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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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The General Public is Meant to be Deceived: The American Food Conspiracy

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By HANS DUVEFELT

Everybody knows how to operate smartphones and understands complex modern phenomena, but many Americans are frighteningly ignorant about basic human nutrition.

I am convinced this is the result of a powerful conspiracy, fueled by the (junk) food industry. Here are just a few examples:

Milk has been advertised as a healthy beverage. It is not. No other species consumes milk beyond infancy. Milk based products like ice cream and yogurt are on top of that often sweetened beyond their natural properties.

Fruit juices make it possible to consume the calories of half a dozen pieces of fruit faster than eating just one. Naturally tart juices, like cranberry, are sweetened the same way as soft drinks (high fructose corn syrup), and therefore no healthier than Coca Cola.

Things made from flour—like bread, crackers, boxed and instant cereal, pasta and snacks like pretzels or chips other than plain potato chips—raise blood glucose levels faster than eating table sugar: The breakdown of flour starts in our mouths because of enzymes in our saliva while sucrose doesn’t break down until it reaches our small intestine.

Sugary foods, even candy like Twizzlers, are advertised as “fat free”, which is a relic from the days when fat was believed to be bad for you. Many fats, like those in olive oil, salmon, tree nuts and avocado are extremely healthful.

Another example of tangential descriptions is when flour based snacks are promoted as “baked, not fried”. Flour is bad, no matter what you do with it and, in fact, the presence of fat slows down the blood glucose rise from highly processed carbohydrates.

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

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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

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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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Will AI-Based Automation Replace Basic Primary Care? Should It?

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By KEN TERRY

In a recent podcast about the future of telehealth, Lyle Berkowitz, MD, a technology consultant, entrepreneur, and professor at Northwestern University’s Feinberg School of Medicine, confidently predicted that, because of telehealth and clinical automation, “In 10-20 years, we won’t need primary care physicians [for routine care]. The remaining PCPs will specialize in caring for complicated patients. Other than that, if people need care, they’ll go to NPs or PAs or receive automated care with the help of AI.”

Berkowitz isn’t the first to make this kind of prediction. Back in 2013, when mobile health was just starting to take hold, a trio of experts from the Scripps Translational Science Institute—Eric Topol, MD, Steven R. Steinhubl, MD, and Evan D. Muse, MD—wrote a JAMA Commentary arguing that, because of mHealth, physicians would eventually see patients far less often for minor acute problems and follow-up visits than they did then.

Many acute conditions diagnosed and treated in ambulatory care offices, they argued, could be addressed through novel technologies. For example, otitis media might be diagnosed using a smartphone-based otoscope, and urinary tract infections might be assessed using at-home urinalysis. Remote monitoring with digital blood pressure cuffs could be used to improve blood pressure control, so that patients would only have to visit their physicians occasionally.

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Telehealth Reality Check: Who’s Really Going to “Win” the Race to Virtual Care Market Leadership?

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By JESSICA DaMASSA, WTF HEALTH

It’s the telehealth market reality check you’ve been waiting for! “Rogue” digital health consultant Dr. Lyle Berkowitz unpacks the numbers and the market potential for virtual care from the unique vantage point of a primary-care-physician-turned-health-tech-entrepreneur with nothing to lose. Having been 1) a clinician, 2) the Director of Innovation at Northwestern Medicine, 3) the founder of a health tech startup (Health Finch) that successfully exited to Health Catalyst, and 4) the former Chief Medical Officer at one of telemedicine’s biggest players, MDLive, few can boast such a wide-reaching, deep understanding of the inner workings of both the innovation and incumbent sides of the virtual care market — AND have a willingness to talk about it all with complete candor!

This is an analyst’s perspective on the telehealth market — with a twist of insider expertise — so expect to hear some good rationale behind predictions about how much care will remain virtual once hospitals and doctor’s offices return to normal, how “real” health system enthusiasm is for building out telehealth capacity to execute on the “digital front door” idea, and whether or not all these well-funded telehealth startups will have what it takes to win market share from traditional care providers.

BONUS on Primary Care: Is this the area of medicine that’s going to be the “battleground” where digital health and virtual care companies will be going head-to-head with incumbents for market share? Lyle says 50-plus percent of primary care “can and should be automated, delegated, virtualized, etc.” and boldly predicts that in 10-20 years we won’t even have primary care physicians anymore. Tune in to find out why starting at the 8:00 minute mark, where we shout out Crossover Health, Oak Street Health, Iora Health, and more.

Telehealth die-hards, don’t think for a second I’d miss this chance to also get some input on Teladoc-Livongo, Amwell, Doctor On Demand, SOC Telemed, the impending IPOs there, digital first health plans, virtual primary care, health systems (who Lyle hopes “don’t shoot themselves in the foot” with their opportunity to jump into the space) and, ultimately, who’s really going to ”WIN” in virtual care moving forward. For this, jump in at 17:00 minutes and hold on!

Why Primary Care Should Run the Healthcare System

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By KEN TERRY

(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.

The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.

Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.

One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.

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Meaningful U’s

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By HANS DUVEFELT

Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.

When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.

The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.

The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.

For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.

I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:

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