A Country Doctor Writes:

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A Country Doctor in his Sixties

Published August 6, 2014 Reflections 1 Comment

“Once you start studying medicine you never get through with it.”

Dr. Charles Mayo

Marcus Welby, M.D. was 62 in the first episode of the TV series. My father, not a physician, retired at 62. As I am now beginning my sixty-second year, I seem to be thinking a lot about my place in time and in medicine.

Thirty years ago people often told me I looked too young to be a doctor, and I felt I had to work extra hard to seem wise. I developed a habit of carefully explaining what I understood of each patient’s condition, what I saw as the options for further testing and treatment, and what I expected the outcome to be. I also made a point of being respectful and seeking out each patient’s views and preferences.

That is still how I work, but I have found that over time, as my appearance more and more plainly suggests my years in the business, patients are more and more willing to take my advice with fewer explanations. They are also more openly seeking my opinions, support and advice in matters that go beyond the purely medical aspects of life.

It is an honor and a humbling responsibility to be in that position. It comes from not only looking like you have lived through a lot, and I have, but also from being privileged to see up close the joys and travails of so many fellow human beings.

Few professions see as much of the human condition as we physicians, and especially in these secular times, our role can sometimes have similarities with that of the village priest, especially because we deal with matters of birth, life and death.

Early on, I wrote a post titled “The Apostolic Nature of Our Profession”. The older I get in my vocation, the more I see of that; I feel more kinship and indebtedness to the ancient physicians and to my own mentors that guided me to where I am now, and I feel more tangibly the responsibility that goes with years of practice, suddenly graying hair and the earnest requests from some of my patients to fill their archetypal need for the services of a physician.

At the same time, I feel a strengthening of my desire to understand more of medicine. This truly is a lifelong pursuit, and every year I know more, but also wish for deeper and deeper knowledge than I have achieved. Dr. Charles Mayo said it succinctly in the quote above, and Sir William Osler elaborated eloquently:

“The hardest conviction to get in the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.”

Like Osler, I believe medicine is a genuine calling for many physicians, but unlike him, I believe it can be practiced into old age, as long as we have the physical and mental vigor this kind of work requires.

I bring the enthusiasm of a young man and the experience of a sixty-one year old to my remote clinic five days a week, and most nights and weekends I read, think and write about doctoring.

I hold these words by Dr. William Mayo close to my heart as I imagine myself following in the footsteps of mentors like my senior colleague Dr. Wilford Brown, III:

“The keen clinician, as he grows in experience, becomes more and more valuable as age advances.”

In order to be as valuable as I can be to my patients thirty-five years after medical school, I need to read a lot. I need to read the major medical journals not only to learn what applies directly to my everyday work, but also to be cognizant of how the basic sciences are evolving. I need to translate my life experience and what I have learned from well over 100,000 patient encounters into a language with many dialects that I can use in familiar and unfamiliar situations with patients from a multitude of backgrounds. I need to continually learn about psychology, philosophy and religion in order to be a support to patients who face life altering circumstances and diseases.

I need to maintain my equanimity through busy clinic days in our tumultuous national health care environment, so that my patients don’t become pawns in the system any more than they have to. I need to maintain my sense of proportion in everything I do: in differential diagnosis, in helping patients set priorities, in managing agendas imposed on me by “the system”, and in my own expectations as only one mere human.

This is what I hope to continue to bring to work with me every day for as long as I can do it well.

Context, Always

Published August 3, 2014 Reflections 3 Comments

Question: What do you do when presented with abnormal lab results?

Answer: Ask lots of questions.

The nursing home just sent over a urinalysis on a patient of Dr. Carlyle. I am covering his practice for a few days. The test showed that an 82 year old woman had 3+ white blood cells in her urine. “NKDA” was written in the margin, indicating she had no allergies.

I sighed internally and called the nursing home. The charge nurse seemed a little surprised at all my questions.

