A Country Doctor Writes:

St Elsewhere, medical drama, first episode 15 months after I started my family medicine residency in Lewiston Maine. Tonight, I watched it again.

In 2017, I published a piece about the no longer common or even existing inpatient workup. I often think about how efficient it would be if we went back to doing them again. If we could do the necessary tests to diagnose or rule out cancer and other serious diseases in one or two days at a dedicated diagnostic center, healthcare would be a lot more efficient.

Not only would patients get their diagnosis quicker, but equipment like MRI and CT scanners could be used more efficiently – scheduled tighter- when patients are right there, already registered and on site. Both imaging and labwork could have more reflex testing – if the result of test A is x, then also run test B.

Compare this to today’s multiple steps, with wait times in between: First the patient has the less expensive ultrasound. Then the overworked primary care doctor, who is seeing patients all day long, eventually sees the result and orders a CT scan. Then there is the wait for a Prior Auth, then the wait for an appointment, followed by the same steps again before am MRCP reveals a pancreatic mass, suspicious for cancer. Then there is the referral to gastroenterology for tissue diagnosis via an ERCP.

Inpatient workups could virtually eliminate Prior Authorizations at the Primary Care level. The doctors overseeing such centers could have direct access to the insurance companies’ algorithms. The insurance companies could then eliminate many of the clerical staff that listens to or reads outpatient doctors pleading their cases for getting imaging tests approved, just like the primary care offices could get by with less clerical staff working the prior authorizations.

And just think about how much a system like this would reduce patient anxiety by shaving many weeks off the time to diagnosis. In some cases, this could also affect clinical outcomes by avoiding the inhumane bureaucratic delays we now have to deal with. I have seen too many times how patients end up in the emergency room with advancing symptoms while waiting for the imaging I ordered for them.

In a world where a blood pressure of 140/90 is a failing grade and 139/89 is a winner, seasoned physicians sometimes get accused of not moving with the times. But, of course, we still remember the world we grew up, trained and practiced in – Medicine, as opposed to today’s Metamedicine, which is a parallel universe where data is king, regardless of just how valuable it is for individual patients. A one point difference in a numeric parameter could easily be compensated by non-quantifiable things like how good this patient’s diet is and how good their social support system is.

I have written many times about the different views of physicians as either professionals or skilled workers. So many things in medicine today can easily be done by skilled workers with less training than physicians. But, like it or not, I think there are two things that require professionals with their greater depth, gained through more years of training in a more scientific environment. The first one is making a correct diagnosis when unsorted patients present with a jumble of symptoms. The second is explaining their disease or condition and guiding patients through the process of choosing the treatment approach that best suits their own phenotypes, circumstances and preferences. You have to know your diseases well to be able to individualize treatment for a variety of real people with real differences, even though they have the same diagnosis.

Rapid and accurate diagnosis for patients who are sick and scared is not a priority we hear a lot about these days. The low hanging fruit of public health and preventive medicine is, like flu shots, blood pressure control and recommended screening tests. Fancy procedures and expensive pharmaceuticals are getting a lot of attention, but nailing a difficult diagnosis by really knowing your stuff is an almost a forgotten and neglected, certainly undervalued, art form. And I have a hunch why that is. You can’t do prospective, double blind research about it. It’s hard to measure and probably even hard to conceptualize for non-clinicians. It’s sometimes even hard to identify when care is fragmented without a centralized EHR.

The other day, I saw a woman who was interviewing me in order to decide whether to transfer her care to my practice. That happens now and then.This woman had the diagnoses of hypertension and of general anxiety, as well as a few other things that I didn’t think immediately related to the reason she was considering finding another doctor.

In some office visits with her various specialists and primary care doctor her blood pressure was as low as 118 but most of the time in the mid 120s and occasionally it hit 145. At home, she ranged from 140 to 200.

This is what we call reverse white coat hypertension. This woman had essentially normal readings in the office and almost always ran high at home. It is much less common than white coat hypertension where the medical office environment triggers an adrenaline rush that raises a patient’s blood pressure sometimes.

Her primary care doctor had tried her on many different blood pressure pills without much luck. Her psychiatrist had her on the maximum dose of venlafaxine plus a few other things. In addition to that, she is prescribed 14 tablets of clonazepam with instructions that it has to last her a whole month and not to call for an early refill.

Clonazepam is a benzodiazepine just like Valium or Xanax. The only real difference between the benzodiazepines is how fast they kick in and how long they stay in your system. For people who take them for anxiety in certain situations, Xanax is often used. It is viewed as more addictive because patients feel the relief when it starts to work and experience dread a few hours later when it starts to wear off. Most prescribers think it is good only for rare situations like when flying in an airplane or going to the dentist. Clonazepam on the other hand is slow to kick in and slow to wear off and most of us use it only for chronic anxiety when the usual preventative medication aren’t working. It is dosed once every 12 to 24 hours, so it seemed odd to me that an experienced psychiatrist would dole out 14 tablets a month to be used as needed for somebody with anxiety every single day.

She lives in a housing development where she hears her neighbors through the walls. She sleeps on the living room couch, where she can see the front door, and never uses her bed or even her bedroom for that matter. She worries about people breaking in and sometimes she doesn’t even know exactly what is making her feel anxious. She doesn’t know where she might feel safer or happier, so she feels stuck and paralyzed without even any vision of how or where her life could be better. She completely rejected my suggestion of considering a roommate, maybe even in a different place, living a little bit like in the old sitcom “Golden Girls”.

I know exactly what is going on here. They teach you in medical school that if you try several blood pressure medications without success, it is time to look for what’s driving this. It could be hormonal problem with the thyroid or the adrenal glands. It could be too much alcohol, narrowing of the kidney arteries and many other things. Or it could be stress and anxiety. In this case, it seemed obvious that the anxiety is the driver because this woman, who spends every day and every night alone, has better blood pressures when she is in the presence of another human being.

I know exactly what is going on here in another way. Doctors who work for big hospital systems are often bound by policies and guidelines or simply an unwritten bias within their organizations. Benzodiazepines are like opiates in the sense that they are potentially addictive drugs that may be appropriate for short-term use, but they both have a phenomenon called tachyphylaxis. What that means is that people often develop a tolerance to the medication and over time need more and more for the same effect that they had when they first seemed to benefit from it. For this reason, hospitals, group practices, medical boards and various watchdog are working hard to minimize unnecessary use of these drugs.

This patient’s primary care provider is part of the same big organization so they would also be under pressure to avoid continuous prescribing of benzodiazepines.

So what I did was tell this anxious woman to really talk seriously with her psychiatrist in her upcoming visit about how the venlafaxine is not preventing the anxiety, she feels stuck where she is in an environment where she doesn’t feel safe and the clonazepam gives her good relief on the days she takes it, but if she cannot have it every day, she needs her psychiatrist’s help in getting something else that reduces her anxiety. There are many options for this, but taking a long acting drug only some days and not at all on other days doesn’t sound like a good long-term solution to me.

In some ways, prescribing the long acting clonazepam to be taken when she feels like she needs it the most, essentially, would be like taking a blood pressure pill on days where she thinks her blood pressure might be going extra high. We hardly ever do that, so what’s different in this case?

Skimming through posts by other writers on Substack, I came across a short piece that started a chain reaction in my brain. Its title was Who did I meet in my clinic?

The author described the diseases in his patient encounters as personas who had more or less invaded the lives of the people afflicted by them. Suddenly that made a lot of sense to me, and I saw all the parallels to how we use the concept and the word personas or sometimes personalities for not just our patients, but medications and diseases and also, from a psychological perspective, archetypal individuals who shaped the life of our patients and, really, all of us.

I had never myself quite claimed the insight that diseases have personalities, but they do. Some diseases are always slow, some always fast and dramatic, some wax and wane and can sneak back up on you even when you think you are cured. Some follow a course of tightly scripted stages. Seasoned clinicians are intuitive masters of pattern recognition, which really means recognizing the personalities of diseases.

I often speak and write about how medications have personalities. Prozac can be energizing, Paxil can insulate you from emotional pain, Wellbutrin can make you less angry, Remeron can make you hungry, steroids can de-stabilize your mood and so on.

In all types of sales and marketing, the term persona can be used for training purposes in describing customers with varying degrees of interest or ability to buy a product. Are they just looking, do they want lots of information or will they make an emotional decision?

As a doctor meeting a new patient, I need to read them and try to figure out what they are looking for and I need to behave in a way that I believe is effective in building rapport and trust and a therapeutic relationship. I try to assess the patient’s personality or persona, and I show more of certain aspects of my own personality as the situation might require. Some people think this is dishonest, I feel very strongly that it is necessary if you want to reach people and help them heal.

Another important application of the concept of personas is those individuals who shaped our lives, archetypes in Jungian terminology. Being raised by a narcissistic mother is just one example of common personality types ability to influence others.

All this reminded me of the title of an Ingmar Bergman film, Persona, which I never watched as a young man in Sweden. The trailer on YouTube was not appetizing, so I don’t know that I will take the plunge and watch the movie, but it is supposed to have lot of Jungian stuff in it.

The bottom line here is that everything has personalities, breeds of dogs, brands of cars, types of wood, digital recordings, vinyl, albums, printed books and e-books.

It’s just a useful analogy in most walks of life.