A Country Doctor Writes:

Our electronic medical records prompt us to do what we do in our patient visits and also in many cases in what order to do those things. We could fairly easily change the order, but it may seem like extra work to do that.

But following the script we are given often seems rude. It can threaten our chance of building a therapeutic relationship and could even keep the patient from answering our rapid-fire initial questions truthfully.

So many initial office visit templates have the drug, sex, smoking and alcohol questions right in front, followed by probing of income, sexual orientation, pain, depression, domestic abuse and many more intimate questions that would be classified as appaling if you were at a dinner party with a new coworker or a first date with someone.

Our medical records serve many purposes, and the most important part of the record, particularly an initial visit, in my opinion, is the patient’s story. The best way to build a relationship with someone you just met is to ask them to tell you about themselves and then to ask follow-up questions to prove your interest.

Once you have taken the medical history and done an appropriate exam for their concerns, it is more natural to say something like “there are some background information we always gather when we see someone for the first time, so I hope you don’t mind if we take care of that also today”.

I think of that data as somewhat like the metadata that’s attached to your iPhone photographs or “Gracenotes” on a music CD. It’s information that can be retrieved if it is needed, but it doesn’t drown out the patient’s story and your clinical assessment and plan.

Of course there are times when some of those screening questions lead you to explanations for the patient’s symptoms or are abnormal enough to warrant a place on their problem list and in that case that part of the screening protocol should get included in the main part of the visit note.

For example, if someone has numb, tingling feet and admits to heavy alcohol use when you get around to asking about that later in the visit, it can open the door to a conversation about alcoholic or even diabetic neuropathy.

Our profession has practiced the art of asking the right questions in the right way and at the right time for centuries. We shouldn’t let non-medical programmers take our finely tuned skills and tools away from us. We need to work around their machines sometimes.

Am I the only one who thinks new drugs have worse and worse names as time goes on? I mean Zepbound, Wegovy, Mounjaro? Those names make me think of words and phrases like hell bound, we go why and mañana (Spanish for tomorrow). And isn’t there a Nissan car model called Murano?

There are some odd rules for naming drugs in this country. For example, they can not hint at what the drug does, which would seem the most logical criterion for naming a drug. One older drug that was named after what it does is Antabuse or Alcoban (disulfiram) in the US and UK, respectively. That is a medicine that makes you sick if you drink alcohol. Think anti-abuse and alcohol-banned. Another logical older drug name was Glucophage (metformin), which sounds like Latin for “someone who eats sugar”. In the over-the-counter market we have Gas-X and I’m not sure if that was grandfathered in or someone at the FDA had a senior moment. 

Think how much easier it would be for people to keep track of their medicines if we had names that hint at what they do, instead of just looking and sounding abstract. I mean Peemore would be an ideal name for a diuretic, Hackless a good one for a cough medicine, Quitcig for a smoking cessation drug, Remember for a dementia drug and Chill for a tranquilizer. I could go on, but you get my drift. 

Some drugs have had to change names because of late realizations of their risk of confusion with other pharmaceuticals. Omeprazole, developed in Sweden, was named Losec. It still has that name in many countries, but in the US, presumably because vowels are pronounced less distinctly here, it was felt that the name could be confused with Lasix, the diuretic. So it was renamed Prilosec here.

The antidepressant Trintellix (vortioxetine) used to be called Brintellix. That name was scrapped because of concerns that it could be confused with Brilinta (ticagrelor), a blood thinner. 

One odd thing about drug names is that one generic can have two brand names when a drug has been approved to treat more than one condition. Wellbutrin (bupropion) was used as an antidepressant for many years before it was discovered that it could help people quit smoking. It was rebranded and sold as Zyban because the worry was that smokers would resist taking an antidepressant to quit smoking because of the unfortunate stigma of antidepressants.

Viagra was launched years after the first formulation of sildenafil, Revatio, was approved for treating pulmonary hypertension. After the last phase of testing Revatio, many male patients refused to give back the pills they had taken in the study. The researchers asked why, and started hearing stories of enhanced erections. They went back to the drawing board and did a formal study of this indication and the rest is pharmaceutical history.

The Internet is full of suggestions for funny drug names. One of the better ones I have seen is that Viagra should be called Peniscillin. But that wouldn’t fly because it would be too easily confused with the antibiotic…

(Pictures below…)

Just over a year ago I wrote about mixing telemedicine with in person visits. 15 months into my new practice, I see very plainly how making the initial visit and maybe a few more as in-person housecalls, I am able to establish a stronger connection and a deeper understanding of my patients and their circumstances than I did in my office based practice. 

Now, I am blessed to do more and more of my follow-up visits using the technology of video visits. And we are adding new technology to let both our doctors and our patients listen to heart sounds together in real time, for example.

In some cases I do my video visits alone with the patient in their home in front of their smartphone, tablet or laptop. In some cases I do them with my assistant in their home, setting up the technology on her laptop, doing the vital signals and, soon, using a tech enabled stethoscope and otoscope. We already have the ability to do EKGs that way, too. 

