A Country Doctor Writes:

I love medicine. I love being a doctor. I thrive on making diagnoses and treating disease. I find deep satisfaction in educating and empowering patients.

But, as I have said many times, I am a problem solver and not a bookkeeper.

Doctors today are required to do more and more EMR data entry in more and more stilted ways with less and less team support. All the while we are under pressure to be both productive in terms of patient volume and comprehensive in terms of both disease management and an ever increasing burden of public health that really shouldn’t require a medical degree at all.

We have become bottlenecks in the flow of information. Our electronic inboxes exist so that our EMRs can document exactly when we saw a test result and what we did about it. This creates a tight bookkeeping workflow but ignores the fact that we can’t be in two places at the same time: We are scheduled to see patients all day long, so our inboxes fill up with unsorted data, unseen by the nurses and medical assistants, who used to help prioritize incoming data before the EMRs changed all that.

I have finally made the decision to move away from working in this unsafe, unsustainable and wholly unsatisfying way. I am transitioning away from traditional fee-for-service Family Medicine.

I will be the lead physician in the entire state of Maine for a new kind of practice that eliminates the hamster wheel of counting face-to-face encounters. I will personally and through supervision be responsible for the care of a fairly small number of complex, high risk Medicare, and later Medicaid, patients. My organization will be paid per member per month. This will avoid unnecessary visits, and it will make it practical to use remote monitoring, phone calls, video visits, and any other means of communication to stay in touch with my patients.

The foundation is house calls. I loved doing house calls when I worked full-time in Bucksport many years ago. These days house calls are viewed as not very profitable because by the time you drive to somebody’s house and see them and then drive back to the office, you could have seen two or three people in the office. But with the capitated payment model, a house call will teach you a lot about how the patient lives, and what their circumstances are, and that will help you make better decisions for their future care.

I will document my process of getting to this decision and my progress in entering this new type of practice on my Substack in a post category titled PROGRESS NOTES. This is a learning experience for me and a growing experience. My patients will be those in managed Medicare, also called “Medicare Advantage”. I already have many patients with that type of insurance, and many of them are very complex. It has been difficult to give them everything they need because in the traditional type of clinic I work in, we don’t get paid more when we spend more time with the patient. Any visit is paid the same, so there is no financial reward for being comprehensive, except some minor bonuses for the practice when quality standards are met.

I have been skeptical of managed Medicare, in part because they are stingy with authorizing and paying for CT scans when I think my patient has cancer, but in terms of outcomes for chronic diseases, the statistics are clear, because of the extra support managed Medicare provides, patients with that type of insurance have better outcomes. One insurer, WellCare, even sends people healthy food through a program called Mom’s Meals.

In “PROGRESS NOTES“ I will document what I am learning and what I experience in this new phase of my clinical career. Please join me.

https://acdw.substack.com/

In spite of all the talk these days about health care teams and in spite of more and more physicians working for bigger and bigger healthcare organizations, we are becoming more and more isolated from our colleagues and our support staffs.

Computer work, which is taking more and more time as EMRs get more and more complex, is a lonely activity. We are not just encouraged but pretty much forced to communicate with our nurses and medical assistants through computer messaging. This may provide more evidence of who said or did what at what point in time, but it is both inefficient and dehumanizing.

Why do people who work right next to each other have to communicate electronically? Why can’t my nurse simply ask me a question and then document “Patient asked whether to take aspirin or Tylenol and I told her that Dr. Duvefelt advised up to 2,500 mg acetaminophen/24 hours”. It would be a lot less work for me, even if I have to sign off on the darn thing.

And just because it now takes us longer to do our work, there is less slack our day. This makes for less curbside consults, less sharing of clinical experiences between clinicians, less social contact with other staff categories.

All this leads to professional and social isolation.

And, you know me, this reminds me of a James Taylor song, Millworker:

Then it’s me and my machine
For the rest of the morning
For the rest of the afternoon
And the rest of my life

There are a lot more choices these days for hypertension treatment than when I started out. Once several agents became available, we used to choose medications according to what type of patient we had in front of us: A person with leg edema and hypertension would be put on a diuretic, a type A personality with a high resting pulse would get a beta blocker, a patient with heart disease might get an ACE inhibitor and a person who might not show up for their bloodwork or follow up appointment would get a modern calcium channel blocker like amlodipine.

