A Country Doctor Writes:

Perhaps doctors should be more like the President.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.

That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, X-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

“Between patients”, is the way many people imagined this “system” to work. But, how much time do we have between all those back to back fifteen minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code “urgent” or abnormal reports, but when it comes to standard laboratory panels, “normal” patients statistically have 5% of their results outside the “normal range” without being sick, so the majority of Complete Blood Counts and Comprehensive Metabolic Profiles show up red, whether they contain panic values or just statistical noise. (See my post “The Red Blues“.)

Where does a doctor even begin a two minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT Department instituted a similar workflow for the President: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the State Dinner, and hastily types in his multiple passwords on the Executive Computer.

A hundred messages await. One of them contains information about hostile troup movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the President’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the Commander in Chief. But that is exactly how information is managed in today’s medical office, on the frontlines of primary care.

Tick-tock, Doc! Three patients waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The President??

“I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.”

Rudyard Kipling

Medicine has become a very complex, multifaceted science, ranging from pharmacogenetics to psychoneurobiology. Doctoring, however, is increasingly viewed as so simple that you don’t actually have to be a doctor to know how it should be done.

What else could explain why IT people tell doctors what “workflows” to follow, instead of doctors telling them “we need computers that do this in this kind of way, so that we can better take care of our patients”?

What else could explain why the quality of our work can be measured by only a handful of parameters, all simple numeric indicators? Never mind that the target numbers change from time to time, and never mind that even well established individual targets sometimes disappear from the checklists.

What else could explain why it is the government that defines the overarching goals of health care in this country, and probably many others?

I’ve been thinking a lot lately about what it means to be a doctor, and particularly a good one, in the present era and from a historical perspective. Also, I have started to formulate a definition of what it takes to make doctoring a sustainable lifetime vocation in these times.

I think doctoring occurs on three levels, each one necessary for the physician to engage on:

1) The “How”

The most visible, and perhaps most intuitive, level is that of solid clinical knowledge and proficiency. This, of course, takes different forms in different specialties. Knowledge and proficiency are not enough, though. Judgment and critical thinking are essential but seldom emphasized in the lay debate on medical matters. The clinical art of medicine involves an infinite array of decisions about when general principles apply to the individual patient and when they do not. It also involves staying current with medical science and viewing claims, be they by drug companies, medical or political authorities, through the lens of the scientifically trained clinician. Today’s emerging practice of applying genetic research to individual treatment decisions moves us away from blindly following “guidelines”and validates the traditional importance of considering each patient’s unique social and biological makeup as manifested in their family history.

If the “How” of medical practice truly was as simple as some say today, guidelines and “best practices” would largely eliminate the need for independent, critical thinking and make a university education and the years of rigorous clinical training and practice unnecessary for delivering what we call health care today. Obviously, this is far from the truth.

2) The “Who, What, When and Where”

But doctoring goes beyond the technical proficiency and the scientific thinking that goes into each patient encounter. Borrowing from Kipling’s expansion of journalism’s “Who, What, When, Where, Why”, the first level of doctoring is the “How”. The technical “How” cannot be viewed in isolation. The “W” words of analyzing the locus of complex issues date back to Hermagoras’ “seven circumstances“, two thousand years ago.

A doctor doesn’t work without context or in complete isolation, although my wife sometimes (lovingly, I believe) calls me a Martian, implying that I somehow just landed on this planet as a doctor, ready to serve patients. Each doctor usually has a place of practice, a schedule, a way of collecting money for services rendered and these days also assistants, nurses and people who carry out administrative tasks.

In today’s society, doctors are increasingly separated from this necessary aspect of the practice of medicine. As employees of large organizations, they have their office hours, the length of each appointment and the number of patients seen on any given day determined by other employees.

Equipment purchases, from EMR’s to surgical instruments, are made by managers and supervisors with only varying degrees of physician input. And support staff are usually hired, trained and evaluated by management, not by the physicians.

In the day-to-day work of physicians, the seemingly inconsequential practical aspects of how a medical office functions can be significant impediments to good care as well as to both patient and physician satisfaction.

