A Country Doctor Writes:

(After a whole month of radio silence, I am writing here again. I have built my Substack site and I have taken care of some things in my life, most recently the task of making room for the last of my furniture from Sweden. I feel like I am starting a new chapter of my life in a few weeks when I turn 70, still hard at work doing what I set out to do at age four, but looking at it a little differently.)

This week’s JAMA has an essay in its series, A Piece of My Mind, titled The Stories We Tell Ourselves. The author, palliative care physician Danielle Chammas, MD, writes about the importance of the words we choose when we speak and our task as physicians to help our patients view their circumstances in the best possible light and to rewrite their stories.

She Writes:

Stories allow for the integration of loss, fear, and suffering into one’s life. They become the vehicle through which clinicians can help patients redefine what it is they are hoping for (rather than lose touch with hope all together).

Is somebody a patient, a victim, a survivor, a burden? What does it mean to be a fighter? To do everything? Did we give up on a loved one, or did we honor their dignity? Did we choose to not resuscitate, or did we choose to allow a natural death? Whether intentional or not, clinicians are often an important source of vocabulary that these writers draw from. With each choice of words, clinicians affect narratives, and some words wield particular power. Just, for example, has the power to diminish. How boxed in does one feel when their identity slips into just a patient, just a diagnosis; when hospice becomes just about dying rather than living one’s final days to the fullest?

Dr. Chammas’ essay touches at the essence of being a healer. Our duty as clinicians is not only to treat the disease but also the patient — to ease suffering and help our patients move beyond the present, to wherever their abilities and circumstances allow them to go. We don’t “get over” losses, be that the death of a loved one or the loss of our own health or abilities, we will always remember and live with our losses. We must integrate them in a way that somehow makes sense in order to be able to carry on. This really sank in with me when I attended a Harvard course in the Catskills titled The shadow of the Object, which I blogged about back in 2009:

The title of the course was “The Shadow of the Object”, which is a quote from an enigmatic passage in “Mourning and Melancholia” by Freud. It was held in an old, slightly run-down family resort in the Catskills in upstate New York, very similar to the setting of the movie “Dirty Dancing”. In its heyday, this resort was a summer haven for middle class families from New York City – a chance to experience nature and participate in organized activities while mingling with people of their own kind.

The central idea of the conference was that we never “get over” loss or trauma – we just have to find ways to carry it with us in a fashion that makes sense for us. It is a simple notion, but it has profoundly affected how I have counseled patients from that moment on. There is such a tendency in our society to focus on the “positive”, to downplay the importance of sadness in a healthy and balanced life.

One particular thought we brought with us from “The Shadow of the Object” is the concept of moving through grief by finding ways to honor the legacy of the lost loved one. I have found that to be one of the most healing things you can teach those left behind after someone they respect and love passes away.

Helping patients rewrite their stories, which don’t have to be written, I just mean how they explain things to themselves (and perhaps others), is a big task that can take time over several encounters. But choosing our own words very carefully is something we do, or should do, in every visit, every day.

I wrote about this, too, in 2009:

The Power of Words

Lately. I’ve had several patients come in with itching and rashes and reports of feeling and seeing parasites. All of them swear they’re not doing methamphetamine, which is notorious for causing delusional parasitosis.

Most people know about head lice, pubic lice, scabies and bed bugs, maybe even chiggers. A few search the web and know of other conditions, like Morgellons (whatever they really are) and demodex, which is a much more common mite than I would have guessed.

I’m trying to formulate a strategy for helping those who know more and will not accept the possibility that they just have dry, itchy skin. But, I’m thinking I might just make them worse if I tell them what my own research is telling me.

I think I’ll have to start with a reminder about everybody’s intestinal flora, our biome. There are many trillions of organisms living inside us.

Obviously, the bacteria in our intestines help us digest our food. We couldn’t live without them. Minor troubles caused by them might be our moods and appetite or cravings. Major troubles from unwanted intestinal bacteria includes diarrhea and death from dysentery or clostridium difficile.

Having said that, I guess I’ll go on to say that a lot of people have mites, but they’re too small to be what they’re seeing. And when it comes to some mites, they’re impossible to eradicate.

Demodex, also called face mites, live in our hair follicles and some sources say most people have them. Usually they cause no trouble. They may have a role in skin conditions like blepharitis, conjunctivitis, chalazions and also rosacea, sometimes referred to as adult acne. Treatment, when someone has many of these mites and bothersome symptoms, is usually only topical. Cliradex may be the best one but ordinary Tea Tree Oil, which it is derived from, is also effective.

As I’ve been reading up on face mites, I haven’t come across anything good they do for us. So I think I may be speaking for most of us when I say that I’m grateful for my intestinal flora for helping me get the nutrition out of the food I eat. And, those bacteria are, well, in my gut and not in my face, which is where my demodex freeloaders are literally hanging out.

