A Country Doctor Writes:

Bucksport Regional Health Center, where I used to be Medical Director, has a “Friends and Family” support group for family members of our patients in opiate recovery. On Friday March 24, 6-8 pm, we will host a meeting for anyone interested in understanding or helping a loved one who is in or could use a Suboxone program like ours. Our remote main speaker, Dr. Paul Updike, pain and addiction specialist in Buffalo, N.Y., is an adviser to our program and helped start our “Friends and Family” group, which meets every two weeks in person and via Zoom. If you can’t attend our informational meeting in person, here’s the link:

Join Zoom Meeting 3/24 @ 6 pm

https://us02web.zoom.us/j/81788535330?pwd=MDh6dHlaSGJJVjNMSjhkRFNQWDBnQT09

A lot of people don’t know much about how the body works. One of my jobs as a physician is to explain how things work in order to empower my patient to choose how to deal with it when the body isn’t working right.

On my blog I have written about this many times, for example in the 2010 post GUY TALK:

Guy Talk

One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.

Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.

I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.

Other, perhaps less obvious, analogies I have perfected over the years include the following:

Finasteride to slow progression of benign prostatic hypertrophy:

You buy a new car and the dealer sells you a rust proofing job. Five years later, your car is rust free. Is it because you paid extra for the rust proofing, or would the car have been OK anyway?

Why carotid artery stenosis up to 80% can be asymptomatic:

If you water your plants with a garden hose and compress the hose by 80%, the water will actually squirt faster and further than if you just stand there with a soft grip on the hose.

What to do when a test result and your judgment conflict:

When the terrain and the map disagree, follow the terrain.

Why some people with high cholesterol escape heart disease while others get more atherosclerosis than expected because of inflammation, as measured by C-reactive protein (CRP):

Some people’s arteries are like Teflon, nothing sticks, and other people’s arteries are like a scratched-up aluminum pan, everything sticks to the bottom.

Why skipping just one dose of your antihistamine can cause a major allergy flare-up:

If your townspeople are trying to discourage out-of-towners from stopping in and causing trouble at your local hangout and your strategy is to make the place look filled to capacity, be sure you get there as soon as they open, and don’t you all take a break at the same time, or the place will look empty and they’ll be sure to stop in.

Why some people can take an antibiotic several times before they get a rash from it:

Just because your neighbor’s pit bull doesn’t bite you the first time you see it, do you really know it won’t bite you the second time?

Our job as doctors is to meet our patients “where they’re at”, as people say around here. That’s not the English I learned in school, just like the explanations and analogies I use with my patients aren’t exactly the ones I learned at Europe’s second oldest university. But all the book knowledge in the world won’t help you be a better doctor if people don’t like or understand the way you speak.

Today, a nurse I work with at the nursing home gave me the nicest compliment. Her husband had, reluctantly, been in to see me a few weeks ago. She told me that her husband thought that now, for the first time ever, he had a doctor he could talk to – one that talked the way he did and laid things out plain and simple without putting on airs or making things complicated.

Comments like that always make my day, just like hearing that people forget I am a foreigner and “from away”.

Two years ago I made a bunch of videos where I explain medical things. I’m gearing up to do that again and I would love to hear if my readers have topics they would want me to cover. I welcome comments and ideas.

Computers can do wonderful things. In many industries the people who analyze the data are a small, well payed elite and the people who enter the data are lineworkers.

Health care, a few decades ago, was something done by professionals, which is what we called physicians in those days.

Today, healthcare is a place where physicians are increasingly tasked with data entry and, as much as they may be analyzing the data for individual patients under their care, a much bigger purpose of the Electronic Record is the statistical analysis done by administrators, insurance companies, quality ranking institutions and others. Their needs supersede the needs of physicians caring for patients, but it is the physicians who are still tasked with entering the data that those other forces require.

Hippocrates had a word for all those people, long before he even knew who they would be in our era. He called them “the Externals”.

