A Country Doctor Writes:

“Your patient may benefit from X”, “Your patient may be due for Y”, “Your patient may be non-compliant with taking their Z”.

“Care Considerations” is one of the many names for a phenomenon that seems to be exploding. Insurance companies are more and more acting like back seat drivers, hoping that such communications will improve “quality”, “compliance or “conformity” – whatever you want to call it. They are trying to tell us what to do.

Most of the time, there is some sort of admission that we are the doctors and that we may know something about our patient that they don’t. But the underlying idea is that we are not doing our jobs. Ironically, the more reminders we get, the more distracted and ineffective we might actually become.

There are two problems with what these middlemen are doing: They spew out generic data that may or may not be relevant for our patient’s unique circumstances and they try to steal our attention away from the patient’s we are actually scheduled to see today.

These back seat drivers are essentially babbling about which way to turn on a different road trip from where we are driving in the moment and saying things like “you might be out of gas” because they must have been napping when we stopped to fill up a little while ago – trying to be helpful, but ultimately doing the opposite.

This is because today’s primary care doctors are essentially working in synchronous mode, scheduled to see one patient at a time. The dirty little secret in primary care is that anything to do with patients who are not present in our clinics, physically or in a telemedicine appointment, happens “between patients” even though there are no breaks between patient appointments in our schedules. Not infrequently such tasks are done after hours, during what is quaintly called “pajama time”. (Can you spell burnout?)

Clinic driven messages are generally fairly specific and appear in our electronic records linked to each patient’s “chart”: If I get a question if a patient could increase their dose or get a refill or get a referral to go back to their specialist, all their information is there, linked to the request.

But the “Care Considerations”, arrive on paper, sometimes even in a format with several patients’ information on the same page. In order to consider any of them, we have to locate the patient’s electronic file and spend more or less time searching for their relevant information. This is time consuming and basically interrupts the workday of busy primary care doctors whose working conditions make no allowance for asynchronous communication or considerations.

In a different world, if clinics become reimbursed for managing patients and populations, maybe we could look at these kinds of letters, but in today’s reality they are essentially junk mail, trying to interrupt our clinic flow.

Most of us just toss them in our shred basket. Can you blame us?

Between Patients: The Myth of Multitasking

American Primary Care is a dinosaur, threatened by extinction. It is too large and too slow moving for today’s fast paced society. The Fed made us that way.

When this country needed to vaccinate more than a hundred million people, nobody imagined Primary Care offices could be of any help. Instead, pharmacies became the outlet, along with temporary sites in sports arenas and community centers.

Why were clinics like mine excluded?

It all happened because of all the requirements of comprehensiveness we slave under. Even if a patient only comes in once a year for something simple, we have to screen them for everything from food insecurity to depression to domestic abuse. We also have to address any elevated random blood pressure or gaps in preventative care, like annual flu shots or smoking cessation counseling.

This cumbersome requirement stems from the misguided notion that people who choose not to partake in preventative medicine should be ambushed (see my 2018 post Upselling in Medicine: Would You Like a Pap Smear With That ankle Brace, Ma’am?) if they happen to seek us out for a medical concern they themselves see as a priority.

We do offer those screenings when people come in for a physical or a Medicare Annual Wellness Visit, but why are we held responsible for doing them with people who elect not to come in for health maintenance visits?

In today’s reality, a quick visit for a wart or a urinary tract infection creates a lack-of-comprehensiveness quality liability. What if the patient doesn’t return for another year and we missed our opportunity to address everything our payers require of us?

The irony here is that the buzzword for Primary Care these days is Patient Centered. But it is anything but that when our required agenda pushes our patients’ own concerns aside.

The quick and easy patient driven services we could so easily perform are instead being delivered at freestanding urgent care centers, in pharmacies and big box stores, even through telemedicine companies. This fragments care and removes from our workday the less complicated, lighter visits that could give us a welcome variety in our otherwise chronic care focused workday.

Family doctors were trained to offer a broad variety of health care services according to our patients’ needs. We are instead now more and more working as geriatricians and public health policy enforcers.

Comprehensiveness is Killing Primary Care

Today I saw my young adult patient with a distant history of Crohn’s disease and new, chronic abdominal pain. Amitriptyline, 10 mg twice a day, has worked like a charm with no pain remaining, confirming my diagnosis of visceral hyperalgesia.

A few hours later I saw a 10-year old girl who has been to the emergency room several times with belly pain. Her family moved to this area a few months ago and we still don’t have the pediatric gastroenterology records her parents had signed a release for.

This girl has depression, anxiety and maybe more, and quickly established with a mental health provider in the area. She is on several medications. Today’s visit was an emergency room followup with labwork and a CT scan showing nothing abnormal.

Heather will double up with poorly localized belly pain most mornings, many evenings and not infrequently during her school day. The pains start and stop fairly suddenly and can last a couple of hours, sometimes more. Her bowels used to be on the constipated side for most of her life, but someone started her on Miralax and this has helped.

As I talked with Heather and her mother I learned she is often nauseous and pale looking during her attacks. And she sometimes has a very slight headache.

