A Country Doctor Writes:

Life as we knew it and medicine as we had viewed it shapeshifted so dramatically in the past year that it is still hard to believe.

Medicine has started to move from an in-person only profession to one that finally recognizes that clinical assessment and treatment have fewer boundaries than people assumed. A patient of mine with newly diagnosed mastocytosis had a productive first consultation with an immunologist hundreds of miles away right from her own living room.

Efficiency increased when we could handle straightforward clinical issues electronically, even over the telephone, and still get paid. We were liberated from the perverted and miserly view by insurers that services not delivered in person should be free, as if fast food restaurants couldn’t charge for food at the drive through.

We delivered more virtual services to allow patients the safety of staying at home and avoiding lobbies, waiting rooms and exam rooms where airborne particles might linger.

Yet, when a primary care or mental health patient is in crisis or a person with new symptoms needs to be evaluated, a video visit is sometimes not enough. Step by step, we improvised screening protocols, not knowing which would be efficient or relevant as we didn’t know quite how the coronavirus behaved and transmitted.

We had to put in place telephone triage protocols in order to steer potential Covid cases to the most appropriate sites or levels of care. We also had to find ways to promote, guide and support self care.

Americans have widely held the inappropriate belief that conditions like the common cold or a viral gastroenteritis need to be fought or treated. The infinite variety of cold remedies and the overprescribing of antibiotics illustrate the public disbelief that most viral illnesses run their course and resolve without permanent after effects. Many of my patients, for example, don’t seem to know that drugs that decrease nasal discharge can cause mucous stagnation that leads to sinus infections.

Self care is an obvious strategy to avoid overburdening the health care system and in fact to decrease community spread of the Coronavirus. But it is a psychological challenge for many people to see their symptoms for what they are instead of what they could be. A mild case of Covid-19 is less dangerous than a bad case of influenza or a typical pneumococcal pneumonia. Knowing the cause of mild symptoms isn’t necessary unless you decide to risk exposing others to whatever you have. If you hunker down, stay home and use common sense to monitor your symptoms, everyone is safer than if you go out to buy useless remedies or clog up clinic waiting rooms.

It suddenly made less sense to encourage more visits to generate more revenue. It made sense to consider not only our patients and our organizations welfare but also our communities.

Giving video or telephone advice has come into focus and for many emphasized the value of providers and patients knowing each other. The simple fact that it is easier to “read” someone you know than someone you don’t know is often overlooked by system designers and health care entrepreneurs.

Sometimes patients themselves or their family members have an easier time determining that someone is getting seriously ill than a random provider hampered by the limitations of electronic communications.

So, it seems like this pandemic will bring on more of two seemingly opposite strategies: self care and high tech innovation ranging from telemedicine to vaccine development. I applaud all of it.

I have written a few articles for ALLMÄN MEDICIN, the Swedish Journal of General Medicine, over the years. Their December issue has the theme General practice and the art of medicine in fiction and reality. They write very kindly about my patient centered view of medicine and my book, CONDITIONS. This mention follows the recent launch of Amazon’s Swedish website, which makes my books now available there, too.

Many clinics allow the practice of ordering antibiotics for women who claim to have symptoms of a urinary tract infection. In some cases patients bring in a sample, and in some they produce the sample in the clinic in a free “Nurse Visit”. The doctor is then expected to prescribe without evaluating the patient.

The only provider on duty one Saturday this fall, I was asked to do just that. I asked the medical assistant: “Exactly what are the symptoms and is this a patient who gets UTIs all the time?”

“Doesn’t look like it, she’s only been seen once before and that was over a year ago.”

“Gotta be seen, just double book her”, I said.

The woman was in her fifties, came in as a new patient a little over a year ago. She had a history of colon cancer and was behind on her followup colonoscopy surveillance. In that one and only visit she expressed some hesitation about getting that done because she was new in town. She wanted to think about it. She did agree to getting a mammogram scheduled, and she agreed to get some basic bloodwork – but never did. From what I could tell, the mammogram was actually never done.

Her urine had a trace of leukocytes, white blood cells, and a trace of blood, both common findings even in healthy women.

“What kind of symptoms do you have?” I asked.

“I’ve got this pressure but I don’t always go very much.”

“How long has that been?”

“About three weeks now.”

“Does it burn or sting when you go?”

“Only sometimes.”

“Do you get urinary infections often?”

“I’ve only had one in my life”, was her answer.

On exam, she was a little tender over her bladder and deep to the left, but her belly was soft and I couldn’t feel anything suspicious.

I pointed out that she had hesitated about Dr. Grogan scheduling a colonoscopy. She said she had thought that was going to happen but she never heard back.

