A Country Doctor Writes:

A few years ago, a medical journal piece about electronic medical records with built-in “decision support” announced that the days of super-physicians and master diagnosticians were over.

Being a doctor isn’t very glamorous anymore, and being a good one seems rather obsolete with so many guidelines and protocols telling us what to do.

A hundred years ago, William Osler, a practicing physician, had single-handedly written the leading textbook of medicine, reformed medical education, helped create and chaired Johns Hopkins and become the chair of medicine at Oxford.

Today, it is virtually necessary to be a researcher to teach at a university, let alone chair a medical school. The only other way to advance in medicine is to go into administration. Leaders in medicine are not chosen for their mastery of clinical practice, but for their managerial or business acumen.

The culture of clinical excellence has few heroes in our time. Pharmaceutical companies sometimes speak of “thought leaders” on the local level, which is more often than not only their way of building momentum for their drug sales through promoting early adoption of new medicines. Doctors today practice on a level playing field, where we are considered interchangeable providers in large organizations and insurance networks. Media doctors don’t earn their position based on clinical mastery, but rather their communication and self promotion skills.

What happens to medicine when it has no heroes? Who defends the ideals of a profession that is becoming commoditized? What keeps new physicians striving for clinical excellence with only numerical quality metrics and policy adherence as yardsticks? How are the deeper qualities of doctoring preserved for new generations of doctors, and how are they kept in focus with all the distractions of today’s health care environment – because people still worry and suffer; they are more than bodies with diseases or abnormal test results.

Every day, doctors on the front lines treat two dozen fellow human beings with every imaginable condition. How do we carry on, with only our own ideals as beacons in the fog, if we are left to ourself to defend our higher purpose, without champions, mentors, or heroes?

Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against Herpes Zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?

What has happened is that our local Rite-Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.

I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.

The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.

The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.

For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.

Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.

I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.

Many patients believe that since we can effectively cure some previously deadly diseases, like Hodgkin’s lymphoma, and control others, like AIDS, we probably have even better success rates when dealing with more ordinary diseases.

True, many conditions we see in primary care do go away – sore throats, coughs, sinus infections and rashes – but not necessarily thanks to our treatment, since they usually go away even without a visit to the doctor. No, sadly, a 50% success rate is considered very good for most of the interventions we do in primary care.

The same 50% effect is seen in many clinical scenarios, that are often misrepresented, even by doctors, as much more effective:

Lipitor, mentioned above, and all the other statin drugs, can reduce heart attack risk by at most 50%.

Tight blood pressure control in diabetics only reduces cardiovascular risk by 50%.

Quitting smoking only reduces heart disease risk by 50%. (And, no, these three interventions are not additive; nobody gets a 150% reduction in risk by doing all of them.)

Early detection and treatment of lung cancer can reduce mortality, but only by 50%.

Mammography screening, according to one recent study, reduces death rates from breast cancer by only 50%.

And the list goes on. Patients are encouraged to take shots or pills to protect themselves from bad diseases, but do they know how effective the intervention is, or how long it will last? In the case of shingles shots, nobody actually knows yet.

As if 50% success rates weren’t bad enough, there are other interventions that have an even lower likelihood of being helpful, for example taking antidepressants when you are depressed: 30-40% is the commonly cited success rate here. Yet, how many patients want only the pill and not also the counseling that can bring the success rate to 60%?

That is still a surer bet than having cardiac stenting or coronary bypass surgery in an effort to cut the risk of cardiac death. There is no convincing evidence that either of these common and costly interventions saves lives. They often improve quality of life, but most patients and many doctors believe they are essential, life-saving procedures in most instances.

Something as seemingly straightforward as surgery for a torn meniscus of the knee, if you are old enough to also have some arthritis, is no better than physical therapy in relieving pain and restoring function over a six month period.

Who else, but the primary care provider will have these discussions with patients? I don’t hear the cardiologists explaining the evidence impartially to patients, and how many orthopedists are that reluctant to do surgery? They make their living doing the procedures that patients assume are necessary.

We seem to be caught in two opposing currents. One is the idea of primary care providers directing and coordinating patients’ health care in “Patient-Centered Medical Homes”, helping patients navigate today’s complex health systems. The other current is to give pharmacies, retail clinics and specialists who aren’t trained or experienced in whole-patient care direct access to patients or populations of patients and having primary care doctors only gathering and storing the information after the fact.

I worry about where the fragmentation in the second scenario could take us. Who will help patients see the big picture, and who will support them in making decisions that take their entire health status into account? In a world where 50% success is considered good, there are a lot of judgment calls. And the more you carve up the care of the patient, the more random those judgment calls will be.

50% success rate doesn’t mean a half cure for everyone; it means half the patients get the desired outcome and half don’t. If we think of it that way, it might be clearer what this is all about: It is about knowing the patient, and having the kind of relationship with them that supports and empowers them in choosing between many different fifty-fifty propositions, some of them conflicting and most of them changing very fast.