Her mother is on topiramate for migraines. That clinched it for me. I think little Heather has what people call abdominal migraines. I didn’t feel comfortable starting her on topiramate because she’s on the thin side, but as her mother had told me her hay fever wasn’t controlled by cetirizine, cyproheptadine seemed like a good place to start. This lesser known antihistamine is the second choice according to most experts. And for some reason, propranolol is the first choice for abdominal migraines, not topiramate. My thinking was that a nonselective beta blocker might worsen Heather’s depression.

We shall see. Is my gut feeling going to help modify hers? Just like it did for Wanda, who got her diagnosis ten years after I first met her.

The Correct Diagnosis – Ten Years Later

A year ago this week, I made a stir with my post about five common weight loss myths. Today I had a patient conversation I have had so many times before: Someone was trying to eat healthier and lose weight at the same time. They are not necessarily the same thing.

This person was using flavored coffee creamers. I pointed out that they often have harmful fats, like palm and coconut oil, and chemicals that may not be good for humans to consume (corn syrup, trans-fats, milk protein [yet it’s called non-dairy], phosphoric acid [found in Coca-Cola, pesticides and fertilizer], mono- and diglycerides, sodium aluminosilicate [also known as feldspar, a ceramic glaze; it is explosive in powdered form] and proprietary artificial flavors). I even told her about Björn Gillberg, the Swedish chemist who in 1971 washed his shirt on TV with the powdered non-dairy creamer Coffee Mate.

“So what kind of creamer should I use?” She seemed flustered.

“Cream or half and half”, I answered. “They’re not all that good for you, but better than the alternatives.”

I pointed out that most of us want to do both things, eat healthy and achieve or maintain a healthy weight. But salmon, avocado, almonds and olive oil have calories, just like pizza, ice cream and Coca-Cola.

So it helps to prioritize a little. My recent patient, after some thought, wanted to attack the weight first. So my advice was about what to eliminate, rather than what to substitute it with. My point is that it makes little sense to skip the nightly ice cream and start eating yogurt instead if your number one objective is to lose weight. “Eat the real thing that you love, but only do it on the weekend”, I might say.

I scribbled down the math behind the lazy man’s guide to calorie counting, the theoretical 1 lb weekly loss if you eliminate 500 calories (kcal, to be correct) from your daily routine. I do it often enough I might save some time if I created a handout, but I believe in showing the math evolve on the paper as I talk – it’s more like telling a story.

Only after someone who wants to lose weight has eliminated some things do I discuss substitutions in earnest. People want to see results, and giving up ice cream, soda, donuts or beer brings results and makes people believe they can do it. Then, it makes more sense to talk about adding back something with fewer calories.

Like in so many other clinical scenarios, I like to “chunk it down” (see Leveraging Time by Doing Less in Each Chronic Care Visit) and to focus (see The Power of Focus): Reversing a disease process that has been going on for a long time is not usually something that happens quickly.

Five Weight Loss Myths I am Constantly Fighting

Just in the past few months I have had three patients with crippling chest pain brought on by exercise who were dismissed as having noncardiac chest pain. All three are now essentially symptom-free on isosorbide and metoprolol – common antianginals. I may not know exactly how this treatment works, but I am passionate about providing for my patients the common medications we know work. Even a simple country doctor can do that.

Once upon a time there was only one common kind of angina and only one kind of heart failure. Now we know there are two kinds of each. For some reason doctors are all excited about the new epidemic of heart failure with preserved ejection fraction, but skeptical and uninterested in angina with normal coronaries. Both of these more recently discovered diseases turned the old definitions upside down. Doctors of my generation (and younger) have had to unlearn what they taught us in medical school. Many are still bucking.

Angina pectoris is a syndrome, a group of clinical signs and symptoms with several possible causes. When I went to school we talked of blocked coronary arteries or a rare form of angina occurring during sleep and caused by spasm, Prinzmetal‘s angina. We now know that many people, perhaps half of all angina patients, have normal coronaries as far as we can see them on catheterization but poorly functioning smaller blood vessels rather than pure spasm. This type is triggered by exertion, just like angina caused by major blockages.

Heart failure is also a syndrome. For the longest time it was believed that the problem was that the heart didn’t push the blood out well enough with each beat. Only relatively recently did it become obvious that about half of all heart failure patients have poor relaxation of the heart. We have been measuring what percentage of the blood is pumped out with each heart beat. That number should be greater than 55%. But if there is less than the normal amount of blood in the heart and you pump out only half of that, you don’t get enough pumping done for things to work.

Neither angina nor heart failure are strictly disorders of a mechanical system of plumbing. These days the term neuroendocrine pops up everywhere in the literature. Our arteries, big and small, and our heart muscles are not static but constantly changing and adapting. And our understanding of how this all works is still in the early stages.

Maybe we should trust our clinical assessment more often and not look blindly at the results of imperfect tests like Lexiscans, crude angiographies and blurry echocardiographies: If it walks like a duck and talks like a duck, maybe it really is a duck?