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Why We Need Good Primary Care Physicians

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By HANS DUVEFELT

I have made the argument that being the first contact for patients with new symptoms requires skill and experience. That is not something everybody agrees on.

One commenter on my blog expressed the opinion that it is easy to recognize the abnormal or serious and then it is just a matter of making a specialist referral.

That is a terribly inefficient model for health care delivery. It also exposes patients to the risks of delays in treatment, increased cost and inconvenience and the sometimes irreversible and disastrous consequences of knowledge gaps in the frontline provider.

UNNECESSARY SPECIALIST REFERRALS ARE COSTLY

Seeing a high charging, high earning specialist when the primary care provider can’t diagnose and manage the condition involves higher cost and, in many cases, a comprehensiveness that is based on the fact that the patient traveled 200 miles for their appointment. In such cases patents aren’t likely to come back for a two week recheck. Consequently, specialists tend to do more in what may be the only visit they have with a patient.

UNNECESSARY SPECIALIST REFERRALS CREATE TREATMENT DELAYS

For my patients, seeing a neurologist involves a one year wait for the out of state neurologist who does consultations almost 100 miles from my clinic, or a three to four month wait for an appointment more than 200 miles away in Bangor. The situation for rheumatology or dermatology is about the same.

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The Art of Asking: What’s Your Biggest Fear?

By HANS DUVEFELT

When a patient presents with a new symptom, we quickly and almost subconsciously create a hierarchy of diagnostic possibilities. I pride myself in my ability to effectively share my process of working through these types of clinical algorithms.

But sometimes I seem to get nonverbal clues of dissatisfaction or simply no reaction at all to my eloquent reasoning. And only then do I remember to ask the important questions, “do you have any thoughts on what’s causing this” and, most importantly, “what’s your biggest fear that this could be”.

It doesn’t matter how brilliant a diagnostician you are if a patient with less medical knowledge than you has a thought, fear or hunch that diseases and symptoms work in ways that don’t make sense to you.

An uncle may have had a burning sensation in his nose minutes before a stroke, so this symptom may seem like a much more obvious harbinger of disaster to your patient than it does to you. How would you know, if you didn’t ask, what the number one question is that your patient wants the answer to?

We are often so focused on our own thinking process, especially with our time pressures and the bureaucratic requirements of medical encounters these days, that we risk forgetting our patients may not think the way we do.

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The Art of Prescribing (Or Not)

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By HANS DUVEFELT

I have learned a few things about prescribing medications during my 42 years as a physician. Some are old lessons, and some are more recent. I thought I’d share some random examples.

First: I don’t like to have to use medications, but when they seem necessary, I choose, present and prescribe them with great care.

CHOOSING MEDICATIONS

Medications are like people. They have personalities. With so many choices for any given diagnosis or symptom, I consider their mechanism of action, possible beneficial additional effects and their risk of unwanted side effects when selecting which one to prescribe. To some degree that goes against today’s dogma.

Blood pressure medications, for example, have what I call an A-list and a B-list. The A-list contains drugs with a proven track record of not only reducing blood pressure, but also actual heart attack and stroke risk. Why we choose from the B-list, the drugs that don’t decrease cardiovascular risk or actually increase it, is a little beyond this simple country doctor’s ability to understand.

ACE inhibitors like lisinopril and diuretics like hydrochlorothiazide are the two recommended first choices in this country. But the A-list also contains amlodipine, a calcium channel blocker and, further down, metoprolol, a beta blocker. I make those less favored A-listers my initial choice in two scenarios:

Amlodipine is my choice when I see a hypertensive patient who prefers a set-it-and-forget-it treatment plan. No bloodwork is required after starting it to monitor for kidney or electrolyte problems, so even if the patient doesn’t come back for a year or more, there is no real risk involved.

Metoprolol, which blocks the effect of the stress hormone adrenaline on the cardiovascular system, is what I talked my own doctor into prescribing for me. That was back in the day, when I was a hard working, somewhat Type A personality with high blood pressure. With the passage of time, life experience, weight loss and my transformative relationship with my Arabian horses, my blood pressure normalized and I didn’t need medication anymore.

Years ago, we all selected blood pressure medications according to the “phenotype” (appearance or general impression) of the patient: metoprolol if intense, hydrochlorothiazide if swollen, nifedipine if cold-handed, lisinopril If naturally hypokalemic (low potassium).

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The Art of Explaining: Starting With the Big Idea

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By HANS DUVEFELT

We live in a time of thirty second sound bytes, 280 character tweets and general information overload. Our society seems to have ADHD. There is fierce competition for people’s attention.

As doctors, we have so many messages we want to get across to our patients. How many seconds do we have before we lose their attention in our severely time curtailed and content regulated office visits?

I have found that it generally works better to make a stark, radical statement as an attention grabber and then qualifying it than to carefully describe a context from beginning to end.

Once a person shows interest or responds with a followup statement or question, you have a better chance for a meaningful discussion. Just starting to explain something without knowing if the person wants to hear what you have to say could just be a waste of time.

Here are some of my typical conversation starters – or stoppers, if you will:

“The purpose of a physical is to talk about stuff that could kill you, more than about symptoms that annoy.”

“Nothing makes a cold go away faster.”

“Urology is about plumbing, nephrology is about chemistry.”

“Most headaches are migraines.”

“Sinus headaches don’t exist in Europe.”

“I don’t care what your blood pressure is today if you’re scared or in pain.”

“A healthy lifestyle is at least as effective as taking Lipitor.”

“We now know that eating fat makes you lose weight.”

“Cholesterol only causes damage if there is also inflammation.”

“Fat free means high in sugar.”

