A Country Doctor Writes:

Twenty years ago, I changed the name and focus of the “annual physical” I offered my patients. I designed a new form on my laptop with Geoworks, my favorite DOS-based (pre-Windows) desktop publishing program, and rolled out my “Annual Health Review”.

I explained to patients that many of the things we used to do in routine physicals every year had proven to be of little value, but there were more and more screening and preventive services we simply needed to talk about. It was also a time to do a thorough review of systems, and to update the family history.

When patients started talking about sore knees, allergies or frequent urination, I would try to gently steer the conversation by saying something like “those are things we can look into some time, but today I’d like to focus on the big health issues that could kill you”.

This approach was generally well accepted, and my homemade form made documentation quick and efficient. As the years went by, and as guidelines changed, some things disappeared from my routine. For example, screening or baseline EKGs were proven to be of little value, and I also stopped doing visual screenings on adults, because I wanted them to go to an eye doctor to get their intraocular pressure checked. My own Schiotz tonometer had become a veritable museum piece as it is so much more awkward for patients than modern tonometers.

I never did have a set of routine blood tests for a routine physical. Even when PSA testing for prostate cancer screening was de rigueur, I reasoned “this is America, and nobody has to do anything; who am I to boss people around by requiring that they have certain tests?” Ordering blood test was something I always did with the patient’s informed consent. Even with cholesterol, I always had plenty of patients who felt they had a healthy lifestyle and simply didn’t want to know what their cholesterol was.

I talked with patients about diet, alcohol, seat belts and all kinds of lifestyle issues. But I didn’t screen for things we essentially cannot treat, like early dementia. In our annual conversations, I usually got a good sense of who was high-tech in terms of wanting “everything done” in case of a cardiorespiratory arrest, but I admit I wasn’t quite systematic in collecting Advance Directives.

Of course, my Annual Health Review was not covered by Medicare, since it was perhaps technically a physical. But Medicare did pay for long visits where three or four chronic health conditions, even stable ones, were reviewed, so sometimes it was possible to add the Annual at no charge to a chronic care visit.

The other doctors in my practice used the same form, but I know each one carried a slightly different conversation with their patients. This visit was in the hands of my colleagues a reflection of each one’s style and of their patients’ preference. Dr. A ordered a few more blood tests, Dr. B recommended vitamins and supplements, and Dr. C promoted exercise with more passion than I did, and so on. These differences caused patients to gravitate to the one doctor among us that resonated most with their own ideas. This was personalized health care before patient-centeredness became formalized and formulaic.

All of us were pretty comfortable with our combined physical and health review visits.

Fast forward twenty years.

Today, under the new world order, doctors are mandated to perform Annual Wellness Visits on their Medicare patients, but not according to their own best efforts or their patients stated preference – one item missed or omitted out of deference to conflicting guidelines or common sense, like the kindergarten-style visual exam for new Medicare beneficiaries in their first six months of coverage, and no payment is collected. And similarly, check a few basic things like lung or heart sounds, the presence of leg edema or skin cancer, and the free insurance benefit is forfeited.

What was a naturally evolved focused physical combined with an individualized health risk assessment has been replaced by a tightly scripted no-touch session that leaves many doctors and most patients confused and bemused.

This new “Annual” feels like an administratively reinvented wheel, downright square and not rolling very well at all, at least on the roads where I travel.

“The last thing Edward did was bring in the groceries from the car. I saw the perspiration rolling off his forehead and I heard him moan, but he didn’t stop to rest. I should have told him to come inside and sit down for a while. The next morning, he was gone”, an eighty-two year old widow said to me the other day in a voice filled with the pain of a secret guilt she had harbored for almost a year.

I stretched my hands out toward her and she put her thin, arthritic hands in mine. I held them gently, careful not to squeeze so hard that I might cause her pain.

“Oh, Mary”, I said, “Edward had hardening of the arteries everywhere in his body. He could have had a heart attack many, many years ago if you hadn’t gotten him to quit smoking when you did twenty years ago.”

Her hands returned my gentle squeeze and she smiled faintly as the tears streamed down her furrowed cheeks.

Today, as I familiarized myself with the medical history of a delightful little preschooler, her forty-something mother blamed herself for the little girl’s speech delays. “With my husband’s first losing his job when the mill closed, and then having a stroke less than a year after that, I just wasn’t there for Hayley to nurture her the way I should have”, she said as her eyes turned red and her voice grew faint.

“Look at this wonderful little girl”, I said. “See how she waits for her turn to speak and see how engaging she is with Autumn and me, even though she’s never been to our office before. She exudes a sort of gentle confidence that comes from being loved and cared for. It seems to me you have done a wonderful job with her, in spite of all the challenges you’ve had to deal with.”

“Thank you”, she whispered as she bit her lip, turned her head toward the ceiling and closed her eyes.

I am often reminded of the power of a physician’s words and the role our patients put us in of advisers in matters that go beyond diagnosing and treating illness.

A doctor, as the word “docere” was originally used, is a scholar and teacher, and the office we hold in the conscious or subconscious minds of many patients is like that of a priest or a judge.

