Tag: Hans Duvefelt

Brief is Good

May 28, 2019• 1

By HANS DUVEFELT, MD

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

The Folly of Self Referral

May 17, 2019• 6

By HANS DUVEFELT, MD

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The Cruelty of Managed Medicare

Mar 18, 2019• 1

By HANS DUVEFELT MD

Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying,” she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that,” I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

Medicine is Not Like Math

Feb 14, 2019• 2

By HANS DUVEFELT MD

We do a lot of things in our head in this business. Once a patient reports a symptom, we mentally run down lists of related followup questions, possible diagnoses, similar cases we have seen. All this happens faster than we could ever describe in words (let alone type).

And, just like in math class, we are constantly reminded that it doesn’t matter if we have the right answer if we can’t describe how we got there.

So the ninth doctor who observes a little girl with deteriorating neurologic functioning and after less than ten minutes says “your child has Rett Syndrome” could theoretically get paid less than the previous eight doctors whose explorations meandered for over an hour before they admitted they didn’t know what was going on.

Does anybody care how Mozart or Beethoven created their music? Or do we mostly care about how it makes us feel when we listen to it?

Checking Boxes

Feb 1, 2019• 1

By HANS DUVEFELT MD

I pay $500 per year for UpToDate, the online reference that helps me stay current on diagnostic criteria and best treatment options for most diseases I might run into in my practice. They also have a rich library of patient information, which I often print out during office visits.

I don’t get any “credit” for doing that, but I do if I print the, often paltry, patient handouts built into my EMR. That was how the rules governing meaningful use of subsidized computer technology for medical offices were written.

If I describe in great detail in my office note how I motivated a patient to quit smoking but forgot to also check the box that smoking cessation education was provided, I look like a negligent doctor. My expensive EMR can’t extract that information from the text. Google, from my mobile device, can translate between languages and manages to send me ads based on words in my web searches.

When I do a diabetic foot exam, it doesn’t count for my quality metrics if I freetext it; I must use the right boxes. If I do it diligently on my iPad in eClinicalWorks, one of my EMRs, even if I use the clickboxes, it doesn’t carry over to the flowsheet or my report card.

The Perfect Office Note? SOAP, APSO or aSOAP?

Jan 16, 2019• 3

By HANS DUVEFELT MD

I’ve been toying with this dilemma for a while: SOAP notes (Subjective, Objective, Assessment, Plan) are too long; APSO just jumbles the order, but the core items are still too far apart, with too much fluff in between. We need something better – aSOAP!

Electronic medical record notes are simply way too cumbersome, no matter in what order the segments are displayed, to be of much use if we quickly want to check what happened in the last few office visits before entering the exam room.

It is time we do something different, and I believe the solution is under our noses every day, at least if we read the medical journals:

I can be aware of what’s going on in the medical literature without reading every article. How? Think about it…

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

Jan 2, 2019• 6

BY HANS DUVEFELT MD

Too many specific theories about physician burnout can cloud the real issue and allow healthcare leaders to circle around the “elephant in the room”.

The cause of physician burnout isn’t just the EMRs, Meaningful Use, CMS regulations, the chronic disease epidemic or any other single item.

Instead, it is simply this: Healthcare today has no clear definition of what a physician is. We are more or less suddenly finding ourselves on a playing field, tackled and hollered at, without knowing what sport we are playing and what the rules are.

Historically, physicians have been viewed as professionals and also, more lately, as skilled workers. But we are more and more viewed and treated as neither. Therein lies the problem.

Where is Relationship, Authority, and Trust in Health Care Today?

Dec 28, 2018• 8

By HANS DUVEFELT MD

Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

Where to Apply Artificial Intelligence in Health Care

Dec 10, 2018• 2

By HANS DUVEFELT MD

I have seen the light. I now, finally, see a clear role for artificial intelligence in health care. And, no, I don’t want it to replace me. I want it to complement me.

I want AI to take over the mandated, mundane tasks of what I call Metamedicine, so I can concentrate on the healing.

In primary care visits in the U.S., doctors and clinics are buried in government mandates. We have to screen for depression and alcohol use, document weight counseling for every overweight patient (the vast majority of Americans), make sure we probe about gender at birth and current gender identification, offer screening and/or immunizations for a host of diseases, and on and on and on. All this in 15 minutes most of the time.

Never mind reconciling medications (or at least double checking the work of medical assistants without pharmacology training), connecting with the patient, taking a history, doing an examination, arriving at a diagnosis, and formulating and explaining a patient-focused treatment plan.

Medicine is Child’s Play: Where’s Waldo, Spot the Difference and Whack-a-Mole

Oct 30, 2018

By HANS DUVEFELT, MD

I started writing a post a few days ago about the challenge of quickly finding what you’re looking for in a medical record. As I came back to my draft this morning, it struck me how much this felt like some of the games my children played when they were young. This got me thinking…

Where’s Waldo: Finding what’s important in the medical record

I did a peer review once of an office note about an elderly man with a low grade fever. The past medical history was all there, several prior laboratory and imaging tests were imported and there was a long narrative section that blended active medical problems and ongoing specialist relationships. There was also a lengthy Review of Systems under its own heading.

In what would probably have printed out over ten pages long, the final diagnosis was “Urinary tract infection” and the man was prescribed antibiotics.

This final diagnosis seemed to come out of left field. I didn’t recall reading anything about urinary symptoms, urinalysis, an abdominal exam or pain on percussion over the back.