A Country Doctor Writes:

I have made the argument that being the first contact for patients with new symptoms requires skill and experience. That is not something everybody agrees on.

One commenter on my blog expressed the opinion that it is easy to recognize the abnormal or serious and then it is just a matter of making a specialist referral.

That is a terribly inefficient model for health care delivery. It also exposes patients to the risks of delays in treatment, increased cost and inconvenience and the sometimes irreversible and disastrous consequences of knowledge gaps in the frontline provider.

UNNECESSARY SPECIALIST REFERRALS ARE COSTLY

Seeing a high charging, high earning specialist when the primary care provider can’t diagnose and manage the condition involves higher cost and, in many cases, a comprehensiveness that is based on the fact that the patient traveled 200 miles for their appointment. In such cases patents aren’t likely to come back for a two week recheck. Consequently, specialists tend to do more in what may be the only visit they have with a patient.

UNNECESSARY SPECIALIST REFERRALS CREATE TREATMENT DELAYS

For my patients, seeing a neurologist involves a one year wait for the out of state neurologist who does consultations almost 100 miles from my clinic, or a three to four month wait for an appointment more than 200 miles away in Bangor. The situation for rheumatology or dermatology is about the same.

Even if a primary care provider makes a correct referral, patients risk getting sicker and suffering needlessly because of these delays or, for them, nearly insurmountable barriers to travel.

And the days are gone when a rural medical provider could call city specialists several times a month and get free curbside consultations about tricky cases.

Rural America is almost like a different country in terms of the availability of specialist physicians, so less knowledge on the frontlines of medicine is a big deal here. Distance is an overlooked health disparity. I even have patients who hesitate traveling 20 miles to Caribou for an x-ray.

THE DANGER OF NOT KNOWING WHAT YOU DONT KNOW

The biggest concern with the you-can-always-refer mentality is that it actually takes good training and real life experience to know what constitutes an emergency when the clinical signs are subtle and similar to more trivial conditions.

In my own writing I have described the inexplicable phenomenon of clinical instinct and the newbie hubris of the Dunning-Kruger effect and also illustrated many common primary care triage situations:

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Why are so many people systematically belittling the skills that are needed to be a safe and effective primary care provider? In many other countries, primary care physicians are the backbone of their health care system.

Oh, I almost forgot, our system was never actually designed. It looks the way it does because of market forces, corporate strategies and all those kinds of things.

When a patient presents with a new symptom, we quickly and almost subconsciously create a hierarchy of diagnostic possibilities. I pride myself in my ability to effectively share my process of working through these types of clinical algorithms.

But sometimes I seem to get nonverbal clues of dissatisfaction or simply no reaction at all to my eloquent reasoning. And only then do I remember to ask the important questions, “do you have any thoughts on what’s causing this” and, most importantly, “what’s your biggest fear that this could be”.

It doesn’t matter how brilliant a diagnostician you are if a patient with less medical knowledge than you has a thought, fear or hunch that diseases and symptoms work in ways that don’t make sense to you.

An uncle may have had a burning sensation in his nose minutes before a stroke, so this symptom may seem like a much more obvious harbinger of disaster to your patient than it does to you. How would you know, if you didn’t ask, what the number one question is that your patient wants the answer to?

We are often so focused on our own thinking process, especially with our time pressures and the bureaucratic requirements of medical encounters these days, that we risk forgetting our patients may not think the way we do.

Of course, sometimes things work the opposite way: The patient may think they just have something simple, like the woman I saw with throat pain who ended up getting a cardiac stent for a major coronary blockage.

So it isn’t always obvious when we need to ask the “biggest fear” question. That’s a judgment call that requires paying attention: Watch your patient’s facial expressions and body language, listen carefully to their words and the character of their voice.

Basically, start by ignoring what the listed chief complaint is, ask an open ended question and then shut up and let the patient speak uninterrupted so you can listen and observe.

I have learned a few things about prescribing medications during my 42 years as a physician. Some are old lessons, and some are more recent. I thought I’d share some random examples.

First: I don’t like to have to use medications, but when they seem necessary, I choose, present and prescribe them with great care.

CHOOSING MEDICATIONS

Medications are like people. They have personalities. With so many choices for any given diagnosis or symptom, I consider their mechanism of action, possible beneficial additional effects and their risk of unwanted side effects when selecting which one to prescribe. To some degree that goes against today’s dogma.

Blood pressure medications, for example, have what I call an A-list and a B-list. The A-list contains drugs with a proven track record of not only reducing blood pressure, but also actual heart attack and stroke risk. Why we choose from the B-list, the drugs that don’t decrease cardiovascular risk or actually increase it, is a little beyond this simple country doctor’s ability to understand.

