A Country Doctor Writes:

Last year I saw an elderly man with mild peripheral neuropathy that had not been evaluated before. He was not a diabetic. I ran some basic tests and his vitamin B-12 level was extremely low. We started him on injections and monitored his response. He needed the injection every two weeks to stay in range. He said he felt better.

Recently, he saw a very respected neurologist for something unrelated. The in-depth report stated that the patient had undergone no testing for his peripheral neuropathy and the neurologist ordered a very extensive, undoubtedly expensive, set of bloodwork, part of which was eventually denied by the man’s health insurance. All of those tests were normal, starting with the first one on his list – an RPR test for syphilis.

This illustrates what I see as a fundamental issue in the practice of medicine, not often talked about: How far do you take the workup for mild, common symptoms?

In my 42 years in medicine I have never heard of a single case of syphilis (even before I stopped testing for it) in any patient I or a colleague saw, for example. But there it is, a recommendation passed down from the days of the Wassermann test (1906) and Portnoy’s RPR (1963). The incidence in Maine (1 million people) is reported to be about 50 cases per year. How likely is my octogenarian with mildly tingly toes one of them? Especially if we already know his B-12 was extremely low?

The syphilis test probably doesn’t cost much, but it is a fair illustration of consideration of probability. That is happening in some areas where the unreliability of testing is perhaps more accepted: Cardiac tests have different accuracy depending on pretest probability. Why have we forgotten that blood tests are also fraught with sensitivity and specificity problems that make them less useful in low probability clinical scenarios?

Maybe it’s the Swede in me, but my thinking is that healthcare spending cannot be limitless and needs to match the risk of the clinical situation.

When I trained, we didn’t compete about who could come up with the greatest number of esoteric differential diagnoses. There was more emphasis of what was common and what were the most dangerous and significant pitfalls in diagnosis.

We now have the insurance companies curtailing our workups, albeit often for profit reasons. Wouldn’t it have been better if we as diagnosticians practiced more stewardship and common sense in ordering tests?

Nora Lippmann was a new patient. She was only 52, but she had a large dossier of old medical records from multiple contacts with many kinds of medical providers.

Our first visit was fairly brief, accelerated in my schedule because she was running out of some of her medications. She had moved to this area after an episode of domestic violence downstate.

Her prescription needs were fairly straightforward, but as she had already run out of her blood pressure medication, it was hard to know if that was the right one at the right dose.

She mentioned she had been to the emergency room a couple of days earlier. I pulled up the report from Maine Health InfoNet. She had gone there for tingling of the left side of her face. It was all better by the time she was evaluated. Her neurological exam was normal and she was discharged without a diagnosis.

Our visit was a little scattered, but I did a quick physical exam. She had a very loud bruit in her right carotid artery. I felt a chill in my spine. She had had a transient ischemic attack, and that was one of the loudest carotid bruits I’ve ever heard. What if she had a critical carotid artery stenosis?

I now know she appears to have just that. Her ultrasound showed a “greater than 70% to near total occlusion” of her right Internal carotid artery. She needs a CT angiogram of her carotid arteries ASAP.

I routinely listen to carotid arteries, although the current US Public Health Service Taskforce on Prevention doesn’t recommend it. So maybe it is no surprise nobody had listened for bruits and caught this whopper before I did, but when somebody has a possible TIA, it should be standard operating procedure to listen for bruits.

More than a decade ago, I confessed to not picking up a critical carotid artery stenosis until the third visit of a new patient without symptoms. It all ended happily, but I still remember how humbled I was when I realized I almost missed it.

A Quick Listen

“Can I run a case by you”, my younger colleague asked.

“Certainly”, was my obvious answer.

She proceeded to tell me about a patient who had been to the emergency room recently with abdominal pain, jaundice, profound fatigue and itching. Her liver enzymes were elevated but her imaging did not show anything abnormal, from the appearance of her liver to her gallbladder, bile ducts, pancreas and everything else.

