A “frozen shoulder” can be manipulated to move freely again under general anesthesia. The medications we use to put patients to sleep for such procedures work on the brain and don’t concentrate in the shoulder joints at all.
An ingrown toenail can be removed or an arthritic knee can be replaced by injecting a local anesthetic – at the base of the toe or into the spine – interrupting the connection between the body and the brain.
An arthritic knuckle can stop hurting and move more freely after a steroid injection that dramatically reduces inflammation, giving lasting relief long after any local anesthetic used for the injection has worn off.
The experience of pain involves a stimulus, nerve signaling and conscious interpretation.
Our brains not only register the neurological messages from our sore knees, shoulders, snake bites or whatever ails us. We also interpret the context or significance of these pain signals. Giving birth to a long awaited first baby has a very different emotional significance from passing a kidney stone, for example.
Even when we are awake, we can reduce orthopedic pains with medications that work on the brain and not really in our joints. A common type of arthritis, such as that of the knees, is often treated with acetaminophen (paracetamol), nonsteroidal anti-inflammatory drugs (NSAIDS) like ibuprofen or even opioids.
I did it with a drug that has been on the market since 1969 and is taken once a day at a cost of 40 cents per capsule at Walmart pharmacies.
Hives are usually treated with antihistamines like diphenhydramine (Benadryl). My super drug has a 24 hour duration of effect and is about 800 times more potent than diphenhydramine, which has to be taken every fours hours around the clock.
Histamine is involved in allergic reactions, but it also plays a role in stomach acid production. The allergic response happens mostly through stimulation of Histamine 1 receptors and the stomach acid output is regulated mostly via Histamine 2 receptors. Typical antihistamines are blockers of the H1 receptor, or binding site; they don’t do anything except sit there and prevent the real histamine from attaching and starting the allergic chain reaction. While diphenhydramine sits there for 4 hours, loratadine and the other modern, nonsedating (and less itch-decreasing) antihistamines work for 24 hours. Because there is some overlap between H1 and H2 blocking effects, H2 blockers like famotidine can boost the antiallergy effect of the typical H1 blockers. My mastocytosis patient still had hives on diphenhydramine, loratadine and famotidine combined.
The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.
In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:
3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)
3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.
3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.
3/8 Phone call: Now has yeast infection, prescribed fluconazole.
Each of these notes took virtually no time to create and you could see them all in one glance.
The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.”
Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their dosage limits are. And if it isn’t a covered drug, the covered alternatives are usually not listed.
So the insurance company is hoping for one of a few possible reactions to their fax: The patient gives up, the doctor tries but fails in getting approval, or the doctor doesn’t even try. In either case, the insurance company doesn’t pay for the drug, keeps their premium and pays their CEO a bigger bonus.
First problem: This may be in regards to a medication that costs less than a medium sized pizza. And the pharmacy generally doesn’t even bother telling the patient what the cash price is.
Second problem: A primary care physician’s time is worth $7 per minute (we need to generate $300-400/hour). We could spend half an hour or all day on a prior authorization and there is absolutely zero reimbursement for it.
The hackneyed windows phrase, about what a domestic employee will and will not do for an employer, represents a concept that applies to the life of a doctor, too.
Personally, I have to do Windows, the default computer system of corporate America, even though I despise it. But in my personal life I use iOS on my iPad and iPhone and very rarely use even my slick looking MacBook Pro. I use “tech” and machines as little as possible and I prefer that they work invisibly and intuitively.
In medicine, even in what used to be called “general practice”, you can’t very reasonably do everything for everybody. Setting those limits requires introspection, honesty and diplomacy.
In my case, I have always stayed away from dealing with machine treatments of disease. But I do much more than just prescribe medication. Since the beginning of my career, and more and more the longer I practice, I teach and counsel more than I prescribe.
I have decided not to be involved with treatment of sleep apnea, for example. It may sound crass, but I don’t find this condition very interesting: The prospect of reviewing downloads and manipulating machine settings is too far removed from my idea of country medicine.
Worse than CPAP machines are noninvasive respiratory assist devises. I won’t go near those.
The woman had a bleeding ulcer and required a blood transfusion. The hospital discharge summary said to see me in three days for a repeat CBC. But she had a late Friday appointment and there was no way we would get a result before the end of the day. She also had developed diarrhea on her pantoprazole and had stopped the medication. As if that wasn’t enough, her right lower leg was swollen and painful. She had been bed bound for a couple of days in the hospital and sedentary at home after discharge.
She could still be bleeding and she could have a blood clot. There were no openings for an ultrasound until almost a week later. Normally, with the modern blood thinners, we can just start anticoagulation until the diagnosis of a blood clot can be confirmed or disproven. But you don’t do that when somebody has a bleeding ulcer.
