A Country Doctor Writes:

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.

I deleted my Twitter account when Elon Musk took over. I briefly tried Threads but found it useless and boring. Now I’m trying Bluesky (@hansduvefelt.bsky.social). Anyone of my contacts who’s also there, “friend”/ FOLLOW me there or let me know here and I’ll soon find out if Bluesky is a place for me to share links, photos and shorter observations.

Exchanging ideas with Dr. Lilian White about what each one of us might write on this topic, I ended up focusing very hard on the word HEAL. In Swedish, the word for physician is LÄKARE, which literally means HEALER. But the sad truth is that we treat a whole lot more than we heal. The way I understand healing is restoring natural and at least nearly perfect health. That may be the case with repairing a laceration or casting a fracture, but it hardly characterizes what we do when we prescribe medications for chronic health conditions, substances that mitigate symptoms but often cause secondary, unwanted, and sometimes downright dangerous side effects.

By now we know that there are just a few disease mechanisms that cause most of the chronic conditions affecting modern human beings. There is inflammation, which in large part is related to the foods we eat. Ultraprocessed foods and foods with too much sugar or unnatural additives are drivers of many such conditions. We also know that physical inactivity lies behind many conditions. Stress, screen time and sleep quality also threaten our health these days.

If these drivers of disease and ill health are recognized early enough, healing is possible, but sometimes all we can do as physicians is harm reduction. 

I believe the fundamental principle behind the phrase PHYSICIAN, HEAL THYSELF is that we need to be stewards of our own bodies and our health and demonstrate and share that ideal to our patients. I also, naturally, believe that by taking care of our own health, we can do more good for more people as we decrease our own risk of illness and burnout. Ignoring our own needs in order to maximize our output, productivity or whatever you choose to call it is ultimately wasteful. 

Now, I readily admit there were times when I put my work before my own health and there were times when I could have been more present for my family. There were the years when I worked 6 days a week, 40 hours in Bucksport and 20 in Aroostook County, 223 miles between my two houses, 4 hours when the weather allowed, much longer many times in the winter. Three times, I swerved around a moose that was standing still in the middle of I-95 as I was driving almost 80 miles an hour in the early morning or late evening hours during my self imposed commute. During those years and a few other times in my life I put my work so far ahead of my own health and wellness that I definitely didn’t live up to the adage of healing myself so that I would be likely to do more good for my patients in the long run. 

It is often said that physicians make the worst patients. I’m definitely in that category. There are two aspects of this, at least in my own case. One is that I’m pretty opinionated by virtue of my knowledge and experience. I know the back story to many of the things we now consider axiomatic, but that have changed more than once during my years in this profession (or should I use the word business – no, that’s another topic). The other is that, also in part because of my many years of doctoring, I have become more than a little fatalistic in my views on preventive medicine. What makes sense when you look at populations doesn’t always make sense for individuals. I sometimes say “I provide health care but I don’t partake in it”.

I have seen too many times that bad things, bad diseases, happen to people who do all the screenings and follow all the rules to try to stay healthy. 

Here’s a 2 year old article I happened to read tonight:

The Nordic-European Initiative on Colorectal Cancer (NordICC) was a large, multi center, randomized study that investigated the effects of population-based colonoscopy screening on the risks of colorectal cancer and related death at 10 years. It was published in 2022. Its conclusion was “The number needed to invite to undergo screening to prevent one case of colorectal cancer was 455 (95% CI 270 to 1429). The risk of death from any cause was 11.03% in the invited group and 11.04% in the usual-care group (risk ratio 0.99; 95% CI 0.96 to 1.04).” 

I wonder if this has anything to do with the statistic that a quarter of all polyps are missed during the average colonoscopy.

So what’s a skeptical, seasoned senior physician to do if he doesn’t like to partake too much in healthcare for himself? I have hypertension and there have been times when I refilled my own medication, but for a few years I asked one of my partners to refill them for me. Now I see a nurse practitioner I once helped train, who is in her own private Direct Primary Care (DPC) practice. She’s always respectful of my clinical suggestions. 

When Lilian and I collaborate, one of us usually gets to share their draft first, then the other shares theirs and then we publish our finished pieces more or less simultaneously. This time, she shared hers first. Because of that, I will tag on to her paragraph about moral injury, a concept closely linked, but perhaps not always synonymous with burnout. But my own healing journey has involved two things directly related my work:

First, in 2008, during a time when I felt a lot of pressure in my work, I started writing my blog about my experiences, feelings and reflections. Doing this helped me focus on what really mattered to me in my day to day and long term view of my work. I often slipped my personal experiences and reflections into my writing, too and the course corrections they inspired.

Second, when the computerized medical record started to more and more control my actions and monopolize my time, robbing me of quality time with my patients and time for my life outside of my work, I quit. I joined a practice with a different business model, not piecework, not Fee-For-Service but results driven. Not “get them in, get them out”, but “make’m better”, whether it’s a house call, video visit or phone call. Where I work now it doesn’t matter how it happens – as long as it does. 

So that’s how I try to preserve, protect or regain my own health: I eat healthy, do lots of manual labor on the farm, spend time with my dogs and my horses, enjoy healthy relationships with those I love, reflect and write about my role as a doctor, and view each one of my patients as more than a number, more than a Ka-Ching, but another human being I have the privilege of helping or guiding, for however how long.