We need to be aware of how a single, careless word or even our body language can hurt or undermine a patient’s hope or confidence. And we need to use our words and the authority some of our patients grant us as a kind of surgical instrument that can cut away festering doubts, fears or guilt. We have the power to ease suffering by wisely accepting and judiciously exercising that power. It is our responsibility to use it when that is what our patients need.

Sometimes, after crafting an important or complex plan of care with a patient, I say: “Let me type all this into the computer so that, in case I run into that big bull moose up on Vaillancourt Hill on my way home tonight, the next doctor who sees you will know what we were thinking today.”

Patients sometimes squirm or laugh nervously at that, but then they usually indicate understanding and appreciation of what I am doing.

I am a physician who started out in the era of handwritten office notes. I often reminisce about the pediatricians who simply charted “LOM Amox” when a child had come in with a left-sided ear infection and received amoxicillin. From a medical point of view, there’s usually still little more to say, but now we don’t document for ourselves or other doctors anymore. These days we have to document for the insurance companies, the government, the legal system and for all kinds of lay people. And what we document isn’t just the medical facts of each visit, but also to what degree we did our job as the eyes and the voice of the government.

Treating the sick or counseling the well, we now have our agenda dictated by the government, from what we do when a patient’s body mass index is in the obese range all the way down to the sources of our patient education handouts – if I provide the best written information I have gathered over years of practice, instead of the rudimentary boilerplate materials from my EMR, I fail at “Meaningful Use” (of my EMR)!

I have seen the documentation requirements of what we do to fulfill the government’s public health agenda grow so much that what we think, beyond the patient’s ICD-9 (soon 10) diagnosis code, has become harder and harder to discern in many colleagues’ medical records, possibly also in my own.

Just before our clinic bought an electric medical record system, I walked through a much larger office with their Executive Medical Director. He and one of the clinic doctors explained, “with the EMR, we start with the superbill and work backwards”. I was used to start with the undiagnosed symptom or the presenting known diagnosis and work forward, carefully crafting a plan of action.

I didn’t quite grasp at the time how significant his statement was. Now, years later, I see the depth of this: In the first few years that we used our new system, I and all our doctors in our organization lost our quality certification with NCQA for diabetes and cardiovascular care because our new EMR didn’t track what we did for our patients. It wasn’t enough to do foot exams and to write (type) when patients last saw their eye doctor: Anything we do or even think we might track must appear as an “order” in the superbill, because our EMR is hardly a medical records system at all, but essentially an accounting or bookkeeping program. (We did re-qualify with NCQA last year.)

Referrals, imaging and lab tests are all “ordered” from pick-lists in the “superbill”. If I want to send a patient to a specialist in Connecticut, where my patient will be visiting with her family, I can’t enter the order, even though I have the doctor’s name, address, phone and fax number. I must call the EMR coordinator on call to have the specialist entered in the master list so I can “order” by clicking. Anything just typed in doesn’t exist in a bookkeeping sense.

When I do a foot exam, I also have to “order” it. And later, when I sign off all my incoming test results, there are all the foot exams I did myself, requiring my electronic signature, as if I hadn’t already noted what the findings were. Such ordering and sign-off becomes central in our new “workflows” – a word I never needed to contemplate until I started to understand my new role as a medical line worker, feeding the government-imposed computer.

When eye doctor reports come in from doctors who have been following my patients since long before our EMR, my nurse has to create a “non-billable encounter” for each one, and “order” the eye exam, so she can scan and “attach” the report to the order.

Between rooming patients, she is supposed to be “working her pending orders“, starting at the list of electronic orders I have entered, not organized by patient, but by order type, devoid of any personal connection: First all the X-Rays, then all the lab tests, and so on.

My nurse has a lot less time these days to read my office notes, so when patients call with questions, she isn’t as aware of what’s going on with them as she was before the computer.

And with all this “ordering”, there is simply less time for me, too – not only to think, but also to document what I am thinking. There is only so much you can accomplish in fifteen minutes!

Which brings me back to the A&P, or Assessment and Plan. In the beginning, documentation of those two things was the purpose of the medical record. Clinical notes were just that, clinical, not billing instruments or government compliance documents. So many other things got piled on top of the purely clinical agenda that we have almost lost what we all set out to do as doctors.

No wonder I feel a little sentimental sometimes and wish for a system that serves the clinical process more than today’s EMR.

“Listen to the patient, he is telling you the diagnosis.”

William Osler

Sir William was right, but listening for the diagnosis when patients speak isn’t quite as straightforward as it may seem. This is particularly the case in the fifteen minute universe of American health care today.

In America we call it “history taking”. Our use of the word “history” somehow implies that there is something very objective about it. This has led people in the medical field to even delegate the listening to and documenting of patient histories to non-professional office staff.

In Sweden we used the word “Anamnes”, derived from the Greek words “ana” (back again) and “mimnesco” (remember). “Anamnesis” is found in Plato’s teachings about memory. There is a subjective quality to the use of the word “anamnesis” for patient or case histories, as the word in English can also mean, simply and non-medically, “recollection”.

