A Country Doctor Writes:

https://jamanetwork.com/journals/jama/fullarticle/2839306

I read an interesting and a little provocative article in JAMA this weekend, Critical Thinking for 21st-Century Medicine—Moving Beyond Illness Scripts by Richard M. Schwartzstein, MD; Alexander A. Iyer, ScB

In the opening paragraph, they describe diagnostic errors this way:

Most diagnostic errors involve common diseases the physician did not consider rather than rare diseases the physician did not remember; they are thinking errors, not knowledge deficits.

They then start out describing how much of medical education views diagnosis as relying on pattern recognition. They describe it as “Illness scripts”, trying to match up the patient’s presentation with differential diagnoses and then ranking these by probability. AI uses pattern recognition and can be very good at it. But the authors advocate using a more pathophysiological way of reasoning. This sounds to me like taking a step away from the knee jerk rattling of differential diagnoses and envisioning what the processes are inside the body that could cause a given symptom, before naming a plausible diagnosis.

They continue:

Educators can cultivate adaptive expertise by focusing less on pattern recognition and more on teaching learners to engage in critical thinking, starting from foundational principles of human biology and pathophysiology. In particular, instead of asking trainees to move directly from a patient’s clinical presentation to differential diagnoses, educators can push trainees to develop testable, intermediate hypotheses that explain a patient’s presentation in terms of pathophysiological processes.

I can think of two cases in my career that I have written about, where I pondered what could be happening inside their bodies and arrived at the correct diagnosis, albeit not instantly. Both were patients with shortness of breath whose final diagnosis wasn’t one of the commonest, but certainly not esoteric, Two Red Herrings from 2011 and An Uncommon Cause of Shortness of Breath from 2021.

Two Red Herrings

An Uncommon Cause of Shortness of Breath

Two months ago, I reposted a 2021 piece titled I am a Decision Maker, not a Bookkeeper. Tonight, looking at the stats of my WordPress blog, I saw that a 2022 post, where I had written almost the same thing, had a couple of views. There, I wrote “I am a problem solver, not a bookkeeper”. My piece was a short review of a New England Journal of Medicine article by Christine Sinsky and Jeffrey Panzer titled The Solution Shop and the Production Line – the Case for a Frameshift for Physician Practices.

I think that title is brilliant. I also think it is depressing – when did doctors offices stop being solution shops? Because they weren’t always production lines. Rereading my piece, I don’t believe much progress has been made in shifting the framework for how a medical practice works.

One frightening thought that comes to me when I think about the healthcare climate today is that medical practices may be becoming even more like production lines than they were a few years ago. Today’s solution shops seem to a large degree to be freestanding non-provider entrepreneurs. I see them position themselves between the medical practices and the payers/insurance companies with promises to get better results or more savings by data mining, analyzing and influencing provider behaviors and performance.

I also see niche medical practices who provide specialized services, like supporting or even managing the care for patients with respiratory illness, obesity or other high Total Medical Expense (TME). For pulmonary patients, they typically provide phone support, video coaching of inhaler techniques, etc.

There are also companies that analyze insurance claims for prescription refills and send reminders to PCPs that a heart disease patient hasn’t filled their statin drug that should have run out two weeks ago. Such things lead to lower quality scores for us, even if the patient was in the hospital with a serious infection and got their cholesterol from the hospital pharmacy, for example.

Those types of middlemen, or whatever you want to call them, seem to be where the action is today, while many medical practices struggle with high costs, low reimbursements, staff shortages and burnout.

I was taught, back in the Stone Age (late 1970’s), that clonazepam, introduced in 1975, had distinct antidepressant properties, besides being just another benzo. I had a patient who reported not feeling well on one particular generic version of it, but doing great on another, who was switched to an equipotent lorazepam and became very depressed. I checked what the literature is showing now and here it is, a little more recent: 2009, 30 years after medical school and 25 years after residency:

Abstract:

Clonazepam, first used for seizure disorders, is now increasingly used to treat affective disorders. We summarize the use of clonazepam to improve the management of depression. Clonazepam is useful for treatment-resistant and/or protracted depression, as well as for acceleration of response to conventional antidepressants. Clonazepam is at this time recommended for use in combination with SSRIs (fluoxetine, fluvoxamine, sertraline) as an antidepressant, and should be used at a dosage of 2.5-6.0 mg/day. If clonazepam is effective, a response should be observed within 2-4 weeks. It is significantly more effective for unipolar than for bipolar depression. Low-dose, long-term treatment with clonazepam exhibits a prophylactic effect against recurrence of depression. Although the mechanism of action of clonazepam has not yet been established, some investigators have been suggested that it involves enhancement of anti-anxiety effects, anticonvulsant effects on subclinical epilepsy, increase in 5-HT/monoamine synthesis or decrease in 5-HT receptor sensitivity mediated through the GABA system, and regulate in GABA activity.

https://pubmed.ncbi.nlm.nih.gov/19330803/#:~:text=Although%20the%20mechanism%20of%20action,receptor%20sensitivity%20mediated%20through%20thehttps://pubmed.ncbi.nlm.nih.gov/19330803/#:~:text=Although%20the%20mechanism%20of%20action,receptor%20sensitivity%20mediated%20through%20the

We all learned about type 1 diabetes in medical school. That is a disease where the bodies ability to produce insulin vanishes very quickly. Type 2 diabetes, which only affected 2% of Swedes when I went to medical school, is more a problem of insulin resistance. It used to be called a disease of old age, but it is now common in Children with overweight. Lately, Alzheimer’s disease has been nicknamed type 3 diabetes. We are also screening our patients for Prediabetes in order to offer early intervention. With recent drug development and expanded indications for various medications, we suddenly have an entirely new class of people who take diabetes medicines because they have been proven to at least to some degree improve cardiovascular outcomes. Voilà, welcome to the bizarre phenomenon of Pseudodiabetes.

Let me explain:

A recently developed class of antidiabetic medications, the SGLT2 inhibitors (Jardiance and Farxiga) can lower blood sugar by inhibiting the body’s ability to reabsorb glucose that is about to be excreted in the urine. These medications can help improve or preserve kidney function in people with type 2 diabetes. They have also been shown to reduce cardiovascular event risk. I don’t know exactly how that works but I sure know how it has affected my daily work as a primary care doctor.

Primary care physicians are held to many treatment standards for our quality ratings and in many cases our insurance reimbursement. For example, if we have patients who refuse colon cancer screening, we get dinged for it. If we have diabetics with normal cholesterol, who don’t believe us when we say that cholesterol pills can reduce the heart attack risk even for people with normal cholesterol, we risk getting bad report cards and less money coming into our practices. In the case of this new class of anti-diabetic drugs, the SGLT2 inhibitors, even if somebody gets put on them purely for cardiovascular risk reduction, they are now in the eyes of the insurance companies, full-blown diabetics. We are obligated to check their urine for microalbumin and send them to the eye doctor for annual eye exams to look for diabetic eye disease.

This makes no medical sense and it is downright stupid. I would think a clever high school student or a simple AI program could find a way for the actuarial people to see whether this class of drug was started to reduce heart risk or control blood sugar, but so far that has not happened.

We can transplant hearts and do surgeries on fetuses, but we can’t eliminate the unnecessary Pseudodiabetes silliness.

A patient appointment for a physical could yield a cancer suspicion or diagnosis. An appointment for chest pain could lead to an intervention for domestic violence. A quick visit for a skin rash could land a high school senior in the hospital for a leukemia workup.

In this business we can never assume that a visit will be about what we somewhat callously have been calling the “Chief Complaint”. You have to be prepared to shift gears, sometimes because the patient drops a hint or a bombshell revelation they didn’t tell the scheduler, front staff or medical assistant. And sometimes because you hear, see or palpate something suspicious.

In some ways, we always have to be triaging, before we settle into a “routine” visit. Triage comes from the French word “trier”, which means “to sort” or “to select”.

Primary care is messy. We have to sort who needs something done quickly for a high risk symptom or finding, who needs a different level of care, who needs simple reassurance and who needs a long term plan.

All of this without forgetting the screening and preventive health agendas, which is what we are graded on. There is no formal tool to evaluate our diagnostic acumen. So we are measured for what is easy to measure, the so called “street light effect”.

An Innocent Looking Rash

The Art of Listening: Beyond the Chief Complaint

Primary Care is Messy