Involvement and input into the workings of the medical office are important aspects of being a doctor. Why would Michelangelo not care and instead have someone else pick out his paints and brushes for him? If a company of firefighters were issued pairs of only two left boots, would they perform to the best of their abilities, running toward the fire?

Another aspect of “Who, What, When and Where” is how medical practices relate to their customers, their physicians’ patients. All physicians, I believe, should be involved with how the office treats its patients, from telephone triage to billing and collections practices. Those things frame the office visit and may determine its outcome in many instances.

Only a one dimensional, disillusioned physician would have no interest at all in what happens in the medical office outside the exam room and the allotted fifteen minutes of appointment time. No disease can be effectively treated out of the patient’s context, so how can we imagine treatments working entirely without considering the clinic’s context?

Sir William Osler said: “The good physician treats the disease; the great physician treats the patient who has the disease.” The patient relates and reacts not only to the physician, but also to to the organization that employs the physician and defines the terms of engagement between doctor and patient.

3) The “Why”

The government wants most people to be healthy enough to be productive citizens, so it has defined health care with that purpose in mind and will sacrifice individuals to protect the collective. This happens when we go to war, too, for example.

Physicians generally feel a very strong obligation to their individual patients, and seldom face the choice of helping one patient over another.

So, why do doctors take on such obligations as their vocation?

I see doctoring as a calling with a higher purpose. My main professional motivation is to relieve suffering. In some specialties the purpose may be finding ways to enhance well-being, something I do to a degree as well.

Then, what defines a doctor?

The word “doctor” is derived from the Latin “docere”, which means “teacher”, and can also mean someone who has been taught, or educated. And if we think about this, every physician has been taught by another physician, which is the way it has been for thousands of years. Even though the profession has changed, just like the science of medicine, we are still carrying the legacy of those who went before us.

I really didn’t just arrive one day as a fully capable doctor from another planet; I went to a five hundred year old university, home of Linnaeus, Celsius, Ångström, Berzelius and Bárány. I owe whatever acumen I have acquired to the dozens of teachers and mentors, who shared their knowledge with me.

In a moment of passion, I thought of the phrase “The Apostolic Nature of our Profession”. It points out that physicians today are still carrying out an ancient tradition and also a fundamental role in our society and in people’s lives.

That sense of our place in history is necessary to navigate the rapidly changing currents in health care today. Without it, we are just technicians with ever-changing repair manuals, while our patients, just like patients two thousand years ago, are looking for a “docere” – someone learned, who knows not just the facts, like Google or Wikipedia, but understands their context and can help weigh their significance.

When the increasingly complex “How” of daily practice doesn’t always make sense, and when the “Who, What, When and Where” doesn’t take physicians’ accumulated experience into account, the “Why” is the ultimate question that defines us and our place in society as well as in history. All three sets of questions demand consideration as we think about our vocation as physicians.

Sir William Osler also spoke of three dimensions of medicine. His eloquent words define three somewhat different aspects than my musings, but the idea is still the same: Doctoring is something that takes place simultaneously on many levels. He placed doctoring in the arena of disparate definitions of medicine (religious in his day, political in ours), in the cross point of art and science and in the realm of morals and noble ideals:

“The critical sense and sceptical attitude of the Hippocratic school laid the foundations of modern medicine on broad lines, and we owe to it: first, the emancipation of medicine from the shackles of priestcraft and of caste; secondly, the conception of medicine as an art based on accurate observation, and as a science, an integral part of the science of man and of nature; thirdly, the high moral ideals, expressed in […] the Hippocratic oath…”

Physicians in today’s politicized, technocratic and materialized society are at constant risk of becoming one dimensional robotniks in a healthcare machine whose purpose is not the same as our ancient forbears’. We need to always remember “Why” we are here; we must be a strong voice in all discussions about “Who, What, When and Where”; and we need to guard our scientific integrity as we practice the “How” of our profession.

Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.

Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then. How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care. Each one has their own set of checklists, many only slightly different, and none of these lists actually improve diagnostic accuracy; this is somehow taken for granted, or perhaps not addressed because the creators of these checklists, as non-physicians, simply have nothing to say about that aspect of healthcare.

