A Country Doctor Writes:

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/

It should be no secret by now that this rural family physician is pretty much unimpressed by today’s EMRs.

There are many little things that range from annoying to dangerous, but which don’t have a global impact on how I get through my day.

For example, in my Epic, the date when a blood test was ordered displays much more prominently than when it was actually drawn. This makes perfect sense for accountants, who keep track of when the order was received or when the bill went out. They have no idea that in medicine, it makes a difference whether the panic value reflects the patient’s status before they went to the emergency room last week or after they started their new potassium replacement.

More dangerous is when controlled substance prescriptions have an automatic stop date inserted if the provider follows the prompt and enters a numeric duration. What then happens is that a pain or anxiety patient who takes fewer pills some days when they feel better falls victim to having their medicine removed from their list on the day that is supposed to be the minimum time the drug is supposed to last, not the maximum (although Epic displays “up to X days”). Then, either my covering provider will refuse to refill a prescription because it is no longer on the patient’s list or that provider or I will need to re-create the medication from memory of another screen we have to visit, because you can’t “restart” an expired medicine in many EMRs. I have at least once prescribed the wrong potency of a pain pill that had fallen off the list. I caught myself because I had a funny feeling, and jumped through several hoops to retrieve the information from the old prescription.

But my absolute major gripe with today’s EMR’s is how much more difficult it is to glance at a report and get the gist of it. I don’t know if it is a generational thing, but I can glance at a report that follows the format of an 8 1/2 x 11” printed or faxed report and instantly get the essence of it and often even find the typos (for my readers outside this country, that’s approximately an A4 page). Even in my personal life, on my iPhone 13 mini, I can just take my myopic glasses off my nose and read a PDF of such a page and instantly understand what it means. Scrolling through screens that occupy maybe 20% of my laptop screen is slow and annoying and increases my screen time by many multiples.

Very seriously, if I get an emergency room report from my hospital, I only want to see the last page because that’s where the key information is. With the other hospital in the area, I only need to read the first page. But with an electronic medical record it’s not that easy to skip between the pages.

So, yours truly is a speed reader only if the page looks like a page. Maybe I should put up a poll: Page view or screen scroll preference by age?

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

It takes a lot of years to become a doctor, and sometimes many more years to become a good one. I don’t know whose harebrained idea it was to require us to do all the data entry to serve those other purposes that were never part of practicing medicine before. It has been said that seeing two more patients per day will pay for an assistant/scribe or whatever is needed.

So… Why is this not happening? In my own personal experience, we survived 15 minute visits with a previous EMR. With our new one (Epic, the probable industry leader), that is simply not possible. What’s wrong with this picture?

With clerical support, there wouldn’t be a doctor shortage and the burnout epidemic would not have the proportions it now has.

Let the doctors do the doctoring and leave the bookkeeping to someone else, at least until the EMR technology catches up and speeds us up instead of slowing us down!