A Country Doctor Writes:

Archive Page 171

Journey’s End

Published April 30, 2012 My Father's Eyes 10 Comments

The long journey that began a year and a half ago ended suddenly this morning.

The Swedish ringtone sounded four times after I dialed the number I had dialed the same time every morning for several years as well as every weekend afternoon, the number I knew would suddenly become meaningless any time as my mother’s disease progressed.

A strange voice answered and in one instant I was orphaned at age fifty-eight, never having said a final good bye. My last words had been “get a good night’s sleep and I’ll call you when I wake up in the morning”.

Hers had been “I am content, take care of yourself”. She was ready, even if I was not.

I have lost count of how many deaths I have attended as a physician, but it is always with an eery swiftness that the moment passes, no matter how long the wait has been.

Instantly the moment is gone, the chance to say the words we wanted to have said. Instantly the feeling of loss overwhelms us as we are hurled from one way of existing to another, just like our loved one is whisked away from our presence.

Hearing a young Hospice nurse struggle to find the right words to tell me what must have happened before she arrived for her scheduled visit, I realized what had happened with the speed of my imagination as her words continued to form in slow motion. Through the receiver, across three thousand miles of frigid ocean and across a time difference of half a day I gathered up the pieces of my mother’s last hours on this earth.

Somehow, I knew it would end like this. I knew it the day my father died and I was the one who walked across my home town to tell her, confined to her hospital room across the river. I knew it every time I said good bye on the telephone, that one day the phone would ring and ring, she would not answer and the familiar number wouldn’t be hers anymore.

I just didn’t know it would be today.

QS, Ad Lib and PRN

Published April 30, 2012 Reflections 4 Comments
Tags: Prescription Latin

Our hospital has a list of approved abbreviations. It is shorter than the list I had to memorize during my training. The reason some long-established abbreviations have been banned is their similarity to other abbreviations with different meaning. Even when doctors type orders instead of writing them by hand, the concern is that nurses and pharmacists may mistake them for something other than what the doctor ordered.

For this reason both QID (quater in die; four times a day) and QD (quaque die; once daily) are off the list; a hurried nurse or pharmacists could inadvertently quadruple a patient’s daily dose by imagining an “I” that wasn’t there to begin with.

At the local pharmacy, thanks to e-prescribing, we are forced into a specificity we weren’t tied to before:

Gone is the universal “QS”, (quantum sufficat; sufficient quantity), which made it the pharmacist’s responsibility to figure out how many pills it takes to do a prednisone taper with 6 pills the first two days, 5 the next two, then 4 a day for two days etcetera until zero.

“QS” also got us doctors off the hook with liquid medicines for children; while the printed “Monthly Prescribing Reference” listed the size bottles all the common antibiotics come in, the new e-prescribing software doesn’t tell us that. Consequently we have to prescribe the exact volume needed for a full course, hoping there is a bottle of just that size or that the pharmacist will be allowed to pick the closest size up without having to call us back.

“Ad Lib” (ad libitum; “freely as wanted”) has fallen by the wayside in medicine, and now seems mostly a term used in theater, public speaking or music.

Curiously, a theatrical synonym for ad libitum, extempore, was often used in my native Sweden for a custom prescription, usually for a cream or ointment, less often a hand-made capsule or pastille. In the United States, this term is seldom used, although the concept of specially compounded medications is not uncommon.

“PRN” (Pro Re Nata; “as the circumstance arises”) seems to have survived the abbreviation cutbacks. It allows the patient or caregiver to use the medication as needed.

Prescriptions were historically a vehicle for doctor-to-pharmacist communication that was written specifically to exclude the patient. This is to some extent why so many abbreviations were used. Somewhere near the bottom of most prescriptions typically was the word Label with a check box in front of it. Only when checked did the patient get to see the name of the medication on the bottle. That was before the era of informed consent, but the word and the check box can occasionally still be found on prescriptions.

