A Country Doctor Writes:

Once a voracious reader, I now find myself listening to Blinkist or audiobooks

Joy is a Skill that We Can Develop by Neuroplasticity

-Max Lucado

“We have neuroplasticity on our side. In other words, your brain can rewire itself at any age, creating new pathways that override old patterns. When you deliberately interrupt a negative thought spiral and choose a different mental direction, you’re not just changing your mood – you’re physically reshaping your brain, one thought at a time.”

From the ancients to Jung to modern science, we understand that our thoughts can change how our brains work. 

Maybe a thought to consider as a possible New Year’s resolution?

There’s an incredible confusion in some medical practices about which outgoing orders are referrals and which are not.

According to healthcare.gov, a referral is:

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

As a primary care physician, I can refer a patient to an individual specialist, to a specialty practice without naming the doctor, or to the hospital – often to the emergency room because immediate testing or treatment is needed, sometimes directly to the hosptalist service for admission.

If I order lab work or imaging, those are not referrals, they are orders. The results come back to me and I have to decide what to do with them. Even if a radiologist who interprets an X-ray makes a diagnosis, it is still up to me to make a medical decision as to what to do for my patient. Neither lab or X-ray orders are technically referrals.

Why is this distinction important? Let me tell you a story.

John McCall is a 76-year old man who just had a triple bypass. Almost a year ago I saw him for exertional chest pain that he had had for over a year and it wasn’t getting worse. I put in an order for a nuclear stress test in his electronic chart. It seemed to take an awful long time to get that test results back, but that’s not entirely unusual in a shortage area like where I practice. Resources are few and weights can be long. I wasn’t all that worried because his angina seemed stable, I just wanted to see, roughly, what the extent of his coronary disease was.

I was surprised when I got a fax from the cardiology office. It was a consultation note from a part-time cardiologist in the two doctor office. The conclusion was that Mr. McCall needed a nuclear stress test.

I scratched my head and looked back in his chart. This is what happened. In some hospitals, the X-ray department schedules nuclear stress test because it’s an imaging procedure. In the hospital, John wanted to have the test at, the cardiology office schedules such tests.

In our medical record, we have the option to initiate a referral or the option to initiate an imaging order. The referral template automatically includes patient demographics like address and insurance information. An imaging order does not automatically include that. The referral order also has a text box that states referral for treatment, including consultation visit. The imaging order template has no such phrasing in it. Somebody in my office sent my imaging order to the cardiology department using the template for referral rather than what in my record is called just “provider letter”.

So somebody in the cardiology office saw, presumably, that I wanted a nuclear stress test, but the comment at the bottom of the page about treatment and consultation made them put my patient on the waiting list to see the understaffed cardiology practice for a consultation.

We lost months due to this glitch. Fortunately, his angina remained stable and he had a follow up with the cardiologist after the test was done. It was not considered a high risk scan. Medication was tried, but didn’t make much difference so he ultimately ended up with a locally done catheterization and then referral to cardiovascular surgery in the big city, where he ended up with an uneventful bypass operation.

This could have gone worse, but it is a lesson that referral is the accepted word for requesting a medical opinion, and I feel strongly that it should not be used for a test order where the ordering physician will deal with the results.

Today I had reason to review a medical chart of somebody I had never met before. They hadn’t been seen for a while. The most recent notation in the medical record was a fax from Cityside hospital’s urology practice. The fax, dated in October, stated that our clinic’s referral of this patient was rejected due to lack of information.

I had to search far back in the medical record for the referral. It was sent in January of this year, almost a year ago. The virtual fax contained about 25 pages of some brief notes and messages and a lot of laboratory reports.

Before opening that fax, I went into the lab section of the medical chart and there was a mildly elevated PSA result from January. This made me think that the reason for the referral was the elevated PSA, possibly indicating a significant prostate problem.

Quickly going through the 25 pages in that fax I did not see the PSA level. And the fax did not contain a headline to indicate the purpose of the referral.

