A Country Doctor Writes:

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Outdated Equipment

Published January 17, 2015 Progress Notes 3 Comments

Friday noon, in typical fashion, I seemed to have an emergency on my hands. This time, it was an ocular one.

Philip Brown had driven 35 miles in a steady snowfall to see me. Four days earlier he had been to the Cityside Emergency Room for modest pain and a couple of small blisters on the right side of his forehead. They diagnosed him with shingles and put him on an antiviral. Now he had 48 hours of severe, burning pain in his forehead, where at first there had been only mild discomfort, as well as a new, piercing pain and profuse tearing in that eye.

“Well, we’ve got two things to take care of”, I began. “The pain can be managed with the same medication you took when you had that pinched nerve in your back last year, but we have to figure out exactly what’s going on with your eye.”

He grimaced and struggled to open his eye. With his left eye he could see 20/30 but with his right only 20/200. His squinting eye had a mixed injection – redness that extended all the way to the limbus, or corneal margin.

“Let me get some more equipment to examine your eye with”, I said and headed to the procedure room for the Wood’s light and some fluorescein strips to look for signs of zoster ophthalmicus, the dreaded dendritic fluorescence you can see when the virus attacks the cornea.

I reached for the eye tray on the top shelf in the cabinet over the large stainless steel sink. My heart sank as I fumbled around among its contents. The fluorescein strips were gone.

I knew exactly what had happened. The half full box had December of last year printed as the expiration date. I remember thinking the last time I used them that we needed to order new ones. The ordering of supplies is done by one of the younger nurses at the other end of the clinic.

“Autumn, have you seen the box of fluorescein strips?” I asked, but she hadn’t.

I returned to Philip with the bad news: “I’m going to have to refer you to an eye doctor today, because we ran out of the stuff to look for shingles in the eye. Who do you usually see?”

“Dr. Pomeroy.”

I looked at my watch.

“An hour from here, in good weather.”

“With good eyesight”, Philip added.

Just then, there was a knock and the door opened. A triumphant Autumn handed me the box of fluorescein strips.

“They were on Sally’s desk, ready to be thrown out”, Autumn said. “I left a note for her not to get rid of the old box until the new one comes in.”

Moments later, I knew that Philip didn’t have shingles of his cornea. What he had was a peripheral superficial corneal abrasion at twelve o’clock, caused by a curled eyelash. With the eyelash out of the way, his eye stopped tearing and his pain was instantly reduced by half. On his second trip to the eye chart, he scored 20/25 with his right eye.

With prescriptions and instructions taken care of, I went back to my office, opened my thermos and ate my sandwich.

Just then, Sally, back from her lunch, came in.

“What’s this about the fluorescein?”

I swiveled around and looked up at her.

“Let me tell you a story about how, with outdated equipment, I saved a man from pain and agony and a dangerous two hour round trip in a snow storm…”

All the President’s Mail

Published January 5, 2015 Reflections 4 Comments

Perhaps doctors should be more like the President.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the President needs in order to manage his, and all our, business.

That is how things used to work in medicine, too, before computerization revolutionized our workflows: Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and X-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature-needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the X-ray department faster via their Internet connected computers. But in the typical medical office, we have now turned decision making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, X-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

“Between patients”, is the way many people imagined this “system” to work. But, how much time do we have between all those back to back fifteen minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code “urgent” or abnormal reports, but when it comes to standard laboratory panels, “normal” patients statistically have 5% of their results outside the “normal range” without being sick, so the majority of Complete Blood Counts and Comprehensive Metabolic Profiles show up red, whether they contain panic values or just statistical noise. (See my post “The Red Blues“.)

Where does a doctor even begin a two minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT Department instituted a similar workflow for the President: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the State Dinner, and hastily types in his multiple passwords on the Executive Computer.

A hundred messages await. One of them contains information about hostile troup movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the President’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the Commander in Chief. But that is exactly how information is managed in today’s medical office, on the frontlines of primary care.

Tick-tock, Doc! Three patients waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The President??

The Man with the Up and Down Blood Pressure

Published December 27, 2014 Progress Notes 4 Comments

Gordon Grass had fallen three times. He said he was always lightheaded.

A slender chain smoker with nicotine-stained fingertips, he didn’t go to doctors much. He was on a blood pressure pill, though, started years ago by a colleague over in Danderville.

I looked at his vital sign display in my EMR. His blood pressure had never been high in the years that I had known him. In fact, sometimes it was on the low side. His typical systolic blood pressure was 130-134, but occasionally it was in the 100-110 range.

His exam was unremarkable when I saw him a couple of weeks ago. I listened carefully for bruits in his carotid arteries, did a standard neurological and ENT exam and even took out my tuning fork to check his Weber and Rinne; everything was normal.

Sitting on my stool opposite Gordon in the drafty, north facing Room 4, its old windows rattling as a powerful nor’easter pounded on the brick walls of the former hospital, I pulled the portable blood pressure cuff stand closer and tightened it on Gordon’s right arm. Sitting, his blood pressure was 136/68, and standing, it was 122/60.

