A Country Doctor Writes:

Archive Page 127

Too Early or Timely Diagnosis

Published November 12, 2017 Progress Notes 2 Comments

I went to a thought provoking series of talks about dementia the other day.

One of the first PowerPoint slides listed “Early Diagnosis” as being important.

Having watched my father in his final days of end stage Alzheimer’s disease seven years ago, I have no sympathy for screening the general population for this gruesome disease. Why would anybody in their right mind want to know that such is the fate that awaits them?

If you have no symptoms, and if you are enjoying your family, career, community and intellect, could you still appreciate whatever time you have left on this planet if someone told you that you are doomed to die emaciated, nonverbal, incontinent, immobile and contracted?

Screening for incurable and essentially untreatable conditions is only cruel and meaningless, I challenged the speaker.

She clarified her viewpoint by saying that she didn’t mean to make the diagnosis as early as possible, but rather in a timely way so that patients and families can start making decisions.

Thinking back to my own practice, I know that I have perhaps not always called a spade a spade by spelling out the diagnosis of dementia and putting it on the problem list until late in the course of the disease. I can see that it is my obligation to do that when symptoms are only beginning to threaten a person’s judgment and abilities. Making sure Advance Directives are in place is important, and a couple with one spouse showing signs of mild dementia probably shouldn’t buy a two story home far away from public transportation. The speaker also advised estate planning and considering options to pay or qualify for aid for long term care.

Another topic was driving, a situation where I certainly have been the non-family bearer of bad news many times (see my post “A Very Careful Driver”).

So, I did mellow in my resistance to labeling patients with dementia before they become debilitated.

In the same vein, what keeps me from putting other emotionally loaded labels on the problem list, such as:

F10.20 – Alcohol dependence, uncomplicated
Z72.53 – High risk bisexual behavior
F52.22 – Disorder of sexual arousal, female
N52.9 – Erectile dysfunction

One thing is the patient’s overall perception of privacy when the (mandatory) visit summary contains a loaded diagnosis. Specifically, in a very small community, there is the possible concern that staff members without direct clinical involvement (front desk staff) may see such diagnoses. And, perhaps most importantly, with health care law changes in our country’s future, concerns about future uninsurability.

Because making a diagnosis isn’t just a matter between me and my patient anymore.

How to Write Like a Dockter

Published November 8, 2017 Reflections 2 Comments

Many physicians have become world famous writers and in Greek mythology, Apollo was the god of both poetry and medicine.

I can personally think of many prominent physician writers I have come across in my reading over the years:

There was the 12th century rabbi Maimonides, Copernicus in the 15th century and the poet John Keats in the 1700’s.

In the late 1800’s to early 1900’s there were Anton Chekhov, Sir Arthur Conan Doyle and William Somerset Maugham.

Examples from our time (or at least mine) are A J Cronin (Dr Finlay) Robin Cook (Coma), Viktor Frankl (Man’s search for meaning), Michael Chrichton (Jurassic Park), the Polish science fiction writer Stanislav Lem, M Scott Peck (The Road less traveled), Oliver Sacks, Frank Slaughter, Sherwin Nuland, Walker Percy and more recently, Mainer Tess Gerritsen.

But you wouldn’t think doctoring and literature are even remotely connected after reading what my colleagues and I are producing every day in our electronic medical records.

In journalism school and writing classes they tell you how to capture the reader’s attention and make your point effectively. They teach how to make the readers feel like they are witnessing real events and experiencing the emotions of the characters of the writing.

In medical charting class, and when using EMRs, the priority is to prominently list the items that are required for payment and compliance purposes.

Evaluation and Management (E&M) reimbursement codes are built around how many aspects of a symptom or a physical exam are documented. Sometimes called “bullets”, each one is usually a separate sentence in the “printout” display of a medical record whereas to the documenting physician they may be a click box. Looking at the computer screen, they are sometimes quick to review, much like the paper forms I used to create for upper respiratory infections, urinary tract infections and physicals etcetera in the days of paper records. But when our computer programs turn these checkboxes into sentences, they look more like “See Spot run” grade-school English than an expert clinician’s narrative.

Here are two screen shots from a clinic a couple of towns north of here:

Writer’s view:

Reader’s view:

Anybody who tries to quickly read such notes would probably just as soon see the original clickboxes, instead of the stilted English produced by the EMR.

