Archive Page 3

A Country Doctor Reads: February 16, 2019

Find Nutrients Depleted by Medication – Nutrient Depletion Calculator –

I came across a cute website that lists common deficiencies associated with medications, for example B12, iron and many others from Nexium, esomeprazole:

— Read on

How Long Do Hip Replacements Last? -The Lancet

There is concern about hip replacements performed in middle aged adults. Will they wear out? The Lancet has an open access impressive review, which outlines the odds of failure over the remaining lifetime of 50-something patients:

“Moreover, these results are particularly important because of the growing number of younger, more active patients receiving hip replacements, as well as increasing population ageing and life expectancy.7,  8 In fact, lifetime risk of revision of total hip replacements for patients aged 50–54 years is estimated to be 29%, but only 5% in patients aged 70 years.9 Much of the increased risk of revision is due to component wear. The findings from Evans and colleagues’ study can therefore be used to more appropriately counsel patients”

Medicine is Not Like Math

We do a lot of things in our head in this business. Once a patient reports a symptom, we mentally run down lists of related followup questions, possible diagnoses, similar cases we have seen. All this happens faster than we could ever describe in words (let alone type).

And, just like in math class, we are constantly reminded that it doesn’t matter if we have the right answer if we can’t describe how we got there.

So the ninth doctor who observes a little girl with deteriorating neurologic functioning and after less than ten minutes says “your child has Rett Syndrome” could theoretically get paid less than the previous eight doctors whose explorations meandered for over an hour before they admitted they didn’t know what was going on.

Does anybody care how Mozart or Beethoven created their music? Or do we mostly care about how it makes us feel when we listen to it?

We know that stress, meditation and Thai Chi can alter metabolism, immune response and neurotransmission. But do we endorse them based on how many minutes, elements, movements or postures they involve over what their results are?

Of course not!

We also know that physician demeanor can affect treatment efficacy a whole lot more than the number of minutes spent or boxes checked in the EMR. So why are we so fixated with proving the monetary value of our process, instead of the value of our results?

Medicine, at least in the non-procedural specialties, is a relationship based business. If a hostile stranger spends fifteen minutes trying to change your behavior, is that more effective or more valuable than if a trusted doctor, friend or admired mentor mentions the same thing almost in passing?

Of course not!

So why is medicine viewed as an easily quantifiable and standardized endeavor? The manufacturing analogy is outdated; we are more like old-house renovators or art restorers most days, and, on perhaps rare but inspiring and memorable occasions, like composers. We sometimes find ourselves creating something new in the lives we touch and interact with. In those instances we should take little credit for anything except how we were able to awaken the healing potential within our patient.

Health care professes to value outcomes, but we are a long way from doing that. We are stuck in a thick soup of surrogate endpoints and ignorant overemphasis on standardized processes in an era where we are only beginning to understand how genetically different we all are.

Or, are we really suggesting our patients are all 70 kg white males with only one, typical and standardized, medical problem?

Paralyzed by Insurance Drug Formularies? Don’t Forget Cash!

I haven’t counted how many times this happens every month, but I find it annoying:

I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a Prior Authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) make a toll free call and spend unpredictable amounts of time pleading to have it paid for.

My time is worth (opportunity cost) $7-14 per minute, depending on if you count only my basic (E&M) professional fees or also the ancillary revenue (lab, x-ray and additional procedure charges) I generate.

This may be for a prescription with a cash cost of $10.

Sometimes I don’t even know if the new drug I prescribe will work. In the case of self-pay, a patient can buy a few pills cash to try them, and if they work, it may make more sense for me to offer my unreimbursed time to plead for coverage.

Because, of course, the cash cost is per pill whereas the insurance copay, and the amount posted toward your total drug plan benefit, is per prescription (same cost for anything up to the allowable monthly quantity), thus counting toward deductibles and the slide toward the dreaded (Medicare D) doughnut hole.

So even if I do my patient a favor and get the new drug “covered”, they may ultimately and in reality end up paying for a month of a medicine they couldn’t use.

Even worse than my own Prior Auth faxes, sometimes a specialist prescribes something esoteric, and when they get this dreaded fax, they forward it to me.

How am I supposed to justify a drug I didn’t choose?

And my biggest gripe with Prior Authorizations is that it can be hard to figure out what is covered and what isn’t.

