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Doctoring at Christmas

I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.

This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.

As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.

Many people in this country routinely say things like, “have a good weekend”. I’m not sure that is such a universal high point in life. For some, it is a time for dreaded chores, for others a time to muster enough energy for that second job to help pay the bills.

Christmas is a more universal time of feeling celebratory and unselfish, and for me it marks the passage of time as well as the consistency of it. It was my time of awe and delight when I was a child, and now it is that for my grandchildren. As Christmas week culminates in the New Year celebration, it also helps me think about what’s next – for me and everyone in my family.

During the coming weeks, I will make sure to share some of the joy and peace I feel in my own heart with my patients and I will be more than usually sensitive to signals of holiday blues or distress in them.

This is not a time to flaunt what we have – lavish presents, successful relatives, gourmet food, fancy decorations or invitations to fun parties. It is a time to share some simple human warmth in the darkness and bitter cold of the northern Maine winter in a time of divisiveness, strife and unrest.

It is a time of “peace, good will toward men”, of greater openness to others. It is a good time for reconciliation or rekindling of relationships we may have neglected since the last time we wished each other Merry Christmas.

The Public Health To-Do List is Choking Doctors and Jeopardizing Patients’ Lives

“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”

Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.

But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.

You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?

Public health in its broadest sense is what drove down morbidity and mortality in the last 100 years. But most of those things are, at least in many places, easily and successfully done by people without medical degrees.

I don’t mean to be uppety, it is not beneath me to promote those things – I’m doing it gladly, but since I am not a solo practitioner, I believe those things can be done just as well by other staff, if necessary with standard protocols where a physician’s order is required. Ideally I would then just support or explain these things when patients have questions.

People are sick, people are worried about symptoms, treatments need adjustments, information from outside providers could affect our patients’ health or our own assessments and treatment plans for them. This is what we need doctors for, and experienced Nurse Practitioners and PAs.

Medical professionals are trained to diagnose and treat disease. Are there so many of us and are we so underutilized that our healthcare “system” can afford to fill our time with tasks that could easily be done according to protocol by non-providers?

It’s your choice, America. If you think there just might be a doctor shortage, an aging, sicker population and a looming decline in the health of our population – who should do what in healthcare?

Thou Shalt Not Try to Outsmart Me

Medical researchers and their groupies – early adopters, thoughtleaders, those easily influenced or whatever you want to call them – never seem to learn that when you try to outsmart Mother Nature or Our Heavenly Father, whichever appeals more to your world view, you usually get your hand slapped.

When I was a resident (1981-1984), I got penalized if I didn’t offer postmenopausal women estrogen-progesterone replacement therapy because it seemed obvious that if women with endogenous estrogen didn’t get many strokes or heart attacks and women without estrogen did, all we needed to do was make up for God’s or Mother Nature’s oversight in not keeping the estrogen coming after age 50.

Then the Women’s Health Study in 2000, almost 20 years later, showed that women on Prempro had more strokes, blood clots and heart attacks, and more breast cancer on top of that, than women who accepted the natural order of things – menopause with all its symptoms and inconveniences.

The same things has happened with osteoporosis – more subtrochanteric femur fractures after five years of Fosamax than in untreated women.

A simple thing like hypertension has played out similarly: People who take certain third tier blood pressure medicines, like alpha blockers, don’t have the benefit of lowering blood pressure that you might expect; those medications actually increase risk of death from cardiovascular causes.

The typical blood sugar targets that have been drilled into our heads, hemoglobin A-1 C under 7%, have been found to be detrimental to older patients who are more sensitive to low blood sugars than younger patients, so now we have a hemoglobin A-1 C target of 8% for older folks (thank goodness, especially for those with classic late onset diabetes).

And even my own affliction, gastroesophageal reflux, has a downside when you rely entirely on medications instead of lifestyle measures for management; escalating proton pump inhibitor doses are now known to increase the risk of iron and vitamin deficiencies, osteoporosis, pneumonia and C. difficile infections.

Just like prednisone and Humira work brilliantly when you feel like you have do decrease autoimmunity, rather than say “what it is making the immune system overreact” (gluten, artificial food additives and antibiotics in the food chain), reaching for medications instead of asking “what is my body/God/Mother Nature trying to tell me” sooner or later might come back to haunt us.

We must always ask: “Is this a symptom caused by unhealthy lifestyle choices that need to change rather than medicated with more or less risky medications” or “Is this an aging manifestation normal enough to make medications unnecessary” or “Is this premature aging and possibly worthy of intervention?”