My colleague saw the patient in follow up and all the hepatitis and mononucleosis tests from the emergency room had come back negative.

She asked “What do you think this could be?”

“Well they checked for all the usual things“, I said and started googling on my laptop. “I have an idea.“

I soon found what I wanted, and said “I’m printing an article. This is something I learned about not all that long ago, but it made a big impression on me.“

The printer rattled behind me and my phone rang. It was a specialist at Cityside needing to talk to me. I said to my colleague “read this and see what you think”.

After I finished my call I went down to her office. Her nurse exclaimed as I walked through the door “you’re a genius”.

Sally was reading the article I had printed about G.I. manifestations of tickborne diseases. “It fits”, she said as she ticked (Sorry, but love puns…) off all her patient’s symptoms from the table in the article.

I told her about the lesson I learned from Dr. Kim about anaplasmosis and very soon afterward was able to share with a young colleague. It still isn’t that well known a disease, but its incidence in Maine is increasing dramatically.

So Sally softend her nurse’s compliment and said “experience counts“. I don’t deserve to be called a genius, but I do like being recognized as experienced. After all, it’s been 42 years since I graduated from medical school.

A Lesson Learned

Travis no longer had the severe belly pain he went to the emergency room for last month. He was just in for a routine physical. He seemed healthy enough, but as we talked, I saw that the ER note in my EMR made reference to a CT scan that we never got a copy of. The ER report just said that the scan showed nothing acute.

The pain he had experienced was excruciating and lasted a few hours. It made him vomit and it was right in the epigastrium, just under his breastbone. It went away as suddenly as it had appeared.

I logged in to Maine Health InfoNet and located his CT report. It contained two abnormalities.

First, there was “streaking” around the gallbladder and sludge or small stones. I showed the report on the screen of my laptop and explained that very small gallstones can pass down the bile ducts into the small intestine. When they do, the pain is just like the one he had. If they get stuck, the pain doesn’t go away like his did, you get jaundiced and need to get an ERCP hundreds of miles away to relieve the obstruction.

“You need a gallbladder ultrasound”, I told him. “Believe it or not, ultrasound is better than CT at showing stones and sludge in the gallbladder. If you have lots of little stones there, you’d be better off having your gallbladder removed in order to prevent a disaster later on.”

The second abnormality was an unusual appearance of the bones in his pelvis, possibly a bone cancer, but statistically more likely to be completely benign. But the report recommended additional X-rays of his pelvis.

“Why didn’t they tell me all this?” He seemed incredulous.

“This happens all the time”, I explained. “They may only have a preliminary report from a teleradiologist in a different time zone, stating just ‘nothing acute’, or they may rely on making a blanket recommendation to ‘follow up with your PCP’ even if you feel well.”

“They did say that”, he admitted. “But I felt fine.”

“Their job is to decide if a patient needs emergency procedures”, I went on. “Their system would be completely bogged down if they had to arrange followups for what we jokingly call incidentalomas, things that may or may not be signs of disease. Many people think primary care doctors go through outside reports in great detail as they come in, but there is no time in our schedules to do this when we see patients all day long. Thinking we can do all that on the fly or in our spare time is a flawed business model. So the safest and most practical way to handle things is to have a followup visit after an emergency room workup has taken place.”

“Boy, I’m glad I happened to have this appointment”, he said.

“Like I said, this is so common. A couple of years ago I saw a young man like you for something routine and he had been to the ER, too, at a different hospital. When I went over his CT report, it turned out he had a small kidney cancer. He had surgery and is fine now. But I possibly saved his life. And I have many other stories like that.”

I have written about this kind of situation many times. It is an important reason to have a primary care doctor, a medical home. The bureaucrats have created many models and “workflows” for following up on emergency room visits, but as they rely on non-physicians, they risk adding fluff without medical insight.

“Follow up with your doctor” is a safer bet, because as much as I would like every doctor’s motto to be “If you find it, you own it”, that is not the way things work in healthcare these days.

If You Find It, You Own It