A Country Doctor Writes:

When we take a medical history, there is a modern tendency to concentrate on simply listing symptoms. This is evident in many EMR notes, since the number of items in a medical history or review of systems for many years has driven reimbursement.

This, and clinician compulsion to quickly get to the diagnosis in a time pressured visit, has kept us from letting the patient tell their story.

The order in which symptoms appeared is an important part of solving a diagnostic dilemma.

A simple example is the mysterious rash I read a case description of a while ago. Someone had an itch that turned into a severe rash on one leg and later developed a similar rash on the other leg. The timeline (if I remember correctly) revealed that a harmless itch was first treated with a cortisone cream to no avail and later treated with topical neosporin. This worsened the itch and caused a local allergic reaction. Rubbing one leg against the other during sleep exposed the other leg to neosporin, which the patient was by now allergic to. This case made it all the way to the medical journals. A simple question, like “tell me what happened, from beginning to end” would have solved this case very quickly.

When a patient is on multiple medications and has a new symptom that could be a side effect or interaction, the timelines of symptoms and treatments can sort things out. In my experience, patients aren’t usually able to recall which drug was started exactly when. Modern EMRs don’t display a graphic medication timeline the way our old paper charts used to. For this reason it takes more work than our patients would expect to correlate medication stops and starts with symptoms.

My 2011 post, A Deadly Interaction, illustrates how the stopping and starting of statin drugs can severely affect INRs in patients on warfarin, sometimes to the point of causing death. In the case I saw, the patient fared better, but it took the timeline to understand what had happened.

Speaking of statin drugs, I’ve lost count of the many times patients ignore their own timeline. People will say, “I think the medicine is causing my legs to hurt”. I then often get a positive answer when I ask, “did they hurt before you started the medicine?”

A dry cough from lisinopril and other ACE inhibitors is another case where I try to tease out the timeline. But if a patient with a preexisting cough still blames the medicine, I don’t argue the point; I just move on.

Twice so far this year I have seen a diabetic suddenly present with dramatically increased blood sugars. In both cases they had decided to eat healthier on the advice of helpful relatives and increased their fruit consumption. These patients had been diabetics for a long time, and somehow had forgotten that if something tastes sweet, it probably raises your blood sugar.

The detailed timeline is time-tested tool in making a correct diagnosis, just like the broad view of asking “what else is going on”.

I used to wonder why my Irish butter was soft enough to spread almost right after taking it out of the fridge, whereas cheap stick butter is hard as a rock.

The explanation is that in some countries, like the U.S. and Canada, where there is now an uproar quaintly named BUTTERGATE, cows are fed palm oil which is then excreted in their milk, changing its physical properties.

Of course, this is also changing the healthfulness of butter. Palm oil causes heart disease, and when margarines had to eliminate partially hydrogenated oils, trans fats, from their ingredient list, the sneaky makers of non-butter spreads put some palm oil in their products instead.

And now we have it in domestic butter. People think they are buying relatively healthy butter (which raises levels of the good HDL) but it is contaminated: palm oil masquerading as cows milk.

Beef is sometimes labeled as grass fed. And my Irish butter is, too. I’m embarrassed to confess that I never really thought cows were fed fat when they’re so good at excreting it themselves. But palm oil laced feed makes them produce more fat — just not the kind we’ve come to expect.

Another example of how the food industry keeps deceiving us.

Canadian CBC writes, in a piece titled ‘Buttergate’ goes viral, putting palm oil fat supplements in spotlight:

“There are health concerns, there are environmental concerns, all kinds of concerns around the use of palm products, which mostly come from Indonesia and Malaysia,” Van Rosendaal said. “And it’s something that typically you can look for on the label — if you want to avoid palm fats, you can look on the ingredient list. But since it’s in the feed itself, it’s harder to decipher whether it’s part of the process.”

The hackneyed windows phrase, about what a domestic employee will and will not do for an employer, represents a concept that applies to the life of a doctor, too.

Personally, I have to do Windows, the default computer system of corporate America, even though I despise it. But in my personal life I use iOS on my iPad and iPhone and very rarely use even my slick looking MacBook Pro. I use “tech” and machines as little as possible and I prefer that they work invisibly and intuitively.

In medicine, even in what used to be called “general practice”, you can’t very reasonably do everything for everybody. Setting those limits requires introspection, honesty and diplomacy.

In my case, I have always stayed away from dealing with machine treatments of disease. But I do much more than just prescribe medication. Since the beginning of my career, and more and more the longer I practice, I teach and counsel more than I prescribe.

I have decided not to be involved with treatment of sleep apnea, for example. It may sound crass, but I don’t find this condition very interesting: The prospect of reviewing downloads and manipulating machine settings is too far removed from my idea of country medicine.

Worse than CPAP machines are noninvasive respiratory assist devises. I won’t go near those.

I similarly defer to my local hospital’s diabetes nurses to manage insulin pumps. This, too, is too much of a mechanical task for my temperament.

In my personal life, I have done wound care for horses many times, but I have never changed the oil of any of the cars I have owned and loved.