It’s been five years since I started this blog. Looking back at what my posts were like in the beginning, I can see that I have gradually found a style of writing that goes deeper and touches on subjects that are more challenging for me.

Over the years I have seen which topics seem to get the most pageviews, and which ones seem to interest fewer readers. I have been flattered by links and re-postings by more famous websites than mine and by primary care and teaching sites.

Generally speaking, postings like “What if Physicians Worked for Free” get the most attention in the short run, but medical topics like “The Art of Measuring Blood Pressure…” have had consistent interest over time.

Clinical vignettes like “Snap Diagnosis” are generally well received but never blockbusters.

From time to time I have posted interesting articles and excerpts from my inconsistent and eclectic reading list on a sister blog, “A Country Doctor Reads“. I didn’t want to put things that were tongue-in-cheek or “newsy” on “A Country Doctor Writes”. Just recently, I created custom tabs that link between the two blogs.

Some older pieces that I have, also very recently, collected under the category “Short Stories” have had relatively little attention, but I feel especially accomplished in having put a few medically related glimpses of life in a form that goes beyond personal essays or blog posts.

As I think about what the rest of my years as a doctor might look like, I also think about what I want to write about and how my voice or style should evolve.

It seems tempting to ride the wave of recognition I have gained with pieces about the time pressures, financial constraints, conflicting demands and administrative burdens of primary care doctors in this country, but I don’t want that to be the main focus of my writing.

I hope to be able to continue adding to the body of work that captures the timelessness and essence of doctoring, because that, more than what is happening today (good or bad) is what anchors me in my profession and calling.

In my practice, I have consciously let go of some of my obsessive tendencies for efficiency, and I have allowed myself to be more and more sensitive to what the situation requires when patients seem to drop a hint that they need to tell me something or when there seems to be a crack in their armor.

Years from now, I imagine people will remember if I helped them get through a difficult time or if I made a difficult diagnosis more than whether I was perfectly punctual.

I also imagine that years from now what I write today about a technicality in the practice of medicine will have less value than something that isn’t sensitive to time, place, party in power or healthcare budget priorities. I am not expecting to be in the history books, but I will confess my deepest hope:

I hope I can write about my life in medicine in a way that inspires some to follow the same path and helps a few doubting younger colleagues keep the faith in their chosen profession. I have seen and practiced medicine on two continents and under several very different systems, and it really isn’t that different if you manage to keep the focus not on the tools you have available, but on the patient.

We are the pilots, not the designers, mechanics or flight controllers. We may not always like the equipment or the traffic situation, but we still have to get our passengers safely to their destination.

I guess this was the first time I wrote about writing, rather than doctoring. I’ll get back on topic next time.

Thanks for listening.

(Midsummer’s Eve, North America 2013)

As a Swede, I know all about Socialized Medicine. I grew up with it and I learned my trade in it. I worked under budget constraints, treatment protocols and formularies in the late 70’s and early 80’s while American doctors were essentially practicing the way they wanted here.

I remember one of my surprises when I arrived in this country: I had learned in medical school that trimethoprim-sulfa was the drug of choice for urinary tract infections. Here, I was asked to consider what the bacteria looked like under the microscope and which antibiotics historically worked best for those bacteria. Even though the treatment choice was the same most of the time, I was encouraged to think it through for myself and not just follow convention.

In Sweden, I was often frustrated with “the system” telling me what to do. I felt curtailed in using the knowledge and skills I had acquired, and I admired the ability American doctors had to make independent clinical decisions based on their knowledge and experience, rather than some local government policy. Of course, since then, both the insurance companies and the Federal government have stepped in and regulated many aspects of medical practice, so now I am back in the kind of waters where I once learned to swim. And I still remember how! It isn’t called Socialized medicine here, but it amounts to almost the same thing from the doctor’s vantage point.

I am now trying to understand another “S” phrase – Social Marketing. So far, it looks like that one is much harder for me to get a handle on.

The other day I threw away a chance to make $150 in 10 minutes. I also put an unendorsed $10 check in its enclosed prepaid postage envelope. With a certain amount of satisfaction I placed the envelope in our mailbox at the bottom of our driveway on my way to work. “Make them pay 46 cents to learn about my rejection”, I thought to myself.

Both opportunities for easy money were surveys. The first one wanted me to list colleagues in my own specialty I trusted and might seek advice from regarding pain management for my patients, and the second one asked which specialists I usually asked for advice on certain topics.

I am used to getting surveys and throw away just about all of them. Occasionally I take the opportunity to voice my opinion in one of them if I happen to feel strongly about the topic. But these are a new breed of survey that has appeared very recently. This is part of the new age of Social Media.

Social Media can provide a community of support for doctors, who otherwise risk being alone with the stresses and challenges of their work – that much I understand and respect. But the dark side of Social Media for doctors is when this becomes a channel for influencing doctors’ practice or prescription habits and for discouraging critical thinking.

