A Country Doctor Writes:

(As I hit PUBLISH for this post, I got a notice from WordPress that this was my thousandth blog post on ACDW!)

When I started out, most specialists were in private practice, as were most primary care doctors. Fresh out of my residency, the specialist consultants I referred to were obviously a little older than I. They were well established, made good money and were their own bosses. The grace in their lives was obvious to me.

Their consultation reports were typed on delicious, thick, often colored, stationery and signed with flair, often with a fountain pen. If I called them for what we call “curbside” advice, they were gracious and never seemed rushed. They took pleasure in sharing their knowledge with younger colleagues like me. I’m sure they also expected our referrals over time to be better and more appropriate.

Times have changed. Most of the specialty practices were bought up by the hospitals and specialist doctors became employees with a little less control over how their day went. I could tell when I called for advice that they had tighter schedules than they used to. Many of them also had less help in the office than they were used to having.

The other thing that happened over time was that, since they were all older than I was when I began practicing, one by one, most of them have now retired. The new generation of specialist isn’t as easy for me to call for curbside consultations because we don’t have as much history with each other.

My new practice has a subscription to a nationwide service that I was late in starting to utilize, but now I am hooked. I go to the service’s website, type my question and the clinical background, import labs or imaging reports and, typically in half an hour or less, get a helpful reply from a specialist with at least comparable credentials to what I was used to years ago, and often from somebody with an academic background.

I have received no-nonsense, real-world guidance with a urine culture growing enterococcus faecalis, with a case of Todd paralysis and once got ammunition in the case of an elderly cholecystitis patient with a cholecystotomy tube my local surgeons didn’t want to deal with.

I am now telling my patients here in this physician shortage area that I have almost instant access to specialists and subspecialists my patients would have to wait many months and travel hundreds of miles to see. This sometimes lets me handle more things myself and at the very least it helps ensure that my patients will get the right treatment while they wait for their “local” consultation here in Maine.

My practice actively encourages its doctors and nurse practitioners to use this service. This is such a time saver and worry reducer for both us frontline clinicians and for our patients.

Between first being too busy and then catching something protracted that has felt just like Covid, I have finally regained enough energy for some future posts, still in title only or first paragraph only format – I don’t draft and edit. I put down a start and if I don’t finish it right away, I do it later in one fell swoop.

Here is my recent Facebook post:

Recovering slowly from a virus that drained all my batteries, I remembered a favorite poem from my youth: FEVER, by John Updike.

I have just brought back a good message from the land of 200 (degrees):
God exists.
I had severely doubted it before:
but the bedposts spoke of it with utmost confidence,
the threads in my blanket took it for granted,
the tree outside the window dismissed all complaints,
and I have not slept so justly for years.
It is hard now to convey
how emblematically appearances sat
upon the membranes of my consciousness;
but it is a truth long known
that some secrets are hidden from health.

A blood pressure of 139/89 would be considered okay, but a reading of 140/90 on the last visit of the year gives the treating physician a failing grade, also called a “Care Gap” in the category of Controlling Blood Pressure. Never mind if that last appointment happened while the patient had a broken rib and was in pain. The same binary standard applies to hemoglobin A1c as to whether diabetes is controlled or not co The same binary standard applies to hemoglobin A1c as to whether diabetes is controlled or not compare that with the Fed, changing interest rates by a quarter of a point every so many months and making big news in the proces. Compare that with the Fed, changing interest rates by a quarter of a point every so many months and making big news in the process.

The practice of medicine is getting sillier and sillier the more we are held to “quality” measures. That is a substitute marker for outcomes. If you think about it, I could start a heavy duty blood pressure medication on my patient with a broken rib and reactive blood pressure from that and bring him back for a recheck before the end of the year and thus meet my quality parameters. In early January, when the rib fracture is no longer causing pain, the patient has an orthostatic blood pressure drop, falls to the ground, landing on cement and dies from a subdural hematoma. I would still be in good shape with my quality metrics.

The modern risk calculators that we use to assess cardiovascular risk in people with elevated cholesterol make it very plain that cardiovascular risk is a multifactorial calculation. Why we don’t have a similar view of blood pressure when we could use the cholesterol risk calculators to illustrate the difference between two different blood pressure numbers, whether with or without medication is, simply, ignorant.

In medicine today, not even gender is considered a binary metric. Why in the world are we then viewing cholesterol, blood pressure, or even blood sugar for that matter, more clearly defined than gender? If medical providers are too lazy to plug in blood pressure numbers into the cardiac risk calculators to determine the value of treating such blood pressures, perhaps AI can be of help doing the math for us?

The other day I had to handle an issue for another provider’s patient. In my conversation with the patient, I learned that they had gone through a relationship breakup and a major health crisis two months ago. One month later they had seen their PCP for a brief visit to recheck on a chronic problem. The note from that visit was full of details pertinent to that issue, but made no mention of the double crisis the patient had just gone through.

There are two forces behind situations like this. One is the time pressure in primary care practice and the other is the template driven documentation. So many EMRs have specific templates for specific problems. Most also let us providers create our own templates, which may not even have fill-in-the-blanks, but a whole normal visit that you can populate the chart with in just one click.

In today’s clinical documentation, the individuality of each patient tends to get lost. So much of the data in our office notes is structured and so much is boiler plate or copy and paste. The story is missing so much of the time.

Many if not most other “industries“ drill down on the uniqueness of their customers. Our social media feeds bring ads for things we have searched for on other websites, for example. Advertisers pay big money for such information so they can customize their approach to each of us. Medicine is the opposite: Doctors are encouraged or downright required to cover the same things in each office visit and to document it in the same, easily extractable, fashion. Narrative Medicine is a minority fringe, it seems. And this is in spite of everything we know about social determinants of health, genetics, epigenetics, mind-body medicine and psychoneuroimmunology.

My visit with this patient that I had never seen before lasted all of 10 minutes. You can learn a lot in such a short time. Why don’t we?

I do house calls in my practice, but I also do remote work with follow-ups done via telemedicine and sometimes even see new patients for wellness visits with a medical assistant at the patient’s home doing vital signs, etc. I also do a weekly telemedicine Suboxone clinic for my old practice in Bucksport.

Remote physician work was once unthinkable. In very few specialties like psychiatry, it has been around for a long time because of the scarcity of providers and, I suppose, because there was no expectation of doing any sort of physical exam. But it was really the pandemic that opened this way of practicing up for other specialties.

I just took a screenshot from a Google search for remote physician jobs. LinkedIn has more than 2,000 of them.

From once unthinkable to now almost mainstream, we are finally at the point where physicians are paid for cognitive work. This means we listen to the patient’s story, we evaluate the testing they have done, or that we order, and formulate a diagnostic and treatment plan based on that in collaboration with our patient. To be honest, I’m not so sure today’s doctors are all that diligent or skilled in performing physical exams. And even if we do, imaging and laboratory testing provide a better documentation than a physical exam if we ever end up in a medicolegal situation. This is, sadly, particularly true when so many medical providers use templates in their documentation.

Imagine being asked in court: “Can you really swear before this jury that you checked all those elements in the physical exam and still missed that dreadful diagnosis? Especially since all your office notes seem to have the same, normal, exam documented, word for word.”

I can see telemedicine continuing to expand along with an increased reliance on laboratory and imaging as more “objective” than old fashioned physical exams. Paired with things like remote monitoring technologies for heart failure patients, and nurse/medical assistant facilitated video visits, my prediction is that more and more of us will be working from home, mitigating many of the obstacles and disparities of rural living, such as gas prices and lack of reliable of transportation as well as local physician shortages.