A Country Doctor Writes:

Three days ago I wrote about a patient who stopped his old medicine when he started a new one, while I had intended for him to take both. That episode made me think about how I communicate medication adjustments.

Well, I saw two patients yesterday who should have called me about problems with their medications. I don’t understand why they didn’t.

Samuel, a diabetic with both neuropathy and sciatica came in to follow up on his new prescription of duloxetine two weeks earlier.

“That new medicine you prescribed – I took my first one and soon after I was on the flush with the waste basket between my knees blowing out both ends of me. Never took another one.”

“And here we are, two weeks later. I never heard that you had a problem with it. If I had known, I would have suggested something different for you earlier. There are many options. Do you dare to try something different?”

He did, and I made very sure he knew to let me know if he had any worse side effects besides the typical ones I described.

Tristan was three weeks into his topiramate titration. I always start with 25 mg at bedtime the first week, twice a day the second and one in the morning plus two at night the third. Then I follow up in person to see how effective the medication is.

“That stuff”, he said, “is giving me these terrible headaches. I can’t take any more of it.”

“Did you get it even with just the one at night in the beginning?”

“Oh, yeah, first pill, and the higher the dose, the worse it got.”

I sighed. “Okay, I wish I had known that this happened, so you wouldn’t have suffered for three weeks. Here are a couple of other options…”

Both men left with new prescriptions and repeated instructions to notify me of any problems with their medications.

Just like the man with alarming new symptoms, who delayed getting evaluated and said “I thought I’d wait until my appointment”, so many people seem locked into the thinking that their doctor only exists in the physical sphere of the office visit. When I wrote about it two weeks ago, I described it as a systems problem. I blamed our clinics for making it hard for patients to stay in touch with us.

Samuel is from the older generation that may not feel comfortable “bothering” his doctor, but Tristan is young with friends in healthcare and service industries. He calls me by my first name and isn’t viewing me as unapproachable as far as I can tell.

I still haven’t mastered the Art of explaining new medications, obviously.

The Art of Prescribing (Or Not)

Hélène described her chest pains as a pressure across her entire upper torso with shortness of breath. It happened with exertion and got better if she sat down. It also made her a little sweaty, even in her air conditioned home.

Her chemical, nuclear stress test report revealed no EKG changes, but “imaging suggested a small inferior and apical reversible perfusion defect not verified by the software” and “mild apical dyskinesia, probably artifactual”.

Stress testing is not as precise as people imagine, just like many other tests. In this case, what percentage of medical providers would trust Hélène’s reassuring report that stated in its summary that her risk of a cardiac event was average?

In many other radiology reports I read caveats like “depending on the clinical presentation, this could…”. But in the stress test reports there is no mention of pre-test probability. Perhaps there should be!

Particularly in women, where a stress echo may be a better test – but only available hundreds of miles away from where I practice – we need to avoid minimizing test abnormalities if our clinical index of suspicion is high.

I prescribed isosorbide and sublingual nitroglycerin the day I saw Hélène for her angina (that’s the diagnosis I used for the stress test order, not “atypical chest pain”) and after the stress test she told me her symptoms were greatly reduced. But she did have some side effects from her isosorbide mononitrate.

She appears to have at least significant microvascular disease, but I often see cardiologists showing little interest in this disease. I told her I wanted to adjust her medications and that we would involve cardiology but that her major coronary arteries were probably okay. She reminds me so much of a handful of other women with angina, like Doris Delaney, whose story I posted 11 years ago:

“But I Still Have Chest Pain!”

Medicare sets the tone for other insurance companies about which symptom justifies what test. Some of these coverage rules are hopelessly outdated and downright silly. Most patients have no idea how nitpicking this maze of rules really is. Most people probably believe that their doctor determines medical necessity.

I have such a hard time accepting that a healthy person with no symptoms is entitled to several free test panels per year as long as they are billed under the diagnosis Z00.00 – routine physical. (It’s almost ironic that the letter Z followed by four zeros spells out an exaggerated “zoo”.) At the same time I have to warn patients that tests to evaluate symptoms and diagnose disease have copays and may not be covered at all, because Medicare doesn’t know or acknowledge everything most doctors learned in medical school.