“What are the symptoms? What is the patient’s kidney function? Is she on blood thinners or any other medications that might interact with an antibiotic?”

The presence of bacteria or white blood cells in the urine should not usually be treated if there are no symptoms. That’s not always been our belief, but most doctors agree with this approach today.

Looking at a test result without knowing the story behind it, we cannot decide whether or how to act.

Last week we got a critically high potassium result on a patient with normal kidney function and no prescription medications in her profile. I did nothing about it, except order a repeat test that was normal. The obvious explanation was hemolysis; red blood cells contain more potassium than the serum that transports them and if the cells break during blood draw or handling of the vial, serum potassium will be falsely elevated.

A seizure patient of Dr. Carlyle had a high phenytoin level. I pestered the nurse to give me several past results and to track any previous dose changes. It turned out this patient had stable levels for a year and a half and suddenly had a low level last month. Dr. Carlyle raised the dose. In retrospect, the patient probably had missed a few doses, and would have been fine staying on the same dose. I dropped the prescribed dose back down and expect the patient to do fine.

A hypothyroid patient, Diane Green, was hospitalized with abdominal distention and constipation. She is nonverbal, and fearful of medical procedures. The hospitalist checked her thyroid function, as undertreated hypothyroidism can contribute to constipation. The test suggested Diane needed a higher dose, so she was discharged on a substantially increased dose of levothyroxine. As soon as I saw her again, I reversed the medication change; her TSH had been normal one week before her admission, and a severe illness or traumatic experience can affect thyroid values. I figured the hospitalist did not notice Diane’s old TSH result in the hospital computer.

Context is crucial when deciding what to do with abnormal test results. But doctors are often pressed for time, and finding the story behind the results takes time. Even when all the data is in our electronic medical records, it takes time to see the patterns: The test results are usually in one place, the prescriptions in another, the office notes in a third, and the phone messages in a fourth. My own EMR can produce flowsheets with lab results, but each test is identified by the date it was ordered instead of the date it was performed, so correlating lab values with prescription dates becomes confusing, for example when following thyroid cases.

In times past, when solo practice physicians cared for their patients in the office, hospital and nursing home, they kept the threads of context and continuity together more easily. Today, with more providers sharing the care, and with other office staff also interacting with patients and their families, there is more room for errors, gaps and confusion. The tools we have right now are not always as effective as we would like, and they certainly can be cumbersome and slow to use. Reading each other’s notes can take a while, as the EMR format is primarily built for coding and not for ease of following the clinical “story”.

A few words doctor to doctor, doctor to nurse or doctor to patient can sometimes do what half an hour on the computer might not. Treatment without context is essentially just random reflex actions: Killing the innocent bacteria, lowering the falsely elevated potassium, treating the lab value and not the patient – none of it does anybody any good, and probably will cause harm to some unfortunate patients.

Our temptation to view test results as obvious facts in a predictable process instead of possibly misleading clues in a complex mystery reminds me of these words from a Sherlock Holmes novel:

“There is nothing more deceptive than an obvious fact.”

Sir Arthur Conan Doyle

Med School, Day One (1974)

Published July 31, 2014 Progress Notes 5 Comments

The corpse, laid out on a gurney and covered with a white sheet, was wheeled onto the stage by two women in long, white lab coats. A middle aged man with a bow tie welcomed us, the incoming class of the spring semester, to Uppsala University and the Biomedicine Center, where we would spend the next two years in “pre-clinicals”, until we knew enough to start our three and a half clinical years at the Academy Hospital.

The Biomedicine Center was almost brand new, a glass and concrete labyrinth with a large sculpture depicting Watson and Crick’s DNA molecule by the front entrance. The vast complex lay near S-1, the Uppsala military regiment. The brick buildings diagonally across the street were very familiar to me as the place where I had met the biggest failure in all my twenty years only months before.