Aging phenomena that happen to everybody, such as osteoporosis, are perhaps, just possibly, better left alone, at least as far as drugs go, but certainty a subject for lifestyle exploration and intervention?

Which makes me think of all the hype about “Low T” (testosterone). Isn’t that the estrogen story all over again? I guess time will tell…

The Liability of Outside Provider Orders and What Could be Done About It

As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.

Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.

But how possible is it really to do a good job with that task?

How much time would I need to spend on this to do it well?

Is there any time at all set aside in the typical primary care provider’s schedule for this task?

I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.

10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.

But emergency room medicine is shift work, just like hospital medicine; providers may not be around when the abnormal result comes in, and the next shift worker perhaps can’t see what is in the first doctor’s inbox.

As I click through the “orders to sign off”, I end up prioritizing “my” orders, because I “own” them. The “Outside Provider” orders are in my inbox as a double check, but nobody double checks my results. I have to make them my priority if my time is limited and time, by definition, is always limited.

There is more and more data in medicine, and while I hope technology will make it easier to sort, view and prioritize data, I don’t believe artificial intelligence will do that well for frontline medical providers anytime soon.

I keep thinking that we really need to have a serious debate or examination of what we need primary care providers to do. The Patient Centered Medical Home movement (see my personal take on that here) held a promise of better care coordination by people like me in clinics like mine, but the way we do things hasn’t changed nearly as much as many of us had hoped.

I seriously believe that it would be a worthwhile investment for our whole healthcare “system” to structure and reimburse the care coordination work we primary care providers could do for our patients.

We can certainly use the help and collaboration of other professionals like nurses, but ultimately we need to know what’s going on with our patients. Otherwise their care will continue to suffer from more and more fragmentation as subspecialization brings more different doctors into many patients care “teams”, as hospital stays grow shorter with more loose ends at discharge, as options for urgent care walk-in and virtual visits increase and as more and more patients become afflicted with multiple chronic illnesses because of the declining health of people in this country.

When I started my residency in Lewiston, Maine back in 1981, family doctors were enthusiastic and idealistic. Much has dampened that enthusiasm since then, but I still believe we have a crucial role we could fill for the health of our nation.

If the “system” would only let us.

The Polyvagal Theory: The Science Behind Therapeutic Relationships, Stress Related Illness and Long Term Effects of Trauma

The vagus nerve runs from our brain to our gut and along the way it connects with our heart. We used to think of it as a one-way signaling, but 80% of the activity in the vagus nerve travels the other way – from our gut to our brain.

As many times before, I read an article in The New York Times that made me dig deeper into a medical subject, this time the vagus nerve, and the term “Polyvagal Theory” got me going.

We now understand that there are three levels of activity in this system, and that each one of them can influence our bodily functions, our emotions and even our perception of reality.

This deeper understanding of the vagus nerve has been named the Polyvagal Theory.

The three functions of the vagus nerve represent three different stages in evolution and the newest one, involving our conscious mind, can’t necessarily override the older two.

The oldest part of the system regulates our intestinal functions and has the ability to decrease our heart rate to the point of unconsciousness and our brain function to the point of shutdown or, in psychological terms, dissociation – playing dead, if you will.

The middle aged system can raise pulse and blood pressure and is the carrier of our famous flight or fight responses.

The newest vagus function is involved with social connections and whatever conscious regulation of the influences of the other two systems we are capable of.

Dr. Stephen Porges explains this in his books, articles and videos:

The fight or flight response is well studied and well accepted and I think most of us understand fairly well how it works. What I find the most fascinating aspects of the vagal system are the other two.

The shutdown ability of the oldest part of the system appears to explain a lot of the late effects of trauma, including dissociation and some cases of irritable bowel syndrome, for example. These conditions are associated with heart rate variability differences resulting from altered vagus nerve signaling by this system.

The younger system of social regulation was one I hadn’t really heard of and it suddenly made me understand therapeutic relationships not only in a social context like mother and child, friends or loved ones but also clinical ones, in a way that I had only intuited up until this point. This part of the vagal system is involved with control of our facial expressions, intonation of voice, gestures and all kinds of emotions involved in human contact.

Our ability to interpret things like facial expressions and intonation is dependent on whether we feel threatened in any way, and the polyvagal theory includes something called neuroception. Dr. Porges writes:

“Neuroception is proposed as a ‘reflexive’ mechanism capable of instantaneously shifting physiological state. Neuroception is a plausible mechanism mediating both the expression and the disruption of positive social behavior, emotion regulation, and visceral homeostasis.”