One of my EMRs gives me an “emoji”, green smiley, yellow quizzing or red frowney, depending on status for many insurances, but only a question mark for some. My other EMR often just claims it doesn’t know.

In the case of our biggest payer for medications, Mainecare, they avoid the Prior Auth hassles fairly well by publishing rules like:

60 days of a preferred Proton Pump Inhibitor, like omeprazole, thereafter PA if you can’t wean down to an H2 blocker, like famotidine.

Coverage for preferred stimulants only if ADHD is mentioned on the prescription.

AARP Medicare D required a phone call, with hold time, to get non-valvular atrial fibrillation to justify a prescription for Eliquis, and another Medicare D plan a similar holdup to explain Suboxone was for opiate dependence and not for pain. In both those instances, the drugs are simply only indicated for certain conditions.

There are bigger foes to contend with than the insurance companies if you break those rules…

Maybe there should just simply be a CPT code and an RVU for obtaining a Prior Authorization?

A Country Doctor Reads: February 9, 2019

Feed a Cold, Don’t Starve It – Cell via The Atlantic

“Feed a fever, starve a cold”, the saying goes. But, unlike many old adages, this one is turning out to be dead wrong, literally.

A 2016 article in The Atlantic, number 3 under “Popular” on their website, quotes an article from the same year in Cell with a longer and less catchy title: “Opposing Effects of Fasting Metabolism on Tissue Tolerance in Bacterial and Viral Inflammation”.

The Atlantic staff writer James Hamblin, MD, explains, “Sometimes sugar causes inflammation. Sometimes it does the opposite.”

Researcher Ruslan Medzhitov conducted a series of distasteful experiments on mice with various infections, and found that mice with listeria, a bacterial infection, survived when they were refusing to eat and perished if they were force fed, but only if their diet was essentiallly sugar; they survived if they were fed fat and protein.

Mice with influenza fared better if they were force fed glucose than if they were allowed to refuse food.

The Cell article concludes: [In influenza infection,] “inhibition of glucose utilization is lethal.” Whereas glucose was “required for survival in models of viral inflammation, it was lethal in models of bacterial inflammation… Glucose Utilization Promotes Tissue Damage in Endotoxemia”.

And the article implies that ketosis has a protective effect in bacteremia.

The conclusion: Drink juice and tea with sugar or honey when you have the flu. But don’t eat if you don’t feel like it when you have pneumonia.


Association of Thyrotropin Suppression With Survival Outcomes in Patients With Intermediate- and High-Risk Differentiated Thyroid Cancer – JAMA

A dear friend and an anxious woman with a history of thyroid cancer is simply not tolerating suppressive doses of thyroid hormone, so with the blessing of my go to endo, she is on suboptimal suppressive doses. This article helps me sleep better at night:


Eczema and Our Skin Biome – The Wall Street Journal and the AAAAI

The prevalence of eczema in children has doubled in the past 17 years. Now we are starting to think of our bacterial skin flora as another area where promoting good bacteria can improve health. The Wall Street Journal reports on two small studies that demonstrated that applying healthy bacteria to eczematous skin brought clinical improvement.

“15 pa­tients, in­clud­ing five chil­dren, sprayed their rashes with bac­te­ria that re­searchers sus­pected could im­prove eczema. Two-thirds re­ported less itch­ing, less need for top­i­cal steroids and bet­ter sleep af­ter us­ing the spray twice a week for four months. On av­er­age, these mea­sures im­proved by 84% in adults and 78% in chil­dren.”

This led me to look for more information, and it’s out there:

The Dangers of Practicing Medicine Without Context

We once had a locum provider who spent a great deal of time reviewing each patient’s record before each visit. He would then enter the room and proceed to “clean up” medication and problem lists. Everything he did was done without eliciting the back story from the patient or the record. All he looked at was the data, never the narrative. Patients were often bewildered, saying “he changed my medicines without even talking to me”.

It may sound great to only act on the facts, but real medicine is a lot messier than that.

Sometimes we prescribe medications for more than one purpose: Amitriptyline may not be the theoretically best drug for neuropathy, but if the patient also has trouble sleeping and a history of migraines, it could solve three problems at once.

