A Country Doctor Writes:

I got an email Saturday from Laurence Bauer of the Family Medicine Education Consortium. 

Larry said that when he talks to doctors and residents about saving lives they usually think of their preventive medicine efforts and few people have stories about the short term impact they have on people’s lives. Larry asked me if I had anything to say or write about that.

The first thing that comes to my mind is my work with substance abuse, our medication assisted treatment, which I still do for Bucksport via telemedicine even though I live and otherwise work 200 miles north of there. Statistics show that immediately upon entering a Suboxone program participants risk of dying from an opioid overdose is reduced by 50%. So it’s possible I’ve saved a life or two there. At the annual staff appreciation day in August patients from the Suboxone program had written greetings to me on the whiteboard and a couple of them had written that I saved their lives.

The other thing I think of is the triage type of decisions we make. Somebody comes in with chest pain and we have to decide whether or not to send them to the emergency room or order tests for heart disease or blood clots in their lungs. We’re supposed to make the right decision and when we do we don’t necessarily get a thank you card or anything. Perhaps if we don’t, there would be all kinds of repercussions. Very often in our line of work our reward is the absence of negative feedback.

In less dramatic cases, we make choices all the time that could be life altering or life saving. When we order an x-ray or CT scan rather than say, “let me know if it doesn’t get better”, we could be in a lifesaving situation, but once you have been practicing for a few years you don’t reflect on that as much as when you first start out. 

In my post “Primary Care is Messy” I wrote about this five years ago, although I didn’t even remember the incident until I searched my own blog for “saved my life”. For non-physicians it may seem incredible that one might not remember a story like this one, but when you see sixteen to thirty patients day in and day out for forty years, you can only make so many personal notes and still keep up the pace. 

“Knowing what constitutes success in frontline medicine is not easy. Let me illustrate:

A middle aged smoker comes in for a follow up on his blood pressure treatment and mentions that he would like to try Chantix (varenicline) to help him quit. My nurse has already secured our practice credit for documenting his smoking status. I can use certain billing codes to document my counseling on the subject, and I can get credit for printing out the drug information, even though the pharmacy also provides a printout. This is a successful visit, it might seem.

But I also ask, “Ron, what makes you want to quit at this particular point in time?”

“Well, I’ve had this funny cough, like a dry hack, for the last two weeks whenever I take a deep breath”, he answers. 

Ron turns out to have a very small, resectable lung cancer. My question about the reason for his request probably saved his life, and catapulted us from shallow administrative success to probable or at least possible clinical victory, without making any further difference in my own quality metrics.”

So, Larry, I think there is a lot of focus on doctors supporting each other when they feel burned out or inadequate, but I’m not hearing much about taking notice and stopping to celebrate the small and large clinical and relationship progress or downright victories we have in our everyday work. With no doctors lounge to visit anymore (another blogpost of mine from just four months ago), how do we do that?

A patient who hadn’t felt good for many years came in the other day and told me an osteopathic physician she had gone to for OMT, manipulative treatment, had suggested she take a basic 400 mg magnesium supplement and it had been life changing for her.

She handed me a xeroxed little essay the osteopath had written about the many functions of magnesium in the human body and the symptoms of deficiency.

All her vague gastrointestinal symptoms were gone, her skin had cleared, her energy level had improved and she felt more clearheaded.

“What was your level?” I asked.

“He didn’t check it” was her answer.

I didn’t know what to think, I mean it’s probably harmless to take, but without knowing the level…

I started looking into this and the more I read, the more intrigued I became.

I found several articles from the last century (the 1990’s) all the way up to last week (news that excess vitamin D can lead to osteoporosis, apparently through lowering bone magnesium levels), all saying mostly the same things:

Even though magnesium is abundant on this planet, many people (for example 80% of postmenopausal women with osteoporosis) have low intracellular magnesium. Almost half the US population consume less than the recommended daily amount of magnesium.

Serum levels of magnesium tell us nothing about total body magnesium, because we are programmed to pull magnesium from our tissues to keep blood levels in range. Only 1% of our body’s normal 25 grams of magnesium is found outside our cells, and about 90% is found in bone and muscle cells.

Magnesium is essential for the function of 300 enzymes, mitochondrial ATP production and activation (cellular energy), synthesis of DNA, RNA and protein and regulation of ionic gradients (keeping sodium and potassium levels normal).

