A Country Doctor Writes:

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?

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