A Country Doctor Writes:

There is a lot of talk about team based care nowadays, and I have seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.

But at the same time, there are so many decisions – judgement calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.

I talk to patients all the time who ruminate, often at night, about the choices they made every day, and replay their conversations, reasoning and actions to the point of losing sleep and experiencing distresss.

I also know of a few clinicians who do the same thing.

I think there are a few fundamental tolerances clinicians must have:

One is tolerance of uncertainty. The other is a tolerance of being where the buck stops.

“Medicine is a science of uncertainty and an art of probability” is a famous quote by my hero, Sir William Osler, the “Father of Modern Medicine” and of bedside teaching.

This is a dichotomy: On one hand, the diagnostic possibilities in most cases are nearly endless, thus uncertainty, but at the same time, the major probabilities are usually pretty clear cut.

Our mission, should we chose to accept it (Mission: Impossible – in my case, the original series; I assume that quote is still relevant) is to embrace both the uncertainty and the need not to accept indecision.

In that moment, we are often alone.

The only way to balance these seemingly opposite notions is to acknowledge that no one can know for sure but the probability is…that is, being human and being fallible, but also possessing a certain amount of knowledge based confidence.

In my Swedish training, it was considered appropriate to consider and make a clinical decision based on “the odds”. In America, that isn’t always recognized. I agree you cannot completely skip over considering the probability of the esoteric, but how much weight do you give it?. If we don’t reign in the temptation to overestimate the odds of the esoteric, our health care will bankrupt us even faster than I imagined.

The kinds of decisions we usually need to make on our own are ones we have to live with and ones we cannot let ruin our sleep or our sanity:

Antibiotics or not? Hospital admission or not? Imaging or clinical diagnosis?

You do your best. It is all you can do. Without obsessing. Osler called that Aequanimity.

Treating a headache with Imitrex and having it turn out to be a brain tumor instead of a migraine is every primary care provider’s nightmare.

That is a dramatic illustration of treating a symptom instead of a diagnosis. But even when we do everything by the book, how often are we treating a manifestation, or symptom, rather than the underlying cause of a disease when we believe we know the right diagnosis?

Consider diabetes and dementia (now called “Type 3 Diabetes”), depression and irritable bowel syndrome (both responding to serotonin reuptake inhibitors), are we getting deep enough at the root of the problem in either case? And, since we now know that both MS and Myasthenia Gravis have immunologic mechanisms, aren’t we just scratching the surface with our current treatments?

Since I wrote my post titled “Treating Symptoms” five years ago, it has become clearer and clearer that that is almost all we do in modern medicine.

Other than infectious diseases, there are fewer and fewer diseases where we have any reason to believe our pills and potions are getting to the ultimate cause or mechanism behind the disease. And even with infectious diseases, we don’t always treat the root cause of why some people who are exposed get sick and why others are not.

One glaring area of medicine is psychiatry, where we know one genetic abnormality can lead to manifestation of any of a whole group of diseases.

The Broad Institute of MIT and Harvard published on this topic:

“Researchers explored the genetic connections between brain disorders at a scale far eclipsing previous work on the subject. The team determined that psychiatric disorders share many genetic variants, while neurological disorders (such as Parkinson’s or Alzheimer’s) appear more distinct. The results indicate that psychiatric disorders likely have important similarities at a molecular level, which current diagnostic categories do not reflect.”

The Journal of Immunology Research wrote about similar underlying mechanisms behind SLE and Rheumatoid Arthritis, psoriasis, multiple sclerosis and myasthenia gravis, conditions often treated quite differently, but never quite at their now known root cause level.

“…the role of HLA-DRB1 alleles has been evaluated in a large cohort of patients affected by different autoimmune diseases, identifying associations between specific alleles and different diseases and the HLA-DRB13 underrepresentation in all diseases evaluated [e.g., SLE, Psoriasis (PS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Systemic Sclerosis (SSc), Multiple Sclerosis (MS), and Myasthenia Gravis (MG)].”

Yet, the way we approach and name the chronic ailments of modern humans is based on organ systems: Neurologists treat MS and Myasthenia Gravis, Dermatologists treat psoriasis and rheumatologist treat SLE and RA, ophthalmologists treat uveitis and so on.

So, should we have more geneticists? Or more immunologists?

Not necessarily.

Since the same gene can cause widely variable diseases, there is a step between the gene and its expression, and that is where lifestyle, environment, diet, climate and everyday modifiers play in.

We need medical practitioners who can translate what we are more and more understanding into practical, individualized interventions.

It is almost like before phenylketonuria was discovered. You didn’t need a corps of geneticists on the frontlines once the understanding was there. You just needed to know who shouldn’t eat what (a simple blood test) and proper labeling of foods.

That is the future we are seeing the very beginning of.

Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women’s Health Initiative – Stroke

You can’t cheat the system. Eat sweets and take more or less known risks, but eat artificial sweeteners and go where no one has fully charted the territory:

“In women with no prior history of cardiovascular disease or diabetes mellitus, high consumption of ASB (Artificially Sweetened Beverages) was associated with more than a 2-fold increased risk of small artery occlusion ischemic stroke hazard ratio =2.44 (95% confidence interval, 1.47–4.04.) High consumption of ASBs was associated with significantly increased risk of ischemic stroke in women with body mass index ≥30; hazard ratio =2.03 (95% confidence interval, 1.38–2.98).”

https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.023100

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Food Protein-Induced Enterocolitis Syndrome (FPIES) – AAAAI

I took an online Functional Medicine class last week and was intrigued by the concept that food allergies aren’t always IgE mediated (and therefore not all that easy to test for), and they’re apparently not IgA mediated either; I always thought intestinal allergies were…

“There are differences that set FPIES apart from a typical food allergy. Most food allergy reactions happen within minutes or shortly after coming in contact with a food allergen. FPIES allergic reactions are delayed, occurring within hours after eating the trigger food. In most allergies, the immune system overreacts to the allergen by producing Immunoglobulin E (IgE) antibodies. FPIES reactions are thought to involve cells of the immune system rather than IgE antibodies.”

https://www.aaaai.org/conditions-and-treatments/library/allergy-library/food-protein-induced-enterocolitis-syndrome

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(Interoception) We’ve Lost Touch with Our Bodies – Scientific American Blog Network

I’m more and more fascinated with mind-body medicine and ran into a new word, INTEROCEPTION, in this piece in Scientific American:

“This lack of connection to our bodies can be looked at through a concept called interoception, which describes our awareness of internal bodily signals, including the detection of sensations such as hunger, thirst and heartbeat. Interoception is a process by which our brains/minds make sense of these signals, which serve as a running commentary or mental map of the body’s internal world across conscious and unconscious levels of perception.

Our culture, technology and medicine have progressively made us into poor interoceptors.

Disrupted interoception is now understood to play an important role in mental health conditions including anxiety and mood disorders, eating disorders and addiction, and it is thought to be a feature of most psychiatric disorders. Scientific American has previously explored the role of interoception in eating disorders (“A Broken Sense of Self Underlies Eating Disorders”), emotional awareness (“Emotional Ignorance Harms Health”), and the location and function of such awareness in the brain (“Where Mind and Body Meet”). And results from relatively recent neuroanatomical and neuroimaging studies have shown how dysfunctional interoception can cause or exacerbate anxiety and depression.”

“The history of interoception science goes back to Charles Darwin, who discussed the role of visceral sensations in emotion in The Expression of the Emotions in Man and Animals.”

This type of training is, of course, what Yoga and many forms of meditation and mindfulness are all about.

Which brings me back to my old friend Alexithymia:

Brewer, Cook and Bird wrote in Royal Society Open Science in 2016:

Alexithymia: a general deficit of interoception

“While it was originally assumed that the interoceptive deficit in alexithymia is specific to emotion, recent evidence suggests that alexithymia may also be associated with difficulties perceiving some non-affective interoceptive signals, such as one’s heart rate. It is therefore possible that the impairment experienced by those with alexithymia is common to all aspects of interoception, such as interpreting signals of hunger, arousal, proprioception, tiredness and temperature.”

In this country, we bulked them up and renamed them Transition of Care Documents, and they made life more complicated in many ways. The Australians are thinking of a different name:

I ran into an Australian video clip on Twitter that proposes a renaming of the Hospital Discharge Summary. It advocates for the term Clinical Handover and stresses the importance of timely summaries from the hospital to the primary care provider as readmission rates are exceedingly high when discharge summaries are not issued on the same day the patient leaves the hospital.

They propose a name change because the story doesn’t end when patients are discharged; instead, patients are returning to where the bulk of their health care takes place, and just like the Americans, they need their home team to safely continue their care.

https://vimeo.com/307594856

Where I work, the fictionalized hospitals, Cityside, Mountainview and so on, are pretty good about sending out summaries right away. The problem here is the bulk of the documentation.

I think it was Obamacare that brought us the concept of a massive data dump at the time of discharge. Just like doctors are accused of interrupting within seconds of patients beginning to speak, when we receive a discharge summary, or whatever we want to call it, we are intuitively feeling a sense of dread and panic:

Quick, what do I need to know to care for this patient?

It’s gotten so cumbersome that we now have had to hire care coordinators to read the voluminous discharge notes for us, extract the essential information, put it in a standardized format and send it electronically to us providers, and then incorporating that summary in our Transition Of Care (TOC, CPT Codes 99495 or 99496) visit documentation.

Well meaning bureaucrats figured doctors need to know everything to assume care of a patient, so they created a system that, as with EMRs, obscures the essence of the transition of care. Here too, we can’t see the forest for all the trees.

Actually, I recently did get just an ER note from Cityside, elegantly formatted in their new EMR with a right sidebar containing past history, medication list and so on, almost like the left sidebar in my own eClinicalWorks. After five minutes desperately looking for what medication my patient was started on, I called their Medical Records Department and asked them what was prescribed. They couldn’t figure it out either. There was a section in the clinical note for treatment, but the new medication wasn’t there.

They put me on hold, and while waiting I finally found it on my own, in the sidebar under “Medications” with a discrete “New this visit” over it. In eClinicalWorks, the medication list in the side bar contains only what each patient was on before the visit started. Greenway’s EHS in my other clinic reconciles medications at the end of the visit instead.

There is no standard in the VHS-Betamax wars of EMRs.

I was able to educate the Cityside Medical Records person about how their own documentation is set up.

So, what would constitute a practical Clinical Handover note? The future lies in the past: Emulate the old fashioned, laconic yet conversational style of old (just like a verbal handover would be like):

Just like with my proposed aSOAP office note, we need to incorporate a down-and-dirty quick take at the very top of every massive medical document that doctors actually have time to read.