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.

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…