A Country Doctor Writes:

We FaceTime or Messenger Video with friends and relatives, even with our loved ones. I do this with my American brother from my exchange student year every couple of weeks and with my lady friend almost every night. That does not take the place of time spent doing things together. But if we just want to talk, a video conversation is for most of us more satisfying and feels closer than a telephone call.

Since the pandemic and continuing now, one of the gastroenterology practices in Bangor has been very open to doing video consultations with new patients. In their specialty as in many others, the patient history provides 80% of the diagnosis. Their new patients have usually had a CT scan of their abdomen and sometimes even a local colonoscopy or upper endoscopy, so palpating their new patient’s abdomen is not usually necessary. If a procedure is necessary, it is almost never done at the initial consultation anyway, even if that is done in person, but will be scheduled later if it is needed.

Traditionally in medicine, procedures have paid much better than cognitive work. And the number of questions we asked and how many elements of our physical exam we documented helped determine our reimbursement. But for a long time, there has been a provision for charging for a visit where more than 50% was spent on counseling and education. As we move toward value-based care, clinical outcomes are mattering more than how exhaustive our investigation was.

The pandemic provided an opportunity to get paid for telemedicine and value based care does not incentivize us to start from scratch and turn every stone if we can tell right off the bat what ails our patient based on what has already been asked and documented.

Especially in remote and underserved areas like the one I practice in, it is such a blessing to be able to get a telemedicine consultation for a patient who can ill afford traveling hundreds of miles and perhaps staying overnight in a motel just to have a 30 minute consultation with a specialist.

I welcome seeing more of this for the benefit of my patients.

This morning I reposted a piece from 2017, A Lesson Learned, about my first case of Anaplasmosis, as a link in a new post about this disease and Lyme disease today according to the Maine CDC’s most recent report. I made reference to the fact that I had just posted the 2017 piece on my Substack, which I made my primary blog when WordPress no longer supported the theme (template) I have used here since I started this blog in 2008. Within a month or two of my migration, my old theme here started working again, but then I was already enamored with my growing viewer numbers on Substack.

I have found that Substack is a more immediate medium than my WordPress blog. If I go a couple of days without posting anything, almost nobody visits my Substack, whereas on WordPress, there’s always a trickle of people reading both the latest and prior posts. So even though I have half-neglected my WordPress blog, many of its readers have remained loyal, quickly reading my less frequent posts on this platform.

The lesson I have learned is not to put all my eggs in one basket. Some people have commented that they don’t like Substack and will only follow me here on WordPress. Therefore, I will put new material here when I put it on Substack and if I repost something old from here on Substack, I will only put it here if I have something new to say about that topic or perhaps the back story to that piece. In a way, this platform will be for my old friends who may have followed me since the beginning or at least longer than I have been on Substack.

If you are one of my old friends, I thank you for your patience while I figured this out and learned my lesson.

Today’s post on my Substack was first published here in 2017. It describes my first encounter with Anaplasmosis, one of the tick-borne illnesses that is slowly creeping north into Maine. When I wrote that piece, I was living and working in Hancock county, which has more tick-borne disease cases than most other counties in Maine. In Aroostook, way up north, where I now live, we hardly ever see Anaplasmosis (one case in 2022, compared to 78 in Hancock), and even Lyme disease is pretty rare here (12 cases in 2022, compared to 360 in Hancock).

A Lesson Learned

Fresh back from almost back-to back oceanside beach vacations with my significant other, I feel called to write about being on vacation as a physician these days. But first, we had a great time on Old Orchard Beach during Fourth of July week with her siblings, all older than we are, and then in Bar Harbor with my children and grandchildren to celebrate my birthday.

Large healthcare organizations often have many different “service lines”, some acute and 24/7, some totally prescheduled and elective. But they often end up with the same personnel policies and benefits across the board. Because of this, I ended up in my previous job having to budget “PTO” time or else not get paid for Christmas Day, for example, even though my clinic was closed so there was no way for me to work that day. And in my current job, I forgot to ask for the Fourth of July off, but even though my clinic was closed, there seemed to be a remote possibility that I would be deployed on a house call or video visit. That didn’t happen, but there was definitely some confusion there.

A few other things are happening to many doctors when they take time off. One is that we get messages from nursing staff or sometimes covering providers about patients that we know particularly well. That happens to me fairly often in my telemedicine Suboxone clinic for Bucksport patients. I have made it clear with them that I do not log into the EMR unless I get a text message saying there’s an issue for me to handle. That way I’m less tied down looking for interruptions in my vacation.

Another issue that sometimes cuts into our vacation time is refills of controlled substances. I see medical providers, colleagues, who would trust me with their patients or even their own lives either refuse to refill stable patients’ controlled substances or only do it for a limited number of days until I’m back at work. This either means I’ll be contacted on my vacation to refill the prescription they would not or I will have to do the math all over when I want to resume my patient’s usual intervals between refills. In that case the patient may have to pay a full copay for a 3-7 day prescription and another one when I refill their usual amount.

I was around when pagers were the most high tech handhelds (and cell phones back then were all over-the-shoulder). It was easy to be unreachable then. Instant connectivity can be great for those who need us, but how much of that is too much for us? The higher the constant availability pressure is during our normal work weeks, the more sense it makes to disconnect when you’re on vacation. Maybe if you’re the only one in your specialty in your county or state, you can’t disconnect completely, but in primary care, there are options – we are probably not quite as indispensable as we think we are…

And, as an aside, I have gone from one extreme to the other, then back again a few times in my publishing endeavors, sometimes posting twice a day and sometimes not for weeks. So, yes I’ve been a little quiet lately, but that is what happens when you pay attention to friends, family and other parts of your life besides “performing”. I’ll never stop, I’ve just been busy with some of those other things.

Why is it that every visit note has to rehash past medical and surgical history, active problems, allergies and sometimes even long narratives about the initial presentation of the problem at hand and long lists of prior testing?

In the electronic health record, when we start a new encounter, those things are usually right there in a scrollable sidebar. And when we print or fax completed office notes from the EMR, most systems could automatically include all those lists, if only as attachments.

Imagine the possible time savings and mental health benefits (less burnout) if, during visits, doctors wouldn’t need to click “import to note” a kazillion times, indication we had rigorously reviewed everything in the sidebar (because how much does anyone really think we can do in the few minutes available in each encounter for review of past medical, surgical, social history and so on?)

And during return visits, or just scanning old notes, we could quickly and easily catch up on the progress of the patient’s case if all the fluff didn’t gum up the chart note. Because in most notes in most cases, those things are fluff. If a diabetic has started on a new medication and they come back to review their blood sugar log, which is improved, and they report no side effects, those things we pretend to review in detail really are fluff. Of course we need to cover them in more detail with annual visits or with brand new problems, but most of what we do is following up on specific issues in the care of specific diseases.

Let us get right down to the purpose of the visit instead of trying to, or pretending to, do everything for everyone every single time they come in.