A classic example is BNP, brain natriuretic peptide. This is a screening test for heart failure, the symptoms of which are usually shortness of breath and leg edema. Only shortness of breath covers the test, not swollen legs. Go figure. These bureaucratic rules constitute what I call the parallel universe of Metamedicine.

I question the cost savings of these restrictions for essentially routine testing. Doctors waste time wading through the Byzantine rules, laboratories waste time chasing silly numeric codes, and sometimes middlemen eek out profit from overseeing our work. I can understand that we need stringency about big ticket genetics panels (like in the fraudulent faxes I get for Medicare patients whose data must have been stolen), but an iron level? In a system that spends twice as much on healthcare as any other country on earth? Look at this:

Restless Leg Syndrome is sometimes caused by iron deficiency, even if there is not yet significant anemia. This was shown by Professor Ekbom at Uppsala, my alma mater. But G25.81 (RLS, Ekbom’s Syndrome) won’t buy you an iron level. I have a fax on my desk right now from the lab, asking me to find another diagnosis? Do I just pretend my patient has anemia?

Imaging is even trickier than blood tests when it comes to “medical necessity”. My 2019 post The Cruelty of Managed Medicare illustrates the frustrating, torturous, heartbreaking challenge of getting patients with nearly obvious cancer the proper imaging to make their diagnosis. There should be an ICD-10 code for “looks like cancer, need to figure out where”!

The Cruelty of Managed Medicare

It happened again. A patient was on bumetanide for heart failure. It worked well in the beginning but seemed to be losing its punch over time. Plus we were concerned about lowish potassium levels.

So, I thought I went over my logic pretty well: Add spironolactone, which works differently and is potassium sparing.

A few days later my patient reported minimal weight loss and no improvement in his leg swelling or shortness of breath.

I started thinking out loud:

“Okay, so you’re taking one spironolactone and two Bumex now, right?”

“Oh no, I stopped the Bumex, because you said it wasn’t working.”

“Well, I think it was doing something, but it wasn’t working like it did in the beginning, and your potassium was starting to drop. So I thought the combination would probably work better for you.”

“Okay, I can do that.”

“Yeah, why don’t you, and call me after the weekend with your weight and an update on your swelling and your breathing.”

“Roger that”, he said. As I hung up, I thought to myself: “Why do people always assume I stop instead of add?”

The way my brain works, if you have a partial response with one drug, you keep that and add something else. If that works like a charm, you can taper or stop the first drug and maybe titrate the effective new one upward. But it can be a risky gamble to stop a partially effective drug and start sumething unproven – I mean, things could get worse in a hurry with that kind of strategy.

The only time I stop one drug completely and start another is if the patient doesn’t tolerate the first drug or if there is absolutely no benefit from the first one. Of course, I know that hypertension, heart failure and many other conditions usually require several drugs in order to achieve good control.

Hypertension patients in particular are often disappointed when they end up on three or more drugs. I tell them there are three drug combination pills out there just because it is so common to need several drugs to treat a stubborn medical condition.

So, anyway, I need to do a better job describing how my thinking goes: Keep the partially effective drug until the new one proves to be effective, then consider a full switch.

You’d think after 42 years in this business I wouldn’t have patients musinderstand me like that.

I need to do a PDSA on that one – I’ll need to do one for my Board recertification process anyway.

https://acountrydoctorwrites.blog/2019.03.29/pdsa-for-dummies

I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.

His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.

I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.

The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.

That patient and many others think that health insurance is such a complete package deal that everything should be covered. They feel moral indignation if they have to pay out of pocket.

Even Sweden’s socialized medicine system has copays. Why do some Americans balk at a one-time cash cost of $14 for a non-covered drug when monthly, lifelong copays for modern COPD inhalers that many fixed-income seniors depend on can be over $100?