A Country Doctor Writes:

I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)

I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.

I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.

My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.

Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.

I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.

But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.

When I, as many other people, realized that this pandemic could wipe out countless people including myself, and completely change the living conditions for those who survived, it completely freed me from worrying about the small stuff. Or, rather, from considering the small stuff, because I’m not really a worrier. I just used to run a lot of what-if scenarios through my head. I used to be several steps ahead in my mind and have not only Plan B figured out. I would have backups to my backups.

Now I fully accept the unpredictability of life and that has freed up a lot of mental capacity and even time for me.

I have published three books and my blog has continued to grow. At this writing I have posted every single day for the last three weeks. The more I write, the more ideas I have. And my writing is inspired by my engagement with patients and the thinking about medicine they provoke in me. My clinic work informs my writing and my writing makes me a more curious clinician. I go to work thinking “what interesting things will I see today?”

How could I feel burnout when every clinic day is where I go for writing inspiration?

The pandemic has also, ironically, brought me closer to friends and family. Pre-pandemic, I felt too busy to connect, especially in person, never liked to talk on the phone, and I was not into social media. Now I text, call or chat often with my children. I FaceTime biweekly with my exchange student year brother from 50 years ago. I email and chat with cousins in Sweden and some of their children are in my Facebook feeds.

I am also more connected to my home. I take greater joy in doing the little fix-ups. In years past, my home improvements were on a grander scale. Now I do the little, low key things with just as much pride.

I only leave the property to work in my clinic (my second job is via telemedicine from my kitchen island) and to go shopping. The animals thrive on being all together and mild summer nights we all sleep in the barn with the top doors open. I love falling asleep to the sounds of summer, the snoozing of dogs and the chomping of hay.

I am so content with my life as a country doctor.

https://hansduvefeltmd.com/2021/08/28/burnout-not-even-close-video/amp/

Today, I had a medical assistant covering for Autumn. Near the end of the day, she handed me one report from our emergency room and one from the competing healthcare system’s walk-in clinic.

A patient of mine had gone to the walk-in clinic for a toothache.

“I wonder why he went to the walk-in clinic for a toothache”, I said.

“I sent you a Task about it this morning”, she said.

That’s the workflow In Greenway’s Intergy. In eClinicalWorks, my other clinic’s EMR, “task” is called “Jellybean”, because the icon with the number of messages is one of several different color ovals on top of the computer screen. But it’s the same flawed idea: Pass messages to the clinician in the order they came in instead of according to urgency.

“Oh well”, I said. “I saw the task about a note for the landlord about a cat and the one about wanting a backdated referral and a hundred other non-urgent messages. Listen, I’m drowning in messages while I’m busy seeing patients. What Autumn does is put a stickie on my computer monitor about important or time sensitive messages. I would have sent in an antibiotic for that guy.”

“No problem, I can do that”, she answered.

I can think of lots of posts I have written about this before, but it needs to be said again:

There is a real danger that providers and patients will waste time doing the wrong thing at the wrong time when nobody directs and prioritizes the inflow of information.

Computer people, who sit at their screens all day, don’t acknowledge that providers are looking into patients eyes, ears and other orifices, listening to convoluted histories and solving clinical problems in the exam room most of our working day. The patients in the office are our priority unless someone with the appropriate triage savvy declares that a not-present patient’s issue should be prioritized.

Where else is the decision maker for a million-plus-dollar-revenue operation surrounded by helpers who dump everything on the boss’s desk without even trying to sort it?

I’m not the president, would not want to be – or even compared with one – but think about how ridiculous my workflow would be if applied to other arenas besides primary care (posted in 2015):

All the President’s Mail

Yesterday I wrote about Sphincter of Oddi dysfunction, SOD, a problem where bile accumulates temporarily in the common bile duct.

Burt’s case reminded me of how often I’ve hit the nail on the head suspecting a bile problem to be the cause of a patient’s symptoms.

