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.
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.
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.
By HANS DUVEFELT
The Art of Medicine is such a common phrase because, for many centuries, medicine has not been a cookie cutter activity. It has been a personalized craft, based on the science of the day, practiced by individual clinicians for diverse patients, one at a time.
Unlike industrial mass production, where everything from raw materials to tools to manufacturing processes are standardized and even automated or performed by robots, physicians work with raw materials of different age, shape and quality in what is more like restoration of damaged paintings or antique automobiles.
The Art of Medicine involves knowing how and with which tools to take something damaged or malfunctioning and make it better. There are general principles, but each case is different to at least some degree. In many cases there are different ways to improve something that is malfunctioning, but patients may prefer fixing certain aspects of a complex problem because of their individual needs.
By HANS DUVEFELT
Today a patient told me a cancer doctor had told her husband that he only had a year to live. She was angry, because she felt that statement robbed her husband of hope and she knew well enough that doctors don’t always know a patient’s prognosis in such detail.
“Would you want to know if you only had a year to live”, she asked me.
I thought for a moment and then answered that I probably would want to know. I explained that I would want to make decisions and provisions because I live alone and am responsible for my animals. As I told her, I am well aware that if I dropped dead right now, things would be pretty chaotic for a while.
Two and a half years ago, I wrote a post titled Be the Doctor Each Patient Needs. In it I presumptuously coined the phrase I later put right on top of the sidebar of this blog:
Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.
I still believe we need to be incredibly sensitive to all the verbal and nonverbal clues our patients give us about what they need. In my 2018 post, I used the analogy of being like a chameleon. That’s not the same as being dishonest. It is a matter of knowing that your education and title give you an authority, an opportunity and an obligation to use your position of trust in your patient’s life to say things they need to hear in order to carry on or perhaps to take the first step in a new direction. We all wear the mantle of a superhero in a sense, and we can use this symbol for good. But that carries a responsibility to use our powers wisely.
By HANS DUVEFELT
Words can be misleading. Medical terms work really well when shared between clinicians. But we can’t assume our patients speak the same language we do. If we “run with” whatever key words we pick up from our patient’s chief complaint, we can easily get lost chasing the wrong target.
Where I work, along the Canadian border, “Valley French” expressions tripped me up when I first arrived. The flu, or in French le flu (if that is how you spell it – I’ve never seen it in writing) is the word people use for diarrhea. Mal au cœur (heart pain) doesn’t mean angina or chest pain, but heartburn, a confusing expression in English, too.
But even if we are all English speaking, clinicians need to be careful not to assume common words mean the same to everyone.
I have seen many patients complain of anxiety, but not actually be worried about anything. A number of bipolar people have used the word anxiety when, in my personal vernacular, they are really describing pathological restlessness. I once had a patient complain of “nerves” but not have a worry in the world except for his hereditary essential tremor, which he assumed was a sign of untreated anxiety.
People often resist my labeling their symptom as chest pain, insisting that I am wrong about the location and the character of their discomfort. Instead, they might insist it is indigestion or prefer pressure, tightness or heaviness in their throat, epigastrium or even between their shoulder blades. “Chest pain is shorthand for all that”, I tell them.
I hear people use the word dizzy for a gnawing feeling in their epigastrium, and nauseous for a sense of early satiety after eating.
By HANS DUVEFELT
1) EXERCISE MORE
I talk to people almost every day who think they can lose weight by exercising. I tell them that is impossible. I explain that it takes almost an hour of brisk walking to burn 100 calories, which equals one apple or a ten second binge on junk food. To lose a pound a week, you need to reduce your calorie intake by about 500 per day – that would be the equivalent of five hours of moderate exercise every day. We’d have to quit our jobs to do that.
2) EAT MORE FRUITS AND VEGETABLES
The other fallacy I hear all the time is that, somehow, adding “healthy” fruits and vegetables can make a person lose weight. I tell them that adding anything to their daily calorie intake will have the opposite effect. I more or less patiently explain that our job is to figure out what to take away instead of what to add. Maybe substituting a fruit for a Whoopie pie is healthy in other ways, but it has almost nothing to do with weight loss.
3) EAT BREAKFAST
A third fallacy is that eating a healthy breakfast will ensure weight loss. To explore this one, I ask: “Are you often hungry?”
So many of my overweight patients deny ever feeling hungry – that gnawing feeling in the pit of your stomach and the low blood sugar onfusion and weakness I feel by 9 or 10 am after doing barn chores on an empty stomach (only coffee).
When I hear “I never feel hungry”, I don’t recommend starting a good breakfast habit because that would likely increase a person’s daily calorie intake. But when I hear that a breakfast skipper goes for the doughnuts mid morning due to hunger, I certainly recommend eating breakfast. When I do, I always point out that the typical American cereal and banana breakfast, along with soft drinks, is actually the major reason for our obesity and diabetes epidemics.
By HANS DUVEFELT
Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy.
“Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of medical students. Even the US Public Health Service Taskforce on Prevention admits that depression screening needs to take into consideration whether there are available resources for treatment. They, in their recommendation, refer to local availability. I am thinking we need to consider the availability in general of safe and effective treatments.
If the only resource when a patient screens positive for depression is some Prozac (fluoxetine) at the local drugstore, it may not be such a good idea to go probing.
The common screening test most clinics use, PHQ-9, asks blunt questions about our emotional state for the past two weeks. This, in my opinion, fits right into the new American mass hysteria of sound bites, TikTok, Tweets, Facebook Stories, instant messages, same-day Amazon deliveries and our worsening pathological need for stimulation and instant gratification.
By HANS DUVEFELT
Almost every day I catch a suspicious fax needing my signature. Often it is an out of state vendor who wants my permission to provide a back brace for a diabetic patient, a continuous blood glucose monitor for a non-diabetic or a compounded (custom made) ointment of some sort that makes no sense from what I know of that patient’s history.
Often, I get a fax appearing to be from Walgreens, just asking me to sign and certify that so-and-so is under my care. Those faxes have Walgreen’s logo, my patient’s correct address and my own DEA and NPI numbers already printed. The problem is that 90% of my patients don’t use Walgreens 20 miles north or south of my clinic, but the local Rexall pharmacy. Once, I called the phone number on the fax and it just rang and rang.
I am convinced that his is just an illicit way to collect physician signatures, so the scammers won’t even have to get my signature on one form at a time. This way it’s like they’ve got their own rubber stamp to use again and again.
I suspect these scams are successful often enough to be quite profitable. I know this because I sometimes sign these forms almost automatically before I catch myself and toss them in the shred box under my desk.
One of the many dirty little secrets in medicine is that doctors get so many papers to sign that there is actually no way we could read them all before scribbling our signature if we still want to see patients, meet clinic revenue projections and match our own productivity quotas.
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.