Then came the statistics that showed slightly better outcomes for diuretics and ACE inhibitors and all of a sudden we were supposed to take those small differences seriously enough to force all patients into the same treatment algorithm.

Some time after that came the data that showed that Black hypertensives respond differently to ACE/ARB drugs, which led to race based hypertension guidelines, which are now being debunked. Some people are now saying treat all hypertensives the same, while others are again suggesting making treatment decisions based on “individual factors”.

https://www.ucsf.edu/news/2022/01/422151/race-based-prescribing-black-people-high-blood-pressure-shows-no-benefit

I, for one, still individualize based on what my patient looks like and their personal preferences and their likelihood of compliance with followup appointments and blood testing.

I will never forget Fran, the chainsmoking, hypertensive woman I started on lisinopril many years ago. This drug was not generic back then and she asked for a 90 day supply because that would save her money. I told her a couple of times how important it was to get the bloodwork after starting this drug and placed the order to check her kidney function within just a few weeks.

When I saw her back 3 months later, I knew immediately something was dreadfully wrong with her. She was in kidney failure and it turned out that she didn’t have renal artery stenosis, which is what we’re supposed to consider and do bloodwork to check for elevated creatinine shortly after starting lisinopril, but she had a coarctation of the aorta. The vascular surgeons cleaned out her plumbing and her kidneys recovered but that was an important lesson, actually two:

Lesson number one is to measure lower extremity blood pressure in new hypertension cases. Ankle Brachial Index, ABI, even has a CPT code and may be billable to the tune of about $78 where I work (I don’t worry about billing but I do use a pocket Doppler and a conventional sphygmomanometer to do it right).

Lesson number two is not to prescribe a bigger supply of pills than you feel comfortable with. I now only prescribe 30 days of a new ACE or ARB. When I get an instant (!) “patient requests 90day supply” request from Walgreens – because they want to sell more pills – I turn it down.

And, now that I think of it, there is a third (bonus) lesson with new hypertensives. If they have a very low potassium and no good explanation for it, like chronic diarrhea, I very quickly consider they might have hyperaldosteronism and check their renin-aldosterone ratio before I put them on an ACE or ARB, since they may be better off on spironolactone than the traditional blood pressure pills. And they may even need surgery.

An Incomplete Workup

1) Always set an agenda: “What would you like to cover in our visit today, before we get into any detail – so we can plan our time.”

2) Always summarize what you understand of your patient’s symptoms, and don’t be afraid to ask “anything else going along with this feeling that I might have missed?” And never take self-diagnoses at face value. Ask for details.

3) Always explain your diagnostic thinking and always emphasize that symptoms can change and then lead to other conclusions or treatment choices. Don’t make snap diagnoses in a way that might seem arrogant or lazy.

4) Always spell out if you are adding a medication or making a substitution. We know hypertension and diabetes often require multiple medications as time goes by, but patients don’t (or don’t want to) understand that. Just the other day I learned that a diabetic patient stopped his pills when I asked him to start insulin!

5) Always make a followup appointment, especially if you just made a new diagnosis and treatment plan – just to make sure your diagnosis was correct and that your chosen treatment works. I have found that “call and let me know if this isn’t working” often leads to less than perfect outcomes and less than happy patients.

An overweight man with high blood pressure asked me about Ozempic the other day. He and his wife have different insurances. She is on Ozempic with a low co-pay. It would be high enough to be difficult for my male patient to afford.

So I asked him: “What does it feel like to be hungry?”

“I don’t know”, he answered. “I can work all day without even eating breakfast and feel fine but then once I start eating, I just go on and on. I’m not much of a snacker, I just eat big meals.”

“I have a large hiatal hernia with spontaneous reflux even standing up”, I started. “If I go too long between meals, I get acid reflux and pain in my upper belly. And sometimes I get cranky and confused”, I explained.

“I don’t feel any of those things”, he said.

My response was instant like a divine flash of lightning from the sky: “Why don’t you let your wife plate your food, just the size portion that she is eating?”

He smiled and raised his eyebrows.

“Because you don’t feel hungry, you just have an appetite. Doing this would save you a lot of money and avoid piling more medication on top of what you’re already taking. It might be worth a try”, I said.

“Let your wife be your Ozempic”, I added. “And if you haven’t lost any weight when you come back to see what this new blood pressure pill is doing for you, we can talk Ozempic and other options if you’re still interested!”

https://badgut.org/information-centre/a-z-digestive-topics/hunger-and-appetite/