Two things are striking about this incident. One is the lack of brevity in the referral our office sent out. The other is the lack of urgency on the part of the urology office in getting back to us questioning what the purpose of the referral was.

As far as our referral, I think it’s crucial to say what the main problem or question is. The other important thing is not to send too much information.. In our state just about every hospital laboratory uploads their results to a statewide database where any doctor can look up those results. This makes faxing lab test and x-rays almost unnecessary. Not all practices upload their office notes, though, so we have to be cognizant of that.

Everybody is pressured in today’s healthcare environment. There’s so much to do and so little time. Everywhere in our society, the attention span is dropping. I found it mind blowing that the urology office took nine or 10 months to raise the issue of what the referral was for, but I’m not completely surprised. They say that you have eight seconds to make a first impression when you meet somebody and in writing, everybody’s looking for a catchy headline. I mean, who would read a novel or even a short story with no title?

I think brevity in medical communications is a virtue. American healthcare today has all kinds of documentation requirements that don’t necessarily speed up the handling of medical issues. Unfortunately, the referral letter and the specialist response have almost gone by the wayside. They used to be valuable exchanges between colleagues, dictated, printed on fancy stationery and signed in ink. EMR’s don’t always accommodate for that type of exchange.

Let me go back and look at what I’ve written about referral letters before…

The Art of the Referral Letter

https://acdw.substack.com/p/remembering-the-specialist-referral

Somebody asked me today what Thanksgiving is like in Sweden and I answered “there is no Thanksgiving because we didn’t have the pilgrims or the Native Americans”.

I was wrong. There is a Thanksgiving Sunday in the Lutheran Swedish state church (shows you how much I attended when I was living there). It takes place in early October and is a celebration of the harvest. In the old days farmers would bring wheat, potatoes, carrots, rutabagas, apples, and other crops to share with the less fortunate in their congregation or village.

Since moving to America, I have more and more embraced Thanksgiving. This year, I even have two Thanksgiving celebrations, one with my lady friend and her large extended family in Van Buren on Thanksgiving Day and one in Bangor on Saturday, when we will join my children and grandchildren for a belated Thanksgiving because my daughter works on Thursday.

I just reread some Thanksgiving reflections that I originally published in 2016 and 2017. I’m linking to them below. Other than the chronology of how long I’ve been here and so on they still describe pretty well how I feel about my life and my choice of living in this country and doing the work I’m doing.

A Thanksgiving Reflection

Another Thanksgiving Reflection

Another Early and Late Career Collaboration with Lilian White, MD

A diagnosis is something very powerful. It can unlock a cure or clinch a death sentence. It can give you protection and benefits or it can exclude you from your chosen career.

Because healthcare is so much about public health, prevention and chronic disease management these days, diagnostic acumen is an underestimated skill in my opinion.

Diagnosis is the foundation of sick care, the oldest iteration of the practice of medicine. Half a century ago, many specialties involved more diagnosis than treatment. Neurology seemed to have very little in the way of treatment to offer back then, for example.

When I was a first year medical student, our university hospital didn’t yet have a CT scanner; the brain CT was introduced in Sweden the following year. The full body scanner came to Sweden in my third year.

So a thorough clinical history and bedside physical examination were the fundamental tools in the diagnostic process. I learned lung auscultation from a couple of old pulmonologists with experience evaluating tuberculosis patients. They were experts at percussion, the almost forgotten technique of listening to the sound created by tapping on the chest wall. People said they could draw a picture that predicted what a patient’s chest X-ray would look like.

We certainly have better imaging capabilities now, but so many diseases don’t show up in pictures. Take movement disorders, headaches, even chronic belly pain. Symptom history and simple observation and examination have not become obsolete.

In our everyday practice, we see diagnoses play many different roles for us as medical providers, for our patients and for the organizations we work within as well as for insurance companies and ultimately Uncle Sam.

