, the new virus variants and the rapidly fading immunity markers are bringing us back to the state of uncertainty we were in 18 months ago.

Life is perilous, even frail, but the odds are on our side. The vast majority of people who contract Covid will do just fine. It’s just that in our culture, every disease is expected to have a cure, a treatment. This pandemic reminds us that most viruses don’t have a treatment. Only if you are desperately ill do we have something – fairly generic – to offer you, such as respirators, steroids or drug cocktails.

I wish more people had a wise old grandmother to ask for advice when they are sick. I do the best I can to play that role to my flock of patients. Common sense is what we need right now.