I showed her his chart entry and explained:

“Your symptoms may or may not be from an infection. I’ll start an antibiotic for you but whether a culture shows anything or not, you’re due for your colonoscopy and you may even need a CT scan if that tenderness in your belly doesn’t go away. For that reason I really suggest we get that bloodwork going, because the CT scan would require contrast. So my suggestion is, take the antibiotic, get the bloodwork and see doctor Grogan to follow up on your symptoms.”

I messaged the receptionist to make a followup appointment and we wrapped up the visit.

A prescription for an antibiotic without a visit could have had tragic consequences. I don’t believe in accepting a patient’s self diagnosis without double checking it. I also don’t believe in prescribing without taking a look at the bigger context of the most apparent presenting symptom.

Sumner Finch is an 80-year old man of few words. He had gone to the emergency room three or four times for constipation but his belly was never tender and his abdominal CT scans always looked benign. The ER doctors were a bit puzzled and so was I when I first saw him for the same thing. He relied on various over the counter laxatives whenever he hadn’t had a bowel movement for two days in a row.

I prescribed a low, steady dose of lactulose, a type of sugary syrup that isn’t absorbed but stimulates the colon in a gentle way (just like many people get loose bowels on common sugar substitutes). He told me this just gave him gas.

I gave him samples of a fancy new medicine for idiopathic constipation. It cleaned him out but he said it then stopped working.

We looked at his medications. He was taking a high dose of an old fashioned calcium channel blocker for his blood pressure. This drug is known to cause constipation. I reduced his dose and his blood pressure did not go up, but he told me he was still constipated.

Every time I saw him his abdomen was soft and nontender.

“Did you ever have a bowel movement every day?” I asked.

“No”, he answered without hesitation.

“So, help me understand, why are you so bothered now if you don’t go every day?” I asked.

“Because when I don’t go, I wake up at night.”

“Why is that?”

“Because of my breathing”, he quipped.

“Tell me more.” I was puzzled.

“When my belly is full, I have to sit on the bed so I can breathe.” He sounded like that was obvious and nobody understood him.

“How long has that been?”

“About six months”, he answered without hesitation.

I repeated back to him what I had understood: “If your belly gets even a little bit distended, it makes it harder for you to breathe lying down.”

“That’s right”, he said.

“But that didn’t happen until six months ago. So I think your heart has changed. I’d like to get an echo to see if it isn’t pumping right. In the meantime, I’d like to give you a fluid pill to help it pump better. Will you try it and see if it helps your problem?”

He agreed, and by the time we sat down to review his only slightly abnormal echocardiogram, he was sleeping through the night. And he didn’t really care how often he moved his bowels.

Instead of complaining about his shortness of breath, he had asked me and the ER doctors for help in eliminating the obvious trigger. He presented us with a succinct cause for his troubles and we fumbled to understand the more ominous cardiac effect of even such a mild case of constipation.

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

I always bristled at “not feeling well” because that is too nonspecific. After all, that could be something that would have been better handled with a 911 call. But there is also a danger in being too simplistic when classifying what people come in for. We like to pigeon hole clinical concerns a little too quickly sometimes.

I had such a situation recently. It hinged on the patient’s choice of one common word over another.

A middle aged woman wanted to be seen for “throat pain”. It was halfway into a busy afternoon and between the three providers in our office, we had no openings to offer her.

Autumn asked me, “can we fit in a throat pain today? I’ve got Nicole Bamford on hold”.

“What kind of throat pain?” I asked. “You mean just a sore throat?” I was working on refills between patients. Autumn asked the patient to elaborate while I continued to work.

“She says she can swallow all right but for the last few days she gets this pain in her throat every time she does anything heavy.”

“Does she have pain right now?” I asked.

Autumn checked. “No.”

“Have her come right over.”

Nicole had no cold symptoms. She had normal vital signs. She had a two week history of throat and occasionally jaw or ear pain after minor exertion, never more than a few minutes. Sometimes she felt a little short of breath at the same time.

Her exam and her EKG were normal. She was a smoker with a family history of heart disease.

“Call the ambulance, 54 year old woman with new angina, no pain right now. I’m calling the ER”, I told Autumn after I explained my assessment to Nicole. She had seemed to accept my diagnosis of unstable angina without questioning and also my recommendation that we get her to the hospital by ambulance without expressing any sign of surprise or emotion.

When I saw her in followup after her ER visit, transport to the tertiary care center and successful stenting of a 95% blockage of one of her coronary arteries, she told me “I thought you were crazy”.

I thought to myself that this could have played out very differently if the nuance between “throat pain” and “sore throat” had gone unnoticed.

It’s nice to know what a patient is coming in for, but that isn’t necessarily the diagnosis they leave with.