A Country Doctor Writes:

Mr. Adams is coming in to follow up on his MRI, but did he have it done? Mrs. Jones is supposed to bring all the medications she is actually taking, but will she remember to do that? And did Billy’s mom get his teachers to complete the teacher version of the ADHD symptom checklists she and his dad were supposed to each do before his appointment?

When doctors ran their medical offices and saw 30 or more patients per day, questions like this were part of how we planned the flow of our clinic days. Many of us called it CHART PREP. Our medical assistants would actually read our last office note the day before a patient’s appointment and try to make sure we would be ready for each visit. Then, first thing in the morning, we often had a quick HUDDLE to talk about what was supposed to happen during the day. The chart prep and huddle were very patient centered; they were about what the patients expected from their visit at least as much as what the doctor expected.

Now, with non-physicians managing medical practices and Medicare and other insurers redefining the purpose of primary care, previsit planning and morning huddles have been hijacked for public health purposes. The nation’s public health agenda is inefficiently squeezed through the bottleneck of a couple of brief in-person visits per year for unsuspecting patients who because of that don’t always then get their own concerns addressed.

Imagine driving up to an ATM for what you think will be a simple fast-cash withdrawal and having the machine start blurting out financial advice and offers of new services instead of giving you the cash you came for. On and on, until you give up and drive off empty handed. Of course, that doesn’t happen. Banks have figured out other, better ways to communicate with their customers.

Why is it so hard to imagine a health care system that lets doctors be doctors? Public health doesn’t require a medical degree or a medical license. Have other staff categories handle that with our general blessing and support.

I mean, seriously, now there are efforts to have pharmacists treat hypertension – while doctors perform routine screenings for depression, alcohol use and domestic violence and give canned one-on-one pep talks about weight loss, exercise and immunizations. Is that a reasonable division of labor???

So, in clinics around the country, and now even with grant money to support this, previsit planning has become the word for identifying gaps in preventive care and morning huddles are promoted as a way to plan how to surprise patients with alternate agendas for their doctor visit.

Mr Adams had his MRI only a few hours ago and the report isn’t available yet. But he will get his depression screen and pneumonia shot. Mrs Jones didn’t bring her pill bottles, but this time she said she’ll consider having that colonoscopy. And Billy’s visit does not clarify his diagnosis but he did get his flu shot.

Is this an efficient way to work? Is it a good use of physician time? Or is it something a non-physician could have, should have, handled?

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Upselling in Medicine: Would You Like a Pap Smear with that Ankle Brace, Ma’am?

Paul Ploetz has a pulmonologist and a cardiologist and I am his primary care doctor. His two specialists work for the same hospital system and I work for a different organization. His specialists send me their notes and I can also look them up on Maine’s statewide database. My organization’s notes aren’t there, at least in part due to the fact that our EMR vendor charges big money for uploading notes to Maine Health InfoNet.

Paul had been increasingly short of breath. His pulmonologist didn’t think this was related to his COPD, so he prescribed a two week trial of furosemide.

I saw him toward the end of that, and he was itchy and had a rash that looked like scattered excoriations and was only located in places he could reach and scratch.

I suspected he had become allergic to the furosemide, which is common and can cross react with sulfa allergy. I marked his chart with allergy to furosemide. I told him to stop it and prescribed something for his itch.

Two weeks later he came back and told me the rash never went away completely. Two medicines and a couple of creams later he was frustrated with my inability to cure him. So was his daughter-in-law.

I made sure his dog wasn’t scratching. I looked as his other medications, none of which seemed likely to be causing his rash.

On a hunch, I clicked the “PBM” button on top of his medication list. It displays what medications have been billed through insurance, Pharmacy Benefit Management. For clinicians, this is read-only; I can’t enter a stop order there.

There, with a date about two weeks after I stopped his furosemide, was a listing for the same drug – this time prescribed by his cardiologist

I showed him this. He shrugged. He wasn’t keeping track of what pills he was taking.

I went back to his cardiologist’s notes. Sure enough, buried in a multi page note was a refill of furosemide. I had signed off on the note when it came in.

I admit, i missed this information.

Office notes are bulky, filled with fluff and pseudo quality measures. Primary care doctors have no time set aside to review anything in their inboxes – we are expected to do that in our “spare” time or during time stolen from our scheduled patients.

A shared medication list, across EMR platforms, similar to the PBM plug-in, could avoid snafus like this one. So could scheduling time for actually reading incoming reports. Something should be done.

If We Can’t Have a Universal Electronic Health Record, We at Least Need a Single, Universal, Medication List Plug-In

Books, or even just book titles, can help us see things differently and feel differently about ourselves. I often recommend Jungian psychologist Robert A Johnson’s little book He to men who in any way struggle to understand themselves. And long before I read Shadow Syndromes, the mere title of the book cemented some clinical insights I had been intuiting but only skirting around for years.

Reading my Stockholm morning paper this snowy January weekend, I came across an article on bibliotherapy. The word hit me with a jolt. According to Wikipedia, it was coined by Samuel McChord Crothers in an August 1916 Atlantic Monthly article, but the medicinal use of books goes back centuries if you consider the use of religious texts and at least to the 1850’s for other literature in the United States.