Magnesium deficiency is linked to inflammation (as measured by C-Reactive Protein, CRP), atherosclerosis, vasospasm, insulin resistance and metabolic syndrome as well as isolated hypertension.

Magnesium deficiency has been linked to sudden cardiac death.

The magnesium content of ur modern diet is decreasing, because of more and more processing of food as well as modern farming practices and soil depletion; we are also consuming things like phosphorus (in soft drinks) that lower body magnesium levels.

According to the NIH:

“Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur. Severe magnesium deficiency can result in hypocalcemia or hypokalemia (low serum calcium or potassium levels, respectively) because mineral homeostasis is disrupted.”

Not only can low magnesium contribute to the development of diabetes, but there are indications that magnesium supplementation may improve blood sugar control in diabetics. Magnesium supplementation has been shown to improve lipid profiles. Other not yet certain possible benefits of magnesium supplementation are migraine prevention and asthma control.

People at risk for magnesium deficiency, besides diabetics, include the elderly, patients taking diuretics or Proton Pump Inhibitors, those with inflammatory bowel disease or chronic diarrhea from other conditions, patients who have had small bowel surgery, people with gluten sensitivity and patients with alcohol or soft drink dependence. Perhaps surprisingly, people who exercise vigorously can also become magnesium deficient.

Foods that supply good amounts of magnesium include almonds (check), spinach (check), black and kidney beans (check) and avocado (check), and also some things that aren’t on my meal plan: Peanuts, soy milk, shredded wheat, bread (presumably whole grain) and yogurt.

So, this is from someone who usually doesn’t think much of vitamins and supplements: Because I’ve been taking PPIs for my hiatal hernia since they first came out and because my blood pressure is higher than I’d like in spite of being pretty ideal weight – I picked up a bottle of magnesium capsules the other day.

And the more I read, the more I worry about the decreasing nutrient value of much of our mass produced foods. The BMJ article cited below points out:

“The loss of magnesium during food refining/processing is significant: white flour (−82%), polished rice (−83%), starch (−97%) and white sugar (−99%). Since 1968 the magnesium content in wheat has dropped almost 20%, which may be due to acidic soil, yield dilution and unbalanced crop fertilisation (high levels of nitrogen, phosphorus and potassium, the latter of which antagonises the absorption of magnesium in plants).”

Here are two comprehensive references:

National Institute of Health Office of Dietary Supplements Fact Sheet for Health Professionals

Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis (BMJ)

I often hear patients speak of vertigo as if it were some brilliant diagnosis made by a genius emergency room doctor. Just because it’s a foreign word, that doesn’t make it any more clever than if they’d been told they were dizzy.

In my native Sweden there seems to be a domestic lay word for almost every disease. The runner up prize in my book goes to FÖNSTERTITTARSJUKAN, “The Window Shoppers Disease”, which we call intermittent claudication, usually caused by poor blood flow to the legs (people feeel better if they stand still for a while, for example pretending to look in a store window) but occasionally we get tricked and the symptom can be caused by pressure on the spinal cord from disc disease.

I absolutely love the number one word on my Swedish Disease Names list: The word they use for the most common cause of true vertigo, “Benign Positional Vertigo” or BPV. The Swedish word is KRISTALLSJUKAN (The Crystal Disease).

I also love explaining to patients how it works, because I think the body is a pretty clever contraption.

Vertigo is the illusion of movement, a spinning or rotatory form of dizziness. It usually originates in the balance organ, called the labyrinth, in the inner ear. Two common causes of vertigo are labyrinthitis, which is a viral infection, and Benign Positional Vertigo, which I wish we also would call the Crystal Disease.

This is how it works:

The labyrinth has two parts, the otololith organ and the semicircular canals. They are connected and filled with a sort of hydraulic fluid that we call the endolymph. Each inner ear, left and right, has this setup, and normally they provide the brain with the same, consistent information on where in space we are – but not always.

The otolith organ has one chamber, the utricle, that registers movement along a flat surface, like me rolling around the exam room on my stool (that’s how I demonstrate this). I hold my hands up with fingers pointing to the ceiling. “There are nerve cells in the otolith organ with little hairs sticking up like this”, I explain. Touching each fingertip with my other hand, I continue “and there is a weight, a little crystal, attached to the top of each of these hairs. If I move like this (stool roll..) the crystals make the little hairs bend, actually exaggerating the movement so I can register the slightest change in my position along this level path…”

The other chamber in the otolith organ, called the saccule, is set up to register movement in a vertical plane. Here I scrunch down or straighten up as I sit on my stool.

