A Country Doctor Writes:

“The young man knows the rules, but the old man knows the exceptions.”

Oliver Wendell Holmes, Sr., M.D.

I have been reading from two e-books lately on my new iPad. One of them, a bestseller published in 2005, is “Blink”, subtitled “The Power of Thinking Without Thinking” by Malcolm Gladwell. The other book, digitized by the Gutenberg project and first published in the late 1800’s, is “Medical Essays 1842-1882” by Oliver Wendell Holmes, Sr., physician, Harvard dean, poet and friend of Emerson and Longfellow.

As I read along I realized the two works both happened to address what clinical instinct really is, compared with pure book-knowledge, a question that is more important now than in recent memory as we strive to digitize and standardize every aspect of the practice of medicine.

In our decade, Gladwell, a British-born, Canadian-raised writer for “The New Yorker”, writes about the value of our subconscious calculations, which are faster and more accurate than our conscious, logic-based, conclusions. This applies also in medicine. Gladwell writes on his website (http://www.gladwell.com/blink/):

“One of the stories I tell in “Blink” is about the Emergency Room doctors at Cook County Hospital in Chicago. That’s the big public hospital in Chicago, and a few years ago they changed the way they diagnosed heart attacks. They instructed their doctors to gather less information on their patients: they encouraged them to zero in on just a few critical pieces of information about patients suffering from chest pain–like blood pressure and the ECG–while ignoring everything else, like the patient’s age and weight and medical history. And what happened? Cook County is now one of the best places in the United States at diagnosing chest pain.”

In “Blink”, Gladwell describes how professional gamblers start avoiding cards from a stacked deck as their biometric parameters, like skin temperature, register stress, long before they consciously become aware of what is occurring.

150 years earlier, in the essay “The Young Practitioner”, Holmes wrote about clinical instinct in the experienced physician:

“Book-knowledge, lecture-knowledge, examination-knowledge, are all in the brain. But work-knowledge is not only in the brain, it is in the senses, in the muscles, in the ganglia of the sympathetic nerves,—all over the man, as one may say, as instinct seems diffused through every part of those lower animals that have no such distinct organ as a brain. See a skilful surgeon handle a broken limb; see a wise old physician smile away a case that looks to a novice as if the sexton would soon be sent for; mark what a large experience has done for those who were fitted to profit by it, and you will feel convinced that, much as you know, something is still left for you to learn.

The young man knows the rules, but the old man knows the exceptions. The young man knows his patient, but the old man knows also his patient’s family, dead and alive, up and down for generations. He can tell beforehand what diseases their unborn children will be subject to, what they will die of if they live long enough….The young man feels uneasy if he is not continually doing something to stir up his patient’s internal arrangements. The old man takes things more quietly, and is much more willing to let well enough alone: All these superiorities, if such they are, you must wait for time to bring you.”

I have seen many examples of situations when you simply can’t get caught up in all the details of history taking and physical exam. Clinical observation, where all the physician’s senses become involved, can be faster and safer. Our whole reimbursement system, however, rewards doctors for asking lots of questions and evaluating as many (even irrelevant) body systems as possible, not for quickly and efficiently making the correct diagnosis.

Early in my career, I was asked to evaluate an elderly woman with shoulder pain. It was of recent onset and without any trauma, and it hurt her to move her arm. I ignored the sweat on her brow and her rapid pulse and high blood pressure and sent her home with instructions for caring for tendinitis of the shoulder. Not long after, an older colleague admitted her to the hospital for a myocardial infarction. My instincts were correct, but my orthopedic exam mislead me.

I vividly remember one day, many years ago, when my wife who is a nurse practitioner called me in to see a young child she was evaluating.

“He just doesn’t look right,” she said.

His vital signs were normal, and his history was benign, but I got the same uneasy feeling.

Moments later, his eyes rolled back, his muscle tone vanished, and he stopped breathing. By that time I already had my arms around his little body and was soon doing infant CPR. My wife and I both knew the child wasn’t right, but neither one of us have been able to describe how we knew.

Would today’s, or tomorrow’s, medical software or artificial intelligence have been able to discern that our young patient was about to slip out of consciousness and why? And if not, how do we ensure that the human beings who practice the art of medicine are allowed and encouraged to cultivate their clinical judgment in this era of standardized and managed care?