I have also found it more and more interesting and rewarding to engage with patients in what might be called nudge therapy. The word microtherapy is already taken and stands for using low levels of electricity on people, which is not my cup of tea. Microcounseling is also already taken, and stands for briefly coaching non therapists about techniques they can use.

Nudge therapy is when I in a brief appointment can apply cognitive therapy principles to gently and quickly nudge a person towards a different interpretation of their symptoms or circumstances. I find this incredibly powerful sometimes. In my Suboxone clinic, for example, I often deliver these kind of messages, which in some cases have a direct result on my patient’s outlook and sometimes sells them on the idea of adding individual counseling to their regular group therapy.

Changing how the mind, or the body, works without drugs, dials or electricity – now that’s inspiring!

(P.S. As I searched for previous use of “Nudge Therapy”, I came across “Therapeutic Nudging“, which basically consists of reaching out between appointments, something I have also found to be incredibly powerful.)

“I worry, so you don’t have to”, is how I explain to patients when something about their story or physical exam makes me consider that they may have something serious going on.

The worst thing you can do is give false reassurance without serious consideration. And the next worst thing you can do is be an alarmist and needlessly frighten your patient. Finding and explaining the balance between those two extremes is a big part of the art of medicine.

A few times in my career I have struggled with doubt or worry after a patient visit. Did I miss anything, did I order the right test? We all have those moments, but we have personal limits as to how much of such doubt we can handle in the long run.

During my training and early career in Sweden there was more tolerance for physician fallability. Doctors have not been sitting on any pedestals for a couple of generations there. Here, the climate is different: We may not be revered like we were in the past, but if we make errors in judgement, the personal consequences for us can be devastating.

The way to navigate this treacherous territory is first of all to not travel alone. Everything we do is for our patient, so we must maintain a partnership. We are the experts, but we should not make decisions that aren’t shared. I keep coming back to the notion that today’s doctors are guides.

I try to gauge my patient’s degree of worry and match my choice of words and actions to some degree to that. If a patient mentions a symptom and then trivializes it, I often cloak my concern with the words “I worry, so you don’t have to”. That works better than “I don’t want to scare you, but you could have a brain tumor”. The way I say it, I suggest to the patient that my recommendation is a safety measure and I quietly suggest that I just might be worried for nothing. My use of the word worry shows a degree of emotional involvement, partnership and guide responsibility.

If a patient seems overly worried, we must be very careful not to brush off their concern. It is easy to seem callous and to make the patient think we aren’t listening. I may ask point blank what their biggest fear is if I can’t tell and if they name one, I say it back to them and talk about how that condition usually does or does not present. If there is a test that could rule out the life threatening condition they worry about, what’s the point in not ordering it?

In the busy flow of any clinic day, I try not to ignore that little inner voice, that clinical instinct, which tells me something could be dreadfully wrong. If it appears after the visit is over, or after I have already formulated a plan, there is nothing wrong with correcting your course. Those few times when I have said “I’ve been thinking about your symptoms, and maybe we should just have you go to the emergency room and get that scan done so neither one of us has to worry tonight”, nobody has faulted me for changing my mind.

When I worked at MedNow, Dewey Richards’ walk-in family practice in Orono, a part time transcriptionist worked in the break room.

She would sit down in front of her old fashioned computer monitor, put a doctor’s micro cassette in her player, the ear phones in her ears and start typing. The screen in front of her was completely empty except for the cursor in the upper left corner. When each office note was finished, she would print it and start again with a completely blank screen.

Most word processors today are full of icons with formatting options. The only time I use that kind of writing platform is when I actually do some formatting, like a pamphlet or layout of a completed book manuscript.

I write on my iPad because it lets me work anywhere, and I prefer a blank screen in front of me as I choose the right words to express my thoughts. Just like I prefer to write in the early morning, when life has fewer distractions, I find the big white space of my favorite writing app helps me open my mind and be inspired. I don’t usually start with a topic already in my head until I see the empty screen in front of me.

The free program I use for creating blog posts and personal correspondence is called Simplenote. It was created by WordPress, which is the backbone of probably the majority of websites, from A Country Doctor Writes to The New York Times.

Simplenote synchs seamlessly between all my devices every time I close a document, so I can open what I created on my iPad minutes later on my iPhone or my MacBook.

This way of writing is as close to a blank page in a typewriter that you can get. I have heard some people are intimidated by sitting down in front of a blank page. I find it inviting and inspiring, because it suggests that anything is possible.

For blog posts, I copy the finished piece and paste it in WordPress, where I can insert graphics, italicize or make text bold, insert links or indents for quotes.

For book chapters, I paste my text into Scrivener, which synchs (although they spell it ‘syncs’) with Dropbox across devices. This is a writing program that lets you create, format and organize chapters. The last step is then to convert the whole project to a Pages, pdf or (if necessary – ugh) Word document.

As I now finish writing this post on my white iPad screen, my eyes also take in the whiteness of the new snow on the trees and the red cedar fence of the horse pasture outside my bedroom window. It is a silent, sunny Sunday morning.

Time to feed the horses.