A Country Doctor Writes:

One of my medical school professors was an internationally renowned subspecialist, whose ward occupied the entire top floor of the medical tower at Academy Hospital in Uppsala.

He had cadres of residents working for him, and for two glorious months I rotated through his ward as part of my internal medicine training in medical school.

One thing that stands out in my memory, to this day, from those two months is how Professor B refused to deal with anything but the esoteric diseases his patients came to his ward for. If anyone had a cough or an ache or a rash, he would scornfully say “I treat diseases, not ailments”.

It seems that nowadays many ailments have been given disease status. Restless legs, premenstrual syndrome, thinning hair and overactive bladder are bona fide diseases now.

Even aging is, in this country, largely viewed as a constellation of diseases. It strikes me as odd that in this age of high regard for Evidence Based Medicine, we so boldly define things that happen to all of us sooner or later as diseases and try out treatments for these symptoms when every shred of available evidence suggests these are actually natural occurrences.

When I was a resident, I got docked if I didn’t offer postmenopausal women estrogen replacement. It seemed like such an obvious thing to do – who wouldn’t want to keep women from aging as nature had so cruelly intended? Who wouldn’t want to save them from heart disease, dementia, osteoporosis, genito-urinary symptoms and decreased joie de vivre? Who wouldn’t want to preserve and prolong youth?

Now, of course, everyone agrees that estrogen replacement increases a woman’s breast cancer risk and also increases her risk for blood clots, stroke and heart disease.

The male aging process seems to be the current frontier for many of those who wish to medicalize the human experience. As if we never learn from our mistakes, we are now prompted to look for low testosterone levels in middle-aged and older men, who might not have their usual vitality, muscle mass or sex drive anymore.

Never mind that there are already concerns about what male hormone treatment might do to prostate cancer and maybe even heart disease risks.

I wonder when the drug companies will focus their attention on the other big transition we all go through.

Adolescence is a life-changing condition for both girls and boys with many undesirable, hormone-mediated “symptoms”. Every generation of parents and teenagers until now has had to go through it without help from the pharmaceutical industry. If we were to follow the menopause-and-aging-as-diseases logic, this is probably the next medical frontier after we conquer the male menopause. Just think of all the “patients”, who suffer their way through this “disease”.

It’s probably only a matter of time until we have diagnostic codes and blockbuster drugs for this, too.

A Primary Care resident wrote in one of the journals recently about making the limited time she has with each patient matter the most.

How refreshing, I thought when she concluded that time ultimately is an absolute and finite resource. We often feel as if we are battling time as much as we are battling disease, and we sometimes have trouble admitting when we are losing either one of those battles. Some of us find it more difficult than others to say “no” to unrealistic demands for clinical output per unit of time.

But the writer had another agenda: By teaming up with Nurse Practitioners or Physician Assistants, she envisioned having more time to spend with each patient.

This type of New Math doesn’t really work in Primary Care. A physician who performs expensive procedures can maximize his or her time in the operating room by sharing office visits with a less trained and lower-paid “midlevel” practitioner, who could never replace the physician in the operating room.

In Primary Care, however, physicians, Nurse Practitioners and Physician Assistants tend to do the same type of work, and if anything, physicians tend to have shorter appointments than “midlevel practitioners”, reflecting their higher level of training and justifying their higher salaries. Every patient deserves the best care we can give them, and there is no reason to believe that patients who see a physician are so much more complicated that they always deserve more time than patients who see a “midlevel”.

If the young writer expects to have “midlevel providers” somehow subsidize her requirements of time and money, she is not likely to find this in today’s medical environment. She may instead find herself in direct competition with them. In states where Nurse Practitioners can practice without physician supervision, she might actually be at a competitive disadvantage, should her productivity drop below that of providers making half her salary.

In Family Medicine it has been common to keep a “Problem List” in patients’ paper charts. Usually placed on the left hand side, on top of the Medication List, it has given doctors like me an instant thumbnail sketch before considering the specifics of each patient’s visit for that day.

A typical Problem List would include diagnoses like diabetes, hypertension, high cholesterol or rheumatoid arthritis. It would list prior surgeries, like gallbladder surgery, hysterectomy and appendectomy, and medication allergies. Many of us also would list important tests done, such as a patient’s last colonoscopy or cardiac catheterization and make note of their Family History.

Because Problem Lists are brief and the page usually has a fair amount of empty space, they can usually be digested in a quick glance, almost subconsciously and without effort.

In fifteen seconds or less I could prepare myself before seeing a colleague’s diabetic patient with abdominal pain, loss of appetite and loose bowels by checking that she had had her appendix out and a hysterectomy but never had agreed to a colonoscopy. I can also note that she is allergic to contrast dye and that her mother died from colon cancer at age 62.

The Problem List can usually be read as I walk down the hall to the exam room – that’s how quick it is to use. Because of its placement to the left in the chart, it can also be seen regardless of what page the chart is opened to on the right side.

My office notes tend to start with the presenting problem, and technically I don’t need to go into the items that are listed on the Problem List, as they are already so prominently displayed on the very first page of the patient’s chart. I may choose to do that anyway, after the presenting complaint. Incidentally, some insurance companies pay better if we spell out what we already registered semi-automatically by just glancing at the Problem List.

Occasionally I have worked with or taken over after Internal Medicine doctors. They do many things the way Family Practitioners do, but their use of Problem Lists is often different. Some of my internist colleagues leave the Problem List blank. Instead, they treat each patient visit as an independent event with no connection to the other pages in the medical record. They introduce the patient as if seen for the first time and begin every office note with an often lengthy summary, such as:

This 65-year old nonsmoking married white female with a past medical history of Type 2 Diabetes, contrast dye allergy, hysterectomy and appendectomy has a family history of colon cancer in her mother, who died at 62, yet the patient has previously declined screening. She presents today with…

As I look at Electronic Medical Records (EMR’s), which will be more or less required by law in this country in the next few years, I see a new type of Problem List, and it makes me sad. EMR’s tend to “populate” their Problem Lists automatically with every single diagnosis the physician makes. Important things like diabetes may drown among diagnoses of ordinary and self-limited things like influenza, colds, ankle sprains, ringworm and poison ivy – things that are unlikely to affect the future care of the patient. They would never be included in the original kind of Problem List unless a patient were to have those conditions often enough to be noteworthy.

One of the things I see happening in medicine today is that physicians are more and more documenting to serve the needs of others. Our own needs for speed and clinical efficiency are not driving the technology. Those who wish to count, evaluate and analyze what happens in the exam room seem to have more of their needs met by the technology we have available today.

Most electronic systems make it easy to document hoards of clinical data by just pointing and clicking, but they lack the ability to prioritize the data. Systems that don’t give clinicians the opportunity to distinguish between important and not-so-important data risk creating information overload and could cause the health care information system to clog up. Intelligent Problem Lists could help keep things in order.