A Country Doctor Writes:

Many clinics allow the practice of ordering antibiotics for women who claim to have symptoms of a urinary tract infection. In some cases patients bring in a sample, and in some they produce the sample in the clinic in a free “Nurse Visit”. The doctor is then expected to prescribe without evaluating the patient.

The only provider on duty one Saturday this fall, I was asked to do just that. I asked the medical assistant: “Exactly what are the symptoms and is this a patient who gets UTIs all the time?”

“Doesn’t look like it, she’s only been seen once before and that was over a year ago.”

“Gotta be seen, just double book her”, I said.

The woman was in her fifties, came in as a new patient a little over a year ago. She had a history of colon cancer and was behind on her followup colonoscopy surveillance. In that one and only visit she expressed some hesitation about getting that done because she was new in town. She wanted to think about it. She did agree to getting a mammogram scheduled, and she agreed to get some basic bloodwork – but never did. From what I could tell, the mammogram was actually never done.

Her urine had a trace of leukocytes, white blood cells, and a trace of blood, both common findings even in healthy women.

“What kind of symptoms do you have?” I asked.

“I’ve got this pressure but I don’t always go very much.”

“How long has that been?”

“About three weeks now.”

“Does it burn or sting when you go?”

“Only sometimes.”

“Do you get urinary infections often?”

“I’ve only had one in my life”, was her answer.

On exam, she was a little tender over her bladder and deep to the left, but her belly was soft and I couldn’t feel anything suspicious.

I pointed out that she had hesitated about Dr. Grogan scheduling a colonoscopy. She said she had thought that was going to happen but she never heard back.

I showed her his chart entry and explained:

“Your symptoms may or may not be from an infection. I’ll start an antibiotic for you but whether a culture shows anything or not, you’re due for your colonoscopy and you may even need a CT scan if that tenderness in your belly doesn’t go away. For that reason I really suggest we get that bloodwork going, because the CT scan would require contrast. So my suggestion is, take the antibiotic, get the bloodwork and see doctor Grogan to follow up on your symptoms.”

I messaged the receptionist to make a followup appointment and we wrapped up the visit.

A prescription for an antibiotic without a visit could have had tragic consequences. I don’t believe in accepting a patient’s self diagnosis without double checking it. I also don’t believe in prescribing without taking a look at the bigger context of the most apparent presenting symptom.

Sumner Finch is an 80-year old man of few words. He had gone to the emergency room three or four times for constipation but his belly was never tender and his abdominal CT scans always looked benign. The ER doctors were a bit puzzled and so was I when I first saw him for the same thing. He relied on various over the counter laxatives whenever he hadn’t had a bowel movement for two days in a row.

I prescribed a low, steady dose of lactulose, a type of sugary syrup that isn’t absorbed but stimulates the colon in a gentle way (just like many people get loose bowels on common sugar substitutes). He told me this just gave him gas.

I gave him samples of a fancy new medicine for idiopathic constipation. It cleaned him out but he said it then stopped working.

We looked at his medications. He was taking a high dose of an old fashioned calcium channel blocker for his blood pressure. This drug is known to cause constipation. I reduced his dose and his blood pressure did not go up, but he told me he was still constipated.

Every time I saw him his abdomen was soft and nontender.

“Did you ever have a bowel movement every day?” I asked.

“No”, he answered without hesitation.

“So, help me understand, why are you so bothered now if you don’t go every day?” I asked.

“Because when I don’t go, I wake up at night.”

“Why is that?”

“Because of my breathing”, he quipped.

“Tell me more.” I was puzzled.

“When my belly is full, I have to sit on the bed so I can breathe.” He sounded like that was obvious and nobody understood him.

“How long has that been?”

“About six months”, he answered without hesitation.

I repeated back to him what I had understood: “If your belly gets even a little bit distended, it makes it harder for you to breathe lying down.”

“That’s right”, he said.

“But that didn’t happen until six months ago. So I think your heart has changed. I’d like to get an echo to see if it isn’t pumping right. In the meantime, I’d like to give you a fluid pill to help it pump better. Will you try it and see if it helps your problem?”

He agreed, and by the time we sat down to review his only slightly abnormal echocardiogram, he was sleeping through the night. And he didn’t really care how often he moved his bowels.

Instead of complaining about his shortness of breath, he had asked me and the ER doctors for help in eliminating the obvious trigger. He presented us with a succinct cause for his troubles and we fumbled to understand the more ominous cardiac effect of even such a mild case of constipation.

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

I always bristled at “not feeling well” because that is too nonspecific. After all, that could be something that would have been better handled with a 911 call. But there is also a danger in being too simplistic when classifying what people come in for. We like to pigeon hole clinical concerns a little too quickly sometimes.

I had such a situation recently. It hinged on the patient’s choice of one common word over another.

A middle aged woman wanted to be seen for “throat pain”. It was halfway into a busy afternoon and between the three providers in our office, we had no openings to offer her.

Autumn asked me, “can we fit in a throat pain today? I’ve got Nicole Bamford on hold”.

“What kind of throat pain?” I asked. “You mean just a sore throat?” I was working on refills between patients. Autumn asked the patient to elaborate while I continued to work.

“She says she can swallow all right but for the last few days she gets this pain in her throat every time she does anything heavy.”

“Does she have pain right now?” I asked.

Autumn checked. “No.”

