A Country Doctor Writes:

Doris Holt had an unprovoked deep vein thrombosis in her leg. Her managed Medicare plan (ironically called a Medicare Advantage plan – certainly not true for patients who get snuckered into signing up) required a Peer-to-Peer call when I ordered a CT scan of her chest, abdomen and pelvis to look for occult cancer. They teach you to do that in medical school.

The man on the phone called himself doctor so-and-so. He didn’t tell me his specialty.

“Has she had any coags (blood tests for clotting disorders)?”

“No, she needs lifelong anticoagulation with apixiban anyway, so that would be moot.”

“Has she had any other imaging?”

“Doppler of the leg. Mammogram scheduled.”

“Colonoscopy? Pap smear?”

“Colonoscopy consult pending, but she’d have to hold her blood thinner then…”

“Hmmm. Has she had any weight loss or B-symptoms (fever, night sweats etc.).”

“No.”

“I’m checking her plan.” (Pause.) “I cant approve the chest without a chest X-ray first, or the abdomen-pelvis without a colonoscopy or Pap smear.”

“So, you’re denying everything.”

“Yes.”

I didn’t even say goodbye.

Pancreas cancer is first on the CDC’s list of malignancies that can cause blood clots:

Some cancers pose a greater risk for blood clots, including cancers involving the pancreas, stomach, brain, lungs, uterus, ovaries, and kidneys, as well as blood cancers, such as lymphoma and myeloma.

Medicare Advantage is a golden goose for the for-profit insurance companies that offer them. They lure patients in with low premiums (and they get Federal subsidies), hearing aids, free vitamins, rides to the doctor and so on, but they waste my time with roadblocks like peer-to-peer calls and prescription prior authorizations. And they deny rapid diagnosis of occult cancers where time is sometimes of the utmost essence.

The Cruelty of Managed Medicare

Numbers ought to be obvious and straightforward in all walks of life, one would think. But there are many sets of numbers in medicine that confuse people.

The other day a patient told me tearfully that her brother’s heart was only working at 25%. I told her I was pretty sure that he had only lost half of his pump function and not 75%. I explained that a beating heart never contracts so completely that there is no blood left inside it. Instead, only about 55% of the blood inside it is pushed out with every beat. That 55% is what we call the normal ejection fraction (EF).

Systolic heart failure with only 25% of the blood volume pumped out is definitely a significant problem, and associated with a risk of deadly rhythm disturbances like ventricular tachycardia. This is why patients in that category often get an implantable defibrillator. But many people with ejection fractions in the 25% range look and act almost like anybody else during ordinary day-to-day activities.

Another set of numbers that can cause panic and confusion is the stages of chronic kidney disease. Specifically stage 3. I tell people that the founders of the nephrology speciality were either idiots or just plain cruel because they defined stage 1 and 2 chronic kidney disease as changes that routine testing can’t detect. So the first sign of trouble is automatically called stage 3. This is possibly designed to make primary care physicians look stupid. We follow patients for years and suddenly they have stage 3 of this feared (and often overrated) problem – we must obviously have been negligent and asleep at the wheel to have missed some early warning signs.

Stage 1 hypertension is a less dramatic numeric disease label that I see stamped on patients unnecessarily, especially by emergency room doctors. Elevated blood pressure when a person is in acute pain or fear is physiologic – an adrenalin mediated fight or flight response we share with all other animals, maybe with the exception of opossums.

“I’m Sorry Mrs. Jones, But You Have Albuminurophobia”

People often want to order their own test. Or, rather, they call and want us to order the test they think they need. I usually decline such requests. Not because I’m mean spirited or money hungry, but because I am a conscientious doctor.

I don’t make any more money by making the patient come in so I can examine them and be sure to order the right test for their symptoms. I’m on salary. But I know anatomy and physiology better than most patients, and I know which test is better for what.

The self-directed imaging request is not a one step process. Whether the test is positive or negative, there are usually followup questions that require medical advice, which takes time and creates liability.

A sparained ankle can be as disabling as a broken one. What (free) advice do I give a patient I didn’t examine?

I, personally, would hate to be asked by a malpractice lawyer why I settled for ordering a plain X-ray of Mr. Barnes severely bruised leg at his request, over the phone, when it was swollen and tender and he in fact turned out to have a deep vein thrombosis that caused his near-fatal pulmonary embolus.