Neuroception can make us misread facial expressions and impair our ability for social engagement, both aspects of the newer vagal system. It can trigger panic attacks with heart palpitations and impulses to flee when the middle aged system is activated. It can also make us faint or mess our pants if we are paralyzed with fear due to activation of the oldest vagal pathways.

Our social regulation happens on many levels, and has its foundation in mother-child bonding. The so-called social neuropeptides, oxytocin and vasopressin are present in the same anatomical areas that are involved in vagal stimulation. The vagus nerve also regulates cytokine activity, involved in immune reactions.

Dr. Porges points out that humans have an inherent but limited ability for self regulation of emotions and their bodily correlates, although we can learn more of that even as adults through yoga or meditation and by exposing ourselves to soothing music for example. The foundation of human emotional regulation however is interpersonal relationships.

He writes:

“In order to co-regulate with another person, we need certain social engagement behaviors to feel safe with that person. Engagement turns off defenses. There are 3 behaviors: Facial expressions, gestures and prosodic vocalizations (intonation of voice the higher more soothing the voice the more safer perceived). Eye gaze can be seen as a threat at times for some trauma clients but prosody of voice is more of a stronger behavior for eliciting safety. Therapists can be mindful of all three behaviors in their therapy sessions with clients. Humans need others because regulators of physiology are embedded in relationships.”

This brings me back to what I wrote earlier this month in a post titled “Ten Building Blocks of Therapeutic Relationships”:

“It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.”

Sounds positively vagal, now that I know a little more…

Changing EMR – Seamless Continuation, Dreaded Chore or Fresh Start?

At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.

I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.

With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.

This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.

Our old EMR will become “read-only”, and who knows how much structured data will “migrate” from the old to the new system. And some information that should have been structured isn’t, because the old system’s search function was clunky enough that if we couldn’t find the exact word for a rare diagnosis in someone’s medical history, we would give up and choose the generic “neurologic disorder” and then free text the thing we might not even be spelling correctly. That still displayed intelligibly enough while the system was live, but will that migrate to the new system – who knows? Of course, there will be opportunities to correct old mistakes and omissions, as long as there is time…

The only way to view this inevitable transition is as an opportunity to undo old beginner mistakes, bad habits and workarounds. Having worked with two systems in my two clinics, I feel this is a bit like learning a new language or instrument; I know better what functionality I am looking for and will recognize it when I see it – just like a Spanish word I don’t know might look similar to a French word I do know for the same thing.

Wise from my positive experiences of screen sharing, I will bring patients along on this journey. I will be sitting next to each one with my laptop in front of us. I will invite them to update their history and increase the transparency of how I work, because there isn’t enough time in the day to keep the EMR invisible from my patient and then do all that work outside the appointment. Also, this is an era of increasing patient centeredness and I want to embrace that as much as I can.

I am determined to become as expert as possible with the new system so that I can document everything in real time in the visit and use more of my non-patient time in front of the screen to build templates and things like that.

In a way I feel a bit like many, many years ago when, as a student or budding writer, I opened a brand new notebook and put my pen to it for the first time. I loved fountain pens, crisp paper, leather bindings and the potential of all that clean, empty space.

Instead of feeling this EMR change will be a chore, I feel like a new school year or a new writing project is just about to begin.

Ten Building Blocks of Therapeutic Relationships

It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.

This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.

We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life

Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.

In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.

I think that is a factor mostly when someone is looking for sophisticated specialty interventions, often one-time-only, like “where’s the best place to go for high risk cardiac surgery”.

When looking for primary care, people still tend to ask, “who’s a good doctor”, rather than “which is the better primary care group, Uptown Medical Associates or Statewide Primary Care”.

How do you as a clinician in today’s restless and mobile society earn trust and build therapeutic relationships in fifteen minute visits with several visible and invisible intruders in the room – the computer and the insurance company, for starters.

I have previously reflected on how to prepare yourself for beginning a clinical encounter. My ABCs are Attention, Behavior and Connection.

But where do you go from there, how do you continue, grow and nurture a therapeutic relationship over time in the kind of environment most of us work within?

Here are a few lessons I have learned myself:

1) Listen and respond. How many times do we hear that patients don’t get to speak for even a minute before we interrupt them? If you hear something that immediately requires clarification, do what you would do in a social situation. Say that what the other person just said is important or interesting, reflect back what you think you understood and then be careful not to give them too many yes or no options, but invite them to continue their story. Imagine that you’re meeting an interesting person at a dinner party, not leading a legal interrogation.

