A Country Doctor Writes:

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

I posted this on my Substack in February 2023 and realized I never posted it here.

The trending post right now on Acountrydoctorwrites.Blog is about the unending stream of calls for medical advice we get in my office and, I’m sure, others like it. We get calls asking how to treat a cold. My suggestion is that we hire some grandmothers. Our own staff, even though most are wise grandmothers and mothers, are not allowed to give “medical” advice in the litigious climate we live in. And the medical providers don’t have a lot (read any) of wiggle room in their schedules to handle non-urgent calls in a timely fashion.

I also recently posted about what I recommend in treating the symptoms of a cold(note that there is no treatment for the cold itself; it’s going to run its course). I don’t know if that will make a difference in our call volume, but it’s worth a try.

All medical bloggers touch on or delve deeply into the pandemic of physician burnout. My 1/22 post, The Future of Doctoring is Already Here: Do More, Give Less or Burn Out,   is the most read in my blog’s almost 15 year history – well over 13,000 views and counting.  On 2/14, The New York Times picked up on broadly the same unsolvable equation (not to say they were inspired by my piece) in their article According to Medical Guidelines, Your Doctor Needs a 27-Hour Workday.

So, how do I, or any of us, stay sane in this crazy system?

I have found my curiosity to be my biggest defense against burnout. Asking why, looking for connections, not settling for I don’t know, but doing a quick google search instead, is my recipe.

This week, for example, I saw a new patient, 27 years old, with foot pain that had been diagnosed in the ER as plantar fasciitis, heel spur. But his pain wasn’t just under the heel, it went partway up toward his knee. And he couldn’t feel light touch there. I asked if he had back pain. “All my life”, he answered. So I tested the strength in his legs, definitely weaker than in a healthy 27 year old. Next I asked him to get off the exam table and sit in the chair with arm rests next to it. “Try to get up from the chair without using your arms”, I said. “I know I can’t”, he answered. He grunted and tilted to no avail.

I don’t have an answer yet to what ails him, but I ordered a bunch of tests. How could I not think my job is interesting and meaningful?

Another patient has low calcium from hypoparathyroidism. The only endocrinologist in northern Maine has been gone for a couple of years, so I am monitoring her lab values. She was running a little lower than the endo or I would want, but she said her calcitrol was so expensive that she skimped on the dose. The other day she told me that when she had Covid last month, she had two strange spells where her body seemed to stiffen up and get a little shaky. Seizure, critical hypocalcemia, I thought. A quick search revealed that the inflammatory response to Covid has triggered hypocalcemia in many cases. I told her she had been on the brink of a grand meal seizure, and she said, “I’ll take them the way I’m supposed to”.

And there were others, not as exotic, but in a handful of cases I was able to connect the dots.

A woman with low sodium was borderline  before and normal years ago. Her first drop happened when she started taking Prozac some time ago, and when her dose was increased recently, her sodium level tanked. That is a known side effect from the SSRI class of drugs. So we reduced her dose as a first step – some people don’t do well stopping medications like that cold turkey, although Prozac’s long half-life makes it less likely that she would have severe withdrawal symptoms.

To be honest, there are many such little pearls, or mental challenges, some of which I can’t even remember when the week is over. So far I’m still very happy to be a somewhat overworked primary care doctor in this underserved corner of our country.