The other day a nurse called and asked me to order a shoulder X-ray of her husband with shoulder pain. When I saw him in the office, he had an A-C separation, a condition better evaluated with X-rays of the acromioclavicular joint – sometimes both of them, carrying weights.

It is important to listen to our patients’ accounts of their symptoms and their fears and concerns about worst-case scenarios. Some people need more and earlier imaging than others: Their past medical history (of cancer, for example) or nuances in their symptoms can make all the difference in the world.

I believe in, and very much encourage, self care for common illnesses and injuries. But when medical tests are called for, a medical person needs to order them and interpret their significance.

I had a medical dream last night. I was in a clinic of some sort and the nurses pointed me in the direction of a talkative woman and a silent man in her company. They weren’t in an exam room, more like a pergola of some sort. I was given a tray with syringes and other medical paraphernalia. There was neither a paper chart nor any kind of computer medical record.

The woman spoke about having Graves’ disease but also a host of symptoms that she connected with it that I knew were likely unrelated and instead signs of florid psychosis. She had seen many doctors before and none of them had understood her or offered to help her. She had her own expectations of what that treatment would look like and it was all endocrionological, but made little sense to me.

The man in her company was deferential, soft spoken, as if afraid to upset her. I couldn’t tell what their relationship was. At one point, I think I heard her refer to him as her driver.

With no medical record and a tray of museum-like medical equipment I felt a little helpless. This woman needed an antipsychotic, that was clear, but I didn’t know where we were, what was available or how to reach her in her delusional state.

I told her I thought that not only did she have Graves’ disease, but she was also suffering from exhaustion trying to figure all her symptoms out on her own. I said that I wanted to help her, even though I didn’t really know how and with what.

I started to become aware that this was probably a dream, but I hesitated rising to full consciousness. It was as if I didn’t want to give up on my patient, my improbable clinical challenge.

The dogs’ rhythmic breathing, the cool morning air through the window and the sputtering noise from the coffee maker in the kitchen drew me away from my imaginary duty and into my Saturday morning reality.

How familiar, I thought to myself. A sort of parallel to the experience I had in the psychiatric ER in late 1980 back in Norrköping.

That time, I admitted a psychotic patient for observation. He was the only one who knew that very soon, earth was going to switch places with another planet and our lives would be switched, too. I got him to accept a sedative so he could get a few winks of sleep while things were still quiet, to gain strength and prepare for the next day; a back door to a first dose of treatment.

I had spent great effort aligning myself with his suffering, not challenging his delusion, but instead focusing on his distress. It didn’t work badly.

A few hours later, he tried to escape through a skylight.

Ever since then, I have used the same non-confrontational, low key frame of mind to try to form a therapeutic alliance for very small or incremental goals when treating patients – psychotic, disbelieving, hostile or otherwise unreachable.

But that time my overnight clinical experience provoked a dream after my shift where his powerful delusion suddenly played out in my own mind. All of a sudden I became him and in my dream I was convinced the planets were actually going to switch places.

Switching Places

Brian Johnson is a janitor at the nursing home in town. He’d been wearing a regular mask at work, but last week he and all the other staff were told to wear N 95 masks.

Today he was in my schedule. I had never met him before, but he had requested a same-day appointment in hopes of being excused from wearing this type of mask because it bothered his breathing.

A smoker, he had never been on any inhalers and the only chest X-ray I could find on him was a normal study from 2016.

Autumn said she got his oxygen saturation at 87% when he walked in from the parking lot with his N 95 on. When I saw him, I recorded 95% with the paper mask the front desk had given him at his request. I asked him to put the N 95 back on and took him for a walk down the clinic halls, but I couldn’t get his saturation below 92%.

His lungs were clear. I excused myself and got my Wright peak flow meter from my top right desk drawer. He removed his mask and blew into the device, twice: 230 each time.

“That’s half of what you would expect a man your size and age to be able to do”, I told him. “It looks like you’ve got COPD. So even that mask is pushing you over the edge to where you feel acutely short of breath. I’d like to give you a sample inhaler. It’ll last you two weeks – so if you see your regular doctor before it runs out, we can see what it does for you by testing your breathing again.

The sample I gave him was Stiolto, a once-a-day, long acting anticholinergic-beta2 agonist combination. I think he’ll be able to work with that N 95 if he stays with the inhaler – unless he has another agenda.