A Country Doctor Writes:

The other day I got a comment and 17 page views on a blog post I published back in 2013. It was also one of the first pieces from A Country Doctor Writes picked up by The Healthcare Blog, based in California. I am now on their masthead as a frequent contributor.

I was quite surprised when my piece about the wisdom of ancient (2500 BC) Chinese medics was featured on The a Healthcare Blog, a platform mostly about the technology and business sides of medicine. But ancient common sense sometimes trumps modern viewpoints:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. [I see in this a reference to archetypal or somatic medicine.] The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

And on the subject of doctoring:

“A good doctor gives medicine in response to the condition of the situation…This is not a matter of adhering to one absolute method. It is rather like a good general who fights his battles well by observing his enemies closely and responding to their changes. His methods are not determined beforehand. He observes the moment and is in accord with what is right.”

(This reminds me of my not-so-ancient post The Art If Medicine is Not an Algorithm.)

I find myself in respectable company on The Healthcare Blog and The Deductible, including one of my favorite lecturers, neurology professor Dr. Marty Samuels.

John Irvine, the editor of The Healthcare Blog, moved on to create The Deductible, where you will also find some of my writings. Matthew Holt, creator of THCB, remains a steadfast supporter of my writing. These two men, along with Kevin Pho of KevinMD, helped me find a wider audience for my writing.

My purpose in writing is not to bring forth the latest advances in medicine, but to remind myself and my readers of older, but still universal, truths about medicine and doctoring.

Imagine watching two people moving around in dim light. You see one person limping and the other walking smoothly.

Then, imagine looking at retina-sharp still pictures of these two subjects. One person has one leg that is shorter than the other and one person is unable to fully extend his left knee.

Which one has a limp and which one doesn’t? That’s anybody’s guess. Form and function don’t always match. Our bodies can compensate for a lot of things.

Then imagine looking at two lumbar MRIs. One has moderate multilevel disc disease and the other one does not. Which person has more back pain that the other? Again, that’s anybody’s guess. They say 10% of asymptomatic people have a herniated disc. Yet, many patients with modest symptoms insist on getting an MRI to “know what’s going on”.

Now, imagine two different radiologists looking at a CT scan of someone’s liver. One of them sees innocent adenomas and the other sees multiple metastases. That happened in a case I was involved with. The two doctors looked at the same pictures and their respective, opposite interpretations were merely opinions, guesses if you will.

I saw a report of a nuclear stress test the other day. My new patient had this test several months ago. He experiences pain between his shoulder blades and profound shortness of breath with moderate exertion. The report said “small reversible perfusion defect inferiorly and apically that appears artifactual”. That sounds very much like just an opinion to me. The cardiologist he saw in consultation took the report at face value and declared his chest pain non-cardiac. I don’t believe that, especially since the man’s echocardiogram showed a slightly abnormal wall motion at the tip of his heart.

To make matters worse, because of COVID, the hospitals around here don’t do exercise stress tests, but instead stress the heart with injectable drugs. I assume they don’t want people huffing and puffing on a treadmill, spreading aerosols in the room. My patient’s resting heart rate was 74 and it peaked at 90. My understanding is that the accuracy of the test is lower at lower increases in heart rate, similar to an exercise test but on a different scale.

I prescribed isosorbide mononitrate and ordered a new echocardiogram. I told my patient he may need a transesophageal echo and possibly a stress echo.

Even something as simple as using a plain chest x-ray to diagnose pneumonia is not straightforward. Does a patient with cough, green sputum, fever and crackles in part of one lung have pneumonia, even if the x-ray looks normal?

Clinical Pneumonia or Virtual Health?

Insulin was discovered in 1921 and first given to a patient in 1922. It used to be cheap. Now, a month’s supply of basal (24-hour) insulin at 50 units per day costs $400 for pens (needles are extra) and $450 for vials (but then you need to also buy syringes with needles). In a perfect world, insulin would not cost as much as the USDA “Liberal” monthly grocery bill for one (the “Thrifty” amount is $200).

Albuterol inhalers, introduced in 1956, were around $10 in the early years of my practice. They are now around $75. Because of environmental concerns, the CFC propellant of older inhalers had to be changed, and that opened the door for new patents that kept prices high for many years. Even though those patents are expiring, the cost of this basic medication is prohibitive for many people.

Epinephrine, first synthesized in 1904, lifesaving for anaphylaxis, is famously priced from $350 upward of $650 for two auto-injectors. Generic vials that require having syringes and knowing how to use them (and nerves and time enough to do it) are around $20, except at Walgreens, where they cost $70.

I once had an elderly patient who scorned inhalers for his asthma and carried a vial of epinephrine and a syringe in a metal box. Is that a practice asthmatics and allergy sufferers will soon have to resort to?

Return Visit: A Shot in the Arm

This is a request I am getting electronically more and more often from pharmacies. I usually turn it down. Let me explain why.

For medications the patient is already on, I pretty much always refill them for a whole year in 90 day increments. Some people get their medications bubble packed in 4 week increments, and then I do the refill for 28 days with 12 refills.

But the reason I turn down the electronic requests I get from pharmacies to change my 30 day script to 90 days is that I have issued a new prescription that requires some kind of monitoring.

New starts of furosemide will require a potassium level and possibly a creatinine before the first 30 days are up. The same is true for spironolactone, in this case because it can raise potassium levels and carries a greater risk for causing kidney damage. The same is true for lisinopril, an ACE inhibitor, as well as the newer angiotensin receptor blockers. I had my own near miss with lisinopril more than 10 years ago, chronicled here.

A new start of a modern antidepressant, like the SSRIs, requires a clinical followup within a few weeks to make sure the patient isn’t getting suicidal or hypomanic. Even a 30 day script without followup is pushing your luck. 90 days in a non compliant patient missing their followup is medicolegally indefensible.

The other day I increased a PTSD patient’s prazosin for nightmares from 1 to 2 mg and sent in a 30 day script for the new dose. She still had some 1 mg capsules left. I neglected putting “FILL WHEN CALLS” on the “Sig” of the script. Boom, instantly the pharmacy shot off a “Patient requests 90 day script” refill request. You can’t split a capsule in two if, after a little while, you decide the higher dose doesn’t agree with you. In this case I authorized the 90 day script ONLY if they didn’t fill it until the patient had used up all her 1 mg capsules at two per day and knew that this dose agreed with her.

My bottom line is:

I am the doctor. I know what I’m doing. I work hard to save my patients money, and look up costs and copays every time I prescribe a new medication. Just like I carefully choose the medication and the dose, I deliberately choose which amount is appropriate for the situation.