A Country Doctor Writes:

Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying”, she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that”, I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

I scrolled around in her chart. She was up to date on her mammogram and colonoscopy.

She was clearly worried.

“We’ll put in requests for the Prior Authorizations for these scans and let you know when they’re approved”, I said.

She looked puzzled.

“I have Martin’s Point Generations Advantage, that’s good insurance”, she said.

I sighed. “Well, it’s managed Medicare by a for profit company, like an HMO, and on the one hand they pay for physicals, unnecessary screening tests like carotid ultrasounds on people without bruits or symptoms, gym memberships and whatever, but on the other hand they don’t automatically pay for things like CT scans for weight loss.”

She looked incredulous.

“We’ll keep you posted”, I promised her.

Sure enough, a day or two later my referral coordinator came and told me:

I’ve just spent 45 minutes on the phone with these people and they’ve denied the CT scans.”

“Here we go again”, I answered her and thanked her.

I called Jeanette up and told her. “You’re due for your liver ultrasound pretty soon anyway, so we’ll do that, and we can get an x-ray of your lungs right here if we stress that you have a smoker’s cough. And, even though your thyroid test was normal six months ago, we can repeat that, plus I can run a test to make sure you’re still making your own insulin and not turning into a Type 1 diabetic.”

The chest film and extra bloodwork came back normal. But the liver ultrasound suggested a problem in the pancreas. A “pancreatic protocol CT” was suggested by the radiologist.

Martin’s Point approved the CT this time.

It showed calcifications in the pancreatic duct and an irregular appearance of the texture of the distal pancreas. Now the radiologist recommended an MRI evaluation of the pancreas and its ductwork.

Martin’s Point denied the MRI. After 45 minutes on the phone with my referral coordinator.

Medicare for all? That’s coming up a lot in the american health care debate these days.

Which kind, would be my question. The Lyndon Johnson kind or the Martin’s Point, Aetna, WellCare, Cigna, United Health kind?

I know the difference. I have a brand new red white and blue card in my own wallet.

And I’m probably breaking some obscure insurance gag rule right now. But this story happens every week in clinics like mine and it’s got to stop.

There is a lot of talk about team based care nowadays, and I have seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.

But at the same time, there are so many decisions – judgement calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.

I talk to patients all the time who ruminate, often at night, about the choices they made every day, and replay their conversations, reasoning and actions to the point of losing sleep and experiencing distresss.

I also know of a few clinicians who do the same thing.

I think there are a few fundamental tolerances clinicians must have:

One is tolerance of uncertainty. The other is a tolerance of being where the buck stops.

“Medicine is a science of uncertainty and an art of probability” is a famous quote by my hero, Sir William Osler, the “Father of Modern Medicine” and of bedside teaching.

This is a dichotomy: On one hand, the diagnostic possibilities in most cases are nearly endless, thus uncertainty, but at the same time, the major probabilities are usually pretty clear cut.

Our mission, should we chose to accept it (Mission: Impossible – in my case, the original series; I assume that quote is still relevant) is to embrace both the uncertainty and the need not to accept indecision.

In that moment, we are often alone.

The only way to balance these seemingly opposite notions is to acknowledge that no one can know for sure but the probability is…that is, being human and being fallible, but also possessing a certain amount of knowledge based confidence.

In my Swedish training, it was considered appropriate to consider and make a clinical decision based on “the odds”. In America, that isn’t always recognized. I agree you cannot completely skip over considering the probability of the esoteric, but how much weight do you give it?. If we don’t reign in the temptation to overestimate the odds of the esoteric, our health care will bankrupt us even faster than I imagined.

The kinds of decisions we usually need to make on our own are ones we have to live with and ones we cannot let ruin our sleep or our sanity:

Antibiotics or not? Hospital admission or not? Imaging or clinical diagnosis?

You do your best. It is all you can do. Without obsessing. Osler called that Aequanimity.

Treating a headache with Imitrex and having it turn out to be a brain tumor instead of a migraine is every primary care provider’s nightmare.

That is a dramatic illustration of treating a symptom instead of a diagnosis. But even when we do everything by the book, how often are we treating a manifestation, or symptom, rather than the underlying cause of a disease when we believe we know the right diagnosis?

Consider diabetes and dementia (now called “Type 3 Diabetes”), depression and irritable bowel syndrome (both responding to serotonin reuptake inhibitors), are we getting deep enough at the root of the problem in either case? And, since we now know that both MS and Myasthenia Gravis have immunologic mechanisms, aren’t we just scratching the surface with our current treatments?

Since I wrote my post titled “Treating Symptoms” five years ago, it has become clearer and clearer that that is almost all we do in modern medicine.

Other than infectious diseases, there are fewer and fewer diseases where we have any reason to believe our pills and potions are getting to the ultimate cause or mechanism behind the disease. And even with infectious diseases, we don’t always treat the root cause of why some people who are exposed get sick and why others are not.

One glaring area of medicine is psychiatry, where we know one genetic abnormality can lead to manifestation of any of a whole group of diseases.

The Broad Institute of MIT and Harvard published on this topic:

“Researchers explored the genetic connections between brain disorders at a scale far eclipsing previous work on the subject. The team determined that psychiatric disorders share many genetic variants, while neurological disorders (such as Parkinson’s or Alzheimer’s) appear more distinct. The results indicate that psychiatric disorders likely have important similarities at a molecular level, which current diagnostic categories do not reflect.”

The Journal of Immunology Research wrote about similar underlying mechanisms behind SLE and Rheumatoid Arthritis, psoriasis, multiple sclerosis and myasthenia gravis, conditions often treated quite differently, but never quite at their now known root cause level.

“…the role of HLA-DRB1 alleles has been evaluated in a large cohort of patients affected by different autoimmune diseases, identifying associations between specific alleles and different diseases and the HLA-DRB13 underrepresentation in all diseases evaluated [e.g., SLE, Psoriasis (PS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Systemic Sclerosis (SSc), Multiple Sclerosis (MS), and Myasthenia Gravis (MG)].”

Yet, the way we approach and name the chronic ailments of modern humans is based on organ systems: Neurologists treat MS and Myasthenia Gravis, Dermatologists treat psoriasis and rheumatologist treat SLE and RA, ophthalmologists treat uveitis and so on.

So, should we have more geneticists? Or more immunologists?

Not necessarily.

Since the same gene can cause widely variable diseases, there is a step between the gene and its expression, and that is where lifestyle, environment, diet, climate and everyday modifiers play in.

We need medical practitioners who can translate what we are more and more understanding into practical, individualized interventions.

It is almost like before phenylketonuria was discovered. You didn’t need a corps of geneticists on the frontlines once the understanding was there. You just needed to know who shouldn’t eat what (a simple blood test) and proper labeling of foods.

That is the future we are seeing the very beginning of.