The Semicircular canals are curved tubes running in three different planes. They have a wider portion at one end with hairy nerve cells, similar to the otolith organ but without the crystals. When we turn our heads, the endolymph (fluid) movement causes the little hairs in each of the three semicircular canals to move a little differently and bend the nerve cell hairs to a different degree and maybe even in a different direction. All this information gives the brain a detailed sense of where in space we are.

Sometimes the little crystals fall off the hairs they’re sitting on top of in the otolith organ and travel with the endolymph into the semicircular canals.

Imagine what happens if the balance organ on one side tells the brain “movement to the left, thirty degrees” (here, I make the fingers on my left hand wiggle in unison just a little) and the other side, because some crystals flattened the nerve cell hairs, reports “wow, we’re upside down” (right hand and arm making a slam dunk movement). For at least a brief moment, our poor brains believe the louder, more dramatic yet inaccurate alarm report and we feel quite ill from that.

This explains why, in Benign Positional Vertigo, head movements in one direction can be much worse than movements in a different direction, depending on which angle causes the most dramatic effect from the little crystals.

This situation can go away spontaneously as the crystals can end up randomly traveling away from where the nerve cells register them.

There are also head maneuvers that can force the crystals away from the semicircular canals. Physical therapists and doctors in the specialties that deal the most with dizziness can put people through these movements, and you can even find instructions online.

Here is one of the most comprehensive explanations of all this that I have come across:

Lastly, a clinical pearl from Harvard’s neurology professor Dr. Martin Samuels. In his classic lecture on dizziness, he warns us never to suggest specific aspects of this symptom when taking a history. Most patients with dizziness will say yes to any description you suggest to them, therefore making diagnosis nearly impossible. Instead, he calls on his physician audience to repeat the word “dizzy”, maybe even a few times, scratch their chin and fix their gaze on something outside the window while rubbing their chin now and them – for however long it takes – until the patient starts to describe their symptoms themselves. Once they do, the diagnosis usually presents itself very plainly.

If medical journals are the religious texts that guide me as a physician, the New York Times has become the secular source of illumination for my relationship to my country and the world I live in.

That doesn’t exactly mean that I feel like a citizen of the world. Quite the opposite, particularly now, with just me and my horses sharing our existence on a peaceful plot of land within walking distance of the Canadian border; my physical world seems quite small even though I am aware, sometimes painfully but with an obvious distance, of the calamity of our planet.

Early Sunday morning, drinking coffee in bed as the gray morning light revealed the outline of the trees and pasture outside my window, I read the Times on my iPad as usual and came across an article titled “What makes people charismatic and how you can be too”.

The article claims that charisma can be learned and cultivated, and that thought resonated with me as I think often about how we as physicians have roles to fill in the stories of diseases and transitions in our patients lives. I try to be the kind of doctor each patient needs as I walk into each exam room.

The article mentions three pillars of charisma: Presence, Power and Warmth.

As I think of my current third guiding light in addition to my medical journals and the New York Times, my DVD collection of the Marcus Welby, M.D. shows, which is shorthand for his character and all the other role models I carry mental images and video clips of, Charisma is definitely something we need to consider and cultivate in our careers.

My job, my reason for being, is to guide and motivate people, and how I come across, how people perceive me, helps determine my chances of filling that role.

So, these pillars of Charisma in the archetypal physician, in my case Marcus Welby, look somewhat like this – first quoting the Times:

“The first pillar, presence, involves residing in the moment. When you find your attention slipping while speaking to someone, refocus by centering yourself. Pay attention to the sounds in the environment, your breath and the subtle sensations in your body — the tingles that start in your toes and radiate throughout your frame.”

Marcus Welby was certainly a keen observer and a good listener. He was also aware of and in tune with his own feelings. Thinking back over my own writing, I recall posts like “The Power of Focus” and “Today’s Masterpiece”. This is about being present so you can connect with each patient, and also so you can do your best under whatever circumstances exist in that moment.

