A Country Doctor Writes:

Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole). The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data. From the late 1960’s to the early 1980’s the tranquilizer Valium (diazepam) was the top grossing drug. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.

So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, both sometimes self-inflicted through dietary indiscretion, to schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.

One cannot help but stop and reflect on this pharmaceutical sales phenomenon.

A country’s medicine cabinets tell us something about its culture and its predominant issues.

The postwar years, although portrayed in media as a time of optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930’s, born in the early to mid 1920’s.

The 1950’s and 60’s were times of change, when traditions were lost and values challenged.

At least to this child of the 1950’s, the Lipitor and Nexium years seemed a time of more selfish pursuits for many Americans.

I don’t know what to think of an antipsychotic now topping the pharmaceutical statistics.

Is it a sign of an epidemic rise in rates of serious mental illness, or is it more an indication of the increasing intolerance of negative emotions and behaviors in our society? Or is it just the result of persistent, powerful pharmaceutical marketing to consumers?

Either way, it is a bit disturbing that such drugs outsell all others.

I never contemplated bananas very much until the other day, after I counseled a patient with diarrhea about the BRAT diet, consisting of bananas, rice, applesauce and toast. The next two patients I saw were in their 80’s, on fluid pills and bothered by constipation. Both patients were eating at least one banana per day for fear of low potassium.

Since that day I have informally polled constipated patients about their breakfast habits. My early results suggest that more constipated patients have cereal with milk and banana for breakfast than their non-constipated peers.

Many processed grains, particularly wheat, can be constipating. Dairy products are also constipating for many people. But bananas, fruits with lots of fiber, are they also constipating?

Reading what scientific literature I was able to find on the subject of bananas and constipation, I found several mentions of a theory that unripe, starchy, bananas are constipating, whereas ripe bananas promote regularity.

The obvious next phase of my inquiry will be to ask my banana eating patients how they prefer their bananas, ripe or more “al dente”. I know that whenever I look at bananas in the store, too many black spots on the skin makes me think they’re about to go bad, and I prefer the less sweet taste of what might be considered unripe bananas.

When I lived in Sweden, I saw a little less constipation than here, so it was a surprise to me when I read that the Swedes eat more bananas than other westerners. I know for a fact that extra ripe bananas are not preferred there. My theory on why the Swedes aren’t plagued by constipation to match their banana consumption is that they are more physically active, even into old age, than Americans. In my mother’s neighborhood, she and many other octogenarians were always out with their rolling walkers, going to the store, the bus stop or just taking a stroll.

I am beginning to formulate a better, more pragmatic approach to geriatric constipation now that I have become aware of the dichotomy of bananas. Of course, I have to also be more diligent in dispelling the myth that everybody on fluid pills has to eat a banana a day.

Another aspect of adult and geriatric constipation I have become more and more aware of is that many people with constipation get worse by eating high fiber foods. Patients with bulky, hard stools can get even bulkier stools from extra fiber. For such patients, high fiber breakfast cereal with milk and unripe banana is the ultimate insult to regularity, and a habit to be discouraged.

An apple a day may keep the doctor away as whole apples relieve constipation.

A banana a day, on the other hand, may bring about more business for the doctor.

“In George Orwell’s Nineteen Eighty-Four, the fictional language Newspeak attempts to eliminate personal thought by restricting the expressiveness of the English language.”
Wikipedia

In my youth, I read George Orwell and Kurt Vonnegut, Jr. I remember thinking that “1984” seemed very far into the future – I would be over 30 then!

Well, 1984 came quickly; it was the year I started practicing medicine. I did a lot of thinking about language around that time. I was refining my use of English, my second language, and working on striking a balance between medical jargon and newly learned Maine colloquialisms.

In my residency, our progress notes were transcribed and cosigned by our faculty, but things were different among practicing physicians. Medical records at that time were handwritten in most offices I had contact with. Our notes were brief and to the point with word choices and symbols that conveyed nuances that made sense mostly to the writer and other medical colleagues. Few outsiders ever read our office notes. Specialists usually had their consultation notes transcribed, and there was often a richness and literary grace in their language. Here also, the notes often contained a metatext of subtle meaning that illustrated impressions and opinions without seeming blunt or offensive to uninitiated readers.

Our notes were our working tools for documenting our observations and our thinking. In my practice we often wrote down contingency plans and differential diagnoses for our benefit and our covering partners’, like “consider X” or “switch to Y if ineffective”.

We rarely elaborated the obvious. I remember my awe at the brevity of Rick and Dave, two pediatricians at the hospital where I trained. Many of their office notes simply read: “LOM. Amox” (Left Otitis Media. Amoxicillin). It made sense; what else was needed? The dose followed the child’s weight, and most ear infections were straightforward medical problems. No wonder they could see more than forty patients per day without getting bogged down.