There was a time when patients knew their doctor, but knew little about their medication until their physician chose it, prescribed it and explained its purpose.

Today, in many cases, it’s the other way around. Doctors come and go and many patients have stronger relationships with their prescription medications than with their prescribers.

It is common to have patients request medications they have researched online or seen advertised on TV, before an agreement even on the diagnosis has been made.

“Ask your doctor if Superpill™ is right for you”, goes the slogan, and that is literally how the subject gets broached sometimes. That is also the way some patients approach diagnosis; instead of describing their symptoms and letting the doctor choose the best diagnostic test and the best treatment, more patients today come with a specific test and a specific treatment already in mind, but without the benefit of considering the differential diagnosis.

How did things get this way, what does it mean, and can we do anything about it?

Did we as doctors allow ourselves to be viewed as pawns in the big health care game being played out between the pharmaceutical and insurance companies, did we lose our personal relationships and our professional standing with our patients, or are we simply victims of an unstoppable tsunami of advertising and an information explosion brought on by the Internet?

Curiously, I am now starting to see more and more patients looking for my “take” on some of the new information, as the volume and diversity of opinions seems to increase exponentially in the media. Somehow, the tide is starting to turn, and patients are turning back to their trusted Family Doctors to help them sort through the massive amounts of information available to them.

I think the backlash is partly fueled by people’s reactions to the many recent withdrawals of former blockbuster drugs that turned out to be medical lemons.

I also think that we, as a society, may be starting, at least to some degree, to mature in our relationship to all this new information. Information has no value without knowledge, and knowledge is not the same as wisdom.

Going back to how doctors are trained, the information is out there for anyone and everyone to read, medical school gives you the knowledge how the information can be applied, and residency and practice gives you the experience and wisdom to actually take new information and apply it to real situations and real people.

So, while many of my patients are still enamored with the latest and greatest, I see a growing need for doctors like me, the somewhat older, wiser Country Doctor type, to help patients sort through the hype and help them find the real story behind today’s wonder drugs and medical news.

As the information explosion continues, the need for clinical wisdom grows. Wisdom cannot only be learned, it must also be earned.

I am seeing more gout cases than I ever used to. I am also learning more and more about the linkages between gout, uric acid and the cardiometabolic diseases – stroke, heart failure, angina, hypertension, dyslipidemia and diabetes.

I have reflected before on the lack of knowledge, even among physicians, about gout treatment. That doesn’t at all mean I am professing to be an expert on the subject, only that I have developed an interest in it.

A while back, while trying all the usual angina medications for my patient with Cardiac Syndrome X, I read about using the gout medication, allopurinol, for angina. Every time I return to this topic I find more interesting facts and theories about allopurinol, gout, and heart disease.

It turns out that this old, generic, gout medication can decrease angina symptoms and heart attacks, improve pump function in heart failure patients, and lower blood pressure. These effects can be seen even in heart disease patients with normal levels of uric acid. We know allopurinol can reduce so called “oxidative stress”, believed to be at the core of many disease processes from heart disease to dementia.

In people without heart disease, but with high levels of the gout chemical, uric acid, allopurinol can improve both cholesterol and blood sugar levels.

Less known, but perhaps even more interesting, is that diets that reduce blood levels of uric acid have effects similar to allopurinol. Traditionally, such diets were severely protein-restricted, since uric acid is a by-product of protein metabolism. Newer research has shown that a high-protein diet low in sugar, fructose and saturated fat is more effective in reducing gout attacks and has better effect on cardiovascular risk than traditional, low-protein, gout diets. Both the high-protein, low-fructose diet and allopurinol reduce insulin resistance, which helps improve blood pressure, blood sugars and lipid levels. They also both increase elimination of uric acid through the kidneys.

I have been aware of the increased heart attack risk among patients with inflammatory conditions, which received attention when Ridker published his papers on C-reactive protein (CRP). Many clinicians, and many laboratories, hold the belief that very high CRP levels are a marker only of autoimmune disease but not of cardiac risk. Somehow, only mildly elevated levels are thought to be dangerous. Unfortunately, very high CRP levels, except perhaps (?) in acute illnesses, regardless of cause, are associated with very high cardiac risk.

