A Country Doctor Writes:

This may come as a surprise for people with business degrees:

Doctors don’t really care when a test was ordered. We care about our patient’s chest X-ray or potassium level the very moment the test was performed. We also don’t care (unless we are doing a forensic review of treatment delays) when an outside piece of information was scanned into the chart. We want to know on which day the potassium was low: Before or after we started the potassium replacement, for example.

In a patient’s medical record, we have a fundamental need to know in what order things happened. We don’t prefer to see all office visits in one file, all prescriptions in another and all phone calls in a third. But that seems to be how people with a bookkeeping mindset prefer to view the world. In some instances we might need that type of information, but under normal clinical circumstances the order in which things happened is the way our brains approach diagnostic dilemmas.

Yes, I have said all this before, but it deserves to be said again. Besides, only 125 people read what I wrote about this six weeks ago, while almost 10,000 people read my post about doxepin.

Patients’ lives are at stake and, in order to do our job, we need the right information at the right time, in the order we need it, even if the bookkeepers prefer it a different way.

We are the clinicians. When non-clinicians design our “workflows”, things can work out just like the Boeing 737 MAXX. The engineers thought their new autopilot was brilliant, but it made no sense to pilots. Planes crashed and people died. Boeing at first tried to blame the pilots. Healthcare systems are still blaming providers when the systems we work with don’t work for us.

What percentage of medical errors occurs because we can’t quickly find the information we need – or, worse, because our systems are so clumsy that we don’t have time to enter it according to the prescribed workflows? The statistics may not reveal the true magnitude, just as the Boeing disaster was not immediately attributed to the autopilot. Many medical mishaps are probably blamed on human error instead of the EMR.

We deserve better and our patients deserve better. People around me think I don’t like technology. That’s not true. I just have no patience for technology that doesn’t work. If online banking worked like my EMR (Hi, Greenway!), the banking system would collapse. Facebook, TikTok, Amazon, Google, WordPress and my old iPhone SE seem to work just fine. Why can’t EMRs?

I saw three patients the other day that seemed to have new problems. But in each case I found that the diagnosis was, or could have been, made years ago.

Stan Huff had a sore and swollen left knee. Several days earlier it had locked up when he felt some soreness and started to manipulate it. He got it moving again after a few minutes but it swelled up and he had a lingering pain near the upper inside of his patella, or kneecap.

Most of the time a locked knee means a meniscal tear, which causes a pain deep inside the knee or a tenderness along the inside joint line. Stan pointed to the edge of his patella.

“Did you ever have pain, swelling or locking of that knee before?” I asked.

“I don’t think so”, he answered.

I looked him up on Maine Health InfoNet, and there was a report of a left knee X-ray from 2017. It described a loose bone fragment under the upper medial portion of his patella.

He had no memory of this.

“Don’t fool around with your kneecap anymore, and if it keeps hurting or locks up a lot in the future, you’ll need to have that loose piece of bone removed”, I told him.

Sue Moran, a fairly new patient to me, but a long term patient in our practice, came in for tingling of her hands and feet. It happened on and off, and she had neither neck or back pain. She told me she sometimes dropped things because her hands felt so numb. Her exam was pretty normal, maybe just a slightly decreased sensation when I tested it with my monofilament.

“I’ve had this on and off for a couple of years, and I had some testing done, even an EMG, but nothing came of it”, she told me.

I was intrigued and looked her, too, up on Health InfoNet. There was a left leg EMG, done for left sided sciatica. It had some minor, nonspecific abnormality. Looking through her lab tests while asking, “you must have had B12 levels and things like that done”, she nodded “yes”.

But there, a year ago, was a B12 level of 170, clearly too low. I went back to our chart and there was a prescription for injectable B12, once a week for a month and then monthly after that. Sue said she never heard of that or got the solution for us or her to inject.

Her provider had left our practice and she had not been in for about a year, which explained why Sue’s diagnosis fell through the cracks.

Such things happen in medicine, more often than they should.

Glenda Bickford had a long history of heartburn and had even had an upper endoscopy a couple of months ago. It was fairly normal with slight inflammation on her biopsies and a negative test for helicobacter pylori. She was on high dose omeprazole plus famotidine and still had both heartburn and upper abdominal pain after eating. She also felt full after eating a small meal, burped a lot and even regurgitated food sometimes. On top of that, she was more constipated than ever before.

I thought she probably had gastroparesis and asked:

“Did you ever have what’s called a gastric emptying study, where you eat a radioactive meal and the check how long it stays in your stomach?”

“No, I don’t believe I did”, was her answer.

“Did anybody ever think your stomach was paralyzed, gastroparesis?” I asked.

“No”, she said.

“Well, that could be what’s going on with you. We don’t have a lot of options to treat that. The only FDA approved drug for gastroparesis is called metoclopramide…

“I had that before, Dr. Dean put me on it twenty years ago”, she answered instantly.

“And did it help your heartburn?” I asked.

“I believe it did”, she said.

“And why did you stop it?”

“I felt good, I guess.”

“Until the past six months?” I asked.

“Yes, I guess so.”

“So, Dr. Dean and I are thinking along the same lines. Would you be willing to try metoclopramide again?” I asked.

She said yes, enthusiastically, and I went on to explain the newer reports of tardive dyskinesia that was never a concern from its introduction in 1964 until 2009, when the FDA issued a Black Box warning. Glenda was not worried and she was eager to retry the medication.

In only one of my three cases did the patient know about their previously made diagnosis, even though Glenda didn’t remember the name of it. In the other two cases, the information was recorded but the patient did not recall being told what was wrong.

We could and should do better than that.

This two minute video over on A Country Doctor Talks is getting a lot of attention:

Click the tab “A Country Doctor Talks:” or go to hansduvefeltmd.com

https://hansduvefeltmd.com/2021/04/25/a-country-doctor-talks-introduction/?amp=1