A Country Doctor Writes:

Diagnosis is the neglected stepchild in today’s healthcare system. The big money, or low hanging fruit from a financial viewpoint, is found in chronic disease management and perhaps (but not definitively) in cancer screening. But in the stories of people’s lives, errors in diagnosis seem more tragic, because those situations involve a patient who is actively seeking medical help. If people choose not to have their pneumonia shot or lung cancer screening, they presumably weighed the pros and cons of those interventions and were willing to take the consequences of their decisions.

In my Swedish medical training, we were told that no doctor can be right 100% of the time and we needed to understand that. There is no comparison between the Swedish no-fault compensation for patients who have been hurt or misdiagnosed and the American malpractice quagmire. If a Swedish doctor makes an error in judgment there may be disciplinary action, but no financial penalty. To a greater degree than in the United States, doing what a reasonable clinician would do in the same situation will usually protect you from disciplinary action.

Does this difference make Swedish doctors miss more diagnoses than American doctors? I don’t think so, but I don’t know if there are studies about that.

The AI answer to my Google search “margin of error in medical diagnosis” looks like this:

A 10-30% error rate seems like a frightening number to me. But I do worry that chronic disease management is such a strong focus in today’s healthcare that diagnostic skills have become a bit marginalized. And this is not just a matter of shorter and sloppier physical exams today, but also an issue with less time and less practice in taking medical histories. This is in part due to the mandated screening questions we have to ask about everything from domestic abuse to depression – all worthwhile, but when a patient has a new symptom or a new concern, maybe we need more flexibility in how many minutes we should spend on what they actually came to see us for.

As a family physician going through residency in the 1980s, I was trained to deliver babies and had the option to qualify for doing Caesarean deliveries, colonoscopies and many other procedures. I also took care of people in the hospital, including the intensive care unit. I don’t do any of those things now, just like many of today’s family docs. Instead, there is growing specialization within family medicine, such as added certification in geriatrics or sports medicine.

Maybe we should consider “Diagnostician” as a carve-out, especially if we work in medical groups with new medical graduates, Physician Assistants and Nurse Practitioners. In some cases, with more experience under our belt, we may make a diagnosis quicker than our colleagues with less training and experience and in some cases, having diagnostic days when we are excused from health maintenance and chronic disease management, we could dig deeper for the correct diagnosis in difficult cases?

My first in-person interview with Galileo was right here in Presque Isle with Dr. Ajay Haryani. He was one of three New York doctors who worked in my territory before i started here. He has now started his own practice and he is writing on LinkedIn about doctoring. His latest post is about the “Worried Well”. It starts like this:

The “Worried Well” is a derogatory label we give to patients who have health concerns but no obvious pathology on our tests. It treats these patients with very little grace, branding them as difficult.

But this misses the mark.

It ignores prevention. These patients are doing exactly what we claim to want – being proactive about their health. When did that become a problem…

I know one very big reason why many doctors today use this term and dread appointments with patients who fit this derogatory definition: Today’s typical primary care provider has about 10 minutes of face-to-face time in each patient appointment, with more time than that required to document the visit, whether that gets done in the office or from home when their family has gone to bed (we call that working pajama time).

The productivity demands of typical primary care has created burnout and eroded clinical curiosity and compassion. But in a perfect world, and in a perfect large practice like Galileo or Direct or Concierge practices, we have more control over our time and the flexibility to really address our patient’s priorities. And if after looking into their concerns we can reassure them that they really are safe, isn’t that as valuable as if we make some kind of exotic or rare diagnosis? We are either diagnosing or reassuring a fellow human being. I think both those things are valuable and good use of our time, skill and experience.

My personal vision, expressed many times before and repeated here again, is that so much of what we do in primary care today, especially the majority of preventive care, could be done by nurses, even on the telephone. This way we could devote more time to our patients, whether they have serious problems they were unaware of or experience normal behaviors of the human body that worry them.

Both of these things are worthwhile…

Our electronic medical records prompt us to do what we do in our patient visits and also in many cases in what order to do those things. We could fairly easily change the order, but it may seem like extra work to do that.

But following the script we are given often seems rude. It can threaten our chance of building a therapeutic relationship and could even keep the patient from answering our rapid-fire initial questions truthfully.

So many initial office visit templates have the drug, sex, smoking and alcohol questions right in front, followed by probing of income, sexual orientation, pain, depression, domestic abuse and many more intimate questions that would be classified as appaling if you were at a dinner party with a new coworker or a first date with someone.

Our medical records serve many purposes, and the most important part of the record, particularly an initial visit, in my opinion, is the patient’s story. The best way to build a relationship with someone you just met is to ask them to tell you about themselves and then to ask follow-up questions to prove your interest.

Once you have taken the medical history and done an appropriate exam for their concerns, it is more natural to say something like “there are some background information we always gather when we see someone for the first time, so I hope you don’t mind if we take care of that also today”.

I think of that data as somewhat like the metadata that’s attached to your iPhone photographs or “Gracenotes” on a music CD. It’s information that can be retrieved if it is needed, but it doesn’t drown out the patient’s story and your clinical assessment and plan.

