A Country Doctor Writes:

A year ago today, from a different galaxy (EMR) I wrote a piece that is equally relevant in my new galaxy (Epic). In fact, even more so. Epic is even more click and encounter heavy than I could imagine.

I wish I could be like Captain Jean-Luc Picard and just say “make it so”. Instead, be it Epic, Intergy or eClinicalworks, I have to do a lot of things that are not medical in order to basically say yes to a request from a colleague or support staffer.

This is what I wrote:

In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).

Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.

This is a basic, binary, programming issue as far as I understand. Yes or no, 1 or 0, stop or go, scope or nope.

I really think EMR programmers have something against doctors.

I often get calls requesting a medication for a recurrent problem, like a sinus or urinary tract infection. And sometimes, after I send something in and my nurse calls the patient to tell them I did, they say “that never works” or “it took two rounds to lick it last time”.

I wish patients didn’t expect me to remember such things, or that – between my old EMR and my new EMR – I have enough slack in my clinic schedule to research those things.

Everyone should know that phone calls and messages are not given specific time in doctors schedules. They are handled on the fly, shortchanging patients with appointments, cutting into lunch hours and quitting time in today’s healthcare environment.

Calling your doctor, if you know what you need, please say so. Whether you get sulfa or ciprofloxacin or nitrofurantoin makes little difference to me, so just tell me – they’re all good choices. Now, hydrochloroquine for Covid would be a different story.

And, I need specifics. If somebody says “what you gave me last time worked really well” it would help me immensely if they also said a month ago or three years ago. Because searching for things in EMRs is not as easy as it should be.

I also need clinical specifics. A call like “What can I take for a headache” is too open ended, just like “I have a cough and I’m raising green phlegm”. Three days of coughing, no treatment as it’s probably viral, much longer and getting worse, that might be bacterial and deserving an antibiotic. Daily headaches for 20 years or headaches with menstruation, make an appointment. The worst headache of your life, started 10 minutes ago, call 911.

And “That salve the dermatologist gave me worked well, can you get me some more” would be much easier to deal with if my patient had the old tube in front of them.

Good clinical decision making requires specifics: how long has it been going on, what are the symptoms, what makes it better or worse, is it stable or getting worse as time passes? There is a lot of intuition in how we work, but first we need basic information. In today’s hectic clinical environment, it helps a lot if people volunteer the specifics when they call for advice.

Twenty questions is a fun game, but not an effective way of practicing medicine. Volunteer the information, don’t withhold it.

Twenty Questions

1) Gout is no longer the disease of kings, or even of the affluent. It is hitting harder in lower socioeconomic groups.
2) A low purine diet is no longer a strongly recommended intervention. Cutting back on organ meats and alcohol is. Purine rich vegetables, once viewed as triggers, may be safe because of their fiber content.
3) Uric acid crystals are involved in gout, but it is primarily an inflammatory condition. So not everyone with high uric acid gets gout. This is just like how high cholesterol and low inflammatory markers seems safer than average cholesterol and high inflammatory markers. And, heart attacks and strokes are more likely to happen in the months following a gout attack.
4) Colchicine, one of the treatment options for both acute and chronic gout, works without lowering uric acid levels at all. It treats inflammation, just like the commonly used attack medicine indomethacin and my personal choice, prednisone.
5) Allopurinol, which we use to prevent gout attacks by lowering blood uric acid levels, can also cause them. It should never be started during a gout attack. If attacks happen in the beginning of treatment, I give short prednisone bursts to get patients through the initiation phase.

Access is a big problem in primary care. We must be available. We are the first point of contact, the gatekeepers who sort the chaff from the wheat. We are the ones who want to see people early in order to decide how serious their symptoms are. If it takes three weeks to get in to see us, people will come to harm.

Maybe this is more essential in a rural area where there are no walk-in clinics and where many people hesitate going to the emergency room even when they ought to, because of traveling distance and fear of hospitals.

I will double book a swollen elbow because it could either be a medical emergency like a septic joint that needs quick triage or a benign but bothersome olecranon bursitis which takes me only a few minutes to drain and instill some methylprednisolone into. But a large sebaceous cyst that needs a delicate removal so as not to rupture its capsule is something I don’t want to take up the time to do. First, the consistency of equipment available is variable and, second, I could see three other patients in the time it takes to prepare for and perform that procedure. The surgeons at the hospital down the road are better set up to do that quickly than I am and even if there’s a wait to see them, nobody will come to harm.

This choice that I have made is in some ways causing me to lose skills; I am no longer very good at injecting “dry” knees, for example. But on the other hand, for every year that I am in practice, I believe I am becoming a better diagnostician, teacher and therapist. I guess my circumstances and my personal interests are moving me in the same direction: The doctor who will see you now and the doctor who will stick with you over time, not necessarily the doctor who will do it all, even if he could do it in a pinch. I think I am putting my abilities to the best possible use, given where I am practicing.

phre·nol·o·gy/frəˈnäləjē/ the detailed study of the shape and size of the cranium as a supposed indication of character and mental abilities.

The article YOUR DOPPELGÄNGER IS OUT THERE AND YOU PROBABLY SHARE DNA WITH THEM in today’s The New York Times was surprising and not surprising at the same time. I grew up reading old medical books and (often racist) cartoon collections from the tail end of the heyday of phrenology in the 1940s. Nobody around me really believed in it, and the idea that our looks are linked to our character doesn’t seem to fit with the ideas of no discrimination and equal opportunity.

But here we are: The NYT article reports on a large study of doppelgängers, people who look like twins without being related in any way. Such couples share more DNA than random pairings. And what is even more interesting is that the degree of similarity in their personalities is more closely linked to the amount of shared DNA than to the similarities of their life experiences.

The article even hints that this research could lead to forensic use, such as predicting the facial features of a suspect just from crime scene DNA samples.

Dr. Esteller also suggested that there could be links between facial features and behavioral patterns, and that the study’s findings might one day aid forensic science by providing a glimpse of the faces of criminal suspects known only from DNA samples. However, Daphne Martschenko, a postdoctoral researcher at the Stanford Center for Biomedical Ethics who was not involved with the study, urged caution in applying its findings to forensics.

How far are we then from again linking facial features to moral character?

“While on the one hand I was pleased to see so many commentators connecting the conclusions of this study to phrenology, physiognomy, and related sciences, this leads to its own problems. Most modern-day commentators (and many historians) continue to frame phrenology primarily as a “pseudo-science,” a term often used to dismiss “bad” science. But in so doing, they neglect the long-term influence of phrenology and related “failed” sciences. By dismissing this study as yet another example of phrenology, without simultaneously recognizing the historic scientific validity, utility, and pervasive nature of the science, commentators highlight its superficial aspects while enabling the continued influence of the underlying principles. This study demonstrates the continued influence of phrenological thinking, language, and imagery in modern culture – both popular and scientific.”