Gawande writes: “There are good checklists and bad….Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brain off rather than turn them on.”

A very simple way to “turn on” or focus providers’ brains is to adhere to a structured format of clinical assessment, but to avoid unnecessary rigidity after that. After all, in my world we have 15-30 minutes at most with every patient for a fee of $50-150. You can only cram so many prescribed agenda items into that kind of time frame before your time is up.

Today’s checklists would have me ask every patient, apart from figuring out what is wrong with them, if they are homeless, home bound, safe from domestic abuse, if they have scatter rugs, firearms in the house (not a legal question in Florida, however), if they are a caregiver and several more things I can’t remember. I am sure the architects of these templates meant well, but the end result of long lists like this is that physicians risk not paying attention to the forest because of all the trees. A more appropriate checklist could summarize all these items in one question: “Have you considered the patient’s home environment?”

One item I haven’t found in my new EMR is what we in Sweden always used to include in our medical histories, “Epidemiology”. This simple word prompted the question “Do you know anybody else with the same symptoms as yours?” It is a question I overlooked at least once that I will always remember:

I was fresh out of residency, working in a small town in Maine. A middle aged man came to see me about nausea, loss of appetite and abdominal pain of more than a week’s duration. I didn’t know what was wrong with him, so I ordered some labs and an upper GI series. His CBC was mildly abnormal and while I was waiting for his x-ray to get done, my partner and employer ran into him in the grocery store one Saturday. Doctor Joe approached me the following Monday and told me not to bother with the x-Ray: “Mr. Billings’ dog was just diagnosed with lead poisoning. You might want to check a lead level on him”.

Talking to Mr. Billings, he had been scraping paint off his old farmhouse with his Golden Retriever faithfully waiting at the bottom of the ladder, inhaling the dust from the dried and cracked paint. It never occurred to me to ask about “epidemiology” the way I had been taught, because I had dismissed infectious causes of Mr. Billings’ symptoms almost subconsciously and never considered environmental exposure, which also falls under the “epidemiology” heading.

A similar but more dramatic incidence in “The Checklist Manifesto” involved a surgeon who thought he had all kinds of time to get ready to explore and repair a small stab wound inflicted at a Halloween party. Suddenly the patient’s blood pressure bottomed out and as the surgeon hurriedly entered the abdominal cavity and found it filled with blood, he remembered he had neglected to ask about the weapon that had caused the stab wound. He later found out it was a bayonet, which turned out to have lacerated the abdominal aorta – he had only assumed it must have been a pocket knife.

Obviously, no check list can be complete enough to include questions about scraping lead paint for every person with abdominal pain and asking about having been stabbed by a bayonet in every laceration – only more general and somewhat open-ended questions will get you all the answers in a reasonable amount of time.

Quoting Gawande again, “The checklist cannot be lengthy. A rule of thumb some use is to keep it between five and nine items, which is the limit of working memory.”

As I contemplate how to continually improve the care I deliver while also addressing the increasing demands for fulfilling and documenting the Government’s requirements, I think I can use my computer and my EMR to streamline the way I meet all the requirements. But I think it’ll be up to me to create my own clinical checklists, because the Government issue doesn’t seem to be my size, which reminds me of another set of Swedish experiences I had – boot camp, blisters and learning to march in formation and follow orders without complaining.

Hopefully, the “official” checklists will evolve over time as people have a chance to assess their impact. Again, quoting Dr. Gawande:

“…no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart….and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Welcome to the real world, any time you wish to see what it’s like, Mr. President, Ms. Congresswoman, Mr. Insurance Executive, Ms. EMR vendor!

When I was a little boy, I had a tendency to walk around on tiptoes. People said I had my head in the clouds. Over the years, I have heard different theories on the pathological significance of my early ambulation habits, from language delays to autism to cerebral palsy and also theories of the spiritual qualities of toe-walkers.

I have long since stopped walking on tiptoes, and I never did have any language delays or serious motor difficulties, but I admit I have always had a tendency to keep my head in the clouds. Since reaching middle age, a few years ago now, I have done a fair amount of reading and thinking about the difference between spirit and soul, and I have worked hard on changing my center of gravity from my head to my heart.

