A Country Doctor Writes:

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?

People are confused when clinics don’t want to see them for their medical problems. All their lives they have been told to get their symptoms evaluated before they turn more serious. Now, with the raging pandemic, the message is the opposite: If you have Covid and feel you are getting sicker, we will talk to you on the phone or via telemedicine, but we don’t want you in our building. If you have milder symptoms that might be Covid, stay home, take care of yourself and good luck. You can’t even get past the receptionist, as the saying goes.

I am always a little bemused when people act either helpless or overly treatment fixated with common colds, for example. Body aches, fever, congestion and cough require no treatment as a rule. That’s a little bit like trying to stop the rain. It is what it is and it will pass. Pharmaceutical companies offer branded products with false claims that the disease process can be altered if you pick the right remedy.

Many people lack the ability to gage how sick they are. Under normal circumstances we, as medical providers, see our role as providing triage and reassurance for those who worry. Now, without the in-person dimension, our ability to do so is hampered. But in this state of emergency, doing what we are used to doing would endanger ourselves, our staff and other patients inside our clinics.

We are in a strange survival mode most of us never anticipated to find ourselves in. And just when we thought the vaccines would open the door to life as it used to be, the new virus variants and the rapidly fading immunity markers are bringing us back to the state of uncertainty we were in 18 months ago.

Life is perilous, even frail, but the odds are on our side. The vast majority of people who contract Covid will do just fine. It’s just that in our culture, every disease is expected to have a cure, a treatment. This pandemic reminds us that most viruses don’t have a treatment. Only if you are desperately ill do we have something – fairly generic – to offer you, such as respirators, steroids or drug cocktails.

I wish more people had a wise old grandmother to ask for advice when they are sick. I do the best I can to play that role to my flock of patients. Common sense is what we need right now.

The other day I got a comment and 17 page views on a blog post I published back in 2013. It was also one of the first pieces from A Country Doctor Writes picked up by The Healthcare Blog, based in California. I am now on their masthead as a frequent contributor.

I was quite surprised when my piece about the wisdom of ancient (2500 BC) Chinese medics was featured on The a Healthcare Blog, a platform mostly about the technology and business sides of medicine. But ancient common sense sometimes trumps modern viewpoints:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. [I see in this a reference to archetypal or somatic medicine.] The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

And on the subject of doctoring:

“A good doctor gives medicine in response to the condition of the situation…This is not a matter of adhering to one absolute method. It is rather like a good general who fights his battles well by observing his enemies closely and responding to their changes. His methods are not determined beforehand. He observes the moment and is in accord with what is right.”

(This reminds me of my not-so-ancient post The Art If Medicine is Not an Algorithm.)

I find myself in respectable company on The Healthcare Blog and The Deductible, including one of my favorite lecturers, neurology professor Dr. Marty Samuels.

John Irvine, the editor of The Healthcare Blog, moved on to create The Deductible, where you will also find some of my writings. Matthew Holt, creator of THCB, remains a steadfast supporter of my writing. These two men, along with Kevin Pho of KevinMD, helped me find a wider audience for my writing.

My purpose in writing is not to bring forth the latest advances in medicine, but to remind myself and my readers of older, but still universal, truths about medicine and doctoring.

Imagine watching two people moving around in dim light. You see one person limping and the other walking smoothly.

Then, imagine looking at retina-sharp still pictures of these two subjects. One person has one leg that is shorter than the other and one person is unable to fully extend his left knee.

Which one has a limp and which one doesn’t? That’s anybody’s guess. Form and function don’t always match. Our bodies can compensate for a lot of things.

Then imagine looking at two lumbar MRIs. One has moderate multilevel disc disease and the other one does not. Which person has more back pain that the other? Again, that’s anybody’s guess. They say 10% of asymptomatic people have a herniated disc. Yet, many patients with modest symptoms insist on getting an MRI to “know what’s going on”.

Now, imagine two different radiologists looking at a CT scan of someone’s liver. One of them sees innocent adenomas and the other sees multiple metastases. That happened in a case I was involved with. The two doctors looked at the same pictures and their respective, opposite interpretations were merely opinions, guesses if you will.

I saw a report of a nuclear stress test the other day. My new patient had this test several months ago. He experiences pain between his shoulder blades and profound shortness of breath with moderate exertion. The report said “small reversible perfusion defect inferiorly and apically that appears artifactual”. That sounds very much like just an opinion to me. The cardiologist he saw in consultation took the report at face value and declared his chest pain non-cardiac. I don’t believe that, especially since the man’s echocardiogram showed a slightly abnormal wall motion at the tip of his heart.

To make matters worse, because of COVID, the hospitals around here don’t do exercise stress tests, but instead stress the heart with injectable drugs. I assume they don’t want people huffing and puffing on a treadmill, spreading aerosols in the room. My patient’s resting heart rate was 74 and it peaked at 90. My understanding is that the accuracy of the test is lower at lower increases in heart rate, similar to an exercise test but on a different scale.

I prescribed isosorbide mononitrate and ordered a new echocardiogram. I told my patient he may need a transesophageal echo and possibly a stress echo.

Even something as simple as using a plain chest x-ray to diagnose pneumonia is not straightforward. Does a patient with cough, green sputum, fever and crackles in part of one lung have pneumonia, even if the x-ray looks normal?

Clinical Pneumonia or Virtual Health?