And propranolol could be used for migraines, tremors, palpitations and stage fright. It may not be the best beta blocker for the average 70 kg male, but there aren’t many of those around.

A high potassium could be a life threatening emergency or a simple case of hemolysis. Without seeing previous values, a provider could easily overreact.

Or, in the case of the previously stable warfarin patient I recently described, her critical INR seemed out of the blue and there was no vitamin K to be had, so I did nothing except hold the blood thinner. The next value was 1.0 and the home health nurse confessed that her device wasn’t calibrated properly.

Again and again I find that asking why before reacting has saved me and my patient all kinds of trouble, even though it takes time. But it is time well spent.

To quote myself (2014):

Context is crucial when deciding what to do with abnormal test results. But doctors are often pressed for time, and finding the story behind the results takes time. Even when all the data is in our electronic medical records, it takes time to see the patterns: The test results are usually in one place, the prescriptions in another, the office notes in a third, and the phone messages in a fourth. My own EMR (up north) can produce flowsheets with lab results, but each test is identified by the date it was ordered instead of the date it was performed, so correlating lab values with prescription dates becomes confusing, for example when following thyroid cases.

In times past, when solo practice physicians cared for their patients in the office, hospital and nursing home, they kept the threads of context and continuity together more easily. Today, with more providers sharing the care, and with other office staff also interacting with patients and their families, there is more room for errors, gaps and confusion. The tools we have right now are not always as effective as we would like, and they certainly can be cumbersome and slow to use. Reading each other’s notes can take a while, as the EMR format is primarily built for coding and not for ease of following the clinical “story”.

A few words doctor to doctor, doctor to nurse or doctor to patient can sometimes do what half an hour on the computer might not. Treatment without context is essentially just random reflex actions: Killing the innocent bacteria, lowering the falsely elevated potassium, treating the lab value and not the patient – none of it does anybody any good, and probably will cause harm to some unfortunate patients.

Our temptation to view test results as obvious facts in a predictable process instead of possibly misleading clues in a complex mystery reminds me of these words from a Sherlock Holmes novel:

There is nothing more deceptive than an obvious fact.”

The Man with Brown Fingernails

I had seen him now and then, but he didn’t come in very often. He was on the thin side, a hard core smoker with chronic bronchitis. But he was still running some borderline blood sugars, a quick chart review revealed.

One day, he came in with a few months of increased “arthritis” in his shoulders, neck, back, knees and hips. There was no sign of small joint synovitis, but the range of motion in his shoulders was poor, and he had a little trouble getting up from his chair without using his arms.

“Polymyalgia Rheumatica?”, I thought, but also remembered how people with lung cancer can develop all kinds of musculoskeletal pain. He had had a screening chest CT not too long ago. So I ordered a sedimentation rate and prescribed some low dose prednisone and asked him to come back in a week.

A week later he was only a little more limber, and his sed rate was only 28, not exactly diagnostic.

As I sat there and looked at him, thinking about what to do next, I made the observation that his skin was a little dark for the time of the year and his ethnic background. Then I looked at his fingernails, brown. Not just the ones that held his cigarette, but all of hem, even his pinkies.

I quickly clicked to his lab section in the EMR to check what kinds of lab tests had been done over the past year or so. His CBCs had not changed much over the past few years, and I had just checked one when I did his sed rate. His chemistry profiles had been okay except for those borderline blood sugars. Nothing more had been checked.

“What?” I thought to myself.

“Hyperpigmentation, Addison? No symptoms, and the nails…”

“Iron”, was my next thought. “Could he have hemochromatosis?”

I’ve never diagnosed a case of it before.

“It is possible that all these pains could have something to do with your iron levels”, I told him. “I hate to do this, but would you mind giving us some more blood for some extra testing?”

Sure enough, his iron level was elevated. I made a referral to hematology.

I was away for a little while and my first day back he was in my schedule for “Followup blood sugars”. He had seen a colleague for urinary frequency and turned out to have a very high random glucose and a glycosylated hemoglobin of 8. He had fallen into the trap of quenching his thirst, which was caused by spilling sugar in his urine, with juice and soda.