“I don’t believe in vitamins.”

“Osteoporosis happens to every woman around 80, so is it really a disease?”

“You have to treat 35 men for prostate cancer to save one life.”

“You know how many cases of testicular cancer I’ve come across in 40 years? Three!”

“It takes 45 minutes of walking to burn 100 calories, but only 10 seconds to drink them.”

My brief experience as a substitute teacher for junior high school students as well as my many years as a scout leader taught me that you can’t assume you have people’s attention just because you’re standing in front of them. They will give it to you if they believe you have something interesting to say. You often have less than thirty seconds to prove that you do.

Is our medical knowledge alive enough in our minds that we can share it in a quick, easy and captivating way with our distracted patients?

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

There Are Three Kinds of Primary Care, Not to Be Confused With Each Other

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By HANS DUVEFELT

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

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This is Not Health Care

By HANS DUVEFELT

We use the word health rather loosely in America today. Especially the expression health care, whether you spell that as one word or two, is almost an oxymoron.

Health is not simply the absence of disease, even less the pharmaceutical management of disease. The healthcare “industry” is not the major portion of our GNP that it is because there is a lot of health out there, but the opposite. What consumes so much money and generates so much profit is, of course, sick care. The sicker people are, the more money is spent and earned in this market segment. It is a spiral, and a vicious one.

Health is a naturally occurring phenomenon, a state of perfection. Modern life has corrupted many natural, self-healing biological mechanisms and upended the natural order of things in our bodies – just the way it has altered our environment.

Our bodies are pretty ingenious in their ability to heal. When I crushed my finger in my garage door a few years ago, my disfigured fingertip, bisected nail and contused nail bed slowly regained their original shape, almost like a lizard grows a new tail. Yet in an opposite scenario, a person with scleroderma can lose their fingertip to gangrene without physical injury because of what we call autoimmunity – instead of self healing, our bodies can engage in self destruction. My fingertip could heal perfectly but some people’s skin or stomach ulcers fail to do so.

We intuitively seem to have accepted that, most of the time, nature takes care of itself if we don’t mess with it. And when temperatures rise, forests burn or species go extinct, we are quick to assume our industrial or agricultural processes are the cause.

Yet, we have this head-in-the-sand view of disease that it is a random occurrence, the sudden manifestation of ancient and rare genetic glitches or I don’t know what. The real answer is that much of it is a consequence of what we eat and otherwise expose our bodies to – how we produce and refine food, how we alter its natural properties and how we over- or under-consume basic nutrients.

Functional Medicine asks and answers many of these questions and promises to be the future of medicine. I believe in this, but I also believe that the sick-care industrial complex is powerful enough to severely slow down this revolution. I also believe the food industry will double down its efforts to continue misleading the public.

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The Year When Everything Changed: Covid, Self Care and High Tech Innovation In Medicine

By HANS DUVEFELT

Life as we knew it and medicine as we had viewed it shapeshifted so dramatically in the past year that it is still hard to believe.

Medicine has started to move from an in-person only profession to one that finally recognizes that clinical assessment and treatment have fewer boundaries than people assumed. A patient of mine with newly diagnosed mastocytosis had a productive first consultation with an immunologist hundreds of miles away right from her own living room.

Efficiency increased when we could handle straightforward clinical issues electronically, even over the telephone, and still get paid. We were liberated from the perverted and miserly view by insurers that services not delivered in person should be free, as if fast food restaurants couldn’t charge for food at the drive through.

We delivered more virtual services to allow patients the safety of staying at home and avoiding lobbies, waiting rooms and exam rooms where airborne particles might linger.

Yet, when a primary care or mental health patient is in crisis or a person with new symptoms needs to be evaluated, a video visit is sometimes not enough. Step by step, we improvised screening protocols, not knowing which would be efficient or relevant as we didn’t know quite how the coronavirus behaved and transmitted.

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Stewardship: We Worry More About the Environment than Our Own Bodies

By HANS DUVEFELT

Sooner, rather than later, we will be driving electric cars because of the environment. We use energy efficient light bulbs and recyclable packaging for the same reason. And there is a growing debate about the environmental impact of what kind of food we produce and consume. But I still don’t hear enough about the internal impact on our own bodies when we consider stewardship of natural resources.

Our bodies and our health are the most important resources we have, and yet the focus in our culture seems to be on our external environment.

Just like the consumption culture has ignored its effect on our planet in favor of customer convenience and business profits, it has ignored the effect it has had on the health of the human beings it set out to serve. And just as we now are fearing for the future of our planet, we ought to be more than a little bit concerned about the future of the human race.

But, just as we really can’t expect the corporate world to lead the environmental effort, unless we can engineer a way for them to see profit in doing that, we cannot expect it to lead any kind of effort to make the population healthier. That is something that has to start with the individual.

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The Art of Listening: Beyond the Chief Complaint

By HANS DUVEFELT

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

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Physicians’ Communication Skills are Overlooked and Undervalued

By HANS DUVEFELT

Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves. 

At the other end of the spectrum of human communication lies our ability to explain and also our ability to influence. These three aspects of what we do—elicit, explain and influence—are far from trivial, and in my opinion quite fundamental aspects of practicing medicine. 

Eliciting an accurate patient history or administering standardized depression, anxiety, domestic abuse, smoking and alcohol screenings are commoditized activities in today’s healthcare. There is little time allotted and these tasks are usually delegated to non-clinicians. 

A complicated patient’s clinical history seldom lends itself to straightforward, structured EHR formats. It can be more like a novel, where seemingly unrelated subplots converge and suddenly make complete sense in a surprising last chapter. 

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