“I think we should stop your blood pressure pill and see how you do”, I said. Gordon said he was happy to get rid of them, and we agreed to check his blood pressure and his symptoms in a couple of weeks.

I knocked on the door to Room 1 and entered the sun-drenched room across the hall from where I had seen him two weeks earlier.

“Feel that solar heat”, I said as he squinted in the warm, bright yellow room. “How are you doing?”

“Better, not as lightheaded.”

I looked at his vital signs. Autumn had entered his blood pressure when she checked him in: 112/62.

“Your blood pressure is lower than last time”, I mumbled, adding “I have read that the effect of hydrochlorothiazide can last for months after you stop it.”

Instinctively, and without speaking, I pulled the wall mounted sphygmomanometer down from the concrete wall between Gordon’s chair and the exam table on his left, tightened it around his arm and pumped up the cuff. Listening carefully as I released the pressure, I, too, recorded a lower blood pressure than last time: 116/60.

“I like the cuff we used last time better, but let me check your right arm also with this cuff”, I said and stretched the tubing across to his right arm. There, his blood pressure was 132/78.

“Hmm, let me check a few things again”, I said and ran my fingers along his neck, his collarbones and in his armpits. I put my stethoscope in my ears again and listened to his carotid arteries and his lungs.

Finally, I took both his wrists and found each radial pulse with my index fingers. I took a deep breath and relaxed. Then I sat quietly as my fingertips registered his pulse, bom-boom, first in his right wrist, and, a split second later, in his left.

“This is the first time I’ve diagnosed this condition in thirty five years”, I began.

I explained Subclavian Steal Syndrome to Gordon; how a blocked artery under his left collarbone causes blood to be shunted from the right carotid artery, across the brain, and downward through the left carotid and into his circulation-deprived left arm, stealing some of the blood that was supposed to fuel his brain.

“There are two ways you can get this condition”, I said. “One is similar to any blocked artery from smoking and all the other causes of poor circulation, and the other is something constricting the artery from the outside, like a cervical rib or a tumor of the lung”.

Gordon made a silent gesture to the pack of Pall Mall cigarettes in his breast pocket.

“Yes, them, either way”, I said. “Let me order some tests…”

A few days later, the Chief of Radiology called me: Subclavian Steal, no tumor.

Next week, Gordon meets with a cardiovascular surgeon to discuss a bypass of his blocked subclavian artery, because he is still symptomatic, even without his blood pressure pill.

The Art of Antibiotic Selection

Published December 23, 2014 The Art Of... 2 Comments

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.

“If you get worse instead of better on this”, I explained, “you’ll need intravenous antibiotics. So, by Saturday, 48 hours from now, you’ll know if you need to go to the hospital or not.”

Monday morning came. There were two ER reports with accounts of late Friday and Saturday visits with intravenous administration of ceftriaxone, a third generation cephalosporin. There was also a CT scan report with a hedged opinion that there was no frank parotid abscess. The third ER note, from late Sunday night, described how the doctor on duty had selected clindamycin and instructed Jacques to see me Monday morning for a referral to an otolaryngologist.

Monday morning Jacques definitely looked worse than the week before. His cheek was bigger and firmer, although not red. It seemed warm, but he didn’t have a fever. He had trismus; his mouth opened very little.

“Wait right here”, I said. “I’m going to call Dr. Ritz, the ENT specialist over at the hospital.”

I logged on to UpToDate and quickly looked at half a dozen treatment regimens for parotitis, and all were multi-drug intravenous protocols with oral step down alternatives.

“He’s in Danderville today, seeing patients at the Outpatient Clinic and tomorrow he’s in surgery all day”, his nurse said. She agreed to double book Jacques for Wednesday morning.

I called the Danderville clinic and asked to talk to Dr. Ritz.

After reassuring me that he never minded taking calls from a colleague, he listened to my story, and said “you’re old enough to remember Duricef, cefadroxil, right?”

“Sure”, I said. “I haven’t used it for years, though.” I remember we used to think of it as having better tissue penetration than other first generation cephalosporins.

“These are all staph. And Duricef works better than any other oral antibiotic. In thirty seven years, I’ve never had to operate on one of these.”

I thanked him and mentioned that I had scheduled Jacques to see him two days later, just to be safe.

“Oh, I’m happy to see him, but he’ll be fine”, the old otolaryngologist told me.

I related my phone conversation to Jacques and told him about his Wednesday appointment with Dr. Ritz at his office, thirty five miles away.

“If I can make it there. It’s going to storm, you know.”

Jacques’ usual drugstore didn’t have any cefadroxil in stock, but the other pharmacy in town did, so I e-prescribed it there.

“I’ll see you back here if the roads are too bad, but if you spike a fever or feel worse, go back to the hospital”, I concluded our visit.

I had a vague, uneasy feeling about just switching from one cephalosporin to another, but Ritz has a lot of experience and he’s the only ENT within a hundred miles.

Wednesday morning brought eight inches of snow with a thin layer of ice. After a slow commute in four wheel drive, I stomped the snow off my boots inside the clinic back door and hung my thick leather coat on the back of Autumn’s and my office door. I changed to my indoor shoes and booted up my desktop and tablet computers.

