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Category: Medical Practice

“Tell Me More”

By HANS DUVEFELT

Words can be misleading. Medical terms work really well when shared between clinicians. But we can’t assume our patients speak the same language we do. If we “run with” whatever key words we pick up from our patient’s chief complaint, we can easily get lost chasing the wrong target.

Where I work, along the Canadian border, “Valley French” expressions tripped me up when I first arrived. The flu, or in French le flu (if that is how you spell it – I’ve never seen it in writing) is the word people use for diarrhea. Mal au cœur (heart pain) doesn’t mean angina or chest pain, but heartburn, a confusing expression in English, too.

But even if we are all English speaking, clinicians need to be careful not to assume common words mean the same to everyone.

I have seen many patients complain of anxiety, but not actually be worried about anything. A number of bipolar people have used the word anxiety when, in my personal vernacular, they are really describing pathological restlessness. I once had a patient complain of “nerves” but not have a worry in the world except for his hereditary essential tremor, which he assumed was a sign of untreated anxiety.

People often resist my labeling their symptom as chest pain, insisting that I am wrong about the location and the character of their discomfort. Instead, they might insist it is indigestion or prefer pressure, tightness or heaviness in their throat, epigastrium or even between their shoulder blades. “Chest pain is shorthand for all that”, I tell them.

I hear people use the word dizzy for a gnawing feeling in their epigastrium, and nauseous for a sense of early satiety after eating.

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Five Weight Loss Myths I am Constantly Fighting

By HANS DUVEFELT

1) EXERCISE MORE

I talk to people almost every day who think they can lose weight by exercising. I tell them that is impossible. I explain that it takes almost an hour of brisk walking to burn 100 calories, which equals one apple or a ten second binge on junk food. To lose a pound a week, you need to reduce your calorie intake by about 500 per day – that would be the equivalent of five hours of moderate exercise every day. We’d have to quit our jobs to do that.

2) EAT MORE FRUITS AND VEGETABLES

The other fallacy I hear all the time is that, somehow, adding “healthy” fruits and vegetables can make a person lose weight. I tell them that adding anything to their daily calorie intake will have the opposite effect. I more or less patiently explain that our job is to figure out what to take away instead of what to add. Maybe substituting a fruit for a Whoopie pie is healthy in other ways, but it has almost nothing to do with weight loss.

3) EAT BREAKFAST

A third fallacy is that eating a healthy breakfast will ensure weight loss. To explore this one, I ask: “Are you often hungry?”

So many of my overweight patients deny ever feeling hungry – that gnawing feeling in the pit of your stomach and the low blood sugar onfusion and weakness I feel by 9 or 10 am after doing barn chores on an empty stomach (only coffee).

When I hear “I never feel hungry”, I don’t recommend starting a good breakfast habit because that would likely increase a person’s daily calorie intake. But when I hear that a breakfast skipper goes for the doughnuts mid morning due to hunger, I certainly recommend eating breakfast. When I do, I always point out that the typical American cereal and banana breakfast, along with soft drinks, is actually the major reason for our obesity and diabetes epidemics.

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Screening for Depression: Then What?

By HANS DUVEFELT

Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy.

“Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of medical students. Even the US Public Health Service Taskforce on Prevention admits that depression screening needs to take into consideration whether there are available resources for treatment. They, in their recommendation, refer to local availability. I am thinking we need to consider the availability in general of safe and effective treatments.

If the only resource when a patient screens positive for depression is some Prozac (fluoxetine) at the local drugstore, it may not be such a good idea to go probing.

The common screening test most clinics use, PHQ-9, asks blunt questions about our emotional state for the past two weeks. This, in my opinion, fits right into the new American mass hysteria of sound bites, TikTok, Tweets, Facebook Stories, instant messages, same-day Amazon deliveries and our worsening pathological need for stimulation and instant gratification.

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Some People Don’t Think Like Doctors (!)

By HANS DUVEFELT

This may come as a surprise for people with business degrees:

Doctors don’t really care when a test was ordered. We care about our patient’s chest X-ray or potassium level the very moment the test was performed. We also don’t care (unless we are doing a forensic review of treatment delays) when an outside piece of information was scanned into the chart. We want to know on which day the potassium was low: Before or after we started the potassium replacement, for example.

In a patient’s medical record, we have a fundamental need to know in what order things happened. We don’t prefer to see all office visits in one file, all prescriptions in another and all phone calls in a third. But that seems to be how people with a bookkeeping mindset prefer to view the world. In some instances we might need that type of information, but under normal clinical circumstances the order in which things happened is the way our brains approach diagnostic dilemmas.

