By HANS DUVEFELT
I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.
This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)
I keep coming back in my thoughts and blogging about drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.
By HANS DUVEFELT
(Desperate times called for desperate measures.)
In the tech world, we have come to expect our devices to become outdated and obsolete very quickly. The biggest tech companies in the world didn’t even exist a few years ago. Bitcoin, a virtual currency which at least I can’t wrap my head around, seems to be more attractive than gold.
I get the sense most people embrace or at least accept the speed of change in tech.
But medical advances that occur rapidly are frightening to many people. Vaccine hesitancy, for example, involves concerns and characterizations like “unproven” and “guinea pigs”.
But can we as a society strive for and reward rapid progress in one area and reject it in another, especially if we feel threatened by outside forces or phenomena – be that a virus, climate change or the collapse of our economy’s infrastructure like supply chains and raw materials.
Tech has its own momentum, more driven by profit motives than altruistism or a desire just to make peoples lives better. Medicine clearly has profit as a driving force, but also a goal of improving life for people. Curing or mitigating disease must rank higher than making life more convenient.
By HANS DUVEFELT
The medication and allergy lists seem like they would be the most important parts of a health record to keep current and accurate. But we all see errors too often.
I think it shouldn’t be possible to enter an allergy without describing the reaction. Because without that information the list becomes completely useless.
The other day I saw a patient who needed an urgent CT angiogram. The allergy list said “All Contrast Materials”, which isn’t even “structured data entry”, and thus not recognized by the computer if my EMR (Me again, Greenway!) would have been clever enough to check for allergies when I order a CT scan.
After a lot of probing, the “allergy” in this case turned out to be a host of nonspecific, chronic symptoms after several lumbar CT myelograms in a short period of time many years ago.
Some people claim to be penicillin allergic because “it never works”. Others list ciprofloxacin or sulfa antibiotics because they get a yeast infection after taking them. Others were slightly nauseous after their first dose of an SSRI like fluoxetine or fatigued after starting gabapentin.
Some symptoms listed as allergies are poorly understood. For example, morphine causes itching in many patients, even skin manifestations like blushing as well as sweating. But this is not usually a histamine mediated symptom, and not an allergy. Other opioids, like hydromorphone, tend to have less risk for itching.
Cough from ACE inhibitors isn’t a true allergy, but we often note that in our allergy lists. People with this side effect can safely be switched to angiotensin receptor blockers, ARBs.
By HANS DUVEFELT
Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.
Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?
The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.
Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.
Primary care here is wasting time in many ways:
When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.
By HANS DUVEFELT
Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.
On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.
In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).
Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.
By HANS DUVEFELT
Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.
Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.
The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.
An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.
He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.
By RONALD DIXON
Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.
It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.
So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout.
While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.
Where it All Began
The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.
The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).
Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue.
By HANS DUVEFELT
Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind.
In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or at last should strive, to reassure those patients whose reactions are normal, considering their circumstances.
A set of emotions we consider normal during the first weeks of the loss of a loved one may constitute pathology of protracted or if there is no apparent trigger.
But what is normal in today’s reality?
People today often have a low tolerance for deviations from the mean. They measure their heart rates, sleep times, steps taken, calories eaten and many other things on their smartphones. They compare their statistics to others’ or to their own from different circumstances.
Is it normal to sleep less when the last thing you do before bed is take in the latest disaster news? Is it normal to have a higher resting heart rate when you are threatened by eviction? Is it normal to feel sadness that life as we knew it doesn’t seem to be within our reach right now?
The worst thing we can do is tell people there is something wrong with them if we see them doing and hear them expressing what many other people also do.
It’s bad enough to feel bad, but even worse if you think your reaction is a sign of psychiatric illness or psychological or constitutional inferiority.
By HANS DUVEFELT
I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)
I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.
I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.
My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.
Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.
I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.
But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.
By HANS DUVEFELT
I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.
His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.
I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.
The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.