2) Set an agenda. Almost every time I ignore this little rule, I get burned. Patients may not reveal their real concern when making an appointment and their priorities may have changers since then. Going all-in with what you think is their main issue and saving “do you have any other concerns” until the end of the visit is a recipe for disaster. That agenda-setting may need to be addressed right away or after hearing a little about the main concern. If you don’t ask what people need from you, how can you ever hope to fill your role as their provider?

3) Budget time. Don’t act frustrated about the reality that time is at a premium, and don’t declare that you have too little of it until you know how serious or urgent your patient’s concern is. The person with a seemingly trivial concern may need you to help them with the biggest or worst problem of their life, so invest your time and attention on listening and understanding early on in the visit. By acting unhurried at first, you are more likely to create an atmosphere of trust and caring; once you know your patient’s concern and their diagnosis or differential diagnosis, if they feel heard, you can move more quickly to wrap up the visit if you need to.

4) Manage the perception of time. If I am running late, I often enter the exam room and demonstrably sit down, take a deep breath and relax my posture as if I am finally arriving at the most important appointment I have all day. That slowing down gesture helps me to undo my patient’s fear that I’m going to be rushing them along. If they think I’m not going to meet their needs, their memory of the visit will likely be just that, even if I do a pretty good job technically for them.

5) Don’t be a hero. My 2018 post “Be the Guide, Not the Hero” points out the fact that everyone is on heir own journey in life and we are at best guides in our patients’ pursuits. If we try to be the hero in their stories, we create unhealthy, dependent relationships that often lead to patient disappointment or even resentment. As guides instead of heroes, we also remind ourselves that we are not the ultimate experts on what is best for our patients. Since our patients are the heroes of their own stories, they must ultimately decide which piece of advice from which guide they will choose to follow.

6) Be true to yourself. On the one hand, I believe we must adapt our demeanor to the situation – reassuring, motivating, inquisitive or sometimes decisive – but we must stay within the range of our real selves. I can be jovial only to a point or I will seem and feel like I am pretending, for example. People can usually sense falsehood a mile away.

7) Balance disclosure. We can not build therapeutic relationships as only technicians; we must engage as real people and you can’t be real without showing emotion, genuine interest, engagement and a good amount of humility. We have to be careful to show that we are fallible like everybody else but also that we ultimately have our act together. Nobody wants a self absorbed, overconfident guide, but nobody wants a weak and insecure one either. If we say we never had tough choices to make or regrets we carry with us, how can we expect patients to allow us to be close enough to build trust?

I tell people things they could relate to that I don’t think would come back to haunt me. I tell them how many miles I have on my car, but not how much money I spent on repairs. I tell them about my life lessons from being a Boy Scout or going through basic training in the Swedish army, the antics of the beagles I’ve had in my life or the way my one-time vegetarian diet made me put on weight. I tell them I was homesick at my first scout camp, but I don’t talk about things that could distance patients from me; not that I am a golfer or a sailor, but pictures and magazines of such things will alienate as many patients as it might build relationship with. My Arabian horses didn’t cost much money, they were adopted from a horse rescue and simply needed a home. Our relationship with animals, I believe, is more likely to show that we have the capacity for relationship building with humans, too.

8) Build continuity. From one visit to the next, find a thread to follow. For some patients, it is their chronic disease, for others their family or their hobby. Reconnecting about what you talked about last time is a powerful and quick way to reestablish the fact that you know each other and that you care about your patient. It brings you straight into a space where you are ready to do the work you do. Even if you have to pull up their last visit in the EMR (maybe even looking at the screen together), that quick reconnection that begins every visit helps make you seem better prepared; maybe you don’t remember the details of the last visit but you do remember your patient very well.

9) Solicit participation. When it’s time to formulate a treatment plan, don’t be too quick to lay it out as if there is only one way to do things.

10) Plan when and how to reconnect. “Followup PRN” isn’t usually the best way to conclude a visit in your mind or the EMR. Friends don’t usually leave each other saying “I’ll see you around”, that’s more for casual acquaintances. It’s important to agree on what to do after the test results come in, when the antibiotic runs out, if the rash doesn’t go away or when to meet up if everything is going well. Not making such plans devalues the relationship and makes you look as if you don’t care about your patient.

Everything on this list is about how we interact with the people we engage with frequently or infrequently. We must always look beyond the diagnosis and the Chief Complaint (which should be Chief Concern – where did “complaint” come from?). Remember Osler:

The good physician treats the disease; the great physician treats the patient who has the disease.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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