“Have her come right over.”

Nicole had no cold symptoms. She had normal vital signs. She had a two week history of throat and occasionally jaw or ear pain after minor exertion, never more than a few minutes. Sometimes she felt a little short of breath at the same time.

Her exam and her EKG were normal. She was a smoker with a family history of heart disease.

“Call the ambulance, 54 year old woman with new angina, no pain right now. I’m calling the ER”, I told Autumn after I explained my assessment to Nicole. She had seemed to accept my diagnosis of unstable angina without questioning and also my recommendation that we get her to the hospital by ambulance without expressing any sign of surprise or emotion.

When I saw her in followup after her ER visit, transport to the tertiary care center and successful stenting of a 95% blockage of one of her coronary arteries, she told me “I thought you were crazy”.

I thought to myself that this could have played out very differently if the nuance between “throat pain” and “sore throat” had gone unnoticed.

It’s nice to know what a patient is coming in for, but that isn’t necessarily the diagnosis they leave with.

Sooner, rather than later, we will be driving electric cars because of the environment. We use energy efficient light bulbs and recyclable packaging for the same reason. And there is a growing debate about the environmental impact of what kind of food we produce and consume. But I still don’t hear enough about the internal impact on our own bodies when we consider stewardship of natural resources.

Our bodies and our health are the most important resources we have, and yet the focus in our culture seems to be on our external environment.

Just like the consumption culture has ignored its effect on our planet in favor of customer convenience and business profits, it has ignored the effect it has had on the health of the human beings it set out to serve. And just as we now are fearing for the future of our planet, we ought to be more than a little bit concerned about the future of the human race.

But, just as we really can’t expect the corporate world to lead the environmental effort, unless we can engineer a way for them to see profit in doing that, we cannot expect it to lead any kind of effort to make the population healthier. That is something that has to start with the individual.

We all need to take responsibility for our actions, large and small, external and internal. Idling your car to warm it up before your morning commute is bad for the environment and eating corn flakes, instant oatmeal or pop tarts for breakfast is bad for your body. And, for lunch, I see cars lined up, idling, at takeout restaurants that don’t have fruit, vegetables or unprocessed grains on their menu. And just think of the soft drinks that come with those meals.

Driving to make a short, nearby errand is bad for the environment. Choosing not to walk that distance on foot is bad for your body.

The one good thing that may have come with the Covid pandemic is that people are cooking and eating more at home and I hear there is a renewed interest in growing your own vegetables. Someone wrote recently that in some way our physical world has gotten smaller and more important to us while the nation and the world have come to feel almost virtual.

Maybe that offers some hope that we will pay more attention to our own health and our own habits.

If we don’t, the chronic diseases plaguing the industrial world will dominate our lives in ways that one day will make the environmental disasters seem irrelevant to the growing majority who will suffer from the failures and breakdowns of their own bodies.

Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.

State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.

Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.

A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.

The pandemic we live under has demonstrated the thin financial margins many Americans live with. A couple of months of missed paychecks and suburban families are lining up at food pantries.

The high deductibles and the high and often undisclosed cost of health care tests and procedures can be more than enough to destabilize an average American family’s economy. Under such circumstances people hesitate seeking care for new symptoms, even if they seem serious.

Historically, the word insurance is derived from the Old French ensurer, meaning “make safe”. The word assure is an even older word, long used specifically for providing a guarantee against loss in exchange for money. American health insurance has drifted into higher and higher deductibles and people now feel less and less safe for having health insurance.

I have many patients who, because of the cost, hesitate getting the lab work to monitor their chronic conditions and to ensure that their medications aren’t causing adverse effects. At the same time, I have patients who are perfectly healthy and take advantage of the “free” physical and random blood tests year after year. But if you feel fine and your weight and lifestyle never change, chances are your blood count, chemistries or lipid profile won’t change much from year to year either.

In fact, annual screening blood tests and even routine “complete physicals” have little or no proven value, depending on exactly who you listen to, including the US Public Health Service Taskforce on Prevention. However, an annual review and conversation around specific health screenings, immunizations and disease prevention, such as the no-touch Medicare “Wellness Visit” has been shown to improve compliance with preventive care guidelines (often called quality).

The whole concept of health insurance is confusing because it is so different from other types of insurance.

My car insurance only pays for accidents. They don’t pay for my state inspection, scheduled maintenance or normal wear and tear, and certainly not for mechanical failures. A brand new or certified used car, on the other hand, may be covered by a “bumper-to-bumper” warranty for a few years, but never for its entire useful life.

There is complete disagreement about how health care should be paid for. Socialized medicine and insurance medicine are two very different models. Americans seem to intuitively, emotionally, want to think of commercial health insurance as something a lot closer to free health care or a car warranty than it actually is. Commercial health insurance is a for profit enterprise that happens to be in the health care field. Their ultimate reason for existing is to make money. They do that by paying out as little as possible and keeping as much as possible of our premiums without looking unacceptably greedy.

I left Sweden with the insight that its socialized healthcare system had many inefficiencies and much bureaucracy. I live in America with the insight that a government bureaucracy, like our Medicaid, is easier to understand and navigate than a hodgepodge of federal, state and commercial payers. And it saddens me to see the insecurity of my fellow Americans who risk getting bankrupted by health care expenses and inadequate sick time benefits or disability income protections – many of them, just like health care, provided by for profit insurance companies.