Taking a patient history or anamnesis can require a fair amount of finesse.

Sometimes a patient comes in with a diagnosis already in mind. He or she will outline their differential diagnostic thought process and resist getting into what the actual symptoms are, as if they’ve moved beyond that stage. They act as if they wish I would please catch up with where they are. My usual reaction and tactic in such situations is to let go of any seeds of frustration I might feel and declare my inability to skip over any steps in the diagnostic process. I usually say something like “I’m a little slow…” in order to not seem to be challenging my patient’s preliminary efforts.

Other times, I run into patients who offer neither symptoms nor interpretation, but tell convoluted narratives about what others have said about them and what happened years ago that might have set the stage for whatever may be happening now, although I haven’t yet become the least bit aware of any of their present symptoms. Before I became aware of the condition now called alexithymia, I would easily become frustrated with this kind of narrative. Now I am more able to consider this kind of “anamnesis” a warning sign that my patient truly might be unable to recognize and describe both emotions and physical symptoms.

I worry about the idea of delegating listening to someone else; even a highly trained colleague could obtain a slightly different history, and every clinical decision is to some degree based on nuances that go beyond the mere “facts” of the case. It often seems that the way a patient’s history and his demeanor appear congruent or dissonant can move the diagnostic process forward quite dramatically.

I also worry about the therapeutic consequences of eliminating or abbreviating the listening process. I couldn’t count the times a patient has seen a well respected specialist who delivered technically excellent care and come back telling me “he didn’t even listen to me”. Patients have again and again told me that they value simple listening in me and other health care providers they see.

This ties in with something I read recently about the difference Between Care and Cure.

My wife ordered a book a few weeks ago by Henri Nouwen, called “Bread for the Journey”. It was published posthumously and contains daily reflections. Nouwen is perhaps best known for his writings about the “wounded healer”. This morning over coffee, Emma asked me to look at today’s reflection, titled “Care, the Source of All Cure”:

“Care is something other than cure. Cure means “change”. A doctor, a lawyer, a minister, a social worker – they all want to use their professional skills to bring about changes in people’s lives. They get paid for whatever kind of cure they can bring about. But cure, desirable as it may be, can easily become violent, manipulative, and even destructive if it does not grow out of care. Care is being with, crying out with, suffering with, feeling with. Care is compassion. It is claiming the truth that the other person is my brother or sister, human, mortal, vulnerable, like I am.

When care is our first concern, cure can be received as a gift. Often we are not able to cure, but we are always able to care. To care is to be human.”

Nouwen was absolutely right. I think the way we take each patient’s history, the way we elicit their stories and recollections – their “anamnesis” – is at the very foundation of “care” in health care.

The letters are usually four pages long and begin by saying that my patient has received a temporary supply of the medication I prescribed.

Next, there are general paragraphs about how the drug either isn’t on their formulary or the quantity exceeds the plan limits. None of these letters contains a reference to an online formulary physicians can access to compare covered alternatives.

Then there are several cumbersome explanations about the appeal process needed to request a formulary exemption. There are always toll free numbers to call.

Missing from 90% of these letters are mentions of which similar or alternative drugs actually are covered on the company’s formulary. This information is also missing from the smartphone app and website most doctors use to try to avoid these rejection letters – epocrates, the industry standard for looking up drugs, doses and formularies, doesn’t have access to this information from more than a handful of Medicare D plans.

This presents a choice between a few courses of action for the average doctor:

1) Desperately Google “medicare D formulary megapharm insurance corporation” (a fictitious insurance company name, to protect this writer from unnecessary litigation), only to end up following links to help consumers choose a plan in their geographic area, and not finding the more or less secret formulary.

2) Switch the patient to the oldest, least effective and least expensive medication in the class, or even in an older generation of generics, and hope it will go through at the pharmacy cash register. This is still not guaranteed to work, since the costs of some very old medications have skyrocketed in the past year or two.

3) Have your nurse call the patient to let him or her know they’ll have to pay for the medicine themselves or go without, since there is no reasonable alternative.

4) Have your nurse dial up the Medicare D provider, wait on hold for ten or twenty minutes, answer several questions about the patient’s policy number, diagnosis and so on and beg them to reveal which alternative drugs are covered or at least fax over a Prior Authorization form you can chip away at if there is ever a “free” moment in your day.

5) Make the calls yourself, contain your frustration as you listen to the Muzak, see your productivity level and patient volume go down, increase the wait times for patients calling for an appointment, and prepare to see your salary go down after your next performance review.

It is hard to imagine that the Megapharm Insurance Corporations of America are unknowingly wasting paper and postage on these letters that say what’s not covered without advising prescribers which drugs are covered. I am making a very educated guess that the purpose and net effect of these letters is that many patients don’t get the intended prescription, or even an alternate one, thus increasing the company’s profits. For the cost of a single presorted bulk mailing, they can easily save a hundred dollars every single month from this moment forward on one single, hapless victim – excuse me, “member”.