“Jacques Johndreau is coming in at nine”, Autumn told me, “he didn’t dare driving down to Dr. Ritz’ office.”

At nine o’clock I knocked on the door to room 2 and entered. Jacques stood up from his chair and greeted me with a handshake.

“I wanted you to confirm”, he said, and paused to show me how far he could open his mouth. “But I am definitely better.”

There was no question. His gland was half the size it had been 48 hours earlier.

“You didn’t need me to tell you that, even. This is very good news, that such an old drug worked better than two newer ones that I and the ER tried, even intravenously. I’ll call Dr. Ritz to let him know just how dramatic the difference is”, I said and patted Jacques on his broad shoulder.

The experience of an almost seventy year old solo doc beat the Boston medical Brahmins this time. I was fortunate to have my senior consultant to back me up.

And as for antibiotics, too, sometimes newer isn’t better.

It’s Time We Talk: A Doctor is a Doctor is a Doctor, Right?

Published December 13, 2014 "It's Time We Talk..." 1 Comment

I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

In many of today’s medical practices, the doctors’ names aren’t on the front door, office letterhead or company advertisements; they’re often not even in the phone book. A group of employed doctors these days can consist of multiple personality types with disparate treatment philosophies and clinical styles. I once worked with a doctor who would give patients with upper respiratory infections half a dozen prescriptions while I would say “go home and get some rest; it’ll go away”. Not knowing what the two of us were like, patients could end up choosing the doctor whose style didn’t meet their needs.

I have worked with colleagues who view every laboratory abnormality as an ominous threat and pursue each one to the ultimate degree, making even the healthiest patients uncertain about their chances of survival. Some of the same doctors also insisted on seeing even patients with mundane medical conditions on a tight schedule in order to monitor them for unforeseen medical disasters. In today’s generic clinics, patients may not know if their new or covering doctor is a reassuring pragmatist or a consummate worrywart. Worse yet, they may be shuffled back and forth between doctors with opposite styles.

2) Training Differs

In Primary Care, we have MD’s and DO’s, Family Physicians, Internists and “Med-Peds” physicians. Each training is inherently different, further complicated by differences between schools, regions and countries.

Internists, trained to treat diseases of adults, are sometimes asked to treat children in the government-sponsored type of clinic I have spent most of my career in. They are also oftentimes faced with treating conditions in ophthalmology, otorhinolaryngology, gynecology and orthopedics – areas where they may have little experience. Their residency training may have been entirely urban and hospital based, but in today’s American job market, the demand and opportunities tend to be in more rural areas, particularly for visa applicant physicians from third world countries, where academic hospital medicine may be fairly similar to US healthcare, but where small town and rural medicine can be very different.

3) Culture Matters

As an immigrant physician with English as my second language, I had to work at speaking comfortably with rural American patients, many of whom were of French-Canadian origin. It must be a bigger challenge for physicians from further away than Sweden. Language is only the beginning. How different cultures view life events and medical conditions can vary greatly. I am told that the Japanese don’t have a word for hot flashes and that in Tibet, most people aren’t familiar with the notion of depression.

People in this country often talk about how doctors need to be sensitive to minority patients’ culture. Less is said about minority physicians’ familiarity with the American majority of patients; whether we are from Sweden, Japan, Tibet or India, we each have a learning curve for understanding those we are here to serve as personal physicians.

I remember one internal medicine physician from a Muslim country who found out that his American employer expected him to perform routine gynecological exams including Pap smears on his female patients. Not only had he never been trained to do any of it, he also had to wrestle with overcoming what his his entire upbringing had told him was improper.

4) What is a Good Doctor?

The industrial view of healthcare imagines that it consists of standardized processes that are easily measured: What is the average blood sugar, or glycohemoglobin, of Dr Andersson’s and Dr Singh’s patients? Their pneumonia immunization rate? How many of their heart failure patients are on a beta blocker? How many seniors have had a fall risk assessment? How many obese patients have an obesity action plan documented in their medical record?

Nobody talks about this, but all those quality indicators make less difference for individual patients’ longevity and for entire populations’ health than healthy lifestyles do. For individual patients’ health as it relates to healthcare, accurate diagnosis of new symptoms can amount to an all-or-nothing disparity between health and disease, even between life and death.

Some of the most basic measurements of physician quality are surprisingly irrelevant: Beta blocker therapy in heart failure patients only increases average survival 6-12 months, it takes 50,000 pneumonia vaccinations to prevent one pneumonia death, and prostate cancer screening, once a basic minimum requirement for men’s health care, is no longer even recommended.

My uncle had waxing and waning paralysis of his left arm, but his doctors never checked his carotid arteries, and soon thereafter he had a stroke. My aunt had a cough for well over a year, but because she never smoked, her doctor didn’t order a chest x-ray until it was too late and her lung cancer was inoperable. This happened in Sweden, where the average life expectancy is the 6th highest in the world, 3 years more than 32nd ranking USA. It could have happened anywhere, because doctors are people, each one different, and the real quality of their work cannot be measured, let alone regulated.

Employers and bureaucrats may think a doctor is a doctor is a doctor. My aunt, for one, doesn’t think so anymore.

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