Gout may be the oldest disease we know. First described by the Egyptians more than 4,000 years ago, gout was called the Disease of Kings, although it is now seen in all socioeconomic groups, but varies in incidence among age, sex and ethnic groups. In most areas of the world, gout incidence is on the rise 

Hippocrates, writing 2,500 years ago, pointed out that eunuchs, prepubescent boys and premenopausal women don’t tend to get gout. These are also the groups of people who are least likely to develop heart disease. The new findings about uric acid, allopurinol and heart disease illustrate that, in medicine, very few ideas are entirely new.

I agree with those who say that men only think of one thing – at least only one thing at a time.

Every week I hear male patients tell me their wives say they don’t listen, especially when they are occupied with reading or watching the news.

Many women, on the other hand, seem to have no trouble doing two or three things at the same time.

Certainly, multitasking has been a necessity throughout history for women, who kept house, raised children, cared for animals and did all kinds of farm chores.

In many early cultures dating back thousands of years, men would go out to catch the tiger or some other dangerous beast. That sort of endeavor was more likely to be successful if the hunter put all other random thoughts and projects out of his mind right then until the tiger was successfully taken care of. 

Today’s men generally operate very much like prehistoric man. If we split wood, we only do that, and if we mow the lawn, we don’t stop in the middle to split some wood or balance our checkbooks, unless we have Attention Deficit Disorder, or ADD.

When I grew up, there was only one channel on Swedish TV (I was five when I first saw a TV program). We played games that followed the pace of our minds and bodies, and we played them one at a time.

The generations born after me have been subjected to far more simultaneous sensory inputs, and they have played games that set the pace for the players; computer games often don’t slow down for the player, who needs more time. Children also often play games while watching TV in the background.

I, who no longer have a TV at home, was reminded at the airport recently of the flood of sensory inputs we can subject ourselves to today. The TV monitors had a news anchor occupying most of the screen. To the right was a live feed from the latest disaster scene and along the bottom of the screen was a ticker-type text with completely unrelated headline stories. A young couple was standing near a monitor, busily talking while each was texting on a Blackberry.

Modern society seduces us into trying to do more than one thing at a time. I often wonder what that does to a developing nervous system.

Are some young brains better equipped to select which outside inputs to process and which ones to ignore? Are some just unable to prioritize, and do they therefore rarely find the level of engagement necessary to complete tasks? It is well known that boys with ADHD can hyperfocus and do extremely well in high-risk situations, where dopamine is released within the central nervous system. But are low dopamine levels at the root of this condition?

What about the simultaneous rise in rates of Asperger spectrum disorders? Are they Attention Excess Disorders? Asperger children are in many ways doing the opposite of ADD children; instead of “taking it all in” and doing everything at once, they “tune out” many inputs others think of as important and focus their attention on details others might think of as irrelevant. Instead of always checking how their peers are reacting (Is anybody laughing at me, the Class Clown?), they fail to read the reactions of others, and tend to be socially awkward.

Or is our society less tolerant of these different coping mechanisms to an increasingly unhealthy environment? Is it so, that as our society becomes more intense, more and more people will fall outside the norm for what we think is an acceptable way to deal with the barrage of sensory inputs?

After a busy Monday at the clinic, I sat down to look at some journals while our supper was warming up in the oven. An article in Medical Economics caught my attention. It made me first a little bemused, but that soon changed into something between anger and sadness.

Under the heading “Coding Cues” a question was posed about how to bill insurances for fecal occult blood testing – those little cards we use to see if a stool sample has blood in it. The answer exceeded 400 words in length. I looked up what the reimbursement is – $4.54, less in some states.

The essence of the article is that, as the simplest of all screening tests for colon cancer, you cannot bill for only one test. You must hand out, and charge for, three of them (CPT code 82270). As a diagnostic test for blood in the stool, if the first one is positive, doing three is a waste of money (CPT code 82272). An unclear clinical scenario may require 3 samples to determine the presence of blood (CPT code 82272). Choosing the wrong CPT code for the wrong scenario means no payment, even though both codes represent stool testing for blood.

A few years ago, our clinic seemed to talk about these hemoccult cards a lot. At that time providers were simply forgetting to charge for them. I had no idea how complicated the subject was, since I am several steps removed from the billing process. It is not hard to imagine why our health care system is in shambles when a test that costs less than $5 is so complicated to charge and bill for that it becomes a full-page article in a Family Practice business magazine.

Someone is clearly watching over us with incredible suspicion and mistrust. And we are surely being micromanaged.