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Category: Physicians

Morning Distort

By MARTIN A. SAMUELS

A 35-year-old woman complains of weakness of the right side of her face and pain behind the right ear.  She lives in an urban environment and denies any recent illnesses.  She is not vaccinated against COVID-19 but is COVID negative. 

What do you think, I was asked at our Morning Report?  Well, I said, it sounds like a straightforward Bell palsy.  The pain around the ear suggests swelling of the VIIth cranial nerve in the facial canal and the stylomastoid foramen, a very common historical point, I opined; so much so that its absence would make me doubt the diagnosis and make me consider other causes of facial palsy such as sarcoidosis or Borreliosis, though the urban environment argues against that tick born disease.  Then we went around the room, expanding the differential diagnosis (as this exercise is often called) to include tumors of the parotid gland, leptomeningeal metastases and many more.  At one minute before the end of the thirty- minute conference, a photo of the patient was shown.  There was only one problem.  There was no facial weakness, but rather she had a definite Horner syndrome on the right with a smaller pupil and subtle ptosis due to weakness of the Muller muscle, a small circular sympathetically innervated muscle that acts as a minor controller of the palpebral fissure.  The patient’s pupils were not tested in bright and then dim light, nor was sweating tested because why would one do those things in someone with facial weakness and pain around the ear.  In fact, this patient had nothing like a Bell palsy but rather Raeder syndrome, a painful oculosympathetic (Horner) syndrome, which implicates a disease of the carotid artery.  Once this was discovered it was learned that the patient had hyperextensibility of the joints and hadn’t suffered any neck trauma.  Now a spontaneous dissection of the right carotid artery becomes the focus of thought with a very different implication for therapy and prognosis.

This experience vividly emphasizes two traps in the diagnostic process:  thinking fast and framing.  As Daniel Kahneman and the late Amos Tversky have articulated and summarized in their book, Thinking Fast and Slow, there are two subsystems within the nervous system that they dubbed system one and system two.  System one is a very rapidly acting, involuntary system which estimates the likelihood of a given circumstance and reacts to it.  System two is a voluntary, tedious, slow system that weighs evidence, considers the frequency of a likelihood in the environment according to The Reverend Bayes’s prior probability.   In neurology, system one is the autonomic nervous system (or the reptilian brain as it was called by the late Paul MacLean in his triune brain).  System two is the cerebral cortex with its complex networks that facilitate various aspects of awareness, an aspect of consciousness.   Neither system is good nor bad, as both have their place.  The first presumably survived the rigors of evolution because it allowed our ancestors to react to potential threats rapidly (i.e. a movement in peripheral vision is not analyzed; it is rather escaped as if it were a snake, even though Bayesian reasoning would predict that it was probably a stick).  System two allows for more accurate conclusions in less time sensitive circumstances.  What happened to me in the conference was that my system one rapidly generated a theory, but this was based on incorrect data (it was a snake; not a stick).  If a mistake is made early in the diagnostic process, the processes thereafter are all distorted and there is virtually no way to reach the correct answer.  Recall Conrad Waddington’s epigenetic landscape, wherein he used a metaphor (marbles rolling down a hill) to describe how mistakes early in a developmental process have enormous effects on the ultimate outcome, whereas errors later in the process are less destructive.   In addition to my system one error, I was also taken in by the framing shortcut (heuristic).  The person who presented the case had a theory of his own, which was promulgated in the headline:  a woman with a painful facial palsy.  In fact, it was a woman with a painful Horner syndrome.  The moral of the story is that I should have looked at the photograph first.  That would have avoided the futile task of elaborating an expanded differential diagnosis which, after all, is a nothing but a list of wrong answers followed by the right answer. 

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“This Doesn’t Usually Hurt that Much”: Patients With Fibromyalgia Spectrum Disorder

By HANS DUVEFELT

Specialists in orthopedics and general surgery often want us, the primary care doctors, to manage postoperative pain. I don’t like that.

First, I don’t know as much as the surgeons about the typical, expected recovery from their procedures. My own appendectomy in Sweden in 1972 was an open one that I stayed in the hospital for several days for (and nobody mentioned that there were such things as pain medications). I’m sure a laparoscopic one leaves you in less pain, but I don’t personally know by how much.

Postoperative pain could be an indicator of complications. Why would a surgeon not want to be the one to know that their patient is in more pain than they were expecting?

Pain that lingers beyond the postoperative or post-injury period is more up to us to manage. I accept my role in managing that, once I know that there is no complication.

I have many patients who hurt more that most people every time they have an injury, a minor procedure or a symptom like leg swelling, arthritis flare or toothache. The common view is that those people are drug seekers, taking every chance to ask for opiates.

I believe that is sometimes the case, but it isn’t that simple. I believe that people have different experiences with pain. We all know about fibromyalgia patients or those with opioid induced hyperalgesia, but pain is not a binary phenomenon. Like blood glucose, from hypoglycemia, through normoglycemia to prediabetes and all the degrees of diabetic control, pain experience falls on a scale from less than others to more than others.

