A Country Doctor Writes:

Our personnel policies require all hourly staff to punch out for their lunch break. As a salaried physician, I can work my entire shift without a break. This requires some juggling with nursing staff, but it works.

The other day, Autumn came back from her break giggling.

“I was reading from your book again, and I still laugh at your story about that ear flush. I remember it so well…”, she said.

“I know, it was wild”, I answered, but I also remembered thinking with some sadness at the time about how misunderstood this patient must have been. But I, too, smile inside when I occasionally reread “A Moving Target”:

Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.

On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.

In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).

Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.

The authorization for the colonoscopy referral does require my clinical judgement: My patient may not be medically stable for their routine colonoscopy because of a recent heart attack, or they may have already had a diagnostic colonoscopy at another hospital because of a GI bleed, or they may now have a terminal illness that makes screening for colon cancer moot.

But, please – when we can land robots on Mars – give me an easier way to say “yes” or “no” in my multimillion dollar system!

A couple of months ago I had a request to connect on social media from a woman named Charlotte something. The name didn’t sound familiar and I didn’t recognize her face. I ignored it, but she tried again a few weeks later. She told me what her maiden name was.

She was my first girlfriend when I was 17. We were explorer scouts and we drank tea together on weekends when I took the bus to see her in the next town over. We once visited her friend, who had an indoor swimming pool. That’s when I decided to have my own some day, which I did. Life happened but we stayed in touch until I was in medical school in Uppsala. Then we lost track of each other.

It turns out she became a social worker, another healing profession. She married and had a son a few years before I adopted my first child. Her son suffered a severe birth injury. When I told her about my books, she told me her son wrote a book with a little help from her.

She sent me two copies, one in Swedish and one in English. I was very touched, by what she told me about her son, how she and her husband have supported him and by the content of the book.

Here are the first two pages of the English version. Note that this boy’s dreams are more about connections with people than his own physical abilities.

My Swedish morning paper has an interesting story about psychiatric prescribing by “net doctors”. 20-39 year olds in Stockholm are heavy users of telemedicine and in this population, 25% of all prescriptions for the antidepressant sertraline (Zoloft) and an even greater proportion of those for escitalopram (Lexapro) are from telemedicine doctors. There is a lot of concern in the psychiatric community about where this might lead, particularly the risk for inappropriate prescribing and inadequate followup.

https://www.dn.se/vetenskap/natlakarnas-forskrivning-av-lakemedel-oroar-psykiatriker/

Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.

Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.

The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.

An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.

He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.

I ordered a pulmonary consult and tonight I was thinking to myself: “Does the vagus nerve sometimes get compromised by hilar masses or adenopathy?”

My first search hit was a 2014 article about a previously unknown association between gastroparesis and pulmonary adenocarcinoma. It has been associated with upper gastrointestinal cancers since 1983 and also with small cell lung cancers and pancreatic cancer.

So my compromised vagus theory may or may not be relevant, but the general link with malignancy was news for me.

As so often in medicine, one diagnosis leads to another.