A Country Doctor Writes:

I’ve started to put all my new material both here and on my Substack. So no need for faithful readers of medical themed posts to migrate. But Substack more or less automatically created a personal platform, which I’ve started to play with just recently. Here is my latest post there, about my two very large, very rare rescue dogs:

https://hansduvefeltmd.substack.com/p/my-snugglebutt-wolf-crusher-alabai

Part of a series

So, here are my top three virtues to cultivate, so far: ARTISTRY, described here;  BREVITY, described here and now the “C” word, CURIOSITY.

In medicine, we need to be sleuths. We are looking for clues in the subjective history of a case, in sometimes seemingly random findings on exam or in our test results. And we are looking for distant factoids from our training or literature references on cases similar to the one in front of us. Even in seemingly straightforward cases, there could be red herrings, things that make our mind go in a logical direction, but are irrelevant, almost as if Mother Nature was trying to trick us. 

If you do almost the same thing day in and day out, you risk becoming complacent. And if you run into things you don’t know, you might not have the energy to find out, especially on a busy clinic day and you may not have enough curiosity to look it up when things quiet down.

But curiosity that makes you dig a little deeper is often very energizing. It raises your dopamine just the way a mystery movie or a new adventure can do. The opportunities to expand your mind, learn something new and become energized are all around us.

Here is something I wrote in 2019, titled Curiosity, Antidote to Burnout.

Curiosity, Antidote to Burnout

Part of a series

The ancient Greeks had five core virtues and the Bible has seven. I don’t know that there is an official number of virtues among the medical community, but I recently started thinking that I need to give more thought to the ones I would like to consciously consider and strive to cultivate.

Somehow I ended up writing first about Brevity as a virtue. Perhaps that is an unusual choice, but certainly not a new one. Shakespeare’s “virtue is the soul of wit” in Hamlet stopped me in my tracks as a doctor today, increasingly frustrated with the logorrhea (a real word, think diarrhea of words) of computerized medical records with their defensive documentation and copious copy-and-pasting.

As I contemplated what my personal list of virtues would look like, I realized my first few choices started with some of the first letters of the alphabet.

So here, catching up to what then should have been the first installment in my series, comes my reflection on Artistry in Doctoring:

Artistry is not a word you commonly hear attributed to primary care medicine, perhaps more to procedural things like cosmetic surgery. But, going back to the dictionary, here as a direct quote from Merriam-Webster:

1
: artistic quality of effect or workmanship
the artistry of his novel
2
: artistic ability
the artistry of the violinist
a lawyer’s artistry in persuading juries

I think most people recognize literature and music as art forms, but may not immediately think of a lawyer’s art of persuasion as real art. I insist that it is, and I also insist that a doctor taking a medical history, arriving at an accurate diagnosis, formulating an individualized treatment plan, explaining complicated healthy and pathological processes and motivating patients to change their habits or behaviors for better outcomes absolutely requires artistry. And I absolutely disagree with the notion that those things can be protocolized to such a degree that individual practitioners’ way of doing them don’t make a very significant difference in the effectiveness of their effort.

Seriously, if we use the word artisan in the context of baking bread (and if I ever buy bread instead of baking my own, that’s what I want), when no loaf looks exactly like the others, that is recognizing the craft and the individualization of even the most basic things that leave room for personal effort and expression. To continue this analogy just one step further, medicine is not always cookie cutter, or at least it shouldn’t be!

https://www.merriam-webster.com/dictionary/logorrhea

Part of a series

It is ironic that the Shakespeare passage in Hamlet that contains the immortal six words “brevity is the soul of wit“, is quite a rambling piece of writing. But his statement, if not his framing of it, has struck a cord with many writers who came after him.

I have been impressed that the majority of the small number of specialist and hospital reports I get on my Maine patients from Mass General and other Boston ivory tower practices are so brief and to the point, while many local discharge summaries are both lengthy and stilted and also very difficult to find the essential information in. Some hospital systems put the Assessment and Plan right on top, but you have to go hunting for the Subjective and Objective. Those charts also belabor the malpractice defense functionality of rattling through which differential diagnoses seemed unlikely.

I’m far from convinced that AI generated clinical notes could even come close to the succinct reports I get from Boston. I have not yet tried using AI for my own notes, but read on, I have a different suggestion.

I hear horror stories about how chitchat about a fishing trip often ends up in the social history of a patient.

Transcription does not require anywhere near the muscle of full-fledged AI office note generating software. But I’m thinking that could be enough:

Imagine office notes that really only contain the important information, the medical corollary to Who, What, Where and How, and each office note had a supplemental file, namely a transcript of the entire conversation for anybody who needs to dig deeper.

The amount of time it takes to find the essential information in the average office note or discharge summary I read is outrageous. Things actually get missed because of all the fluff.

The Greeks had four virtues and the Bible has seven. I think I just started a series on which are the virtues in the practice of Medicine.

Stay tuned.

P.S. Here’s another piece about brevity, in terms of the now nearly extinct “brief office visit”:

Brief is Good

If I have a Medicare patient with a hemoglobin A1c greater than 9, my quality rating goes down. The target value is 7 for people under 80 and 8 for people older than that. But as long as my patient is under 9, I’m in good shape.

The magic number for inadeqate blood pressure control is 140/90 or greater. But 139/89 is a passing grade, even though studies have shown that for high risk patients with known heart disease, a target under 120/80 is desirable.

So what’s a busy doctor going to do? I’m afraid the answer in many situations is just aim for good enough, because that’s all we are being measured by.

I worry a little bit that our quality ratings might make us put so much effort into the outliers that we don’t have enough time or energy left to fine-tune the people who are off the mark but not in the range that hurts our scorecards.

Oftentimes the outliers, for example with diabetes, are people who don’t believe in the severity of their situation or people with social circumstances that prevent them from eating healthy, which is often a money problem relating to lack of financial resources to buy healthy foods.

So where do we put our effort? Bringing the few outliers into a desired range or bringing a large number of “good enough” control patients to more ideal levels? Our incentives are aimed at going after the outliers, but maybe we will do more good if we focus more on the relatively large number of patients who are just a little bit below those panic values.

For an individual doctor with a unique patient population, maybe we need to decide where to cut losses for the outliers so that we don’t neglect a larger cohort of patients who might need more focus and attention from us. Because, really, this is about our patient population’s health and well-being, more than our own scorecards.

There was a time when doctors focused on each patient in front of them without considering how that attention would affect other people with bigger problems, or those who didn’t have a doctor to turn to. Now, we have obligations to others, like the insurance companies, which can create tension in our own decision-making about where to put our effort.