We certainly have an epidemic of gastroesophageal reflux, in part related to our dietary habits and obesity. So many fast foods can aggravate it, like pizza with red sauce, sweetened and carbonated beverages. Eating late at night and going to bed on a full stomach can also trigger reflux. A big belly, whether from pregnancy or obesity, is also a major trigger.

We have developed more and more acid blockers, yet I see more and more people with reflux symptoms not controlled by these fancy drugs. Surgeons seem to be looking for even small hiatal hernias to operate, and I see many patients who don’t feel much better after their Nissen fundoplications.

So consider this: Endoscopies often show bile reflux. Bile is alkaline, but locally irritating just the way acid is. If we suppress production of stomach acid, is unopposed alkaline bile then more important than if it is present in the stomach along with stomach acid – in a way neutralizing each other? I don’t know, but I wonder.

Following up on my recent case of giardia in the stomach of a patient with stubborn reflux symptoms (skip the inserted post if you read and remember it), this is what happened after the antiparasitic treatment:

When I Escalated His GERD Treatment, My Patient Got Worse. Now I Know Why

Pierre Patenaud was heartburn free when I saw him in followup. Killing the giardia seemed to have done that. But he had developed another problem: Yellow, loose stools that caused him anal pain. He seemed like he had a case of post cholecystectomy bilious diarrhea, except he didn’t just have a cholecystectomy. I prescribed my usual treatment, colestipol. One tablet per day took care of his problem.

My second quiet consideration is: If you bind the bile with colestipol (wherever the two might meet, in the stomach, duodenum, jejunum, ileum or colon), can you control bile reflux, bile gastritis and bilious diarrhea as well as what Pierre called his “burning butt”?

Before statins became available, we used colestipol pills or powder to lower serum cholesterol; by binding to our bile, colestipol prevents reabsorption of cholesterol, a major component of bile, thereby lowering serum cholesterol. So there is plenty of experience giving it to patients even if they don’t have post cholecystectomy diarrhea, its major remaining indication.

I will not hesitate trying it in people with treatment resistant heartburn. I will refer people for endoscopy, but even if there is no bile reflux during a procedure done in the morning, fasting, how do we know it doesn’t happen after pizza and a six pack shortly before bed?

High-quality primary care is vital but undersupported in the United States. In communities with more primary care resources, people live longer, health care costs are lower, and there is greater health equity than in areas with less primary care infrastructure.2 More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards.2 One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.3
— Read on www.nejm.org/doi/full/10.1056/NEJMp2109700

Burt had his gallbladder out twenty years ago. But he had these recurring attacks of pain in his right upper quadrant that built up slowly and lasted for hours and then gradually disappeared.

Other doctors had checked him out and an ultrasound showed nothing unusual, such as an abnormal diameter of his common bile duct. He had even had a normal HIDA scan. Both were done fasting, the usual way.

As I listened to his story, I felt sure this was biliary, but what? It came and went and he was fine between. One time he remembered it happened the night after a high fat meal.

I’ve had patients who needed an ERCP to remove small gallstones at the sphincter of Oddi or to dilate or stent sphincters damaged by inflammation or tumors. But his symptoms were not chronic and he couldn’t very well have a stenosis present that way.

“Sphincter of Oddi dysfunction”, I thought to myself and logged in to UpToDate. “I pay $500 per year for this database”, I started. “I think you can have a bad valve, that lets the bile through some of the time and not others. Let me check something.”

And there, on my laptop screen in front of us, I had the classic symptoms, the Rome criteria which he checked off one by one. We scrolled down to the diagnostic testing. Ultrasound or HIDA scan after a fatty meal (of course!!!), invasive manometry (ugh!). Further down, the answer I was looking for: Antispasmodics may work. (I am linking to two different, free, articles here and here.)

So Burt is sticking to his low fat diet with a new prescription for PRN hyoscyamine.

We shall see…

P.S. Am I the only family doc who didn’t have this diagnosis right at my fingertips?