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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.

Negative Expectations

Published April 15, 2012 Progress Notes 1 Comment

Andrea Smythe needed something for her depression, but she was leery of medications. Her counselor had recommended trying an antidepressant, and I agreed.

Andrea told me nobody in her family ever took an antidepressant, and none of her friends ever did.

By the time I had dutifully explained about initial nausea, the risk for suicidal ideation and the possibility of inducing a manic episode in undiagnosed bipolar patients, Andrea was squirming in her chair. I didn’t even get to the risk of weight gain and sexual dysfunction before she told me she’d rather do something “natural”.

“Who wouldn’t, after that introduction”, I thought to myself. So we talked about St John’s Wort and other nonprescription alternatives, all less studied but without foreboding government-mandated warnings.

This is the age of informed consent. Anything you don’t say about possible adverse effects can be used against you. That’s why most lawsuits against cigarette manufacturers fail – after all, they warned smokers about the dangers of using their product.

Even when patients agree to take the medication suggested by their physician, the negative expectations can be a hindrance to the beneficial action of the medication – a real nocebo effect. This is the opposite of the placebo effect that some people tend to dismiss as imaginary. Ancient physicians, the fathers of modern medicine and cutting-edge neuro-immunologists all tell us the human body’s ability to heal is helped or hindered by the patient’s state of mind. In many psychiatric diseases this is axiomatic.

I, for one, always look to align my treatment plan with any potentially available placebo force, for lack of a better word.

“Did you ever know anyone who took an antidepressant?” I usually ask. If the answer is yes, I ask which one and how it worked. If the other person is a family member, I not only have a chance for insight into my patient’s positive or negative expectations but also into their genetic predisposition for response or non-response to certain medications.

If the patient believes one medication is more likely to work than another, I would have to feel very strongly about any other medication I might want to suggest in order to pass up all the positive expectations – call it placebo effect if you want – that the patient just offered to the therapeutic situation.

This is where all the practitioners of non-allopathic medicine have several advantages in today’s health care climate; they are not required to warn patients about rare side effects of their treatment, and they are sometimes more able to listen to their patients’ beliefs and preferences without worrying about what insurance companies, managed care organizations or treatment guidelines tell them to do.

The other day I saw a dramatic example of the nocebo effect; Rachel Ruel had been plagued by horrendous attacks of abdominal pain for several years until I started her on a very low dose of metoclopramide, taken only as needed during these attacks. The medication controlled all her dysmotility symptoms and she was finally able to live a normal life. This was long before the 2009 “black box warning” issued by the Food and Drug Administration about the risk for tardive dyskinesia. We talked about the risk for this rare facial movement disorder and Rachel always felt the relief she got from the medication was so significant that she was willing to take the small risk of side effects.

When I last saw Rachel, she had a tooth infection and secondary jaw pain. She had been sure this was the beginning of tardive dyskinesia, so she had not taken metoclopramide at the beginning of her latest attack two days earlier. She was still miserable with abdominal pain. Her unrelated jaw symptoms had escalated her fear of developing tardive dyskinesia, and I was in no position to talk her out of that fear. I had nothing to offer her, except a referral to a university gastroenterologist.

She left my office still fearful and in pain, but she made the least frightening choice she could make in that moment. I am still wondering if I could have handled our visit differently.

Cell Phones Welcome

Published April 14, 2012 Progress Notes 1 Comment

Many doctors’ offices have little signs discouraging the use of cell phones. Personally, I find them useful more often than annoying or disruptive.

The other day I saw Mrs. Jonah for a sinus infection. She had lost her private insurance and ended up on Medicaid, the insurance for low-income Americans. When her insurance changed, we had to change several of her medications, because Medicaid didn’t cover what she used to take. Mrs. Jonah told me that one of her new medications wasn’t working for her and the step care on the Medicaid website was confusing. I pulled out my cell phone – not a smart phone for this country doctor, but a waterproof one suitable for working around our little farm.

I know our state’s Medicaid office doesn’t keep you on hold forever, and the people who answer the phone actually have the answers to your questions. Within a couple of minutes I had e-prescribed a new medication to her pharmacy along with an antibiotic for her sinusitis and Mrs. Jonah left the office with a smile and the words “you make things happen”.

I also pulled out my cell phone when Mrs. Gordon’s blood pressure was higher than I had ever seen it and she seemed confused about how many blood pressure medications she was actually taking. The pharmacy told me she hadn’t picked up her lisinopril since February.

Bud Swensen told me his little red pills made him itch, so he stopped taking them. I couldn’t figure out which medication he was referring to. He called his wife on his cell phone and we settled the issue right then and there.