Over the years, office notes became interesting to “outsiders” who had claimed a central spot in the doctor-patient encounter: insurance companies sought to control cost and quality, and we had to start writing our notes so that lay people would find them useful.

Writing mostly for non-physicians meant stating the obvious, so chart notes became much longer. This forced physicians to start using transcriptionists, as typing your own notes seemed a waste of time to most of us.

Now, with electronic medical records, we are finally doing our own typing. However, in order for the EMR to be really useful to the organizations we work for and for the government and insurance companies, we are discouraged from free texting our own words. Instead, we are choosing standardized, built-in words from click boxes or drop down menus. The industry jargon for this is “discrete data entry”. It is more quantifiable than allowing doctors to choose their own words or quote colorful descriptions by patients, but like George Orwell’s Newspeak, it reduces human experience and expression to a color-by-numbers exercise.

Even with the power of today’s EMR’s, click boxes, drop down menus and text macros, many busy physicians find the documentation process too cumbersome. Transcriptionists don’t seem to be the solution for most, because each EMR is different and entering the “discrete data” differently in each product isn’t the same skill set as speed typing and knowing how to spell medical words.

Enter scribes, the latest category of support staff in the medical office; a non-provider (now, there’s some Newspeak, as Orwell would have said) who listens in on the conversation between doctor and patient and documents it in the EMR by choosing the right preloaded words in order to translate the visit into computerspeak.

I read rave reviews about scribes, but shudder at the thought of having one more layer of possible distortion between what is said and what is documented. The patient says one thing, the scribe chooses the closest thing from the computer menu, and the doctor or a colleague, insurance reviewer or malpractice attorney later reads the non-medical person’s chosen word and concludes something totally different from what the patient and doctor had understood in the visit.

The whole concept reminds me of the parlor game “whisper down the line”, where people get to laugh at the change in meaning a message can go through as it is relayed from one person to another and another.

Kurt Vonnegut Jr’s spirit, like Orwell’s, thrives in today’s medical records, whether typed, clicked or still transcribed.

Not only did the increased readership of medical records among non medical “stakeholders” (more Newspeak) lead to documentation of what used to be obvious and understood by and between physicians. It also made room for what Vonnegut called “foma”, harmless untruths; lies that, if used correctly, can be useful (quoted from Wikipedia).

Medical records routinely contain the acronym “PERRLA”, which stands for “pupils equal, round, reactive to light and accommodation”. Yet almost no doctor actually tests whether the pupils change size when the patient focuses on a close object. The acronym is just too handy to resist, as it implies a thorough exam of the pupils was done with almost no effort in documentation.

Another white lie is “cranial nerves normal”, as only neurologists seem to carry a vial of ground coffee for testing patients’ sense of smell. The rest of us at most only check cranial nerves II through XII.

EMR’s make it irresistible to pump up chart notes with foma; one simple click can elegantly declare that a patient was counseled on this, that or he other.

The sad result of the proliferation of Newspeak and foma in modern medical records is that it is harder to find the salient points of medical history, exam, assessment and plan. Maybe the back-end users, those who pull statistical reports of how many heart attack victims have crushing versus squeezing chest pain are having an easier time, but busy doctors reading each others’ notes often secretly reminisce about the days when medical records only said “LOM. Amox.”

The other day I received my copy of the periodic newsletter of our neighboring Canadian medical society. It made me realize that both countries’ primary care doctors, in spite of our entirely different health care systems, are facing some of the same issues.

The bulletin warned Canadian doctors not to enforce a one-problem-per-visit policy, but to offer more comprehensive care to their patients.

The way doctors and clinics are paid in most settings here, two short visits are reimbursed at a much higher rate than one long and complex visit that takes up as much or more time. When patients feel the pinch of copays, travel costs and lost time at work for doctors’ appointments, tensions between the agendas of health care consumers and providers are inevitable.

It can be challenging enough to provide a healing atmosphere in a busy clinic. When doctors feel so much pressure that they become mercenary about their time, any hope of healing is lost.

I never understood the logic behind the one-problem-per-visit way of rationing health care. I do accept that the time we have to spend with our patients is finite, but there is usually some wiggle-room. I tend to be upfront with patients about how much time they were scheduled for. Some patients require extra time for even the seemingly most straightforward problem, but I have many patients who can bring up several problems and allow me to address them in a fifteen minute visit.

A patient with abdominal pain and joint stiffness may have an inflammatory bowel disease that explains the two seemingly unrelated symptoms.

A patient with pneumonia and a raging grief reaction needs both issues addressed in that visit, most likely with early follow-up for both problems.