A DIAGNOSIS CAN OPEN DOORS

A patient of mine with chronic respiratory failure on oxygen 24/7 was bothered by thick sticky phlegm. Maximum doses of guaifenesin did not help her raise much of it. I wanted to try an old nebulized medication called acetylcysteine. It required a prior authorization. The diagnosis I assumed would qualify her was chronic respiratory failure with hypoxemia, J96.11. The prior authorization was denied. I managed to find a list of diagnoses that would cover this medication. It turned out that the much less ominous ICD 10 code for unspecified emphysema, J43.9, got it approved.

I think this is a fairly random ruling by Medicare. But little things like that fill our days. Knowing what diagnosis covers what in terms of qualifying for a test or treatment is part of a bigger phenomenon that I call metamedicine. Another example of metamedicine is that even though heart failure can typically cause shortness of breath and/or swelling of the legs, Medicare pays for the blood test BNP that we use to diagnose and quantify heart failure only if there is shortness of breath; leg swelling will not cover it.

A DIAGNOSIS BRINGS MONEY TO PROVIDERS AND INSURANCE COMPANIES

Because so much chronic care is managed and measured, it has become increasingly important to predict how costly each diagnosis is per year. This requires a degree of specificity when choosing the ICD 10 diagnostic codes. The more severe ones give you more “points“. And Medicare does not retain the codes over time. Each year they need to see a claim with active condition codes in order to predict their expenses. And now more and more they pay providers either directly or by making them earn or not earn bonuses if the cost to care for a patient is higher or lower than anticipated.

A diagnosis of depression with no indication of it being severe gives you no brownie points and no extra money in your pocket. Diabetes with complications is more profitable than diabetes without complications. And if we don’t assume that a person‘s mild to moderate chronic kidney disease is actually secondary to their diabetes, we lose an opportunity to score.

A DIAGNOSIS CAN SAVE YOUR LIFE OR MAKE YOU MISERABLE

Low-dose CT lung cancer screening and mammograms are examples of screening tests that may prevent getting a diagnosis too late for any hope of cure. Screening for Alzheimer’s disease isn’t likely to open doors to any radical and successful treatment. Some people might modify their disease trajectory by lifestyle changes, but how many of us would want to live the rest of our lives with the knowledge that we will come down with a disease like that? The benefit of prostate cancer screening has been debated for decades and one thing I learned in my training that still seems to hold true is that you may have to treat around 35 men for prostate cancer to actually save one life. The downside of treatment side effects, and also knowing that you have a cancer, even if most people don’t die from it, is something we may not be able to predict the effect of when we decide whether to screen or not.

A DIAGNOSIS CAN ELIMINATE THE SUFFERING OF UNCERTAINTY

For most clinicians, it can seem obvious that an annoying symptom that has lasted for decades is quite likely something harmless. That’s not how all patients see it. So many times I have found that an appropriate diagnosis or explanation of why they feel what they feel helps people stop worrying. As a primary care provider, we have to live with ambiguity and uncertainty, but that’s not how all human beings are made up. The closer we can come to a reasonable medical explanation of a symptom, the more we can help our patients get on with their lives and help themselves navigate their symptoms by developing an understanding of what makes them feel better or worse.

DIAGNOSTICIAN MAY BE AN EMERGING NICHE SPECIALTY

One of the greatest compliments I ever had, actually more than once, was “he is a brilliant diagnostician”. Maybe AI can help clinicians with less training make more accurate diagnoses as technology moves forward. But, now there is talk of making American medical school three years instead of four, even before medical AI is completely ready for prime time.

My Swedish medical school training was 5 1/2 years. After that, I did a two year rotating internship and then a three year family practice residency in this country. I have been a board certified family doctor for 41 years. I do love a medical mystery and have to confess that following treatment algorithms for chronic diseases all day long can be pretty boring. So at this stage of my career, it would be nice to be the in-house diagnostician who helps point patients care in the right direction. Maybe with an increasing percentage of primary care providers having shorter and increasingly even online training, diagnostic physician will become a new niche specialty?

Read Lilian White’s essay here: