Knowing what to do when faced with a sick patient is relatively straightforward. We learned a lot of it in medical school, picked more up by experience, and usually have the opportunity to look things up quickly on the Internet. Even when faced with a brand new situation, we can usually fall back on our general knowledge of science and medicine.

But in today’s practice of medicine, that’s not enough. Physicians, PAs and NPs all live in two parallel universes these days, the world of medicine and the world of metamedicine.

The world of medicine was created through understanding of life itself. It is vast and complex, and growing exponentially. Its rules tend to follow scientific principles.

The world of metamedicine was created by humans with limited understanding of life, but with vast experience in actuarial calculations and bookkeeping. It is growing faster than medicine itself. Its rules follow a logic not taught in medical school.

Imagine a well-trained physician faced with a patient who has gained some weight and complains of swollen legs. The doctor notices that the patient seems just a little short of breath. But our patient also admits to eating more than he used to and he has been on his feet more than usually in hot weather. He wonders if that may have caused the swelling.

Our wise physician knows that right-sided heart failure predominantly causes edema, whereas left-sided heart failure more affects breathing. Suspecting heart failure, he orders a BNP, a relatively new, fancy screening test for heart failure.

The overlords of the metamedicine universe, in their infinite and inscrutable wisdom, have determined that Medicare will pay for BNP testing in cases of shortness of breath, but not in cases of leg swelling. Our doctor orders the BNP in good faith for the diagnosis of “edema,” but the next day the lab notifies him the test was not run because there was no covering diagnosis.

Yours truly had a patient the other day with new onset of atrial fibrillation and a left bundle branch block (LBBB) on his EKG. They teach us in medical school that a new LBBB in many cases signals a blockage of a coronary artery. I ordered a stress test. The diagnosis I assumed would cover this test was my patient’s LBBB.

Wrong. Today I got a fax from the EKG department, stating this diagnosis didn’t cover the test. Presumably because of some metamedicine code of ethics, they did not tell me what would, but they were kind enough to include several pages of diagnoses that would qualify my patient for a stress test.

Frustrated, I perused the list. Nothing seemed to fit, and of course you can never use “suspected” or “rule out” as a qualifying diagnosis. That is one of the ground rules of the metamedicine dimension. Then, there it was: The very last qualifying diagnostic option was ICD-9 code 794.31, “nonspecific abnormal EKG,” Now, why didn’t they teach me that in medical school instead?

Also today, I had a fax from the pharmacy about a Medicaid patient with anemia and evidence of blood in the stool. She had recently undergone an upper endoscopy that showed gastritis and a duodenal ulcer. I had prescribed omeprazole, an inexpensive acid blocker. She was already on even less costly iron pills for her anemia. Medicaid required a prior authorization. The reason for this is that, theoretically, iron is better absorbed if the stomach environment is acidy. If you have bleeding from too much acid, this is not a worrisome drug interaction.

But Medicaid has enough time and resources to micromanage everyday clinical judgments like this one. I scribbled, “Aware of theoretical interaction. Will monitor.”, as I always do in these cases. The PA always gets approved. I am doing my job and the folks at Medicaid are just doing theirs.

Every day has more examples like these. Unlike the laws of medicine, the rules of metamedicine seem arbitrary, at least to a medical mind, and there are fewer handy resources for looking things up. Besides, people like me sometimes fall into the trap of doing what makes sense to us without looking up what diagnosis covers what in the world of metamedicine. But, how much double checking can you do in 15 minutes?

I have long thought of myself as bilingual, speaking pretty good English and even better Swedish. I’m also learning the language of metamedicine. That is becoming more necessary in my everyday dealings than my rusty German and rudimentary French.

Here’s a quiz:

Which diagnosis covers a lipid profile?

a) Screening for lipoid disorders (V77.91)
b) Screening for other and unspecified cardiovascular disorders (V81.2)

Give up? The correct answer is “b.” See what I mean?

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.