Listening to some loud music from the 70’s at my high school reunion, Della leaned over and asked me if that could make you lose your hearing. The music was too loud for me to hear her well or give a detailed answer, so I signaled “wait”.

After the music stopped, it was like both of us were hard of hearing for a while before everything seemed to return to normal. I explained to her that noise exposure can certainly lead to permanent sensorineural hearing loss, but what we were going through in that moment was a temporary hearing loss, caused by two natural, muscular reflexes we have just to protect our eardrums from bursting. Two of the smallest muscles in the body, the stapedius and the tensor tympani muscles, tighten up when we’re exposed to loud noises in order to diminish the movement of the stapes (stirrup) bone and to tighten each eardrum, thereby decreasing the amplitude of vibration of our eardrums caused by sudden loud noises.

These muscular reflexes protect us from damage by loud music, but they’re too slow moving to have time to react to things like the sound of a gunshot. And in this country, that’s not the worst part of people shooting with guns.

In Swedish, people talk about a different, larger, group of muscles inside the skull that can react faster than the miniscule ones inside the inner ear. We, humorously, use the expression “use your brain muscles” for cerebral activity. But, sadly, even though we may have the capacity for quick thinking, when it comes to speeding bullets, they can travel at twice the speed of sound. So, by the time you hear the gunshot, the bullet has already reached its destination.

Before EMRs, information flowed through nurses and secretaries (remember that word, anyone?) to us doctors. And it was generally prioritized, if not with clinical expertise, at least with a healthy amount of common sense. This allowed us to get to urgent and important results and messages before less urgent ones.

Even with early EMRs, paper reports would arrive, get sorted, reviewed and acted on before getting scanned in – often with a quick signature and comment scribbled on the bottom. We might note “repeat 1 year” on a normal mammogram or instruct our staff to “Order CT w contrast” on an abnormal chest X-ray. This was a very quick way to review and delegate. The doctor did what only the doctor could do and other staff did the rest. It was even possible to have a standing order that all women with a normal mammogram get scheduled for their next one automatically.

You can visualize the flow of information as a triangle, flowing from many sources at the base through support staff to the clinician, at the top, as the decision maker. The information would then flow back one step down the triangle to the person who presented it to the doctor.

(Paper napkin sketches © A Country Doctor Writes, LLC; may be reproduced with back link.)

We often communicated verbally and in person. The nurse or medical assistant might tell the doctor on a Monday morning, “these three patients were in the ER this weekend and need follow ups this week, Mr Jones ideally no later than Tuesday”.

Working this way, we were a team. We communicated effectively in real time.

Now, even if we work at desks in the same room, our communication is mostly asynchronous, very much like email. And our inboxes offer few ways of prioritizing information.

And the worst and most dangerous difference between the old and the new information flow through the EMR is that all results and outside reports arrive directly in the doctor’s electronic inbox (and we often have dozens of different inboxes to monitor) UNSEEN BY ANYONE ELSE.

So it is now, theoretically, up to the doctor on a Monday morning to open up and read the weekend ER reports (scrolling through multiple pages in a small view box on the computer screen, looking for the followup instructions) and then electronically forward the report with comments to the support staffer.

The reason we have to do this is to generate an electronic record of when we read the report and what we did with it. This seems to largely be for liability purposes, so that if anything goes wrong, the doctor can be held responsible.

Today’s information flow triangle is upside down: Its foundation, read entry point, is the medical provider. It is the team leader who has to touch and timestamp (in the background) everything and then electronically spoon feed it to the other team members.

This “workflow” makes sense to computer people, statisticians and malpractice attorneys. But it makes doctors spend inordinately more time staring at their computer screens and less time with their patients.

I guess, if EMRs were more nimble than they are now, this upside-down workflow would be slightly less cumbersome, although equally dangerous.

It is disheartening to hear about AI and how smart computers are supposed to be these days while we have to follow awkward, multistep computer routines to accomplish things that Alexa can do effortlessly in peoples’ homes.

But the bottom line is that, in today’s mostly fee-for-service environment, doctors are under pressure to generate revenue, which means face-to-face encounters. Time at the computer, reading inboxes, refilling prescriptions and responding to patient portal messages are things that practices generally don’t get paid for, so doctors seldom have enough (or any) time set aside to do them.

With all the worry we constantly hear about physician shortages and the burnout epidemic among us, medical practices really must question the current way they want us to manage the flow of information in our offices. It is hugely inefficient and actually quite dangerous.

In what other type of business does the decision maker open the mail and then hand it to the support staff?

How would it be if we borrowed a page from the paper chart playbook and figured out better ways to leverage physician input than we have with today’s EMR-imposed bottlenecking of information? I think it’s high time we turn the triangle back right-side-up!