Abbreviations and secret symbols still find their way into modern medical jargon and documentation, even if they are not allowed on prescriptions or in hospital records, from the handwritten Ψ for psychiatry or psychiatric to classics like GOMER – Get Out of My Emergency Room, ETKTM – every test known to man, and FF – Frequent Flyer, to some newer ones like:

PJAR – Person Just Ain’t Right

SALT – Same As Last Time

TMB – Too Many Birthdays, and

GOK – God Only Knows

Every profession needs its abbreviations…

Art, Science and Charity in Medicine

Published April 29, 2012 Reflections 1 Comment

Sir William Osler spoke of the influence of these three forces on the life and conduct of a physician. He eloquently used temperature analogies to characterize the necessary qualities of a physician – burning hot or keeping cool, but never being lukewarm:

”….of Art, the highest development of which can only come with that sustaining love for ideals which burns bright…”;

“Science, the cold logic that keeps the mind independent and free from the toils of self-deception and half-knowledge”;

“of Charity, in which we of the medical profession, to walk worthily, must live and move and have our being.”

(Aequanimitas, 1904)

Today’s medicine tends to be more tepid, at least in my field, Primary Care. Others clamor to set our priorities, to the point that doctor and patient sometimes both feel marginalized. The personal doctor-patient relationship is sometimes replaced by a more generic consumer-provider exchange, where a patient may see the physician as just a necessary intermediary between their need and the solution they already know they want – as in the case of asking for a drug advertised on television.

We must start with what Osler calls “the cold logic of Science”. It is our role and our duty as physicians to view new claims of clinical benefit from tests, procedures or pharmaceuticals with a critical mind, applying our training and experience. Simply following guidelines is an abdication from our professional responsibility. You don’t need to go to medical school to follow guidelines – in fact, it may make it harder sometimes.

The burning flame behind our passion for the Art and compassion for our fellow human beings, what Osler calls Charity, must never be lukewarm.

We all have to work at the Art of medicine. It is easy to slip into routines of complacency; another case of this or that, giving it our usual “Spiel”. Seeing each patient and each clinical presentation as unique is necessary in order to connect with the other person in the exam room. Finding the right way to approach each one of many seemingly similar case histories is what makes a personal physician just that – each patient needs something slightly different from us. The better we understand those needs, the more effective we can be.

The Art of the medical practitioner lies in the balance between cold science and hot passion. This is where the chemistry between physician, patient and disease takes place.

Call it chemistry, even alchemy: As physicians, we are catalysts in each patient’s transformation. And just as any other catalyst, we cause a chemical reaction to take place without being consumed ourselves in the process.

Our true challenge as physicians in today’s health care climate is keeping the flame Osler spoke of. Without that flame we are at risk for straying from the ideals behind our profession.

Osler warned us never to feel lukewarm about being doctors:

“By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction.”

The Art of the Referral Letter

Published April 22, 2012 The Art Of... 2 Comments
Tags: Meaningful Use, Referral Letters

One of the journals I skimmed through this weekend had a piece about Meaningful Use, which is Newspeak for what electronic medical records need to do in order to satisfy Federal requirements.

One of the requirements we must satisfy in the next round of Meaningful Use is to “send summary of care records in certain referral and transition of care situations”.

The Archives of Internal Medicine reported a year ago that 70% of primary care physicians claimed to inform specialists of patients’ medical history and the reason for consultation, while only about 35% of specialists reported to be getting this information.

I remember the eloquent referral letters I used to dictate years ago, when the administrative burden of a rural family practitioner was a fraction of what it is now:

“Dear Mike,

This is to introduce Mary Calderon, a 53-year-old Gravida 3, Para 2 with a BMI of 30 and a recent onset of postmenopausal bleeding 18 months after a seemingly normal menopause. Her ultrasound shows endometrial thickening….”

“Dear Ned,

Thanks for seeing Bella Beaupre, an otherwise healthy 68-yar-old with six months of migratory polyarthralgias and an inconsistent laboratory profile. Clinically, she appears to have new onset of Rheumatoid Arthritis, but I would appreciate your help….”

After each consult, there would be an elegantly worded, impeccably typed letter on deliciously thick linen stationery, blue from Mike, cream colored from Ned, running a page or possibly two, signed with flair in ink with each one’s favorite fountain pen.

Just as my referral letter would state whether I wanted my specialist colleague to see the patient for a consultation so I could take it from there or simply take over and manage the patient, the consultation report would succinctly outline their thoughts and proposed treatment plan.