As I sat in the large lecture hall with the corpse on the stage, I glanced over at L., my buddy from the Swedish military’s elite division, the Interpreter School, where we had also sat next to each other on the first day, when the Captain in charge told us:

“Soldiers, you may all have been the smartest kids in your school, but it’s different here. Most of you won’t make it, and will be culled over the next two months. The Interpreter School accepts eighty recruits and graduates twenty to twenty-five. If you don’t have what it takes, don’t waste our time or yours!”

L. and I had both thought that learning Russian would be a neat way to spend our compulsory year and a half in the military, but just barely more than a month after that harsh introduction, we were both on our way back to our respective home towns to figure out what to do until we would be able to start medical school. Our military service was put on hold until we could return as medics.

The man with the bow tie went on to introduce our guest professor, on loan from the University of Bavaria. As we all knew, the Germans had been the greatest anatomists since the last century, and all of us had already been to the University book store to purchase Hafferl’s “Topografishe Anatomie”, which would be our constant companion for the next five months.

“Hopefully, most of you took several years of German in High School,” the man continued, “but those of you who chose French instead and only took one year of German are encouraged to take advantage of our German night classes, every weekday from 8 to 9 pm in Hall B next door.”

With that, he gestured to the Bavarian guest professor, who bowed and began speaking as the first slide was projected behind him. He had the most peculiar accent, and spoke in a slow drawl. I strained to get a handle on what he was saying. L. cocked his head and as I turned toward him, I saw many heads shaking.

With every new slide, the German speaker seemed to increase the tempo of his speech and as the slides behind him changed faster and faster, more and more heads were shaking in the lecture hall. Soon, all of us had given up trying to understand as the staccato voice from the stage pounded the syllables faster than a sports commentator and the rapidly changing slides became more and more filled with details. Heads were shaking, many people were talking, some stirred and rose from their seats and turned toward the exit doors.

Then, suddenly, everything turned dark, the speaker stopped talking and all the chatter in the lecture hall ceased. We sat in darkness and silence for maybe a minute. Then, a faint tune from a small flute rose from the dark stage and dim lights began to illuminate the two women in white lab coats. One was playing the flute, the other picked up a clarinet and began to play.

As the lights continued to brighten, the sheet suddenly flew off the corpse, who sat up, pulled a trumpet to his mouth and belted out a tune like something from a Mardi Gras parade.

The stage filled with upperclassmen and the “German” professor took a bow as they all applauded in his direction.

Then, from a side door, a tall man with a very straight back, white riding pants, tall black riding boots and a whip appeared. Everyone fell silent as he began to address the students in the lecture hall.

“I’d like to introduce myself. I am professor A. of the Department of Anatomy. I just came back from riding in the fields beyond here. I want to welcome you all.”

L. and I looked at each other and shrugged – was this part of the joke?

Professor A. continued:

“So, you made it to medical school. And if you really want to, all of you will make it out of here with a diploma. Just work hard, enjoy Uppsala, and don’t worry about the German classes – all lectures will be in Swedish!”

He was right, all of us who wanted to made it all the way through. My friend L. chose to leave medical school for a life as a writer, but he often writes with great insight about doctors.

I remember that first day as if it were last week, but it was forty years ago. It was the beginning of a journey of learning I can’t imagine ever reaching a final destination. In 1974 there was no HIV; we had only Hepatitis A, B and non A-non B; Sweden didn’t have a single CT scanner; mammography screening was just beginning; Tagamet, Prozac, “statin” cholesterol drugs and clot-busters weren’t invented; low-dose aspirin wasn’t known to reduce heart attack risk, and so on.

In spite of all that has changed in medicine since I started, the way I learned at Uppsala how to evaluate scientific information, to elicit a disease history, to examine patients, and to approach them as individuals, not “cases” – that has not had to change in forty years of doing the only work I could ever imagine doing.

(Originally published on The Healthcare Blog, where my friend L. read it and thought I made it sound as if we were “culled” from the elite military school. We chose to drop out. Everything else happened just the way I wrote it…)

P.S. This is my 300th post on “A Country Doctor Writes”.

Medicine is Easy, but Metamedicine is Hard

Published July 24, 2014 Progress Notes 17 Comments

Knowing what to do when faced with a sick patient is relatively straightforward. We learned a lot of it in medical school, picked more up by experience, and usually have the opportunity to look things up quickly on the Internet. Even when faced with a brand new situation, we can usually fall back on our general knowledge of science and medicine.

But in today’s practice of medicine, that’s not enough. Physicians, PAs and NPs all live in two parallel universes these days, the World of Medicine and the World of Metamedicine.

The world of Medicine was created through understanding of Life itself. It is vast and complex, and growing exponentially. Its rules tend to follow scientific principles.

The world of Metamedicine was created by humans with limited understanding of Life, but with vast experience in actuarial calculations and bookkeeping. It is growing faster than medicine itself. Its rules follow a logic not taught in medical school.

Imagine a well trained physician faced with a patient who has gained some weight and complains of swollen legs. The doctor notices that the patient seems just a little short of breath. But our patient also admits to eating more than he used to and he has been on his feet more than usually in hot weather. He wonders if that may have caused the swelling.

Our wise physician knows that right-sided heart failure predominantly causes edema, whereas left-sided heart failure more affects breathing. Suspecting heart failure, he orders a BNP, a relatively new, fancy screening test for heart failure.

The overlords of the Metamedicine universe, in their infinite and inscrutable wisdom, have determined that Medicare will pay for BNP testing in cases of shortness of breath, but not in cases of leg swelling. Our doctor orders the BNP in good faith for the diagnosis of “edema”, but the next day the lab notifies him the test was not run because there was no covering diagnosis.

Yours truly had a patient the other day with new onset of atrial fibrillation and a Left Bundle Branch Block (LBBB) on his EKG. They teach us in medical school that a new LBBB in many cases signals a blockage of a coronary artery. I ordered a stress test. The diagnosis I assumed would cover this test was my patient’s LBBB.

Wrong. Today I got a fax from the EKG department, stating this diagnosis didn’t cover the test. Presumably because of some Metamedicine Code of Ethics, they did not tell me what would, but they were kind enough to include several pages of diagnoses that would qualify my patient for a stress test.

Frustrated, I perused the list. Nothing seemed to fit, and of course you can never use “suspected” or “rule-out” as a qualifying diagnosis. That is one of the ground rules of the Metamedicine dimension. Then, there it was: The very last qualifying diagnostic option was ICD-9 code 794.31, “Nonspecific abnormal EKG”. Now, why didn’t they teach me that in medical school instead?

Also today, I had a fax from the pharmacy about a Medicaid patient with anemia and evidence of blood in the stool. She had recently undergone an upper endoscopy that showed gastritis and a duodenal ulcer. I had prescribed omeprazole, an inexpensive acid blocker. She was already on even less costly iron pills for her anemia. Medicaid required a Prior Authorization. The reason for this is that, theoretically, iron is better absorbed if the stomach environment is acidy. If you have bleeding from too much acid, this is not a worrisome drug interaction. But Medicaid has enough time and resources to micromanage everyday clinical judgements like this one. I scribbled “Aware of theoretical interaction. Will monitor”, as I always do in these cases. The PA always gets approved. I am doing my job and the folks at Medicaid are just doing theirs.

Every day has more examples like these. Unlike the laws of Medicine, the rules of Metamedicine seem arbitrary, at least to a medical mind, and there are fewer handy resources for looking things up. Besides, people like me sometimes fall into the trap of doing what makes sense to us without looking up what diagnosis covers what in the world of Metamedicine. But, how much double checking can you do in 15 minutes?

I have long thought of myself as bilingual, speaking pretty good English and even better Swedish. I’m also learning the language of Metamedicine. That is becoming more necessary in my everyday dealings than my rusty German and rudimentary French.

Here’s a quiz:

Which diagnosis covers a lipid profile?
A) Screening for lipoid disorders (V77.91)
B) Screening for other and unspecified cardiovascular disorders (V81.2)

Give up? The correct answer is B. See what I mean…

Primary Care is Personal and Passionate

Published July 23, 2014 Primary Care is... 1 Comment

It’s been thirty years since Dr. Pete shook my hand on graduation day and slapped my back, his gravelly voice mumbling a wisecrack that couldn’t quite hide his emotions. I was the first foreign medical school graduate in our small residency program and he had trusted me, just as I had trusted him, through three years of hard work and many challenges.

Our residency program was only a few years old, and my specialty was only twelve when I started. Family Practice had begun with the realization in the 1950’s that fewer and fewer medical school graduates chose to enter general practice after their internship year, but instead went on to specialize. With the knowledge explosion of the twentieth century, the need for well-trained generalists gained acceptance and the void left by retiring GPs was filled by the graduates of three-year Family Practice residencies focusing on 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

Medicine has changed a lot, and America is not the same as when I first came here. Primary care is more complex, with more demands from forces outside the physician-patient-family constellation we thought and talked so much about thirty years ago.

In the early 1980’s CT scanning had just been introduced, but there were no MRIs in our state yet. We didn’t have EMRs, there were no Prior Authorizations, no direct-to-consumer drug advertising; we didn’t even have the Internet.

What we did have when I started out was a generation of young doctors with a shared passion for clinical, albeit low-tech medicine, and for taking care of patients and families in their small communities.

My generation had sit-ins over minor injustices in High School. We wore bell bottoms and sang songs about love, peace and justice. We wanted to make the world a better place. Those of us who wanted to become doctors watched Marcus Welby, M.D. – I did, as an exchange student, on a large console TV in my Massachusetts host family’s suburban living room. My determination from a year of illness in early childhood to become a doctor gelled right then, in 1971, into a vision of what I have been fortunate to actually be doing for the last thirty years.

I have better tools now than Marcus Welby had, and the technical standard of care has made huge leaps since my residency days. But something has gone missing. The idealism and passion of physicians has become worn and frayed as a result of the paradigm shift toward the manufacturing view of healthcare. Healthcare is now becoming impersonal. It is organized, delivered and measured like industrial output in automobile plants. It is mass produced and valued by its consistency and conformity, even though no two patients are exactly alike.

Most of our patients still come to us looking for personalized care, but they feel the pinch of our newly imposed agendas in their fifteen minutes with us. We are more and more put in the role of public health officials, collecting data for Government and insurance companies and promoting their population-based agendas.

But when we really engage with our patients we can see the power of the traditional doctor-patient relationship that many others in healthcare have tried to negate.

The passion and commitment of doctors have been de-valued as we are instead building entire systems to do what Marcus Welby and his nurse did, day in and day out, when they practiced their professions and held themselves to their standards and ideals.

But no “system” can replace human effort and commitment. Doctors, nurses and everybody else in healthcare need to be at the center, side by side and face to face with their patients and the “system” needs to capture, rekindle and support their passion, not suppress and replace it.

Family physicians were trained to be capable in areas where our ability to keep up is now challenged, just like the General Practitioners’ sixty years ago. Fewer and fewer primary care doctors now set fractures, deliver babies or perform even minor surgeries and procedures.

Increasingly, we are instead taking on the role that the journal Canadian Family Physician calls “broker of choices”. With the Internet and all the media exposure about medical issues, we are no longer patients’ primary source of medical information, but we are the ones that are best suited to help them sort out information and compare alternatives.

This actually builds on our specialty’s founding principles. We are still the glue that holds the parts together, even when other specialties are involved. We provide the first contact, the continuity, the personal focus and the family view of the patient and their support system; it requires our solid competency in general scientific medicine; and it is comprehensive in the ancient meaning of the word as it derives from comprehendere – ‘to grasp mentally’; we help our patients with the big picture while we attend to their everyday medical needs.

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