Yes, I have said all this before, but it deserves to be said again. Besides, only 125 people read what I wrote about this six weeks ago, while almost 10,000 people read my post about doxepin.

Patients’ lives are at stake and, in order to do our job, we need the right information at the right time, in the order we need it, even if the bookkeepers prefer it a different way.

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Please Sign Below: Fraudsters Phishing for Physician Signatures

By HANS DUVEFELT

Almost every day I catch a suspicious fax needing my signature. Often it is an out of state vendor who wants my permission to provide a back brace for a diabetic patient, a continuous blood glucose monitor for a non-diabetic or a compounded (custom made) ointment of some sort that makes no sense from what I know of that patient’s history.

Often, I get a fax appearing to be from Walgreens, just asking me to sign and certify that so-and-so is under my care. Those faxes have Walgreen’s logo, my patient’s correct address and my own DEA and NPI numbers already printed. The problem is that 90% of my patients don’t use Walgreens 20 miles north or south of my clinic, but the local Rexall pharmacy. Once, I called the phone number on the fax and it just rang and rang.

I am convinced that his is just an illicit way to collect physician signatures, so the scammers won’t even have to get my signature on one form at a time. This way it’s like they’ve got their own rubber stamp to use again and again.

I suspect these scams are successful often enough to be quite profitable. I know this because I sometimes sign these forms almost automatically before I catch myself and toss them in the shred box under my desk.

One of the many dirty little secrets in medicine is that doctors get so many papers to sign that there is actually no way we could read them all before scribbling our signature if we still want to see patients, meet clinic revenue projections and match our own productivity quotas.

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The Parallel Realities of Health Care: Ratio and Intellectus

By HANS DUVEFELT

Every patient is unique, with some common basic and measurable features and parameters. For a couple of decades now, healthcare has professed to be patient centered. But the prevailing culture of “quality” (and the reality of getting paid for what you do) has us spending at least half our time documenting for outsiders, who are non-clinicians, the substance and value of our patient interactions. That means our patients get half of our attention and others get half.

But of course, if you really wanted to be patient centered, you’d have to ask what patients actually care about, like their blood pressure or their cholesterol, their anxiety or their sore knees. Their answers may not align with the payers’ priorities. And then what…

Parents raise their children and never have to file any reports on how they do it. I believe clergy can still counsel their parishioners without filing reports. But doctors, nurses, nurses aides and physical therapists are trapped in the tyrannical dichotomy of “If you didn’t document it, it didn’t happen”, which actually forces us to do less for our patients just so we will have time to document what we did do. We are, to varying degree, robotniks in a big, inhumane corporate and federal healthcare billing machine these days.

Perhaps the most striking example of the micromanaging and patient-uncentered mandates we are subjected to is the Medicare Annual Wellness Visit: Miss one thing, like offering HIV screening to 80 year old devout French speaking, monogamous Catholics in Van Buren, Maine and risk getting your payment retracted. But we are not mandated to ask about personal life goals or how to balance seniors’ independence with reliance on their children.

Which is more real? The work we do, face to face or even screen to screen, behind closed doors with our patients, or the EMR documentation we produce as a result of those encounters? I know many providers generate voluminous notes that don’t reflect in any way what happened in the visit. That is where the money is.

Right now I am reading a Swedish book by philosopher Jonna Bornemark, titled (my translation) RENAISSANCE OF THE UNMEASURABLE – battling the pedants’ world domination. Much of it is about how the professions of caring for others have been reduced to protocols and reporting systems that make it harder to do what we were trained and developed a passion for. It talks about how checklists and workflows devalue and discourage the powerful creativity that arises when professionals interact with their unique clients and with each other. She anchors all this in the writings of philosophers Cusanus, Bruno and Descartes. It talks about the unknowable, which is something pedants usually don’t want to think about.

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The Pain Is In Your Brain: Your Knees Know Next to Nothing

By HANS DUVEFELT

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.

I have written before about how we introduce the topic of pain to our chronic pain patients in Bucksport. Professor Lorimer Moseley speaks entertainingly of he role of interpretation in acute pain and also explains the biochemical mechanisms behind chronic pain.

TREATING PAIN WITH ANALGESICS

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.

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Doxepin, a Little Known Super Drug in My Personal Black Bag of Tricks

By HANS DUVEFELT

A while back I was able to completely stop my mastocytosis patient’s chronic hives, which the allergist had been unable to control.

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.

But, wait, there’s more…

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The Art of the Chart: Documenting the Timeline

By HANS DUVEFELT

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.

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Playing Poker With the Devil: “Prior Authorizations” are Paralyzing Patients and Burning out Providers

By HANS DUVEFELT

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.

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