Today, the “externals” are running the show and we are pawns in their game. They don’t want us to even make clinical decisions – they have pre-programmed prompts in our #EMRs to order or initiate things that, generically speaking, might theoretically benefit our patients.

But people are complex and we do not have the technology to let computers decide what to do with individual patients. We still need well trained and experienced clinicians to make sense of all the data out there and apply it to our individual patients.

I think we, the physicians, need to reclaim the medical record. Its primary purpose absolutely must be to document what we do, how we think and what our patients tell us about their symptoms.

And I think the increasingly clever artificial intelligence systems could harvest what the bean counters need from the notes that we create for our purposes. We could even imagine a concept like metadata, background statistical stuff that clinical readers don’t need but nerds might need.

The other day a hospital outside my service area admitted one of my patients and needed our information. I faxed over my two most recent office notes that included important information about who this patient’s different specialists around the state were. But the hospital didn’t see that important nugget among the s***tload of mostly irrelevant data that printed out.

So let us put in the note what we need and make the computers harvest what the externals need – and make somebody else, besides the clinicians, responsible for entering that data.

You would think simple atomic particles like sodium, magnesium and iron would be evenly distributed throughout the body and that their blood levels would tell us whether we have enough of them in our bodies.

I already knew that that was not the case with sodium or magnesium. Tonight I learned that the same situation exists with iron.

Low sodium can be associated with swelling of the brain and rapid neurological deterioration, but if it develops slowly, the brain may not suffer as much as if it happens acutely.

Magnesium is shuffled from our tissues into the blood stream if our serum levels drop, which means even people with normal serum levels can have severe intracellular magnesium deficiency.

Tonight at 9:51 pm, the EMR still open on my laptop computer, I was in a Facebook messenger video with my lady friend. A patient who I’m not friends with socially sent me a video link to a neurology talk by a neurologist in Spain speaking with an Italian accent about restless leg syndrome. This is a condition that didn’t get much attention in my 5 1/2 year medical school curriculum at Uppsala University in Sweden, even though this disease is also called Ekbom’s disease and named after an Uppsala neurology professor before my time.

It is well known that iron deficiency can play a role in restless leg syndrome. The video stressed the point that brain levels of iron and serum levels of iron and ferritin don’t correlate very well. In this case, just as with magnesium, other bodily functions may be prioritized – If we are trying to overcome anemia we may sacrifice the brain iron levels to make more red blood cells and when we do that both the blood count and the serum iron and ferritin levels may look pretty good while the brain is suffering.

Tonight’s lesson is, once again, that blood tests don’t always tell you what’s going on in the part of the body where the symptoms are. And, by the way, in case anybody thought restless leg syndrome is a disease of the legs, it’s all happening in the brain!

My hospital’s mammogram reports have a space for “Date of last breast exam”. That is a relic from the past. How many women, and how many doctors, know that clinical breast exams are no longer recommended?

And how many men, and their doctors, know that DREs, digital rectal exams, are not recommended as a screening test for prostate cancer – or colorectal cancer, for that matter?

And testicular exams have no proven value as a screening for testicular cancer.

And never mind the annual “routine blood tests”, or even the “routine physical”.

I have seen three cases of testicular cancer in my 44 years since medical school. All three found the lump by chance on their own. The message we should give our patients is “Know Your Body”, but don’t be obsessive.

I know, this is hard. I mean, it makes such intuitive sense: Early detection ought to pay off. But once you know the sensitivity and specificity of a certain screening strategy, you often realize that even a positive screening result is much, much more likely a false alarm than a chance for early cure. And what is the expense and worry worth in all those false alarm cases?

It has been said that it takes 17 years for new scientific evidence to become standard medical practice. I believe it sometimes takes a generation to eliminate debunked practice routines.

But, do I myself follow the evidence? Mostly. But I can’t stop listening for carotid artery bruits – because I still believe I saved a few patients from a devastating stroke by doing that.

A Quick Listen