A Country Doctor Writes:

Quality in medicine is a moving target. I have reflected and written about this topic many times, perhaps most recently in March of this year. When I was medical Director in Bucksport, Maine, I did not allow the use of numeric pain scales for the simple reason that frame of mind influences perception, and even though opiates are often effective as anxiolytics and antidepressants, there are safer treatment options. It is ironic that it takes so long for medical evidence to be adopted into practice (17 years average), and then when it comes to quality metrics there is another delay on top of that. Well, anyway, I was just informed that pain assessments for Medicare patients’ quality scoring is about to be “retired“ with the beginning of the new year. Thank goodness.

Of course, we still need to deal with patients who have pain, but assessing pain is not straightforward, much less numeric. We need to understand the significance, the symbolism and the psychological components of what people view as pain. Narrative medicine, if you will.

Mandatory Pain Assessments Are Such a Pain

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.