A Country Doctor Writes:

I think it was Adam Cifu who made me curious to read more of Dr. Herbert L. Fred’s writings. It was one word that started me on this journey, a brand new word, minted in 2005: “Hyposkillia, Deficiency of Clinical Skills”.

Many forces have created this modern epidemic. The availability and reliance on advanced imaging and more or less affordable laboratory panels have replaced old fashioned history taking and physical exam skills. The corporate demands on physicians’ time have de-prioritized our cognitive skills. It is faster to order a bunch of tests than to take a thorough history and physical exam, and the tests we order instead are fueling the big business of the healthcare industry.

I remember during my Swedish internship I was called down to see the Chief of Radiology. “Duvefelt, you’re ordering too many x-rays”, he said. Our hospital didn’t have a CT scanner yet, so this was not about very expensive tests. His concern was mostly my orders for simple chest x-rays. I also remember learning physical exam skills at Uppsala University, taught by older pulmonologists, who could predict what a chest x-ray would look like after their thorough physical exam with inspection, palpation, percussion and auscultation.

Dr. Fred didn’t really think in 2005 that it would be possible to turn the clock back to when doctors practiced Oslerian bedside medicine. He thought that the skill set, particularly among generalists, had already been lost. And now we are twenty years further down this path.

The only place where that skill set may be called for is perhaps the kind of practice I am in, housecalls and telemedicine for patients who have great difficulty leaving their homes for CT scans, MRIs, echocardiograms and EEGs.

Telemedicine in general may also be an area where a physician’s history taking skill is getting better recognition. I wrote about this on KevinMD five years ago in the early months of the COVID pandemic.

How I Write

Part of a series

Many people view empathy, the ability to understand how others feel, as a virtue. Some even experience the same feelings others are having; they don’t only understand them. Too much of that can make it harder to be objective as the suffering patient’s physician. Our judgement can be clouded by empathy and our clinical stamina can be hurt by it.

Sir William Osler wrote about Equanimity (spelled Aequanimitas in his time). I’m not sure he used the word virtue about it, but he saw it as an ideal frame of mind, recognizing our patient’s feelings, but not becoming so overwhelmed by them that we can’t be levelheaded and logical clinicians. I wrote about this in Aequanimitas – Doctors Stirred, Not Shaken.

“Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”

Aequanimitas – Doctors Stirred, not Shaken

Osler also used the concept of equanimity about controlling the tendency we doctors have to get frustrated about the many limitations and requirements of our positions – yes that was common even in his day!

Sir William Osler put it this way:

“Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.”

Equanimity and the 25% Rule

These two aspects of equanimity are just as relevant today as they were during Osler’s time, more than a hundred years ago.

Prudenta was a stunning gray princess (white to the naked eye but called gray because of the skin color underneath). She had at one point, years before, been abused and neglected and she turned out to be very suspicious of people who tried to dominate her. I was still not a rider. I just brought her food and water and spent a lot of time just being near her.

All I can say is that she took a liking to me and enjoyed being near me. If I had to leave town and travel to Bangor, she would seem depressed until I passed Mount Katahdin on my way home, two hours away. Whenever I came home, even just from work, she would nicker and come up to greet me.

https://hansduvefeltmd.substack.com/p/how-i-became-an-accidental-horse?r=254ice

“Steady, earnest, and energetic effort : devoted and painstaking work and application to accomplish an undertaking”

Another virtue that made my list, coming here in my restored alphabetical order, is Diligence. The dictionary suggests this to be something practiced over time and, at least in my mind, it conjures up the notion of a one-on-one relationship between doctor and patient.

Of course, we are no longer on call 24/7 and hospital medicine is often not part of a primary care doctor’s clinical duties anymore. But even if other clinicians step in now and then, we still have the longitudinal responsibility of carrying out the treatment plan and of pursuing loose ends. We may even be the only ones to recognize that loose ends even exist in a case.

Two side notes here about the word diligence: These days I mostly hear this d-word preceded by another d-word in the expression “due diligence” in legal terminology. I may be prejudiced, but when I hear that term, it gives me the flavor of a mandated process, sometimes a cursory one, certainly not something that goes on for the length of time a doctor may follow a patient with a chronic condition and/or a medication treatment that requires indefinite monitoring for complications.

The other meaning of this word was one I have known since I was a little boy in Sweden, but never realized existed in English too – I assumed it was French because of the way it is pronounced in Swedish. The dictionary phonetic and even its audio clip sounds totally French. This meaning of the word is stagecoach. The –gence ending of the word diligence in this case is pronounced like the beginning of Champs-Élysées.

Anyway, in the medical context, diligence, to me, implies steadfast, ongoing attention to detail, not losing track and not giving up, not being complacent. Our culture has a short attention span and what doctor hasn’t seen that patients often drift away from their treatment plans. It is our job to touch on the elements of our treatment plans when we see our patients in follow-up.

I also think diligence is the way we act on our curiosity. Instead of idly wondering about what our patient experiences for symptoms or manifests in their test results, we need to look it up, as I did in my post about Curiosity the other day.

This reminds me of a case I saw many years ago, a seemingly simple case of a woman with a yeast infection. She turned out to have glucose in her urine all the time but never an elevated blood sugar. This was before Farxiga or Jardiance came on the market, causing this to happen both in non-diabetics and to a greater degree than normally expected in diabetics. I tried, without success, to get the nephrology clinic to evaluate my patient, whom I only saw once as an urgent care case and could have treated for her yeast and put her out of my mind. But my curiosity made me at least try to pursue it.

Here’s that story:

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