A Country Doctor Writes:

It feels like we are moving backwards!

(This is going up on my Substack tomorrow. Links to older posts on the same topic below.)

In the beginning of the opioid epidemic, pain became the fifth vital sign, and we all know what happened after that.

The prescribing guidelines became more restrictive. States and national authorities implemented dose limits. The monitoring of physician prescribing practices and the shaming of physicians who prescribe more opiates than their peers is systematic now.

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And yet, even though opiates have fallen out of favor and many of the non-opiate pain medications have at least come under suspicion, if not downright gotten viewed as inappropriate, we are now required by CMS to make ongoing pain assessments.

Lyrica is a controlled substance, its sister drug gabapentin has become popular with substance abusers, Cymbalta can cause mania, amitriptyline is viewed as inappropriate for the elderly because of side effects, largely anticholinergic. Cyclobenzaprine falls in the same category and requires prior authorization over age 65 with many insurance companies. NSAIDs can cause gastrointestinal hemorrhages and kidney damage and Tylenol had its maximum dose recommendation reduced several years ago because of concerns for liver damage, and so on…

So if we screen for pain with positive findings, there is no obvious, easy and safe intervention to offer. Considering that this is a throw-in when patients are actually being seen for something else, this is a prime example of Pandora’s box.

The common sense approach to screening is that it should be done when there is an effective intervention that can be offered. CMS did not in the past recommend screening for depression, for example, unless mental health resources were readily available. They changed their mind on that. But, where I work in Northern Maine, most therapists have a one year waiting list or worse. And the dirty little secret about antidepressant medications is that they work about 30% of the time – about the same as placebo.

We are mandated to screen for pain with no easy treatment options. The foundation for pain management is largely cognitive behavioral therapy, which is hard to come by as a modality that requires special skill on the part of the behavioral health counselor.

As far as interventional pain management, lumbar steroids etc., the outcomes data is mixed.

So here we are, beginning a routine visit with a patient who scores positive for pain and depression. Meanwhile, their blood pressure, blood sugar or whatever is out of control. The medical provider’s internal egg timer is ticking. How can we best help this patient in the limited time we have available?

Thanks a lot, Uncle Sam…

My Latest Writing Project

A little while ago I offered to mentor a couple of young doctors and two signed up. One of them was Lilian White, MD, who is in her first year of practice. Tonight she and I each posted a collaboratively written post on our respective Substacks. They deal with a physician’s feelings when a patient decides to leave their care. I think we have stumbled on an interesting longer-term writing project from two family doctors at opposite ends of the career spectrum.

https://open.substack.com/pub/acdw/p/early-and-late-career-collaboration

This is exciting news! Early on after my two books were published, there were some comments asking me to record them as audiobooks. It sounded tempting, but more than a little daunting considering the possible distractions like cars driving by and dogs barking in the yard, so I ended up not doing it. Now, with the help of rapidly evolving AI generated narration, I have simply selected which of several voices I wanted to read my books, then clicked “Add audiobook with virtual voice”. That’s it. KDP (Amazon’s Kindle Direct Publishing) even promised to have the books ready and available on Audible in less than 72 hours. I have priced each at $5.99.

Both books are already live on Audible, an hour after I submitted them, and should be up on Amazon shortly.

I thought I moved everything successfully to Substack. But I still get a lot of views here. Please comment below if you are still here , looking for new material and not moving to Substack. Thanks.

I started this blog in April 2008. Over the past 15 years, I have moved three times, twice to the same house in northern Maine, changed jobs a couple of times, and gone through a divorce. I have published almost 1,000 posts here, inspired by my work with patients. I believe I coined the phrase My work inspires my writing and my writing inspires my work.

Sometimes, because I was actively trying not to feel burned out, I saw uplifting or thought provoking things in my ordinary patient encounters that I might have missed if I hadn’t resolved not to sink into despair about how things work in medicine today.

Less than a year after I started this blog, I left the clinic where I had spent most of my career, where I was Medical Director and originator of all kinds of improvements and program expansions, even a major contributor to a massive building expansion design. Then I started over, from scratch, at age 56 in Van Buren, a part of the state where nobody had heard of me.

Writing helped me through the difficult time of not yet having an established reputation and position, and it helped me see everything as a new opportunity; if nothing else, this big move gave me something to write about.

Life happened, my marriage ended (early followers may remember many, many posts about the good days) and primary care changed. To an outsider it may seem petty or even pathetic that a physician might leave their position because of its computer system, but I know for a fact that the EMR is a common and important consideration for physician applicants when considering a new practice.

And this year, I knew I had to do something different. And there, suddenly, was a LinkedIn message from a Galileo recruiter. Housecall practice, first in Maine, backed by a large organization, large territory. I, who put 300,000 miles on my big SUV driving back and forth working on the coast and in the north woods, used to joke “If it paid better to drive for a living, I might want to do that”. Now I drive and make housecalls. Seems like I manifested this life change.

So, I’m starting over, at my age.

And this year, my new lady friend, a retired grade school teacher, returned to work part time and is now the official, full time third grade teacher in Van Buren, where she grew up. She tried being retired, but decided to do more, to start over, doing what she loves.

And last night, after half a year playing with Substack, a bigger platform for my writing than my own little blog, destiny knocked on my door, it seems. I’ve had the same theme (template) for my page design since 2008. WordPress announced years ago they would not be supporting it. But it always seemed to work – until last night. All of a sudden, all you see on a laptop or an iPad is the masthead and the sidebar on regular blog pages. Fortunately, the iPhone still displays everything. The words you are reading right now are not a blog post but a “page”.

So, I could choose a new theme, but that means my masthead would have to have different proportions and all kinds of similar fuss…and the viewership on a day to day basis is multiples more on Substack. Plus I even get occasional paid subscriptions (in case I eventually decide to slow down in my clinical work).

So the more I think of it, the more I think I might just park the WordPress blog and concentrate on Substack. A freestanding blog is almost like when wife #1 (don’t ask) had a BBS, a dial-up bulletin board before the Internet, with only one or two viewers at the same time and she, the “Sysop” (systems operator, I think) chatting via text with them.

Substack is more like YouTube or TikTok, a platform where readers follow their writers but also get glimpses of other writers they might also want to follow.

So that’s the way I feel tonight, two days before Christmas the year I turned 70. All fresh and new. Age is just a number.