Scanning further in the EMR, I saw than the hematology report was back. It spelled out all the possible complications of hereditary hemochromatosis: Joint pain, fatigue, unexplained weight loss, abnormal bronze or gray skin color, abdominal pain, cirrhosis, diabetes, heart disease…

The lesson for me was the nail discoloration, which isn’t often mentioned in the medical texts; I remember noticing it before, but always assumed it was just nicotine staining. I never looked at all his nails. And I should have.

A Country Doctor Reads: February 2, 2019

McDonaldization of Chronic Pain Therapy (and All of Primary Care?) in the USA – BMJ

A recent Open-Access piece in the British Medical Journal about what they called the “McDonaldization of Chronic Pain Therapy” made me think that this phenomenon, which I hadn’t heard called that before, was certainly present in Primary Care, too. I have sometimes found myself saying, or at least thinking, that 15 minute medicine is more like McDonald’s than fancy restaurants.

The article lists four dimensions of what they have termed McDonaldization:

Number four stopped me cold – this is Healthcare today. The BMJ article states:

“The fourth dimension of McDonaldization is control—control of employees, of the system and of consumers. McDonald’s uses a controlled system, comprising a combination of humans, computers and cooking technologies to serve ‘precut and preprepared food’ to hungry customers, eager for their salty fix. This system minimises the need for human creativity and effort on the part of both employee and consumer. In the context of chronic pain management, OxyContin worked very similarly and thus produced a strange control over both doctor and patient. Physicians no longer had to parse out what exactly the cause(s) of a patient’s pain was and what therapies they might benefit from, but rather, now had the option of giving one drug to keep it all at bay.

Purdue Pharma’s aggressive and patently false advertising of the safety of the drug positioned OxyContin as the most rational and efficient choice a physician could make in treating a patient in pain. This only served to benefit the controlled McDonaldized system Purdue Pharma was helping construct, because people—physicians included—are ‘the great source of uncertainty, unpredictability and inefficiency in any rationalizing system’.

The responsibility of treating patients with chronic pain often falls to primary care physicians, and as such, they were Purdue Pharma’s prime target in expanding the ‘OxyContin prescribing base’. With the increasing demands of medical McDonaldization, one of the highest burnout rates of all physician specialties, and the shortage of primary care physicians ever growing, they were understandably susceptible to believing the promises of the drug. Furthermore, these physicians were already fighting multiple American epidemics, like pre-diabetes and hypertension (for which McDonald’s itself happens to be a significant contributor). So, if there was a quick, effective treatment for another complex finding—pain—available, then there was little desire or opportunity to take the time to question the legitimacy of Purdue’s claims. Thus, they prescribed the drugs liberally, as they were instructed to at their Purdue-funded educational conferences.”

Yours truly wrote a little while ago about the downside of even using the word “treatment” for chronic conditions, instead thinking “guidance” better describes what we ought to be providing.

“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Does Anybody REALLY Want to Fix Physician Burnout?

In my inbox the other day was an AMA update that was mostly about burnout:

This is getting out of hand. We have two crises converging to soon cripple and bankrupt our health care system and quite possibly our entire economy:

1) An aging population and people of all ages that are increasingly affected by chronic diseases that were rare a generation ago.

2) A burned-out, disillusioned and hamstrung medical profession, unable to do anything in their allotted 15 minute visits about the lifestyle-dependent epidemics beyond prescribing $400-$1,000 a month drugs that allow the disease snowball to keep rolling and growing, albeit at a somewhat slower rate.

I recently wrote about burnout:

“Put simply: If anybody wants to define and manage our work for us instead of letting us do it, they become responsible for the outcomes if we aren’t given the time or the tools we, as the ones who went to school, know we need.

The cure for physician burnout is simple: Listen to us when we say what we need in order to do our best. We didn’t spend all this time and energy so we could collect our salaries and goof off.

Most of us still have a professional mindset. We want to do a good job and we know how to do it. Let us.”

BUT, as one commenter wrote:

“Well said, and so true. But the solution is NOT ‘simple”, because THEY will never listen to us. The difficult, but only realistic solution is to be independent…”

So, we need some honest answers and some new paradigms here:

What is disease?

What is public health?

What do we need doctors to do if there are so few of them?

Does every “stakeholder” benefit if people get healthier? Or do some profit from continuing worsening of our nation’s health?

That last point is obviously rhetorical. What kind of health care system can reconcile when insurance companies and pharmaceutical companies actually profit from people being sicker?

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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