The radiology department solved my dilemma by pointing out that the emergency room can order an ultrasound and the department will call in an on-call technician. So that is where my patient had to go. Her blood count was stable and the ultrasound was negative. So now we just have to hope that lansoprazole, which she had taken in the past, but stopped because she didn’t have heartburn, would be effective.
Walter Brown’s blood sugars were out of control. Ellen Meek had put on 15 lbs. Diane Meserve’s blood pressure was suddenly 30 points higher than ever before.
In Walter’s case, he turned out to have an acute thyroiditis that caused many other symptoms that came to light during our standard Review of Systems.
Ellen, it turned out, was pretty sure her husband was having an affair with one of his coworkers. And, since this wasn’t the first time, she was secretly working on a plan to move out and file for divorce. She admitted she’d always had a tendency to stress eat.
Diane’s daughter had just announced that she was pregnant by a man she wasn’t sure wanted to be around in the long run.
How do we know whether a patient’s subjective symptoms, laboratory values or even their vital signs are caused by their known medical conditions, a new disease or their state of mind?
We are often tempted to proceed down familiar tracks and tackle seemingly straightforward problems with medications: More insulin would take care of Walter’s blood sugar. Ellen could use a couple of months of phentermine. Diane needed a higher dose of lisinopril or perhaps some hydrochlorothiazide.
As Sherlock Holmes said, “there is nothing more deceptive than an obvious fact”.
“I worry, so you don’t have to”, is how I explain to patients when something about their story or physical exam makes me consider that they may have something serious going on.
The worst thing you can do is give false reassurance without serious consideration. And the next worst thing you can do is be an alarmist and needlessly frighten your patient. Finding and explaining the balance between those two extremes is a big part of the art of medicine.
A few times in my career I have struggled with doubt or worry after a patient visit. Did I miss anything, did I order the right test? We all have those moments, but we have personal limits as to how much of such doubt we can handle in the long run.
During my training and early career in Sweden there was more tolerance for physician fallability. Doctors have not been sitting on any pedestals for a couple of generations there. Here, the climate is different: We may not be revered like we were in the past, but if we make errors in judgement, the personal consequences for us can be devastating.
The way to navigate this treacherous territory is first of all to not travel alone. Everything we do is for our patient, so we must maintain a partnership. We are the experts, but we should not make decisions that aren’t shared. I keep coming back to the notion that today’s doctors are guides.
Kelsey Mellard is CEO of Sitka, one of the emerging companies that’s providing specialty consults online to primary care docs. They’ve been building a specialty care network that can be accessed by asynchronous video, slightly different to some of their competition. Most of their customers are capitated medical groups, like ChenMed, trying to reduce their spend on specialty physician care (as Kelsey calls it the “unmanaged Part B spend bucket”). I asked her how it works, where the company is going (think virtual care integration), and whether it will be needed in the future. (You can guess her answer to the latter!)
A recent email that arrived in my in-box a few weeks ago from an academic hailed the latest “paradigm shift” in cardiology as it relates to the management of stable angina. (Stable angina refers to chronic,non-accelerating chest pain with a moderate level of exertion). The points made in the email were as follows (the order of the points made are preserved):
The financial burden of stress testing was significant (11 billion dollars per annum in the USA!)
For stable CAD, medical treatment is critical. We now have better medical treatments than all prior trials including ischemia. these include PCKS9 Inhibitor, SGLT2-i, GLP1 agonists Vascepa and others
CTA coronaries is by far the most important single test for evaluation of these patients
” the paradigm of ischemia testing may have come to an end”
For stable angina (not ACS!) in most cases, the decision on revascularization should be based only on symptoms alleviation (as no survival benefit).
The general public should find it interesting, and not a random coincidence that the first point immediately gets to the financial burden of stress testing in a communication that is supposed to assess the level of evidence for the management of coronary artery disease. Imagine a cardiologist enters your exam room to talk about the chest pain you get every time you run up a flight of steps, and starts off the conversation with how much the societal cost of stress tests are. The cost of care is certainly a relevant concern, especially if it’s to be borne directly by the patient, but it would seem that the decision of whether a therapy is effective or not should be divorced from how much some bean counter decides to price the therapy to generate a certain return on investment. As such, the discussion that follows will omit any consideration of cost when evaluating the new ‘paradigm shift’ in management of coronary disease that is apparently upon us.
This particular debate boils down to the relevance of diagnostic testing for coronary artery disease. The traditional approach to testing is a functional test that utilizes the uptake of radioactive isotope injected into a patient during stress and rest conditions to identify mismatches in blood flow in the two states to identify myocardial ischemia. The amount of ischemia can be quantified as percent of total myocardium, and has been well correlated with prognosis. Having lots of ischemia typically means a much shorter lifeline than having little or no ischemia. The accepted paradigm in Cardiology has been to use traditional stress testing to triage patients to ‘conservative’ medical therapy or an invasive approach to bypass or open arteries via stents or coronary bypass surgery.