When things work very smoothly, I can do video visits by myself while my assistant travels between patients who can’t manage the technology on their own. My territory is more than 3 hours from north to south, so it takes some sophisticated scheduling to maximize our efficiency and most of the time we do that really well. 

I’m really looking forward to starting to use the virtual stethoscope. There are a couple of ways you can use it. One is having the assistant record the heart sounds and send them to me so I can listen to them more or less on my own and then tell patient about what I hear, but I prefer the modality where the recording happens in real time and both the patient and I hear the heart sounds. I can then say “did you hear that irregularity in the rhythm? That’s a type of extra beat and usually they are very harmless“ or “do you hear that swishing sound, that’s a sign that one of your valves isn’t opening correctly”. Doing that in real time, mimics the in-office auscultation of the heart and enhances it by having us listen at the same time. I never really pictured that a remote visit in some ways can be more informative for the patient than an in-person visit.

I’m indescribably happy with my mix of old fashioned housecalls and modern-tech telemedicine. The fact that the only desk I have is at home is amazing, actually plural – two desks – my kitchen island and the small, white fold-out desk in my library at the other end of the house. 

My two Alabai rescue dogs are super happy. The younger one, the daughter, had some anxiety when I was in my old job and gone all day. She chewed on one of my favorite pairs of penny loafers. That never happens anymore. I have a wonderful work-life balance.

The other day, I reposted a piece from 2010 on my Substack, titled Doing Nothing, about an older woman who elected to leave her blood pressure untreated rather than putting up with the side effects she had experienced with every blood pressure medication she had tried.

When it comes to cardiovascular risk, I often use the American heart Association/American College of Cardiology risk calculator. But it doesn’t go beyond age 79. I use it a lot to show patients that statistical impact of quitting smoking, controlling blood pressure or taking cholesterol medication. Just to illustrate, I imagined a 79-year-old woman, non-smoker, who has high blood pressure and let the app tell me how much cardiovascular risk would be reduced if I put her on blood pressure medicine. Untreated her 10 year cardiovascular risk would be 36.3 if she were 79. The optimal risk is 18.4% and the impact of controlling blood pressure would be a reduction down to a 10 year risk of 26.6%. The woman in my story was much older, so her risk would be much higher than 36%.

I find that people have an easier time handling statistical odds if you also give them the probability of nothing bad happening. So, Ms. perfect would have an 81.6% probability nothing would happen. The 79 year old with untreated high blood pressure would still have a 63.7% chance of being okay, but could improve that to 73.4% by taking blood pressure medication.

The woman in my story was 88 years old. According to the Social Security Administration tables, her remaining life expectancy would be just over 5 1/2 years.

Her decision was to stay away from medications because they made her feel bad. It was a quality of life choice she made. I couldn’t blame her. Doctors these days get graded on what numbers our patients achieve. A blood pressure of 140/90 or more is a failing grade and 139/89 is a passing grade. Statistics like that one impact our practices’ bottom line and possibly our own salaries and at least our quality ratings on various websites.

So how bad do doctors feel if their older patients are not “at target“ with blood pressure, cholesterol and other things that we are being graded on? And how good do we feel if we let patients decide for themselves what their priorities are?

You can’t always both ace your quality metrics and also be patient centered at the same time. It’s easier to be hung-ho in getting a 40 year old to quit smoking than it is to make an 88 year old with a remaining life expectancy of less than 6 years to suffer from medication side effects for the rest of her days.

Something I wrote on my Substack a year ago…with an update.

I don’t think it matters so much how we celebrate the new year, just as long as we pause and reflect, in case we need to make some course corrections. And as long as we celebrate the symbolic new opportunity that a new year brings.

As an only child in a family with a relatively small social circle, New Year’s was never a big hullabaloo when I was growing up. In my late teens, I was a scout and part of a group that wanted things to be more rugged. We hijacked the American name, Explorers,and dressed in green overalls with an emblem painted on the back, and one of the things we did was celebrate New Year’s by hiking in the woods in the snow regardless of the temperature. We had army tents, very similar to the one in this picture and there was a little stove in there, but of course you still needed the most expensive sleeping bag you could buy in those days. I still have mine. When I have had to sleep in the horse barn on cold winter nights, I have resorted to using that, I still have mine, bought in 1970. Pretty amazing durability.

Fast forward to the 2000’s, black tie, multi-course dinners with dancing at Chateau Frontenac in Quebec several years in a row, and now home cooked Swedish holiday meals with children, grandchildren and girlfriend right here in Caribou, Maine. We cook together and eat the traditional Swedish holiday foods and we may play some silly games. Then we melt soldering “lead” and pour it into cold water and analyze the shapes created, which are supposed to foretell the next year’s biggest events.

All ways to celebrate are good, there is a time and a place for everything. In fact, this year will be different from the last few because my daughter just changed jobs and can’t get New Year’s off. So, Della and I will celebrate by ourselves with dinner, a movie and watching the ball drop at Times Square, where we just visited a couple of weeks ago. And Asti Spumante at midnight!

Happy New Year!