A Country Doctor Writes:

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.

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…