ACE inhibitors like lisinopril and diuretics like hydrochlorothiazide are the two recommended first choices in this country. But the A-list also contains amlodipine, a calcium channel blocker and, further down, metoprolol, a beta blocker. I make those less favored A-listers my initial choice in two scenarios:

Amlodipine is my choice when I see a hypertensive patient who prefers a set-it-and-forget-it treatment plan. No bloodwork is required after starting it to monitor for kidney or electrolyte problems, so even if the patient doesn’t come back for a year or more, there is no real risk involved.

Metoprolol, which blocks the effect of the stress hormone adrenaline on the cardiovascular system, is what I talked my own doctor into prescribing for me. That was back in the day, when I was a hard working, somewhat Type A personality with high blood pressure. With the passage of time, life experience, weight loss and my transformative relationship with my Arabian horses, my blood pressure normalized and I didn’t need medication anymore.

Years ago, we all selected blood pressure medications according to the “phenotype” (appearance or general impression) of the patient: metoprolol if intense, hydrochlorothiazide if swollen, nifedipine if cold-handed, lisinopril If naturally hypokalemic (low potassium).

Antidepressants definitely have their personalities, even within a given class, like serotonergic drugs. Fluoxetine is a bit energizing. Sertraline is a bit calming but, in my experience, can bring out an unwanted sensitivity in some “thin-skinned” men. Escitalopram is relatively side effect free and therapeutic in even low doses. Paroxetine is a potent bubble wrap that stops suffering for people stuck in difficult situations but it also dampens positive emotions. It is the hardest one of its class to get off, even with very slow tapering.

The now too popular “atypical antipsychotics” also have differences within the class. Aripiprazole is the least sedating while quetiapine is the most. It is even used primarily for sleep in some situations. But it has greater risk for QT-prolongation and sometimes provokes frightening demonic nightmares in people without psychosis in the first place. Olanzapine is also very sedating and puts on more weight than most drugs in the class, but I haven’t seen it cause psychosis.

SWITCHING STRATEGIES

I often scratch my head when colleagues taper a patient off one drug and start another member of the same class from scratch. I don’t do that. If I need to switch someone from fluoxetine because its energizing effect bothers them to, say, escitalopram, I move directly from one day to the next to a roughly equipotent dose of the other drug. (I hardly ever use escitalopram’s predecessor, citalopram, because it has too many side effects and was fraudulently marketed as relatively side effect free.)

Even switching from a serotonergic drug to a serotonin-norepinephrine drug like duloxetine, I just ballpark it and slide right over to a similar dose (Low, medium or high) and haven’t seen any ill effects of this time saving strategy.

PRESENTING A PRESCRIPTION

I love to tell stories, so I usually talk a bout the history of the medication I am suggesting for my patient. I think it helps the patient understand that I know the medication I am recommending very intimately. There’s probably nothing more frightening than being prescribed a treatment the doctor doesn’t seem to know much about. And only a minority of patients are impressed with descriptions of molecular structure, unless it is when I say things like “the muscle relaxant cyclobenzaprine is related to the antidepressant amitriptyline that is FDA approved for nerve pain, so it can do more than relax your muscles”.

I also talk about how the medication works, what it does and doesn’t do and what the common side effects are. And this is something I started doing recently: Instead of saying “up to 10% of people get a cough from lisinopril, I’ve started saying “one possible side effect is a tickle in the throat kind of cough, but 90% of people have no such problems from it”.

The placebo effect, or the power of suggestion, has often been ignored, but we know very well that treatments prescribed with confidence by an empathic physician produce better results than prescriptions presented as “well, we might try this”.

DOSING MEDICATIONS

“Start low, go slow” is a sound principle. It helps to know how long a medication generally takes to work. It also helps to know what the most commonly used dose is and what the dose-response curve looks like. For example, the blood pressure medication hydrochlorothiazide at 50 mg per day is marginally more powerful than 25 mg, but with much greater risk of causing low potassium. Many people don’t seem to know that the typical step in dosing medications is a doubling: Lisinopril comes in 2.5, 5, 10, 20 and 40 mg – so does anybody really believe we also need a 30 mg dose? I only have one patient on that strength pill.

MEDICATIONS THAT DIDN’T WORK

I sigh internally when I hear that a patient has tried many medications that “didn’t work”. I then have to probe just how much they took, for how long and whether there was any effect at all.

