Posts Tagged 'doctoring'

A Day Without a Diagnosis

Thursday I saw 29 patients, but I didn’t make a single diagnosis. I did three physicals and saw several patients with diabetes, hypertension and high cholesterol. A migraineur came in for a shot, and we double booked a few sick people who already knew their diagnosis and what treatment they needed.

One of my physicals was a Registered Nurse, about my age, who left clinical nursing a few years ago and now does research for a group of surgeons at the hospital up the road. Her research focuses on quality of care.

That got me thinking about the differences in health care between my early days in this profession and today. The spectrum of diseases we deal with has changed, and lately also the notion of what constitutes quality in health care.

Physicians today spend more time managing chronic diseases, some of which weren’t even thought of as diseases twenty-five years ago. A cholesterol level we feel obligated to treat today was considered normal back then; Type 2 Diabetes was something our grandmothers developed in their late seventies, not a multisystem disease we looked for in children and young adults; Attention Deficit Disorder wasn’t something primary care physicians concerned themselves with. And who would ever have thought that Fibromyalgia, a term coined in 1976, would be such a common disease, along with Restless Leg Syndrome (Ekbom, 1944), obesity and toenail fungus?

My conversation with my R.N. patient moved toward the issue of what really constitutes quality in medicine. I worry that some things are measured mostly because they are easy to measure: What percentage of heart attack victims is currently taking beta-blockers? What is the average Hemoglobin A1c among a physician’s diabetic patients (as opposed to how is this value trending over time)? I never hear statistics on how often we as doctors make the right or wrong diagnosis, or how difficult it was to move a particular patient from one set of numbers to another.

The practice of medicine has become more a matter of housekeeping, if not downright bookkeeping. The days of brilliant medical mavericks that could ferret out the correct diagnosis and quickly move on to the next heroic act are history; today’s focus is on long-term management according to evidence-based guidelines (“evidence-based”, now there’s another topic for a post…).

There is no point in lamenting the shift over time in what our patients need from us; I am merely reflecting on what has happened during my years in practice. If we as doctors want to see more bad, untreated and undiagnosed diseases, we need to move to more remote places – my underserved corner of Rural America isn’t the place for that anymore.

Managing chronic illnesses can be very meaningful and satisfying, but it isn’t quite what I imagined I would be doing to this extent. But it is one of the reasons we need to hone our skills as physicians; it is no longer enough to be a good diagnostician when almost every patient we see in a given day already has a diagnosis established. Our challenge is to help them manage that diagnosis. That means we need to practice motivational interviewing for our patients with lifestyle-inflicted diseases, serve as our patients’ medical home in a fragmented health care system and be a voice of reason in an era of information overload.

In a brief moment of worry about what I would do if I didn’t get accepted to medical school I had considered teaching, and I worked as a substitute teacher for one semester between my military service and medical school. I don’t think that was a waste of time at all.

Once in a while as a physician, you’ll make a diagnosis. Most of the time you help patients manage a disease they already know they have.

Doctor Fix-It

Today I visited Ginny Leach. She lives by herself in an old trailer not far from our house. She is an ageless more or less shut-in woman. 

A mild chaos erupted the moment I walked through Ginny’s front door. She was on the phone with her sister; I think they must call each other at least three times a day. Her only other contact seems to be the nuns from a nearby order; they help her out with chores and hand-me-downs. As I walked through the door, Ginny gestured to me, stretched the phone cord, and somehow her Slimline telephone fell to the floor and went dead on her. Ginny worried that her sister would assume something bad had happened.

Before I knew it, I was on my knees on the floor, examining the jack and the telephone. Everything looked all right, but the phone line was dead. Fortunately, she still had her old, black rotary phone handy. I carry a “SwissCard” with scissors and a Phillips screwdriver in my wallet, and soon had the wall jack opened and the old phone connected to the innards of the wall jack, so that Ginny could call her sister and report on what just happened.

I chuckled to myself as I remembered how during my previous house call I had fixed her doorknob. The old one had broken off, and the nuns had installed a new one, which didn’t close right. That time I had used my SwissCard to adjust the strike plate to make the door shut properly.

I take care of Ginny’s blood pressure and cholesterol, and somehow also ended up picking up her prescriptions at the drugstore for her. That’s fine with me, and I never minded that she never asked about the cost; her state insurance covers all but a few dollars co-pay. Gradually my shopping list has grown, so now I also seem to be her only source of aspirin, calcium tablets and Icy Hot patches. The issue of money just never seems to come up.

Ginny enjoys her home visits, but never wants them to drag on. We take care of her medical issues, chat for a few minutes, and she seems ready to return to her TV shows. Living alone in this rural part of the country isn’t easy, but Ginny makes the most of the resources at her disposal, me included!

Shadow Syndromes

A fellow country doctor and blogger wrote a piece the other day about drug companies pushing medications for near-diseases like prediabetes and heartburn. I agreed with his sentiments and went on to think a lot about this.  There is a tendency among drug companies and even some doctors (perhaps looking for business?) to medicalize the human experience. We all have heartburn sometimes, but is it a disease or pre-disease, or did we simply eat too much of the wrong kind of food?

I have said before in these pages that Thomas Moore, the scholar and philosopher about matters of the soul, has said that book titles on your shelf can be inspiring even if you haven’t read the book.

A couple of years ago, at a Harvard psychiatry or psychopharmacology course, the booksellers in the lobby had a book that caught my imagination and has been an inspiration to me from that moment, even though I didn’t start to read it until today. It is by John Ratley, MD (co-author of “Driven to Distraction”) and Catherine Johnson, PhD (author of “When to Say Goodbye To Your Therapist”). The title says it all: “Shadow Syndromes” (The Mild Forms of Major Mental Disorders That Sabotage Us).

People with near-diseases can benefit from comparisons with the full-blown thing only if the analogy provides them with a deeper understanding of their situation and a course of action to change their trajectory away from the disease they are heading towards. This applies to labels in general. Labels are good if they help you understand what’s going on, and bad if they lock you into some sort of fixed category where you either don’t believe you can get out or, perhaps worse, start to feel comfortable and liberated from your own responsibility for your life and health. 

Somehow in the last generation of doctors, we seem to have lost our ability, or perhaps our perceived right, to give patients advice about their health; only if we diagnose them with a disease, or pre-disease, do we have something to tell them. We need to re-claim our position as health coaches, and fight for our right to tell people who are not yet diagnosable with an illness how to stay away from disease, instead of trying to make almost or completely healthy people carry a disease label, just so we can talk to them about how to stay out of trouble in the future.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

2018 Top 25 Doctor Blogs Award

Doctor Blogs

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Mailbox

contact @ acountrydoctorwrites.com
Bookmark and Share
© A Country Doctor Writes, LLC 2008-2018. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.