A Country Doctor Writes:

Out of 2.5 million people in this country with opioid use disorder, a chronic condition with an annual mortality rate of 10%, only 278,000 (11%) are receiving treatment. Consider this: For every patient in Medication Assisted Treatment (MAT), there is one other person who dies.

In 2020, only 10% of primary care physicians had the “X-waiver” to be able to prescribe buprenorphine for substance use disorder. This requirement has now been dropped (although electronic medical records generally have not yet been updated to make this possible for doctors without such a waiver). But in 2020, only 24% of those who had the waiver actually used it to prescribe buprenorphine.

So, how do we get more people into treatment?

Under the waiver restrictions, buprenorphine prescribers were limited in how many patients they could treat, depending on how long they had been qualified and whether they worked in a substance abuse clinic. Back then, many clinics tried to build a “hub and spoke” model, where patients would get induced and stabilized in the hub and then transition out to their primary care provider to continue treatment. But community providers were reluctant to take on these patients. I heard worries about the “clientele” disrupting the waiting room and other such prejudices.

So, even with the waiver gone, I hold little hope that primary care practices that don’t have their own clinics will welcome even stable buprenorphine patients for this part of their continued recovery.

I think for those of us who treat opioid use disorder, the most realistic way to move forward is to try to find ways to take on more patients. But there are restrictions, imposed by insurers, Medicaid in particular. You have to have a certain number of therapists in the recovery group depending on the number of participants, and in order to pay the doctor for prescribing and overseeing the medical aspect, there has to be a face-to-face encounter. And you can only do so many in whatever time your group is scheduled for – in my case 90 minutes.

But, strictly speaking, other reimbursement mechanisms may be available. There are grant monies that could move us away a little bit from the face to face with the prescriber and, just like in other areas in medicine, there could be scribes. We also have peer counselors and medical assistants who can gather information, do drug tests and so on.

As much as I enjoy and value the therapeutic aspects of my long term relationships with relatively stable MAT patients, I am starting to feel that maybe I could see them less often in order to make room in my schedule for new patients. Given the fentanyl crisis, and given the statistic that as soon as an addict enters a MAT program, their risk of dying from an overdose drops by 38-59%, perhaps we are not using ourselves as a resource in the most effective way possible. After all, we are in a crisis. Are we in enough of a crisis mode for the situation we are in?

I sometimes see even supposedly seasoned clinicians taper a person off one SSRI like escitalopram (Lexapro) and then starting from scratch with another SSRI like sertraline (Zoloft).

In my experience, this is almost never necessary. Think about it, the SSRIs hit the same receptors. Each drug has a somewhat different personality; some are sedating, some a little energizing and so on. You would also have to consider the half life, like fluoxetine (Prozac) has a long one and venlafaxine (Effexor) a short one. Switching between a long acting and a short acting one may require a wait period or a partial taper. But the main action is similar enough that tapering completely off one and on to another is more likely to cause unpleasant reactions (SSRI withdrawal) than a straight one-day switch. I do the same when switching from an SSRI to an SNRI like venlafaxine or duloxetine. I just ballpark the SSRI potency of the two drugs and, wham, we’re done.

So, as long as you hit the same receptor, it’s not a whole lot more complicated than going from Corona to Bud Light. You might want to consider the potency, and to some degree the drug half life, but it’s not quite rocket science.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919171/

I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.

We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.

My purpose in writing about these cases is to show how disease, the enemy in clinical practice if wou will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.

Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.

A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.

When I saw her in followup, she was still coughing a little, and she wasn’t her usual happy self. Her lungs were clear. I asked her caregiver if they had done a head CT the last time she was in the ER. I saw no mention of it in the ER report.

“I’m pretty sure they did”, he said.

I retrieved it from the statewide Maine Health InfoNet site. It described that all the sinuses were infected and only slightly improved from the earlier study.

Martha is now on a much longer course of antibiotics, because a sinusitis often takes a lot longer to clear up than most pneumonias. I sometimes compare this to getting the contents of an egg out through a tiny hole in the shell (I never did learn how that is done). And, a sinusitis can sometimes cause pneumonia because of postnasal drip.

I saw another case the other day where I think I was able to piece things together.

Gretchen had seen another provider for headaches. She had migraines in her youth but they stopped after she had her first child. My colleague ordered a brain MRI to make sure there wasn’t something more malignant going on. It showed what the radiologist described as a possible migrainous angiopathy.

By the time I ended up seeing her, she had had the migraine for over a week and she had taken daily doses of over-the-counter remedies, so I figured that she now had an element of withdrawal headache. Normally I prescribe prednisone in such cases, but Gretchen told me she has had severe psychiatric side effects from steroids before.

