A Country Doctor Writes:

(I briefly considered not writing this post and letting the headline speak for itself. But, you know me, I couldn’t resist elaborating a little bit.)

We are drowning in calls for treatment or advice. Many are too nonspecific to make any sense at all, like “can you send something in for a headache”. I mean, there are subspecialist doctors who ONLY treat headaches, and somebody wants me to treat theirs with no information whatsoever.

And many calls are about things most adults should know the answer to, if they had learned anything from their mothers and grandmothers growing up. But the way the world works today, families don’t usually support each other the way they used to.

And in today’s healthcare climate, barely even registered nurses are allowed to give general, commonsensical advice because of liability concerns.

If we can’t hire wise and experienced grandmothers, maybe Artificial intelligence could be of some use here???

Americans hate being sick. There are too many cold medicines out there to remember by name. But there are really only a handful of different drug classes to consider.

In order to choose any one of them, be clear about what you want to accomplish. It’s actually very simple.

1) Make my cold go away faster: Zink, echinacea, visualization/manifesting, sauna, prayer (may be mostly placebo effect ).

2) Stop my nose from running (including post nasal drip): You’ll want the crud to leave your body as soon as possible, so turning off the drain pipe that your nose has become can increase the risk of stagnant mucous in your sinuses becoming secondarily infected. But intermittent use of a decongestant (pills like pseudoephedrine, diphenhydramine or nasal sprays like Afrin) can help you look healthier than you are for an important Zoom meeting.

3) Make my nose run and relieve the pressure in my sinuses: Lots of fluids, room humidifier/vaporizer, shower steam, nasal steroid spray, guaifenesin (Mucinex) or even nasal lavage (Nettipot), but I personally have reservations about that one.

4) Stop my dry cough: Cough suppressants like dextrometorphan or codeine, humidifier/vaporizer, asthma inhaler if you have one.

5) Help me raise that thick, sticky phlegm: Fluids, humidifier/vaporizer, guaifenesin (Mucinex). Don’t try to suppress a productive cough. Just like with a runny nose, get the crud out of your body!

6) Headache/body aches/fever: Acetaminophen (Tylenol), ibuprofen, naproxen. But be aware that a low grade fever actually helps us clear cold viruses faster.

7) Knowing when to get medical help: Worsening symptoms, a second wave of fever; shortness of breath, wheezing, chest pain, severe sinus pain, clouding of the mind…the list goes on. Most people have had colds before. Is this one just like the others or the worst ever in some way?

8) Lastly: We used to think green phlegm meant bacterial rather than viral infection. But we now know viruses often cause up to three weeks of wet cough or nasal discharge. And be aware that we have antivirals for influenza and Covid, but not for the common cold viruses. (Sadly, we can send people to the moon, but we can’t cure the common cold.)

As a primary care physician, it helps me to know if my patient has had their appendix, gallbladder uterus or ovaries removed. I can then reasonably eliminate problems with those organs from my differential diagnosis if my patient comes in with sudden abdominal pain.

Maybe esoteric research will someday look for the incidence of Alzheimer’s disease in people with open versus laparoscopic gallbladder surgery. But, honestly, I don’t care as much about that as I care about efficiently diagnosing the problem at hand.

I am not terribly concerned about whether they had their gallbladder or appendix removed laparoscopically or through an open procedure and as long as the uterus and ovaries are gone it doesn’t usually matter to me if the procedure was abdominal or vaginal.

And, how much does it matter to doctors in the trenches exactly which weight loss surgery our patient had many years ago? The general followup considerations at our level of care are roughly the same.

And don’t get me going on macular degeneration. I don’t need to know if it’s wet or dry or any of its other classifications. All I need to know is that my patient has some form of it and needs to see their eye doctor periodically.

My own EMR displays my chosen diagnosis in words, not as the beancounters’ ICD-10 code. And many of the specialist notes I get have the same setup. So, if the eye doctor notes I get don’t have the code, why do mine need the specificity it implies?

Appendectomy is a very basic surgical history item that does not involve billing, but a crucial factor in making a differential diagnosis. I shouldn’t have to hesitate entering it into a new patient’s chart because I forgot to check how big the scar is.

The specifics of an active diagnosis is very soon going to hit our pocketbooks, or at least that of our employers. A diabetic without complications is worth less to our employers than one with a complication. But only the eye doctor knows exactly which complication they have.

In a future post/diatribe, I will write about HCC Coding, aka “Make your patients look as sick as possible so you get more play money now and real cash tomorrow”.

Stay tuned.

My blog just set all my previous records: Over 9,000 visits and the most views in one day of a single blog post. This one is striking a chord with my colleagues:

Old school doctors like me used to give the vast majority of our time and attention to our patients. Our documentation took very little time and our support staff sorted all incoming data – lab results, x-rays, consults and hospital reports. They would prioritize things for us: courtesy copies to just sign, tests we ordered that came back normal, our tests with abnormal results and so on.

In the new world order, doctors and other medical providers are the first ones to see incoming information. It arrives in our inboxes throughout the day and night, and then it is up to us to sort and delegate everything.

This is something we are never scheduled protected time for – we are supposed to do it “between patients”. What that means is that, in order for us to stay on time, no patient visit should ever be as long as it says in our schedule – since we’re expected to do all this important work “between patients”.

I have to admit this has been hard for me to swallow and adjust to. One reason is all the health maintenance and preventive medicine we are required to pay attention to, even though as I keep saying and writing to no avail, that isn’t usually something that requires a medical degree. The other reason, of course, is that if you ever hope to get people to follow or at least consider your medical advice, you need to have a relationship with them, and that takes a little time. You can’t treat people like cattle in a roundup and expect them to follow your suggestions and prescriptions.

I work hard at delivering technically good care. I put effort into my personal relationships with patients. I don’t mind that.

I keep falling behind in monitoring my 23(!) different inboxes. I think there are too many of them and I think much of what’s in there shouldn’t even be coming my way. It’s just a liability trap, designed to make sure that if anything goes wrong, the blame will land squarely upon us.

So how do I tell my patients I’ll be shaving some more time off what they think is the contracted amount of time they have come to expect with me?

We desperately need to reimagine the primary care visit and the primary care flow of information. Bottlenecking equals burnout.

Between Patients: The Myth of Multitasking