A Country Doctor Writes:

The Swedish word for physician is läkare, which literally means healer. That seems a lot more glamorous than the American word physician, which is derived from physic, the old fashioned laxatives that were thought to rid the body of poisons and impurities. But we are actually the healers a lot less often than we think.

The more we learn about how the body works, the more we have to admit that rather than us doctors, it is each patient that heals themself with at most some guidance from us.

We may recommend a change in diet, but we aren’t there to watch what our patients make of the advice we give them. We may prescribe a medication, but we know that many of the standard treatments in our armamentarium are only marginally better than placebo, and we now understand a little bit about psychoneuroimmunology, so we have to admit that patient expectations greatly influence the efficacy of treatments, even surgical procedures. We have learned this from sham knee operations for meniscal problems, for example. Imagine that, placebo surgery, not just pills.

This goes all the way back to the words of Hippocrates: “Let food be thy medicine and medicine be thy food”, “Walking is man’s best medicine” and “The natural healing force within each of us is the greatest force in getting well”. These quotes seem especially relevant in our struggle with the chronic diseases of the times we now live and practice in – heart disease, diabetes, arthritis; all of them at least in part autoimmune in their pathophysiology. If he body can attack and destroy itself, it also has the potential to do the opposite, to heal.

Our job, then, is to provide basic medical care AND to inspire, empower or whatever one calls awakening the self healing potential that a good diet, physical activity, good sleep, healthy relationships, care of one’s emotional needs and a good measure of faith, trust and optimism can ultimately bring about.

The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.

So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).

So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.

Patients are waiting, I’m behind, the usual time pressure in healthcare.

Can’t find a previously used diagnosis. Search for “nonspecific finding on chest X-ray” and multiple variations thereof.

I see R93.89 – “abnormal finding on diagnostic imaging of other body structures”. Close enough, use it, type in exactly what the chief of radiology had said in his report. Move on. Next patient.

Several days later I get a printout of that order in my inbox with a memo that the diagnosis doesn’t justify payment for a PET scan. Attached to that is a multi page list of diagnoses that would work.

Frustrated, I go through the list. It’s another day, other patients are waiting. Eventually I come across R91.8 “other nonspecific finding of lung field” – not exactly pleura, but what the heck, close enough, let’s use that one.

Why is this – me hurriedly choosing the next best thing on a multipage printout, while my other patients are waiting – any more practical, accurate or fraud proof than having me describe in appropriate CLINICAL language what the patient needs and letting SOMEONE ELSE look for the darn code?

Here I am, trying to order what a radiologist told me to order, without having the tools to do it.

Next thing you know, Henry’s insurance will probably have some third party radiologist deny coverage because he disagrees with my radiologist, and I’ll be stuck in the middle…

Not quite what I thought I’d be doing. Who works for whom in healthcare?

Several news media (I first saw it on BBC’s website) recently published the picture of an insect, invaded by a fungus, compelled to climb high, then killed off only to become a means for airborne spread of fungal spores.

I had also read in The New York Times about how massospora live inside cicadas and spread between them like an STD and stimulate mating behaviors to promote its spread, even though the cicadas become grotesquely altered by the fungus (see the yellow fungal “plug” in its rear). This behavior is caused by the release of Psilocybin, a mind altering controlled substance that eases depression and anxiety in cancer patients, and cathinone, a powerful stimulant.

Interesting that one life form can alter another’s behavior, but does anything like this apply to mammals, or humans? Certainly – maybe not for fungi, but definitely other parasitic (or symbiotic) organisms and viruses. Just consider the behaviors caused by rabies infection:

This seemingly improbable concept that specific microbes influence the behavior and neurological function of their hosts had, in fact, already been established. One prime example of “microbial mind control” is the development of aggression and hydrophobia in mammals infected with the rabies virus (Driver, 2014). Another well-known example of behavior modification occurs by Toxoplasma gondii, which alters the host rodents’ fear response. Infected rodents lose their defensive behavior in the presence of feline predators, and instead actually become sexually attracted to feline odors (House et al., 2011). This results in infected rodents being preyed upon more readily by cats, and allows Toxoplasma to continue its lifecycle in the feline host (House et al., 2011). Further, a variety of parasitic microbes are capable of altering the locomotive behavior and environmental preferences of their hosts to the benefit of the microbe. For instance, the Spinochordodes tellinii parasite causes infected grasshopper hosts to not only jump more frequently, but also seek an aquatic environment where the parasite emerges to mate and produce eggs (Biron et al., 2005). Temperature preference of the host can even be altered, such as observed during infection of stickleback fish by Schistocephalus solidus, which changes the hosts’ preference from cooler waters to warmer waters where the parasite can grow more readily (Macnab and Barber, 2012). Other microbes can even alter host behavior to seek higher elevations, believed to allow the infected host to be noticed more easily by predators or to eventually fall and disperse onto susceptible hosts below (Maitland, 1994). More coercively still, microbes can influence the social behavior of their hosts, causing insects, such as ants, to become more or less social to the benefit of the parasite (Hughes, 2005). In fact, the sexually transmitted virus IIV-6/CrIV causes its cricket host (Gryllus texensis) to increase its desire to mate, causing its rate of mating to be significantly elevated and allowing for transmission between individual hosts (Adamo et al., 2014).
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC4442490/

There is, of course, now more and more interest in the role our microbiome plays in seemingly every aspect of our lives – from mood to metabolism to immunity. The more I read about this, the more humblingly (is that a word?) fascinated I become.