I asked her to wean off the OTC medications and started her on topiramate. Gradually her headaches got better. Then, a few days later we got a phone call, saying her migraine had come back with a vengeance. It was late in the day and she had been vomiting. She went to the ER and they gave her IV fluids, metoclopramide and something for pain.

I saw her in followup and she was better but very worried, telling me her headache was starting to build again.

Then she told me something that jolted my brain I to action.

“Whenever I start to hurt on the side of my nose where I had the surgery, the headache comes on.”

“What kind of surgery”, I asked.

“I had a big cyst removed, se-ba-cious I think it was called.”

“Can you take your mask off”, I asked. I had not seen her uncovered face before.

She did and there was a big scar.

“What kind of pain do you have there”, I asked. Is it steady or, like, pulsating?”

“It’s like jabs and jabs, like someone is sticking needles in there.”

I pulled the monofilament from my pocket and started touching her over the three branches of the trigeminal nerve on each side of her face.

“Does this feel the same on both sides of your face?”

“No, it’s different.”

I took a deep sigh and explained:

“This looks like a nerve pain, a neuralgia, in the nerve that reaches the skin outside your sinus there, and also in the other two branches that go to the forehead and the jaw. It’s called the trigeminal nerve and it comes directly from the brain. I wonder if that is what has made your migraines come back after all these years.”

“Can you stop this from getting full blown”, she asked.

“I probably can’t stop the neuralgia very quickly. Most neuralgia medications take a while to,start working, but I’ll send in a prescription for Imitrex. Take one as soon as you get home and you can take one more later today if you have to. Then call me tomorrow and let me know how you are doing.”

The next day she told me she was headache free after just one Imitrex, and the neuralgia was barely noticeable.

I’m curious how she will do in the long run, and I’m curious if the trigeminal neuralgia is somehow related to the surgery she had there.

Like I’ve said before, curiosity is a powerful antidote to burnout.

I graduated near the top of my class from the second oldest university in the world, and one of the best medical schools on the planet. I have 44 years of post graduate experience in a part of the United States, where there is a severe lack of specialists and where a small cadre of primary care doctors see more and do more than in many other parts of this country.

If and when I look at my personal report card in my new Epic EMR I find that I am average or worse. What that means is that I’m not real quick in responding to routine messages and other such things.

I almost get the feeling that clinical competency in primary care doctors is so much taken for granted and so commoditized that the only thing that matters is how fast we are at getting patients out the door and clerical tasks completed.

Metadata, as I call the majority of items in my EMR report card, is the typically invisible information on a CD, for example: Recording date, copyright holder, maybe the album cover photo for displaying on your device. But imagine if this was all you got, if the piece of music wasn’t there. That’s what it feels like sometimes in primary care: The clinical work we do is invisible while the metadata blocks the view of what really matters.

Would you pick a brain surgeon, if you needed one, based on their speed in the operating room or at the computer? I suspect neither.

There are a few clinical measures also in these report cards, but they are set as if they are absolute, immutable laws. And do they really reflect the quality of our care?

Quality measures in medicine are basically substitutes for the real information we wish we had.

We measure surrogate outcomes, like hemoglobin A1c and blood pressures. But the person with perfect numbers could suffer a fall one day from hypoglycemia or hypotension and break a hip. The diabetic could get urosepsis from their Jardiance pill that causes them to excrete more glucose in their urine. And the perfect blood pressure person could develop kidney failure or a life threatening arrhythmia from spironolactone or valsartan, or lupus from their hydralazine. In studies, such things are tracked and judgements are made that, for a majority of patients, the benefit of a particular treatment outweighs the risk. But, in practice, we don’t know who they are. If our patient is almost “at target” and the next drug we add could be the one that will harm that particular patient, is it worth doing? Polypharmacy is a dirty word some of the time, except when patients have several medical problems and are supposed to meet several numeric targets.

There is nothing in my report card about whether my diagnoses are correct, whether my workups are appropriate, whether my patients trust me or even like me, and what my clinical batting average is when it comes to actual outcomes.

Medicine is full of decisions, judgement calls, that should be made together by physicians and informed patients. The word patient-centered has become meaningless, because doctors who let their patients in on clinical decisions and respect their refusal to do certain tests risk getting bad quality scores.

Originally posted on my Substack.

https://open.substack.com/pub/acdw/p/practicing-at-the-top-of-your-license?r=254ice&utm_medium=ios&utm_campaign=post

You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).

You also don’t really need a medical degree to enter data into an EMR.

And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!

And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…

Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!