Jungian psychology has resonated with my own intuition and perception of the deep-seated causes of my thoughts and my actions. I have come to believe in the power of archetypes in our way of relating to the people and the world around us, and I have started to challenge my intellect and my powers of reasoning as drivers of what has happened and continues to happen to me.

Just lately, I stumbled onto some writings about the Bön tradition, which predates Buddhism, and which pointed the way toward that belief system or understanding of the nature of man.

According to the Bön tradition, man has three parts: Body, located in the head; Speech, located in the throat; and Mind, located in the heart area.

This struck me as a typographical error at first; body in the head and mind in the heart – how could that be? But, the more I thought about it, the more direct the connection seemed; it is in the brain that any and all of my awareness of my body exists, and therefore, it is there that my body “exists” to me. Without my brain registering it, my feet can’t be cold, my stomach can’t feel empty and my knees could never ache.

Equating the body with the mind offers a new perspective on what we in Western medicine have been calling the mind-body connection. It could, even should, be called the brain-body connection. Because our own computing power is inseparable from the nerve impulses it registers and transmits from and to every organ of the body. And if the brain and body aren’t just connected, but actually one and the same, many disease paradigms suddenly must change – some just a little, and others quite fundamentally. Pain becomes the same as suffering, fibromyalgia could become depression in the body, colitis might become anxiety of the gut and psoriasis could become self-hatred.

What, then, is the mind, and what is it doing in the heart area? The heart is the location to which many cultures ascribe our deepest emotions, whatever selfless love we are capable of, and whatever connection we have with our Higher Power or with the Universe.

Before going any further, let me recapitulate what is known today about the heart’s abilities beyond pumping blood around:

There are 40,000 neurons in the heart; the heart not only receives neural stimulation from the brain (for example via the vagus nerve), but also transmits afferent impulses to the medulla oblongata and to the cortex; a transplanted heart, lacking a functioning vagus nerve, still has adequate independent pulse regulation; the heart creates a measurable electromagnetic power field that extends outside the body; the heart produces several hormones – atrial natriuretic factor (similar to Brain Natriuretic Peptide, a commonly tested marker of heart failure), noradrenaline (found in the brain and adrenal glands), dopamine (also found in the brain), oxytocin (released by the brain during childbirth, bonding with infants or lovers and during orgasm), afferent nerve fibers from the heart to the amygdala of the brain can stimulate autonomic responses to stress before any impulses reach the neocortex. Finally, healthy heart rhythm patterns have been linked to emotional well being, heightened intellectual abilities and better judgement.

The heart-mind is not an organ we use to design airplanes, do math or figure out how to get coconuts down from the trees; those are simple brain exercises.

The heart-mind may just be what connects us to what is infinite and eternal, our connection to everything that is not our body. Sometimes, our words, actions or our physical creations can seem to be what we call divinely inspired; then our minds control our bodies and our speech, but we are not the ultimate originators of our music, our poetry or our art. Something bigger is.

If the heart-mind, and thereby our connection to the collective mind of the Universe, is disrupted during heart surgery when the heart is chilled or bypassed by a heart-lung machine, we would suddenly understand the claims that 40% of patients experience significant depression even after relatively simple coronary bypass surgery.

The fact that we can measure the electromagnetic field of the heart beyond the physical boundaries of our bodies and the observation that people in close proximity can experience synchronization of their heart rhythms gives the heart more than symbolic significance in how we relate to our loved ones, mankind and the Universe.

All this is certainly something to ponder, even if it is just with my human brain, or what some Buddhists call the monkey-mind.

After I stopped walking on my tiptoes, I attended a Methodist Sunday School and I was later confirmed in the Lutheran state church of Sweden. In my studies of religion, I have learned that Buddhism isn’t an actual religion, but it does represent an ancient view of the Universe that science is now rediscovering.

A quote by Albert Einstein sums all this up:

“Science without religion is lame. Religion without science is blind.”

Cholesterol is bad. Cholesterol is an essential building block for important hormones.

Eggs are bad. Eggs are a complete protein food.

Salt is bad. Salt is essential for life.