A person with uncontrolled diabetes never has just high blood sugars; there is always a multifaceted story behind the numbers. That story often touches deep seated issues like self worth and depression.

Doctors in today’s health care machines, not just in our country, seem to think of themselves too often as widget makers, and not as healers. If we deliver only cookie-cutter health care, perhaps every aspect of our work is measurable and more of a commodity than a unique, personalized service. But, by reducing ourselves to generic providers of mass market care, we breed discontent among our patients and burnout within ourselves.

My wife often points out that when I hurry to do things around the house, I become less efficient and actually get less done than if I just plod along and do what needs to be done without fretting about it. In my work, I have just that ability. I am blessed to most of the time be able to enter the exam room with a mind free from the clutter of busy-ness and engage with my patients in an unhurried manner. Sometimes, when I am running late, I will enter the room and literally sigh before sitting down with an apology about running late because of a tight schedule. Patients invite me to relax, and I show them that all my attention is on them at that moment. Not being scattered allows me to accomplish more in a short time.

We need to always think of ourselves as “selling” our expertise and experience, not just our time. An appointment of any length can be effective or ineffective. A brief but well planned visit, where we enter the room prepared and where our documentation in the medical record doesn’t detract from the patient interaction, is more satisfying to the patient and the doctor, and gives some room for connecting with the person behind the symptom.

If we don’t fully master our EMR technology, we will be distracted and ineffective during the visit, and we could fail to document our clinical thinking well enough to be effective in follow-up visits.

I also think we as physicians need to always value the personal aspect of the work we do in order to be of any real help to our patients. If everything about our care is ever so correct, but bland and uninspired, we invite demands for more, as patients feel unsatisfied. If we spend our allotted fifteen minutes delivering exceptional care, our professional satisfaction will carry us further. Our patients will not feel cheated the way many do when we are too stressed to even recognize their needs, let alone begin to address them with skill and compassion.

“Suffering ceases to be suffering in some way at the moment it finds a meaning”      Viktor Frankl

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”      William Osler

Back in the 1990’s when pain was the newest vital sign, physicians were mandated to treat it, often with powerful medications and without truly understanding the cause and significance of the pain for individual patients.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

Of course, pain was never measured objectively in antiquity or when it became a “vital sign” a couple of decades ago. It still can’t be measured, which makes it no more of an objective clinical sign than someone guessing their temperature without a thermometer.

“Pain and Suffering” is a legal constellation that equates the significance of the two afflictions; doctors, however, have wanted to think of the two as separate, one or the other, treated differently. In many instances, doctors treated only one – the one we call pain – and skirted around the other. We have pain specialists, but perhaps only end-of-life care formally addresses suffering; it is seldom a topic in everyday medicine.

How many times, when a patient has said “I hurt” have I asked “where” instead of “how” or “tell me more”, assuming the Chief Complaint is physical.

How many patients with chronic pain are unrelieved by our usual pain medications? And how many of them receive the label “psychosomatic”, but little help from their doctors?

A few weeks ago, I came across a short piece by Dr. Thomas H. Lee in The New England Journal of Medicine about suffering. I have continued to think about it ever since.

I think medicine embraced pain assessment and pain treatment in a way that overcompensated for our ineptitude at mitigating suffering. Even as we treat patients’ pain, we sometimes cause suffering through the dehumanizing way our clinics and hospitals work.

Eric Cassell describes suffering as something that happens when our personhood is threatened. Sometimes physical pain, disability or the threat of dying is the cause of suffering, but sometimes the threat to personhood is loss in other spheres. In order to alleviate suffering, physicians need to understand something about the nature and meaning of this threat.

Doctors in our era are trained to treat diseases. We are not often formally trained to explore the person with the disease; this is something we are left to discover on our own, when the disease paradigm doesn’t seem to fit the patient we are trying to help.

The movement we now call “narrative medicine” is focused on the subjective meaning of disease and suffering. It offers a way out of the mechanized mindset of evidence-based medicine that is built solely around the lowest common denominators of diagnoses and treatments. The corporate-scientific medicine of today dismisses the statistical “outliers” and individual variations between patients in its efforts to help the greatest number of individuals, instead of each particular patient in the physician’s exam room.

Doctoring is a personal calling, built on personal relationships. Even statistical outliers deserve health care that works for them, and suffering can never be understood or mitigated without first seeking knowledge of the suffering person’s own fears and beliefs.

Eric Cassell writes:

“The doctor-patient relationship is the vehicle through which the relief of suffering is achieved. One cannot avoid ’becoming involved’ with the patient and at the same time effectively deal with suffering.”

How many doctors are comfortable getting that involved? And how many health care organizations see that as the role of their physicians?