Our university educations strived to make us independent thinkers, but Social psychology teaches that we are easily swayed in our opinions by people we respect or sometimes just by a majority of those around us.

“Social marketing” to doctors uses existing social networks for commercial purposes. It is the pharmaceutical industry’s evolving strategy in response to doctors turning away “drug reps” from their offices and to the escalating costs of keeping a large sales force on the road. What they do instead is make doctors do the sales pitches for them:

Pharmaceutical companies analyze prescribing patterns, through data they buy legally, of all the physicians in their territory. They then survey doctors to find out who the medical community views as trusted and worth listening to – “thought leaders”. This knowledge is then used to focus the pharmaceutical companies’ marketing efforts.

“Thought leaders”, who aren’t high prescribers of the promoted drugs, are targeted with sales pitches to convince them to use the product more often, while socially well-connected high prescribers are showered with attention and positive feedback, sometimes with an invitation to speak to their peers, for a generous fee, about particular drugs. One primary care doctor not far from where I work made over $50,000 one year from such dinner presentations, according to the website http://projects.propublica.org/docdollars/.

This system is said to create even more loyalty and generate even more business from the high prescribers themselves, something that may actually be more important than the business generated by converting their audience.

What this amounts to is creating peer pressure or inflating the ego of high prescribers instead of spreading information, and this is where my old-fashioned thinking gets me a little confused in today’s Social climate:

Why would I listen to a doctor from the next town over with similar or less experience than I have when I am considering whether to start prescribing a new medication? I have listened to plenty of presentations by prominent experts, and I don’t even trust some of them to be objective and not put the drug companies’ interests before our patients’.

Strangely, old-fashioned Socialized Medicine and the peer pressure of today’s modern Social Media can both have the same effect – making physicians think less critically.

I can’t help wondering: With all the world’s knowledge digitized, with UpToDate, The New England Journal of Medicine and The Lancet on our iPads, with Google Translate unlocking websites from all over the world, aren’t we obligated to use today’s technology and our educated minds to look directly to the primary sources of medical information instead of blindly following government edicts or the latest fad within our  peer groups?

“The secret of life is enjoying the passage of time”

                    James Taylor

One of my wife’s mentors has a 104-year-old aunt, who on her 100^th birthday was asked to reveal the secret of her longevity.

“I always have something to look forward to” was her answer.

Wisdom, happiness and longevity aren’t confined to people in cathedrals or ivory towers. They can be found in seemingly ordinary people in the most ordinary places. James Taylor, in his song “Secret O’ Life”, goes on to say, “any fool can do it”. Similarly, the Bible tells us to be more child-like (Matthew 18:4).

That doesn’t mean you have to be childish or think like a fool to enjoy life. It does mean that finding happiness is not complicated, and we sometimes get so wrapped up in our own thinking that we fail to see the simplicity in some of the universal truths about life as well as the beauty of life itself.

Observing which of my patients live well and handle age, illness and adversity the best, I see the power of this every day.

Jungian therapist Robert A. Johnson describes in his book, “Transformation: Understanding the three levels of masculine consciousness”, how the male psyche evolves from simple man (exemplified by Don Quixote), who asks “What’s for dinner?” to complicated man (Hamlet), who asks “What does it all mean?” to enlightened man (Faust), who asks “What’s for dinner?”

Too many of us dwell on the past – what we lost, what we never had, what we should or shouldn’t have done. Too many of us spin our wheels over-analyzing the present. Too many of us fritter away our days and our lives imagining or pining for distant futures at the expense of the present moment.

There is nothing wrong with thinking about the past, but we must each find our own way of making peace with it. There is nothing wrong with trying to understand our present circumstances, but not all of it will make sense to us now. Sometimes it takes years or a lifetime to understand the things we go through in life. There is nothing wrong with having dreams and goals, but we must somehow find joy in the journey towards those goals without feeling that we are wasting our time in our present life, since for some of us, that is all we’ll ever have.

Wisdom, like happiness, can’t be bought or taught. It is only occasionally learned in formal education settings through rigorous study and practice. More often it is earned through hardship and experience. It is gained when we look deep inside ourselves and acknowledge what we see. In the words of C. G. Jung, “One does not become enlightened by imagining figures of light, but by making the darkness conscious”.

In medicine, wisdom is partly gained by being wrong, or at least humbled by facing the limitations of our knowledge. But clinical wisdom must be paired with human wisdom as well as some of that simple joy of life James Taylor sang about, so that we can truly be of help to our patients. Nietzsche, in words that could have been written for practicing physicians, said:

“There is one thing one has to have: either a soul that is cheerful by nature, or a soul made cheerful by work, love, art, and knowledge.”

That is the hope I carry, that my love of medicine, of my wife, my family, and of the arts and the beauty around me will help me be joyful in my daily living. I hope that love will sustain me as the alarm continues to ring at 05:10 on bright summer mornings as well as dark, howling winter ones, this year and for many more years to come.