High blood pressure kills people. No blood pressure defines death.

High blood sugar causes eye and kidney damage. Low blood sugar causes falls, fractures and car wrecks.

Low potassium causes heart rhythm problems. High potassium causes heart rhythm problems.

Too little vitamin B-12 causes nerve damage. Too much vitamin B-12 causes nerve damage.

The ancient physicians, from Hippocrates in Greece to the Yellow Emperor in China, to Ekiken in Japan and Charaka in India, all spoke of the virtues of moderation.

Why do we in our culture go to excess in our pursuit of wellness? We always seem to want to classify foods and nutrients as either good or bad. Depending on how we classify them, we go to excess in consuming them or we deprive ourselves of even necessary amounts of them.

There is even a newish disease, defining the extremes of such behavior, “orthorexia nervosa”.

The latest scuttlebutt of this sort is the new findings that low sodium diets are associated with greater risk of ending up dead than moderate salt diets. The editorial about the studies published in this week’s New England Journal of Medicine made me late for my nightly rounds to check on the barn animals Wednesday night. The piece was interesting, but ultimately no more enlightening than reciting the old adages “everything in moderation” and “nothing to excess”.

Somehow, we here in America have been conditioned to seek expert guidance over our own common sense or our Grandmothers’ advice. We listen to Government advice about drinking eight glasses of water per day whether we are joggers in Memphis during August or mailmen in Anchorage during January. We even listen to medical experts in unrelated fields who promote the latest nutrition and supplement fads on TV for their own profit.

The problem with turning the findings of scientific studies into practical advice or medical treatments is that science only produces data. “Data-driven” has become a buzzword today, just like “evidence based”, or a new one I heard recently, “evidence supported”.

What is wrong with both “data” and “evidence” is that neither entity equals truth, value, practicality or “wisdom”, not to mention the “fact” that the scientific “evidence” has changed many times over about a great many things just in the last few decades. If people wearing astronaut-like Ebola suits are less likely to also get the flu, does that mean we should all wear them during the winter months? Probably not. If tall bachelors have more dates than short ones, should we issue platform shoes to the vertically challenged (my very first blog post)? It was tried to a degree in the 1980’s, but never quite worked out.

Data is meaningless without context or “big picture”. Medical research, by its nature, analyzes small and easily defined parameters within the vast systems we call health and disease. What makes perfect sense to do for the well-being of one corner of our anatomy or physiology may have disastrous consequences for another and possibly for the whole organism. Each scientific study only aims at illuminating one small aspect of life. Only with an understanding of the bigger picture can we decide how to use the nuggets of “fact” science produces.

Even more than a view of the big picture is required to truly make use of data: Common sense, trivial as that may sound, is required when making judgements and setting priorities. This is what has gone missing in our collective enthusiasm at the advances of science in the past century. My Grandmother, who would have been 114 this year, but only lived to be 96, already knew that a little salt, fat or sugar never hurt anyone, but eating anything to excess was not healthy.

Both Hippocrates and Grandma, without the advantages of scientific data, knew in their hearts by virtue of their common sense what science has finally seemed to confirm.

We, as a culture, need to take advantage of both our shared, ancient wisdom and the advances of science, but either one without the other is likely to sometimes lead us astray.

Semmelweis’ analysis of why midwives’ postpartum infection rates were only a fraction of doctors’ and medical students’ is an example of science serving to explain what common sense already knew: Touching the dead before delivering babies made bad things happen.

Population studies, on the other hand, where we seek to find out if vegetarians, salt fiends, runners, nurses or yoga practitioners are healthier than others after decades of doing what they do are so fraught with uncontrollable variables that we are likely to be confused; it took twenty years to find out that postmenopausal estrogen treatment didn’t decrease heart attack rates in older women as the experts had speculated. Too many years of a good thing turned out to be bad.

My Grandmother could have told us that taking drugs to thwart aging didn’t make any sense. So could Hippocrates. They both had common sense. We need to cultivate ours in order to properly make use of today’s exponentially increasing amount of data.

Come to think of it, data seems to be a little bit like salt: Either too little or too much can be debilitating. We should let our common sense regulate our consumption.