A typical example is when a patient takes the necessarily low starting dose of a medication and stops it before they reach the target dose needed to expect any result. The details can be hard to nail down, but it is sometimes well worth finding out when faced with a patient who claims to have failed everything.

Another common scenario is when a 10 day course of an antibiotic only partly relieves the symptoms of an infection. That’s not a treatment failure – the patient just needed another round of it.

Sometimes we get important information hearing about medications that didn’t work. If an antidepressant makes a person feel agitated, it could possibly mean their depression is bipolar rather than unipolar.

In some cases, the sheer number of medications that didn’t work can make us question our diagnosis. With hypertension, that raises the possibility of what we call secondary hypertension. In those cases, we have to start looking for the single cause of the treatment resistance, such as renal artery stenosis, pheochromocytoma, aldosteronism, alcoholism, thyroid disease, sleep apnea and many others. With psychiatric symptoms, such as anxiety, I have seen how life circumstances such as a bad marriage or overbearing in-laws can make medications completely ineffective.

WHEN NOT TO PRESCRIBE, OR AT LEAST LIMIT PRESCRIBING

Sometimes we are quick to prescribe pharmaceuticals because that seems like the most practical thing we can do to help our patient. Getting an anxious or depressed patient an appointment with a therapist takes time, for example.

One of the more profound lessons of my generation of doctors is how the fluoxetine cohort of antidepressants changed the natural history of depression by sometimes or perhaps even often causing permanent brain changes in patients who take them.

As I mentioned, paroxetine can be particularly hard or even impossible to stop. But the entire class has been associated with this SSRI discontinuation syndrome.

There is a growing anti-SSRI movement and increasing controversy about the use of this class of drugs. There are scientific papers, blogs, best selling books, medical practices and clinics offering patients help in quitting antidepressants.

In my own practice, I have become much more conservative when treating depressed patients. The other day, for example, I saw a woman already taking duloxetine for chronic pain and long-standing depression. She was feeling more depressed because of the isolation the pandemic has brought her, separated from her family across the border. She had poor sleep, poor appetite and cried out of the blue, she told me.

I lowered my voice, leaned forward and said, “There is no medication that can take away the pain we feel when life itself changes the way it has. We need to find new ways to carry on, and a good therapist can be like a coach to help us see what we can do, so we don’t get stuck but start moving forward. Our counselor has an opening on Monday and I can prescribe you medication to help you sleep better. Then, next week we can touch base and see how you’re doing. Are you okay with that?”

She wiped her tears and nodded. I was not about to escalate her antidepressant the way I might have considered 10 years ago.

We live in a time of thirty second sound bytes, 280 character tweets and general information overload. Our society seems to have ADHD. There is fierce competition for people’s attention.

As doctors, we have so many messages we want to get across to our patients. How many seconds do we have before we lose their attention in our severely time curtailed and content regulated office visits?

I have found that it generally works better to make a stark, radical statement as an attention grabber and then qualifying it than to carefully describe a context from beginning to end.

Once a person shows interest or responds with a followup statement or question, you have a better chance for a meaningful discussion. Just starting to explain something without knowing if the person wants to hear what you have to say could just be a waste of time.

Here are some of my typical conversation starters – or stoppers, if you will:

“The purpose of a physical is to talk about stuff that could kill you, more than about symptoms that annoy.”

“Nothing makes a cold go away faster.”

“Urology is about plumbing, nephrology is about chemistry.”

“Most headaches are migraines.”

“Sinus headaches don’t exist in Europe.”

“I don’t care what your blood pressure is today if you’re scared or in pain.”

“A healthy lifestyle is at least as effective as taking Lipitor.”

“We now know that eating fat makes you lose weight.”

“Cholesterol only causes damage if there is also inflammation.”

“Fat free means high in sugar.”

“I don’t believe in vitamins.”

“Osteoporosis happens to every woman around 80, so is it really a disease?”

“You have to treat 35 men for prostate cancer to save one life.”

“You know how many cases of testicular cancer I’ve come across in 40 years? Three!”

“It takes 45 minutes of walking to burn 100 calories, but only 10 seconds to drink them.”

My brief experience as a substitute teacher for junior high school students as well as my many years as a scout leader taught me that you can’t assume you have people’s attention just because you’re standing in front of them. They will give it to you if they believe you have something interesting to say. You often have less than thirty seconds to prove that you do.

Is our medical knowledge alive enough in our minds that we can share it in a quick, easy and captivating way with our distracted patients?

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.

Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)

DISEASE PREVENTION AND SCREENING

You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.

My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.

I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.

What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.

(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)

Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.