A Country Doctor Writes:

Ron Beck has a bad back. Sometimes he gets a bout of sciatica. It usually gets better after a week of prednisone.

Over a three day weekend, Ron went to the emergency room twice. The first time he got a shot of Toradol that did little for his pain. The second time, he got X-rays, some basic lab work and a prescription for prednisone and an urgent message for me to order an updated MRI as soon as possible. That message reached me late morning.

I called him up to see how he was doing. He was still in a great deal of pain and his leg had given out under him. But his leg did not feel numb, his back did not hurt, even with coughing, and he had full control of his urine and bowels. And then he told me his toes were blue.

I told him to come right over. His wife drove him.

On exam, his left leg seemed a little cool. His toes were indeed slightly bluish. I could not feel a pulse on top of his foot, at his ankle or even behind his knee. I listened for a long time with my pocket Doppler. There was no pulse.

I have seen a couple of cases of acute limb ischemia where the patient was in a wheelchair, writhing in agony. Ron was uncomfortable but not in agony. And this was day four of his leg pain.

“I’m worried that you’re having a vascular emergency that will need emergency surgery in Bangor. You will need a CT scan of your aorta and the blood vessels to your legs. So I want to send you to the hospital by ambulance”, I said.

“Anything, Doc”, he answered as his wife stroked his hand.

The staff called 911 and I called the emergency room. I told the doctor on duty what was going on.

“Well, if that’s what’s going on”, he said, “you’re better off sending him down the road to Mountainview Hospital, because our scanner is down and may be for the rest of the day.”

“Will you be medical control and order the crew to give him some analgesia on the way”, I asked.

“You’ve got it, we’ll keep him comfy on the way.”

A few hours went by.

“Look at this”, Autumn said as she handed me Ron’s report from the Mountainview ER.

The note said Ron had a palpable pulse on his left foot with good capillary refill. They did an ultrasound to rule out a deep vein thrombosis and sent him home. “Needs urgent lumbar MRI”, it ended.

“How are you feeling”, I asked him on the phone.

“Better, whatever they gave me finally helped the pain fairly well”, he answered.

“I’m still worried about your circulation”, I told him. “Let me see if I can get a CT scan anywhere.”

My hospital’s scanner was still down. Mountainview had no openings until the following week and neither did the only other hospital within 50 miles of us.

I called the vascular surgery office in Bangor and was able to speak to one of their doctors.

“I’ve never seen limb ischemia this outdrawn before, but I’m sure that’s what he has”, I said.

“Well, he’s had this for several days now, why don’t you just have him see me here in our clinic first thing tomorrow morning. We’ll do some noninvasive studies and take it from there.”

His pulse volume recordings were flatlined and his CT showed critical iliac stenosis. He had surgery and his limb was saved. I reported the case to the Chief Medical Officer of Mountainview Hospital.

Sometimes when you palpate for a pulse you can feel your own instead. And sometimes when examining a patient you find what you expect to find. A man with recurrent sciatica might be just another episode of the same thing. And an older doctor in a small rural clinic may just be an overreacting alarmist, looking for Zebras. But not this time.

Growing up in Sweden in the late 1950s, I remember walking past the metal gated entrances to the underground bomb shelters from World War II on my way to kindergarten. Around the same time, mass polio vaccination was introduced.

My parents and grandparents still held on to the rationing coupon booklets they had left over from the war – needed to buy sugar, coffee and other staples.

As the years passed, Russia continued to loom as a threat close to our borders. In 1969, as I traveled around Europe with the Swedish Explorer Scouts, we visited Prague almost exactly a year after the Soviet invasion that crushed the democratic reforms led by Alexander Dubček.

The oppression was palpable and the beauty of the ancient city was shrouded under the dystopian Soviet totalitarianism.

In 1973, Sweden and much of the rest of the world faced a gasoline crisis following the October war in the Middle East.

In 1977 I visited Moscow with my medical school class. We saw underequipped hospitals with underpaid physicians and we saw long lines of people waiting to buy basic groceries.

Also in 1977, the last case of smallpox was recorded in Somalia after a worldwide campaign to eradicate the disease.

And in 1989, the Berlin Wall came down, in many ways ending the Cold War that had started in 1947. The bunker memories of my preschool years finally faded away.

Fast forward, through the bulk of my career as a physician, to 2022:

A pandemic, finally appearing to be less lethal than at its onset. The medical victory of mass vaccinations, but not before our economies almost crashed. Supply chains strangulated and people scrambling to buy toilet paper and other necessities. Lingering chip shortages crippling the automobile industry. A rising awareness that our global marketplace has made us vulnerable in our interdependence.

And now, Russia has invaded its non-communist neighbor. We are at war again, cold or otherwise, a war between communist totalitarianism and democracy. Oil and gas movement across the globe may end. More shortages are looming. Military conflict may erupt in other places; Sweden is mobilizing and reconsidering its independence from NATO.

And here we are, deeply divided, bickering about the right to refuse vaccinations and masks, the right to bear arms, the right to abortion, the right to discuss race or sexual orientation and even the right to vote. Not to mention how to handle the climate issues we are facing.

Meanwhile, our victory over the coronavirus may be only temporary: I am writing this on my iPad from my sick bed on day 8 of my fortunately mild case of Covid-19. Me, triple vaccinated, living alone, N-95 masked whenever I leave the house, goggles at work. If I can get infected, anyone can.

It makes me humble. We are all vulnerable – to illness, war, natural disasters, supply shortages, civil unrest and loss of the freedoms of movement and self expression we have been accustomed to.

Workflows are all the rage with EMR people. But doctors, NPs and PAs are smart. Nothing burns us out as fast or as completely as being told how to do things instead of why. We are not circus animals.

Let me explain:

If we had no professional education at all, we would have clinical workflows memorized instead of clinical knowledge. For example, two weeks after starting an ACE inhibitor like lisinopril, order a basic metabolic profile. That sounds pretty straightforward, but if you add up all the possible clinical workflows we would need if we didn’t know medicine at all, that would be a huge burden – a massive amount of seemingly random and senseless rules.

But, of course, the clinical knowledge we acquired in our training is that ACE inhibitors can act like a stress test for patients with undiagnosed renal artery stenosis and a BMP drawn soon after starting such medications ensures we aren’t causing kidney damage with our prescription.

Such clinical knowledge makes us not only order the blood test, it guarantees that we will always remember to do it because it makes sense. It is like memorizing a beautiful poem instead of a long string of random letters.

Especially since computer workflows are often counterintuitive to clinicians, it helps us to know why they require us to seemingly do the wrong thing. As I have written before, EMRs are workarounds because today’s computer programs can’t replicate how the clinical mind works. Some of us might even take a certain pride in becoming expert at using a less than brilliant tool when we have the admission of our IT people that it is the EMR that is stupid and not us.

Seriously, we deal with worse challenges than that every day, just trust our intelligence and let us know when and why our computers can’t yet do what every reasonable clinician would expect them to.

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