I reject the notion that pain is a vital sign. When I was Medical Director in Bucksport I discouraged the use of numeric pain ratings. But I did encourage talking about the experience of pain as a subjective, nuanced and very valid consideration. We started a comprehensive pain education module for all our chronic pain patients.

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The Call to Be a Primary Care Doctor

By HANS DUVEFELT

I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time.

Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, and there is more and more of a mismatch between what we were envisioning and trained for and what we are now being asked to do. Our specialty is often the first to see a patient and also the last stop when no other specialty wants to deal with them.

We have also been required to do more public health, more clerical work, more protocol-driven pseudo-care and pseudo-documentation like the current forms of depression screening and followup documentation. And don’t get me started on the Medicare Annual Wellness Visit. How can we follow the rigid protocol and be culturally and ethnically sensitive at the same time?

We are less and less valued for our ability – by virtue of our education and experience – to take general principles and apply them to individual people or cases that aren’t quite like the research populations behind the data and the guidelines. The cultural climate in healthcare today is that conformity equals quality and thinking out of the box is not appreciated. The heavy-handed mandates imposed on our history taking and screening constantly risk eroding our patients’ trust in us as their confidants and advocates. The finesse and sensitivity of the wise old fashioned family doctor is gradually being squeezed out of existence.

The call to primary care medicine, if it isn’t going to pave the road straight to professional burnout, today needs to be a bit like the call to be a missionary doctor somewhere far away:

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The Call to Be a Primary Care Doctor

By HANS DUVEFELT

I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time.

Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, and there is more and more of a mismatch between what we were envisioning and trained for and what we are now being asked to do. Our specialty is often the first to see a patient and also the last stop when no other specialty wants to deal with them.

We have also been required to do more public health, more clerical work, more protocol-driven pseudo-care and pseudo-documentation like the current forms of depression screening and followup documentation. And don’t get me started on the Medicare Annual Wellness Visit. How can we follow the rigid protocol and be culturally and ethnically sensitive at the same time?

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Can the Practice of Primary Care Medicine ever be Practical Again?

By HANS DUVEFELT

When I first lost power and then saw my generator fail during a storm last winter, two other failures struck. As I scrambled to fill my water containers for the horses, the failing generator delivered just enough electricity for dim lights and a slow trickle of water. And then, when the power came back on, I had no water and the furnace didn’t work.

I trudged through the snow to the pump house up in the woods and found the water pump clicking as if it tried to start, but couldn’t. I ended up a day or two later with a whole new water pump.

The furnace had power, but I saw a red light with what looked like a stick figure repair man. Other furnaces I’ve had all had a reset/start button. Not this technical wonder that I never had to mess with before.

The repair man showed me that the stick figure light was, in fact, a recessed reset button. He pushed it and the furnace started instantly. But he didn’t leave. He said he was going to make sure there were no other problems. That took half an hour and I later got a $250 bill for the emergency repair call.

I felt stupid for not having pushed the red light on my own and I don’t mind paying $250 for my stupidity. But did he really have to spend half an hour making sure that a furnace that fired and delivered heat REALLY was working?

This long story makes me think of how we practice medicine these days. Nothing is quick and easy. Everything has to be comprehensive. But some problems are really simple enough that we shouldn’t have to belabor them like my furnace repair man. His job was, or should have been, easier than the plumber’s.

Primary care, with our ongoing patient relationships, is in theory ideally suited for quickly taking care of minor problems. After all, we already have background information on our patients and shouldn’t have to start from scratch.

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The Art and Soul of Medicine Exist in the Ordinary

By HANS DUVEFELT

The Art of Medicine is Doing the Ordinary Well

Primary care doctors don’t usually operate any sophisticated medical instruments or perform any advanced procedures. But there is still art in what we do. We take care of ordinary ailments in ordinary people and that can be done well or not so well. There is no obvious glamor in it, but when our prescriptions, basic procedures or simple advice help people feel better, we live up to our own and our patients’ hopes and expectations – and some of the time, we even exceed them.

Art is art, regardless of the medium or subject. Weren’t the old Dutch masters’ most appreciated paintings depictions of ordinary people in ordinary circumstances? Not every artist gets to paint the Sistine Chapel.

So many things in our culture are at the two extremes of poorly done and exquisite: fast fashion or haute couture, drive-up burgers or five star restaurants. Fewer things are made with care by craftspeople for individual users. Medicine needs to be more like that in order to bring real healing in many conditions.

In our everyday encounters with our patients, we are often distracted by things other than what they expect or hope to get from us. We have agendas imposed on us for preventive care and public health purposes. It is sometimes hard to do your best if you can’t concentrate on the issue at hand. Art requires focus. It is not a casual endeavor. It requires attention to detail, just as much as a vision of the big idea. It is – or should be – for each of us, in order to do our best, to find the balance between those two aspects of our work.