Back to the real writers among us – here is how Abraham Verghese explains the deep connection between doctoring and writing:

“I’m really struck by how much of what I learned in medical school has helped me to be a writer, and how much of what I learn as a writer helps my thinking as a physician. They are very parallel disciplines. When you take a patient’s clinical history, what is that but a story? What makes a good doctor is that he or she takes the story down well, sees the links and makes the connections toward a diagnosis. That’s also what writing is about.”

I guess that’s why, after a long day with my patients and my highly structured EMR, I like to sit down in my den next to the horse stalls with a completely blank screen in front of me and just tell stories.

Give Specialist Doctors a Break!

Published November 4, 2017 Progress Notes Leave a Comment

As I scrolled toward the end of a consultation report from Cityside Pain Management the other day, I gasped internally. The pain clinic listed all kinds of mandated “quality” items, by number, that they have no chance of knowing.

Nor should they.

Since our EMRs don’t talk to each other, they have no way of knowing whether I ever ordered a bone density or pneumonia shot for my patient. And if they went ahead and did something preventative, how would I find out about it? Don’t assume I have a realistic opportunity to look for the occasional pearl in the massive number of outside computer printouts I get as PDFs in my electronic inbox.

No specialist should be jealous of my task of trying to stay on top of all my patients’ health maintenance. I send my patients to a specialist so they can spend 45-60 minutes on the single problem that is the main focus of their practice. Why would I want them to spend a significant portion of their valuable time on something that very plainly is my job?

The answer to my rhetorical question is:

Because CMS, the powerful agency behind Medicare, says so – that’s why. It makes no sense to me, but I’m just a country doctor, what do I know?

A Boomerang Patient

Published October 30, 2017 Progress Notes 2 Comments

It is not unusual to see a patient for a timely “Transition Of Care” visit after a hospital admission and within a minute of entering the exam room know with all the bones in your body that this person needs to go back into the hospital.

The funny thing is that when that happens, if the patient has Medicare, we may indirectly suffer financially from such “avoidable readmissions”. We belong to an ACO, an Accountable Care Organization, which is one of the recent schemes Medicare created to save money. The hospital most of our patients go to, Cityside, is not part of our ACO, but we are at financial risk while we have absolutely no control over the hospital’s charges or readmission rates.

I mean, what else could I have done with Allan Beck?

He had rolled his tractor and broken half a dozen ribs a little while ago. Commendably, he didn’t want to go to the emergency room for nothing, so he had called and argued with the triage nurse about coming here instead. She thought she had him convinced, but half an hour later he showed up at the check-in window.

“Triage to the front desk” was announced and Dr. Kim ended up seeing him briefly and ordering ambulance transport to Cityside.

When I walked into the exam room a week and a half later, the muscular could-have-been-a-movie-star farmer was so pale and frail looking that he seemed to blend in with the faintly blue wall paint.

As the story unfolded between his laconic answers to my questions and my speed reading of the hospital discharge papers, it became evident that the day before discharge, he had substantial atelectases and possibly an evolving infiltrate of his left lung, but that his collapsed lung remained expanded with his chest tube gone.

“Yeah, I’ve been coughing up yellow crud since my first day in the hospital”, he told me.

He had almost no breath sounds in his left lung, his white blood count was up and his reds were the same as when he was discharged, one third down from his baseline. His X-ray showed what I had heard, a massive consolidation of much of his left lung – a nasty pneumonia or even empyema, pure pus.

The ER doc sighed. “OK, send him up.”

The irony is that there is a new scoring system that’s supposed to predict a person’s risk of readmission. Allan’s score was low. Everybody loves to use mathematical models, but when it comes down to it, clinical judgment and anticipating “the worst” would have been more valuable in the very moment that his last hospital X-ray was done.

Annual Evaluations

Published October 28, 2017 Progress Notes Leave a Comment

October is when we do our annual provider evaluations. I’m using the same format this year as last, a personal inventory done by each provider as well as three others – support nurse/medical assistant, clinic manager and referral coordinator/radiologist/care manager. This is complemented by assessments of billing/documentation, quality and productivity data and overall assessments by management.

I guess, in a way, I wrote the provider self assessment as a yardstick for myself. It’s hard sometimes in today’s detail driven healthcare environment to remain focused on what it means to be a doctor.

I’m sharing it here for anyone who is interested. Just to mention, only one of my providers gave himself/herself a “10” on every question, and it wasn’t me…