A Country Doctor Writes:

My power company, which stretches in a thin strip from northernmost Maine to the area around Bar Harbor, Maine, has 164,000 customers. This morning 30 minutes after my morning coffee brewed automatically, I lost power along with 68,000 other customers.. By 11 PM only 7300 customers are without power so they did a good job restoring the grid after a terrible overnight wind storm.

Both my little farm up here and the saltwater farm I bought near Bar Harbor have been plagued with power outages. Here I have the largest portable generator, you can buy and down there we invested in a standby automatic generator.

I woke up to darkness this morning thinking I need to get out there and get the generator going to get some coffee, but my coffee had already been made so I could relax and drink my 1st cup before starting the generator.

It keeps you humble to be subject to the elements because you’re living in the northern extremes or near the coastal weather systems.

Here is a post I wrote about loss of power in my very first year of blogging.

There was an interesting thread in the conversation during the weekly Suboxone clinic I participate in remotely as the prescribing doctor. The behavioral health team leads the group and I see patients individually in a Zoom “breakout room” via my iPhone on a little tripod/selfie stick from my kitchen table or my home office/library.

I usually have a chance to listen to at least some of the check-ins before my individual meetings start. Like many groups we start with a check-in and end up with takeaway and homework. I often catch the end of that part of the meeting after I see my patients. After the participants leave, the behavioralists and I go over how everyone is doing. We also touch on what themes came up in the conversation.

Being Dependent on Recovery came up this week. It is common to develop addictive behaviors toward something different when you are treated for opiate addiction. Some people gravitate toward drinking, for example. We also see food addiction and increased use of tobacco or marijuana.

The new concept was that the recovery work in itself can become such a strong focus that others may view it as a dependence, or even an addiction. This is not just a clever play with words. I think it is a natural tendency for some people to create principles and rituals that support, strengthen and sustain their recovery. Others may see that as too exaggerated or unnecessary, but gravitating toward another substitute for the opiates is certainly no healthier.

So the original concept from the group discussion, dependence on the recovery process, is fine with me. The way we use the words dependence and addiction are that people with a dependence function normally but could suffer in some fashion if they don’t have what they are dependent on. Not all dependence is bad. We all need oxygen, for example, and some people with bad lungs need supplemental oxygen. Addiction involves behaviors that ultimately harm the person who uses the substance or people around them. Being extra enthusiastic about your recovery doesn’t hurt anybody in my opinion – it could even be life saving.

This brings me back to something I published in 2008, a condition (because everything humans do seems to need a medical description or diagnosis) called orthorexia nervosa. This is where people adopt extremely healthy lifestyles. Their lives may be more complicated because of the high standards they set for themselves, but we are all on our own journey, so I say to each his own. Extra healthy habits that bring a person joy and not suffering (fretting about not measuring up) have my blessing.

Orthorexia Nervosa – Too Much of a Good Thing

https://youtube.com/@acountrydoctortalks

I’m still very curious after this many years in practice. I Google stuff all the time. A couple of times I have scratched my head about patients of mine with low potassium in the emergency room. I even had that myself in one of my very rare visits to that kind of place. I did not enjoy the flavor of my oral potassium replacement.

This abnormality turned up again the other day, and I finally stopped in my tracks and said to the patient, “I often see this happening when my patients go to the emergency room, but after a little while it normalizes most of the time. It has to be some sort of stress reaction. But we will check your level again just to make sure”.

When I Googled it, everything fell into place. All the stress hormones lower potassium. It’s not their major effect or reason to exist, but that’s how it works. I don’t know if it serves any bigger purpose. But we should definitely not assume that patients under stress with low potassium need lifelong replacement therapy.

Written for a now defunct medical website in 2020

Hello, my name is Doctor Bottleneck. My role is the opposite of a company CEO or a small business owner, even though I am clinically responsible for the care of my patients and the financial impact thereof.

In the business world, CEOs set policy and delegate tasks and responsibilities. They watch the big picture and get into the nitty gritty only if there seems to be a problem or a need for change because of new opportunities.

My role is to literally touch everything that happens to my patients, even if I’m not the doctor ordering a test or responsible for what to do with the result.

This, on paper (for those who still find that analogy relevant), sounds like a good idea: One medical professional maintaining an overview of each patient’s care. Theoretically that would seem to lead to better, more cost effective care.

Each primary care doctor is directly generating perhaps a million dollars in direct practice revenue. (This is only a guess, because I don’t know my own numbers or even an official average.) Then, with the new ways of counting actual cost per patient compared with a theoretical assumed baseline cost, we are more or less held responsible for the financial impact of clinical decisions made by other doctors far beyond our control. So, if we each have 1,500 patients with average annual health spending of $8,000, we could have something to do with $12,000,000 worth of healthcare decisions every year.

But there are two problems with this:

FIRST, doctors see patients all day long and generally have absolutely no time set aside in their schedules to read our own incoming test results or incoming specialist reports, answer questions or even refill prescriptions – all those things are done outside our patient schedules during uncompensated overtime.

What makes these duties even more cumbersome is that our current EMR “workflows” require that absolutely everything that goes into each patient record is electronically signed off by the primary care physician. And given the current level of sophistication of our software, scrolling through a seven page discharge summary or consultation note that may contain medication changes or followup suggestions takes multiples of the time it used to take to do the same thing on paper. In addition, papers were often sorted by support staff and prioritized. In electronic records, the provider is the first and only person who sees anything that comes in. It is then up to us, again in spite of the clumsiness of our software and the lack of time for doing this work, to delegate followup actions to our support staff.

SECOND, doctors know almost nothing about the financial impact of everyday clinical decisions.

We are starting to be held responsible for the total cost of our patients’ care with little or no knowledge of what the real cost is of tests and procedures at the hospitals and specialist offices around us. This is a whole new area for us and I see little progress in spreading this kind of information to primary care providers. If anything, I see this as an emerging area of confusion and resentment between medical administrators and clinicians.

So, even though the world seems to need doctors to maintain a fairly detailed overview of the clinical and financial aspects of our patients’ total healthcare, the world severely underestimates how much time that takes – or should take, if we are going to do it right.

I think it’s high time we have a serious discussion about the best use of a doctor’s time. How many hours per week does it take to manage our patients’ healthcare and how much is that worth? How much time are we wasting right now on perfunctory electronic signatures? To what extent are we allowing workflows that feed the computer but suck the life blood and enthusiasm out of the medical providers who feed it what it wants without getting back from it what they need?

And I don’t like he name Doctor Bottleneck. I want to be Doctor Real.