Frank Garr always gives me a hard time if I happen to be running late. That is what happened when I last saw him. He said he was running out of his sleeping pills. According to my records, he should have had a refill left. I called his pharmacy to verify this. He looked demonstratively at his watch and said “I’m deducting this from our fifteen minutes”.

“I’m making this call for you”, I replied.

“Fair enough”, he said.

Norm Parsons was having a terrible time with his rapid atrial fibrillation. His cardiologist in the state capital had really wanted him on a beta blocker because of his mild heart failure. Norm had tried them before and had to stop because of side effects. He was beet red, huffing and puffing, and said “this is exactly what happened last time I tried metoprolol”.

A quick cell phone call to his cardiologist gave me permission to switch Norm to diltiazem, even though it theoretically is less ideal for rapid atrial fibrillation with heart failure. Norm’s e-prescrition for the new medication, my office note and the cardiologist’s documentation of the medication change happened quickly and in real-time.

One thing I don’t do with my cell phone is take incoming calls. I have my phone on “vibrate” and check for missed calls or messages between patient visits. But for straightening things out with pharmacists and colleagues, I wouldn’t want to be without my cell phone.

A Doctor By Any Other Name?

Published March 30, 2012 Reflections 2 Comments
Tags: läkarblogg

(A reflection for Doctors’ Day)

I am used to being called a “medical provider” instead of a doctor or a physician these days, but it makes me think about the implications of our choices of words. The word “provider” was first used in non-medical contexts over 500 years ago. It is derived from the Latin providere, which means look ahead, prepare, supply.

“Medical provider” is part of the Newspeak of America’s industrialized medical machine. It implies, as Hartzband and Groopman wrote in The New England Journal of Medicine, that:

“…care is fundamentally a prepackaged commodity on a shelf that is “provided” to the “consumer,” rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient”.

The 800-year-old word “doctor” is Latin for Church father, teacher, adviser and scholar. It infers more closely the Hippocratic and Oslerian ideal of what a physician should be like. “Doctor” is used as a title for physicians in many languages, even if other words – like physician – are used to describe the professional role of a medical doctor.

Those other words are often less than flattering in their derivation or usage. Physician, for example, comes from physic, the Latin word for natural science and art of healing, which is noble enough. Less noble is the use of the word physic for a laxative due to the common practice of purging by physicians of the past.

In Medieval times, both physicians and their commonly used blood-sucking worms were called leeches. The Middle English word leche has lived on in many languages’ words for doctors: Läkare (Swedish), læge (Danish) and lääkärit (Finnish). These words are similar to the Indo-European lepagi. It means talk, whisper and incantation and is thought by some to be the true origin of the Scandinavian words for physician.

The Russian word for physician, врач (pronounced vratch), is uncannily similar to врать, which means talk nonsense or lie, and ворчать, mutter. These similarities also harken back to ancient and mysterious rituals of physicians of the past.

The German Arzt is perhaps the most flattering of the words I know for physician; it is derived from the Late Latin word archiater (Chief physician or physician to the Court) and the Greek arch-iatros, where iatros is the familiar word for physician we use in “iatrogenic”.

Personally, if someone asks what I do, I answer “I’m a doctor”, but I never insist on what people should call me.

The language, as it changes, may accurately reflect one very powerful view of what medicine is, but neither the words nor the business model can change what patients need when they are ill or frightened. They need more than generic providers; they each need a human being with knowledge, wisdom and compassion.

Ultimately, whether others call us physicians or medical providers, it is still up to us to define our professionalism and to defend our personal standards. These things are neither generic among providers nor, as some are hinting these days, almost replaceable by technology or treatment protocols.

Star Trek’s fictional United Federation of Planets Starfleet did have a technologic replacement for their flesh-and-blood ships doctors, still nick-named “The Doctor”; installed in most Starfleet ships’ sick-bay was an Emergency Medical Hologram, EMH for short. When its transmitter was activated, it mechanically said: “Please state the nature of the medical emergency”. The EMH eventually evolved into a sort of sentient being, but it is unclear to me how patients really felt about this contraption.

What, then, is a physician? A sixty-year-old answer still says it well:

“The value of the physician is derived far more from what may be called his general qualities than from his special knowledge. A sound knowledge of the aetiology, pathology, and natural history of the commoner diseases is a necessary attribute of any competent clinician. But such qualities as good judgement, the ability to see the patient as a whole, the ability to see all aspects of a problem in the right perspective, and the ability to weigh up evidence are far more important than the detailed knowledge of some rare syndrome, or even the possession of an excellent memory and a profound desire for learning”