“Power, the second pillar, involves breaking down self-imposed barriers rather than achieving higher status. It’s about lifting the stigma that comes with the success you’ve already earned. Impostor syndrome, as it’s known, is the prevalent fear that you’re not worthy of the position you’re in. The higher up the ladder you climb, the more prevalent the feeling becomes.

The key to this pillar is to remove self-doubt, assuring yourself that you belong and that your skills and passions are valuable and interesting to others. It’s easier said than done.”

I think many of us are afraid to use the power we have and just as the Times article points out, power is not about status; in medicine it is about power to help, fix or influence. Consider their words “assuring yourself that you belong and that your skills and passions are valuable” – Marcus Welby certainly didn’t seem to doubt that when he spoke up to his hospital medical staff or to patients and families. He projected a quiet power and confidence that we, today, as cogs in the big healthcare machine may not always feel that we have. My own writing includes “Where is Relationship, Authority and Trust in Healthcare Today?” and “Getting it Right”.

“The third pillar, warmth, is a little harder to fake. This one requires you to radiate a certain kind of vibe that signals kindness and acceptance. It’s the sort of feeling you might get from a close relative or a dear friend. It’s tricky, considering those who excel here are people who invoke this feeling in others, even when they’ve just met.

To master this pillar, Ms. Cabane suggests imagining a person you feel great warmth and affection for, and then focusing on what you enjoy most about your shared interactions. You can do this before interactions, or in shorter spurts while listening to someone else speak. This, she says, can change body chemistry in seconds, making even the most introverted among us exude the type of warmth linked to high-charisma people.”

Marcus Welby, strict as he could be, exuded a well measured warmth, kindness and relatedness. I have speculated, for example in “Role Play”, that this warmth isn’t necessarily of our own making but emanating from the source of everything, whatever people may choose to call that.

When you get right down to it, I think healthcare providers today are too often viewed by others and increasingly also by themselves as interchangeable. That is the opposite of Charisma. Like so many times before in recent years, I’m puzzled by how everywhere else in our society people and businesses strive to stand out and to establish their constant presence, perceptions of power and warm relationships with their customers, while healthcare professionals are hiding too much behind a vail of sameness and anonymity, seemingly even creating distance and projecting a lack of warmth – almost on purpose in a misguided effort to seem professional?

I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find THE STORY. If a note is half a dozen pages or scrolls long, why would I want the medication changes and the reason why they were made at opposite ends of the note? The order means less than the distance between them in my opinion.

The way I approach reading a note is with the two questions “What happened in the last visit?” and “Why was that the clinical decision?” In more and more of my office notes I answer these two questions for future readers, which would include me, in temporal, typographical and spatial connection with each other, right on top.

Let’s face it, how often would it be more useful to try to scan a lengthy Review of Systems and a Comprehensive Exam to find the pertinent positives than to read in the top paragraph that the patient who was placed on a potassium sparing diuretic two months ago and kept rescheduling their followup appointment is now hypotensive and nauseous with an unusually pale complexion and putting out less than normal amounts of urine. Consequently we stopped the medication, sent the patient for STAT labs or to the ER. Seriously, I don’t need to read anything more in that office note: You and I both know this person is in acute kidney failure, caused by the spironolactone. DONT WASTE MY TIME AS A FUTURE READER by mixing those crucial elements with other, less pertinent information. Put it in there, away from the story in case somebody needs to check if we screened for depression or smoking status, but those are filler materials and side plots in this riveting STORY of iatrogenicity.

I admit that in today’s healthcare environment, the office note serves many “stakeholders” (I’m not sure I like that word…), but since I am the clinician who sees the patient, makes treatment plans and then has to follow up on what parts of the treatment plan worked and what parts didn’t, I can’t accomplish anything without the thread of the chain of events I am ending up calling THE STORY. It belongs to the patient, but I’m the one that needs it, desperately sometimes, as even small nuances in the narrative of a life or a disease can change my assessment and the trajectory of care I provide.

And, here’s a confession, if I don’t have time to finish my note in real time, or if (ahem) I’m catching up on a backlog of chart notes, it’s the “a for abstract” segment I focus on; the number of “bullets” and 99213 versus 99214 is not my priority when I’m in survival mode (mine AND possibly the patient’s).

So I am again making the case for a narrative abstract at the top of each office note, an executive summary if you will, just like the world of academic journals has decided to present complex information.

If it’s good enough for The New England Journal of Medicine, it should be good enough for this Country Doctor.