A few years ago, Mike’s group adopted an EMR and the two-page reports on blue linen stationery were replaced by five-page boilerplate reports that all tended to look very similar, to the point of making it hard to see what Mike really thought of the problem I had referred to him. The reports, even though he is a specialist, had smoking status, last pneumonia vaccination and all kinds of “primary care” information. Because Mike never learned to type worth a darn, his thoughts about each case I sent him were often reduced to just a line or two somewhere in the middle of each report.

My own referral letters have also lost some of their flair over the years. Instead of thoroughly summarizing each patient’s past medical history, somewhere along the line I started to focus on the problem for which I was referring the patient. I would have a catch phrase somewhat like “please see enclosed records for additional background information”. It was less satisfying, but it seemed there was never quite enough time to dictate one of those old, delicious doctor-to-doctor notes.

Now, with my own transition to electronic records, I can’t just pick up my handheld recorder and dictate a referral letter anymore. Anything written is the product of my own point-and-click or hunt-and-peck. By necessity, I now type a brief, yet to-the-point paragraph at the end of the office note about why I am requesting a consultation for my patient. It doesn’t say “Dear Mike” or “Dear Ned” anymore, and, just like Mike’s and Ned’s office notes, it has a lot of information that looks the same from patient to patient and visit to visit. But, after all, smoking status as a vital sign and all those other items are necessary to meet our current “Meaningful Use” requirements.

I haven’t asked either one of my colleagues how they feel about my referrals these days.

I, for one, really miss Mike’s thick, blue stationery and his wisely worded reports that always taught me something new or confirmed my own thoughts, signed with that broad nib fountain pen of his.

That was Meaningful Use, too.

When To Take Medication

Published April 17, 2012 Health Topics 1 Comment

Doctors are like mothers. We tell you what to du because we assume we know better than you do.

Take medication administration, for example. If your prescribing physician doesn’t, your local pharmacist almost certainly will tell you when and how to take your prescription medication.

More often than we’d like to admit, we are wrong. Here are just a few examples:

1. ) Levothyroxine, the synthetic thyroid hormone taken by people with low thyroid function, is usually given in the morning on an empty stomach.

At least two significant studies have shown increased effect when this type of medication is taken at night. But since the dose of thyroid replacement is adjusted regularly by the prescribing physician according to a simple blood test, the timing of the dose probably doesn’t matter at all as far as achieving normal thyroid blood levels. What may be of importance is that evening dosing may more closely follow the natural diurnal rhythm of the body’s own thyroid hormone. That may be of importance for how well patients actually feel.

2.) We usually recommend heartburn sufferers to take their omeprazole and similar drugs in the morning 30 minutes before eating.

It sounds logical to give such medications before food, because eating is usually what stimulates acid production in the stomach. However, new research has shown much greater effect when these medications are taken at night. The labeling, at the pharmacy as well as from the factory that invented the drug class, still has the old dosing recommendation.

3.) We are told that cholesterol lowering statin drugs work better when taken at night.

The idea behind this is that the body produces more cholesterol at night than during the day. This has implications for when to take statins with a short half-life, like simvastatin, but isn’t a factor with long acting statins like atorvastatin, Lipitor.

Nobody knows how the timing of statin dosing affects the other mechanisms of statins, from blood clot reduction to plaque stabilization and anti-inflammatory effects.

Whether a medication is best taken with food or not is usually related to how food increases or decreases the absorption of the medication. What many doctors and pharmacists forget in this context is that the potency of the pills themselves can vary by plus or minus 20% if they are generic instead of brand-name drugs. This is all the precision required of generic drug makers in this country. That fact sometimes means more than how and when medications are taken.

Some of my patients have trouble remembering to take their evening medications; even one or two missed doses per week makes a bigger difference in cholesterol values, for example, than taking the medication at the “wrong” time would.

A medicine taken wrong is usually still a whole lot more effective than one not taken at all. I learned in medical school that patient compliance with medication administration three or four times per day is in the order of 50%. I have seen newer reports that it is better today, but I am not sure I can trust that, so I try very hard to keep my prescribed medication regimens as simple and possible. I am also less and less dogmatic about the timing of medications when the evidence that supports our standard recommendation seems shaky.

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