The well referenced review article quoted above illustrates several already known ways our microbiome affects us, and I highly recommend reading it. I’ll zero in on how our behaviors are influenced, leaving cancer, allergies and other aspects of their influence for another post. Here are some highlights:

Germ Feee (GF) mice tend to be anxious and socially impaired. These behaviors normalize when normal gut flora is introduced.

GF mice have an increased permeability of the blood brain barrier both during fetal development and in adulthood. Some strains of clostridium and bacteroides and also the short chain fatty acid butyrate can restore normal blood brain barrier function.

Probiotics (L. Helveticus and B.longum) caused decreased self reported anxiety and decreased urine cortisol levels in humans.

Microbiota metabolize fermentable complex carbohydrate/fiber into short chain fatty acids (SCFAs) such as acetate, butyrate and propionate, which cross the blood brain barrier. Acetate influences the hypothalamus’ regulation of glutamate, glutamine and GABA. It also increases anorectic neuropeptide, which suppresses appetite.

Probiotics from fermented dairy do not alter the composition of gut microbiome, but they alter the transcriptional state and metabolic activity of the microbiota.

Autism spectrum disorder (ASD) patients have an increased incidence of constipation, increased intestinal permeability and altered intestinal microbiome. Mice with ASD like behaviors have a similar overrepresentation of gastrointestinal abnormalities. Introduction of B. fragilis has normalized intestinal permeability and reduced stereotypical behaviors, communication deficits and anxiety behaviors.

“It is becoming increasingly recognized that other psychiatric and neurological illnesses are also often co-morbid with gastrointestinal (GI) pathology (Vandvik et al., 2004), including schizophrenia, neurodegenerative diseases and depression.“

“The enteric nervous system (ENS) is directly connected to the central nervous system (CNS) through the vagus nerve, providing a direct neurochemical pathway for microbial-promoted signaling in the GI tract to be propagated to the brain on mood and behavior, including depression, anxiety, social behavior, and mate choice.“

Bifidiobacterium infantis can normalize depression-like behavior in mice to a degree similar to the antidepressant citalopram.

Finally, I got the impression in medical school that the vagus nerve was unidirectional. Now I understand that it is very much bidirectional, as quoted above. Here is a quote from another article I ran into about that:

The bidirectional communication between the brain and the gastrointestinal tract, the so-called “brain–gut axis,” is based on a complex system, including the vagus nerve, but also sympathetic (e.g., via the prevertebral ganglia), endocrine, immune, and humoral links as well as the influence of gut microbiota in order to regulate gastrointestinal homeostasis and to connect emotional and cognitive areas of the brain with gut functions (1). The ENS produces more than 30 neurotransmitters and has more neurons than the spine. Hormones and peptides that the ENS releases into the blood circulation cross the blood–brain barrier (e.g., ghrelin) and can act synergistically with the vagus nerve, for example to regulate food intake and appetite (2). The brain–gut axis is becoming increasingly important as a therapeutic target for gastrointestinal and psychiatric disorders, such as inflammatory bowel disease (IBD) (3), depression (4), and posttraumatic stress disorder (PTSD) (5). The gut is an important control center of the immune system and the vagus nerve has immunomodulatory properties (6). As a result, this nerve plays important roles in the relationship between the gut, the brain, and inflammation. There are new treatment options for modulating the brain–gut axis, for example, vagus nerve stimulation (VNS) and meditation techniques. These treatments have been shown to be beneficial in mood and anxiety disorders (7–9), but also in other conditions associated with increased inflammation (10). In particular, gut-directed hypnotherapy was shown to be effective in both, irritable bowel syndrome and IBD (11, 12). Finally, the vagus nerve also represents an important link between nutrition and psychiatric, neurological and inflammatory diseases.
— Read on www.frontiersin.org/articles/10.3389/fpsyt.2018.00044/full

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

As we are now starting to think of how to make the transition to a system that pays medical offices not for the number of visits but for the overall health of our patients (as defined by our quality metrics), we should ideally free up doctors’ time to review and act on health data that comes to us in more ways than face to face visits – but there’s a catch: We don’t think we can afford to have our docs see fewer face to face visits, because right now there is no money in what in the future will compare to the bank’s cash flow that their customers generate when they use online banking, ATMs and so on.

If a patient sends me a list of blood pressures or blood sugars, there is a cost for us to review and act on them – lost lunch breaks, unreimbursed overtime (”provider pajama time”) OR lowered productivity targets (for face to face work in an organizational leap of faith that these efforts will actually result in incentive payments some time down the road).

Most medical offices are quaintly or hopelessly old fashioned in our approach to the changing demands and desires of our payers and our patients. It is hard to make the transition to something new: We are being asked to start working differently and potentially making less or spending more without knowing for sure if it will pay off.

(The Banking business analogy can only go so far. After all, healthcare is still a humanitarian endeavor: More and more payers want us to “take risk”. I bet. Your patients cost more to care for, not just in the office but in hospitals you have no control over. Result: You lose money. But when the bank takes risk, they charge accordingly and if you’re a terrible credit risk, they’ll turn you down. Doctors can’t turn away patients because they are too sick and a bad financial risk. We can only view what we do as a business up to a point. Banks and insurance companies have actuaries and people like that whose entire careers involve projecting costs and calculating risk. Even big medical practices don’t have that. So while I think we can emulate banks in our interactions with patients, I don’t think it’s fair to ask us to behave like banks in every aspect of what we do.)

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?