The Soul of Medicine is Connecting as Humans

We are not technicians. We treat the whole person, because most things in primary care are diseases that affect more than just one organ. We now also, again (historically), accept that diseases of the body may have their root causes in what we call the soul. In order to know and treat another person, we must show our own. Only if we do that will we learn enough to be of any real help to the patient who hopes to trust us enough to take our advice. We must create connection.

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The Science of Clinical Intuition

By HANS DUVEFELT

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

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Why I Seldom Recommend Vitamins or Supplements

By HANS DUVEFELT

People here in northern Maine, as in my native Sweden, don’t get a whole lot of natural sunlight a good part of the year. As a kid, I had to swallow a daily spoonful of cod liver oil to get the extra vitamin D my mother and many others believed we all needed. Some years later, that fell out of fashion as it turned out that too much vitamin A, also found in that particular dubious marine delicacy, could be harmful.

This is how it goes in medicine: Things that sound like a good idea often turn out to be not so good, or even downright bad for you.

Other vitamins, like B12, can also cause harm: Excess vitamin B12 can cause nerve damage, just as deficiency can.

Both B12 and D can be measured with simple blood tests, but the insurance industry doesn’t pay for screening. That is because it hasn’t been proven that testing asymptomatic people brings any benefit. In the case of B12, it is well established that deficiency can cause anemia and neuropathy, for example. But here is no clear evidence what the consequences are of vitamin D “deficiency”. A statistically abnormal result is not yet known to definitely cause a disease or clinical risk, in spite of all the research so far, but we’re staying tuned.

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Doctor-Patient Relationships: I Don’t Babysit – I Want to Empower

By HANS DUVEFELT

I have known doctors that cultivated a dependence among their patients by suggesting their health and safety depended on regularly scheduled visits and laboratory testing for what seemed to me stable, chronic conditions. People would come in every three months, year after year, to review cholesterol numbers, potassium levels and glucose or blood pressure logs and have a more or less complete physical exam every time. Patients would also get scheduled for rechecks of ear infections and other simple conditions I always thought patients can assess themselves.

Compare the effort on the part of the physician with that type of practice versus seeing stable patients less often, doing more urgent care, and being more available for new patients. The first approach seems comfortable, possibly complacent, and the second more demanding, but also more satisfying, at least to me. My goal is always to make my patients as independent and self sufficient as they can be. I don’t want them to be dependent on me in an unhealthy way.

It is a matter of temperament, but it is also a matter of stewardship and resource management if we see ourselves as serving the populations and communities around us.

Maybe it is because of my Swedish upbringing and education, but I would feel guilty if sick patients or even relatively healthy people don’t even have access to a personal physician if I were to spend my days over-monitoring stable conditions.

In this medically underserved state, don’t we have a responsibility to consider whether we are getting too comfortable in our chronic care routines? Patients check their own blood pressures and glucose levels. They could get in touch if their numbers worsen. Do we really need to bring them in to make sure they don’t stray when there are people in our communities without access to care?

I sometimes actually use the phrase “I don’t babysit”. I don’t necessarily use the word “empower”, but that is what I always try to do with my patients.

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Did Covid and Telemedicine Finally Make the Physical Exam Obsolete?

By HANS DUVEFELT

Left to my own devices, I would be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for boilerplate normal exams. Any doctor who uses the term PERRLA (pupils equal, round, reactive to light and accommodation) is probably faking it. First, most of the time this isn’t actually tested completely and, second, even if it’s done correctly, it has no relevance in the majority of chart notes I have found it in. I have actually seen it in office note templates for urinary tract infections!

It is well known that the history makes the diagnosis in the vast majority of cases. But that task – or art, actually – is sometimes relegated to support staff or forced into unnatural click boxes. Because reimbursement until very recently was tied to how many items were asked about and examined, there was a loss of the story, or narrative, of the patient’s illness. And you could get more brownie points by including things that were extremely peripheral to the clinical problem at hand.

EMRs make it easy to produce long office notes with lots of reimbursement and quality scoring points of uncertain clinical value and accuracy.

Specifically, the physical exam has in many instances become a corrupted, fraudulent, one-click travesty of the art and professionalism we swore an oath to hold high when we graduated from medical school.

The pandemic and the rush toward telemedicine made it clear to most people that medical diagnosis, advice and treatment is entirely possible without physical contact. It was just a matter of getting paid for it, or the healthcare industry would have come to a stop, or at least a crawl.

Now that we have admitted that listening, talking and a certain amount of looking or observing can be done without being in the same room, it is time for us to be honest about the value of the physical exam.

Our medical education in universities and tertiary medical centers taught us how to handle complex and baffling cases that had eluded diagnosis in the primary care setting: Start from scratch, assume nothing. This is a method we need to use in select clinical situations.

But in everyday practice that is inefficient and unnecessary. Most of what we see is simple stuff and part of our job is to triage, to know when something seemingly ordinary is or has the potential to be more serious.

We need to know how to do a really good and relevant physical exam when the situation requires it. But we also need to know when that would add nothing and only waste our time and effort.

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