Apparently, both therapists and librarians, perhaps more in Great Britain than here, offer bibliotherapy. Libraries sometimes offer group sessions focusing on books about topics like overcoming anxiety.

Without having such a technical word for it, I actually was able to help a young man make huge progress with his anxiety by recommending Eckhart Tolle’s The Power of Now, a book that I myself had only skimmed a couple of years ago. I actually didn’t read it; I listened to the audiobook, sitting in my camping lounge chair in the horse paddock against the south wall of the barn. There were horse related interruptions that made me miss parts of the book. But I got the essence of it and it rang very true to me. As I have alluded many times, being with horses has taught me many things. Perhaps most of all, it has taught me not to think about other things when I am with my large, fast, strong and high strung Arabians. Only now matters with them. Being aware and in tune with them is how to be safe and how to influence their actions without the use of any kind of force.

Jeremy is an articulate young man who seems comfortable in any situation, but he gradually revealed to me that he is plagued by severe anxiety and constant ruminations, catastrophic thinking and self doubt. The more he talks, he explained, the more that means he is feeling anxious. He has a lot of regrets and guilt about the past and even more worries about the future.

The short answer to what he needed to do is well summarized by Karen Salmansohn: “No amount of regret can change the past. No amount of anxiety can change the future.”

Eckhart Tolle’s book, especially the audiobook, is a bit like an outdrawn meditation guide. Only the now matters, because only the now exists. I found a YouTube video that explains very succinctly what he means, and may be a good and quick (16 minute) introduction for anyone who is unsure if Tolle’s thinking is for them.

Jeremy read the book and emerged almost as a new man. He still needs to remind himself now and then to get out of his thinking mind and be fully present in the moment, but his outlook on his situation has changed profoundly.

In everyday clinical practice, we see mostly ordinary things. But our job description requires us to always at least consider the unusual. It takes judgement and experience to navigate between being efficient and not missing something rare or dangerous.

This past week, I have seen a couple of patients that made me dig a little deeper into their symptoms.

One man came in with a six month history of skin rashes. He seemed to have several kinds. Some were isolated little papules on a red background. He said he had had that kind now and then for many years. Some were scaly blotches with bumpy edges and some were red patches with little craters within them.

A few of the lesions reminded me of dermatitis herpetiformis, so I asked “have you had any trouble with your bowels lately?”

“Well, yes, they’ve been real loose.” He seemed surprised by my question.

“How many times a day?” I asked.

“At least three or four”, he answered.

I minimized the EMR and googled images of dermatitis herpetiformis, which is usually seen with celiac disease, but sometimes without full blown bowel disease. He agreed that some of the pictures looked a bit familiar. I ordered a celiac panel. If that is negative, I’ll do a skin biopsy, but none of the lesions I saw were quite classic, so maybe I’ll do a couple of them.

Another patient with longstanding anxiety disorder had a very elevated blood pressure, which I had never seen in her before. She told me she has seen numbers from 120 to 180.

“Why have you been checking your blood pressure to begin with?” I asked.

“Because I break into a sweat and feel dizzy sometimes”, she explained.

Here we go again, I thought to myself. Another instance to look for a pheochromocytoma. Most of the time when we look for this rare cause of spells with high blood pressure, we don’t find it, but you have to look.

We must be careful not to zero in too quickly on the presenting complaint. That is like wearing blinders, like the horses pulling the Amish buggies down the road from me. But at the same time we can’t scan the horizon so much that we become scattered and paranoid.

The Art of Asking: What Else is Going on?

One of the most rewarding things I do in my clinic happens on my iPhone.

When I sit down with a middle aged patient to talk about their cardiovascular risk, I open the risk calculator created by the American Heart Association and the American College of Cardiology. I talk my way through as I enter the parameters – age, blood pressure, lipid numbers, smoking history and so on. Then I write down their ten year risk on a piece of paper next to the “ideal” risk for a person that age, for example 8% risk versus ideal 3%.

I explain that statin drugs may lower anybody’s risk by 30-50%, which is more important to consider the higher their risk is, because half of almost nothing is almost nothing.

I also write down the opposite numbers: 92% chance that nothing bad will happen versus 97%. That number, to most patients, seems less dramatic than “almost tripled risk” in the first set of numbers.

Next, I fast forward a few years. Both my patient and Mr. or Ms. Perfect are then older and have a greater risk. I can then also show what the risk would be if they had quit smoking, controlled their blood pressure or developed diabetes during that time.

I write down the new risk numbers with notations of the hypothetical new blood pressure and so on. And inevitably I also end up pointing out that the guideline that accompanies the calculator would have just about every 65 year old, even Mr./Ms. Perfect, take statin drugs. I always get the same incredulous reaction to that one.

Next, I mention the Hale study, which showed that older patients who follow a Mediterranean diet have 50% less cardiovascular disease than people who eat a more typical Western diet. But, of course, maybe the diet choices are also linked to other lifestyle factors.

Lastly, I mention that this calculator does not take family history into consideration.

The conversation this little app generates is, in a way, what medicine today is all about. We have lots of data, but the Art of Medicine is figuring out if and how the statistics apply to an individual patient. And, of course, laying out the options so our patients see them clearly and can decide for themselves.

(For more on lipid guidelines, statins and the Mediterranean diet, check out the video below. More videos at A COUNTRY DOCTOR TALKS.)