Of course there are times when some of those screening questions lead you to explanations for the patient’s symptoms or are abnormal enough to warrant a place on their problem list and in that case that part of the screening protocol should get included in the main part of the visit note.

For example, if someone has numb, tingling feet and admits to heavy alcohol use when you get around to asking about that later in the visit, it can open the door to a conversation about alcoholic or even diabetic neuropathy.

Our profession has practiced the art of asking the right questions in the right way and at the right time for centuries. We shouldn’t let non-medical programmers take our finely tuned skills and tools away from us. We need to work around their machines sometimes.

Am I the only one who thinks new drugs have worse and worse names as time goes on? I mean Zepbound, Wegovy, Mounjaro? Those names make me think of words and phrases like hell bound, we go why and mañana (Spanish for tomorrow). And isn’t there a Nissan car model called Murano?

There are some odd rules for naming drugs in this country. For example, they can not hint at what the drug does, which would seem the most logical criterion for naming a drug. One older drug that was named after what it does is Antabuse or Alcoban (disulfiram) in the US and UK, respectively. That is a medicine that makes you sick if you drink alcohol. Think anti-abuse and alcohol-banned. Another logical older drug name was Glucophage (metformin), which sounds like Latin for “someone who eats sugar”. In the over-the-counter market we have Gas-X and I’m not sure if that was grandfathered in or someone at the FDA had a senior moment. 

Think how much easier it would be for people to keep track of their medicines if we had names that hint at what they do, instead of just looking and sounding abstract. I mean Peemore would be an ideal name for a diuretic, Hackless a good one for a cough medicine, Quitcig for a smoking cessation drug, Remember for a dementia drug and Chill for a tranquilizer. I could go on, but you get my drift. 

Some drugs have had to change names because of late realizations of their risk of confusion with other pharmaceuticals. Omeprazole, developed in Sweden, was named Losec. It still has that name in many countries, but in the US, presumably because vowels are pronounced less distinctly here, it was felt that the name could be confused with Lasix, the diuretic. So it was renamed Prilosec here.

The antidepressant Trintellix (vortioxetine) used to be called Brintellix. That name was scrapped because of concerns that it could be confused with Brilinta (ticagrelor), a blood thinner. 

One odd thing about drug names is that one generic can have two brand names when a drug has been approved to treat more than one condition. Wellbutrin (bupropion) was used as an antidepressant for many years before it was discovered that it could help people quit smoking. It was rebranded and sold as Zyban because the worry was that smokers would resist taking an antidepressant to quit smoking because of the unfortunate stigma of antidepressants.

Viagra was launched years after the first formulation of sildenafil, Revatio, was approved for treating pulmonary hypertension. After the last phase of testing Revatio, many male patients refused to give back the pills they had taken in the study. The researchers asked why, and started hearing stories of enhanced erections. They went back to the drawing board and did a formal study of this indication and the rest is pharmaceutical history.

The Internet is full of suggestions for funny drug names. One of the better ones I have seen is that Viagra should be called Peniscillin. But that wouldn’t fly because it would be too easily confused with the antibiotic…

(Pictures below…)

Just over a year ago I wrote about mixing telemedicine with in person visits. 15 months into my new practice, I see very plainly how making the initial visit and maybe a few more as in-person housecalls, I am able to establish a stronger connection and a deeper understanding of my patients and their circumstances than I did in my office based practice. 

Now, I am blessed to do more and more of my follow-up visits using the technology of video visits. And we are adding new technology to let both our doctors and our patients listen to heart sounds together in real time, for example.

In some cases I do my video visits alone with the patient in their home in front of their smartphone, tablet or laptop. In some cases I do them with my assistant in their home, setting up the technology on her laptop, doing the vital signals and, soon, using a tech enabled stethoscope and otoscope. We already have the ability to do EKGs that way, too. 

When things work very smoothly, I can do video visits by myself while my assistant travels between patients who can’t manage the technology on their own. My territory is more than 3 hours from north to south, so it takes some sophisticated scheduling to maximize our efficiency and most of the time we do that really well. 

I’m really looking forward to starting to use the virtual stethoscope. There are a couple of ways you can use it. One is having the assistant record the heart sounds and send them to me so I can listen to them more or less on my own and then tell patient about what I hear, but I prefer the modality where the recording happens in real time and both the patient and I hear the heart sounds. I can then say “did you hear that irregularity in the rhythm? That’s a type of extra beat and usually they are very harmless“ or “do you hear that swishing sound, that’s a sign that one of your valves isn’t opening correctly”. Doing that in real time, mimics the in-office auscultation of the heart and enhances it by having us listen at the same time. I never really pictured that a remote visit in some ways can be more informative for the patient than an in-person visit.

I’m indescribably happy with my mix of old fashioned housecalls and modern-tech telemedicine. The fact that the only desk I have is at home is amazing, actually plural – two desks – my kitchen island and the small, white fold-out desk in my library at the other end of the house. 

My two Alabai rescue dogs are super happy. The younger one, the daughter, had some anxiety when I was in my old job and gone all day. She chewed on one of my favorite pairs of penny loafers. That never happens anymore. I have a wonderful work-life balance.