Hans Duvefelt, MD

Hans Duvefelt is a family physician who blogs at A Country Doctor Writes: and the author of A Country Doctor Writes: CONDITIONS: Diseases and Other Life Circumstances.

Alternative medicine: There should only be one standard

Hans Duvefelt, MD

Meds

September 16, 2014

“Doctor, what do you think of alternative medicine?” a patient with chronic fatigue syndrome asked me the other day. She was interested in doing something more for her severe fatigue. “Would acupuncture help me?”

I paused and, as I have done many times before, answered that my training and most of my clinical experience has been in Western, allopathic medicine. (Ironically, the word “allopathic” was first used as a derogatory term …

Doctors must speak like accountants

Hans Duvefelt, MD

Physician

September 9, 2014

You have to think fast in medicine. Not that most doctors handle life and death emergencies all day long, but even seemingly mundane clinical situations require a lot of rapid gathering of data, processing of applicable information and attention to detail in formulating a plan.

I have always been bemused by the so called E&M (evaluation and management) coding that dictates payment by requiring documentation of how doctors think. Ironically, the …

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Doctors must speak like accountants

Health care data is meaningless without context

Hans Duvefelt, MD

Physician

August 30, 2014

Cholesterol is bad. Cholesterol is an essential building block for important hormones.

Eggs are bad. Eggs are a complete protein food.

Salt is bad. Salt is essential for life.

High blood pressure kills people. No blood pressure defines death.

High blood sugar causes eye and kidney damage. Low blood sugar causes falls, fractures and car wrecks.

Low potassium causes heart rhythm problems. High potassium causes heart rhythm problems.

Too little vitamin B12 causes nerve damage. Too …

Medicine has lost sight of the big picture

Hans Duvefelt, MD

Physician

August 16, 2014

We must bear in mind the difference between thoroughness and efficiency. Thoroughness gathers all the facts, but efficiency distinguishes the two-cent pieces of non-essential data from the twenty-dollar gold pieces of fundamental fact.
– Dr. William Mayo

The practice of medicine involves a lot of details, but details without the big picture are meaningless at best and distracting at worst.

The expression, “the devil is in the details” implies that the details can …

Context is crucial when deciding what to do with abnormal test results

Hans Duvefelt, MD

Physician

August 9, 2014

Question: What do you do when presented with abnormal lab results?

Answer: Ask lots of questions.

The nursing home just sent over a urinalysis on a patient of Dr. Carlyle. I am covering his practice for a few days. The test showed that an 82-year-old woman had 3+ white blood cells in her urine. “NKDA” was written in the margin, indicating she had no allergies.

I sighed internally and called the nursing home. …

Welcome to the world of metamedicine

Hans Duvefelt, MD

Physician

July 30, 2014

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, …

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Welcome to the world of metamedicine

Don’t turn primary care into General Motors

Hans Duvefelt, MD

Policy

July 24, 2014

When Uncle Will needed a hip replacement, he chose an orthopedic surgeon, Jason Brockman, and Mountain Memorial Hospital because of their excellent reputations for low complication rates and satisfied patients. The process reminded him of when he bought his first brand new truck.

Norm and Clara Anderson chose Dr. Wheeler as their family doctor once they had made the decision to relocate to Maine and raise their family away from the …

Always start your diagnostic search from the beginning

Hans Duvefelt, MD

Physician

July 16, 2014

It is a trade secret among patients of many practices: If you’d like to be seen by your personal physician with no waiting and without an appointment, just ask for a free blood pressure check and then mention to the medical assistant that you are not feeling well at all. They can’t send you home without being seen and they don’t have enough to go on to call an ambulance; …

Ailments are big business

Hans Duvefelt, MD

Meds

July 8, 2014

Back when Prozac (fluoxetine) and Zoloft (sertraline) were new, I remember the mental acrobatics doctors made to justify giving these drugs to anxious patients. The drugs were approved for treating depression, but we knew they often seemed to help anxiety. The reason, we were told, was that some anxious patients were actually depressed, deep down, and we had just failed to recognize their depression.

Now, with studies to support their use …

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Ailments are big business

A country doctor’s proposal for health insurance reform

Hans Duvefelt, MD

Policy

June 24, 2014

In the forty years since I started medical school, I have worked in socialized medicine, student health, a cash-only practice and a traditional fee for service small group practice. The bulk of my experience has been in a government-sponsored rural health clinic, working for an underserved, underinsured rural population.

Today, I will make a couple of concrete suggestions, borrowing from all the places I have worked and from the latest trends …

Should doctors be paid for outcomes?

Hans Duvefelt, MD

Policy

June 11, 2014

This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like. In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.

Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than health care.

There is …

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Should doctors be paid for outcomes?

A morning in the substance abuse clinic

Hans Duvefelt, MD

Meds

May 27, 2014

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year-old with track marks on her forearms. Her obstetrician and case worker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates?” …

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A morning in the substance abuse clinic

A debate on what we need our doctors to do

Hans Duvefelt, MD

Policy

May 15, 2014

It’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about …

When doctors become mercenary about their time

Hans Duvefelt, MD

Physician

May 8, 2014

The other day I received my copy of the periodic newsletter of our neighboring Canadian medical society. It made me realize that both countries’ primary care doctors, in spite of our entirely different health care systems, are facing some of the same issues.

The bulletin warned Canadian doctors not to enforce a one-problem-per-visit policy, but to offer more comprehensive care to their patients.

The way doctors and clinics are paid in most …

A toxic environment for delivering health care

Hans Duvefelt, MD

Policy

April 29, 2014

A long time ago, when I worked in Sweden’s socialized health care system, there were no incentives to see more patients. In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On call work was reimbursed as time off. Any extra income would have been taxed at the prevailing …

If a doctor isn’t face to face with a patient, is he still a doctor?

Hans Duvefelt, MD

Physician

April 18, 2014

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a federally qualified health center, the payment …

Doing a lot more than the doctoring than bargained for

Hans Duvefelt, MD

Physician

April 9, 2014

The horse that came into my life has made me think about many things from a different perspective. I have learned about the horse’s subtle ways of communicating, her extrasensory (compared to our own) perception, and her instincts of flight. I have also become more aware of the energy I bring to my relationship with her. With no learned tricks or horse management skills, I have established a way of …

When doctors care too much

Hans Duvefelt, MD

Physician

March 27, 2014

Doctors today are often accused of being uncaring: Their eyes are glued to their computer screens and their attention is focused on test results and technology instead of patients.

But some doctors care too much: A seasoned cardiologist blogs about letting his emotions lead him astray in keeping an elderly patient on life support too long. Was it his emotional attachment to the charming, elderly woman, or was it professional hubris, …

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When doctors care too much

When something natural does indeed work

Hans Duvefelt, MD

Meds

January 30, 2014

“I used to be strong, I wrestled the bull,” Sumner Ball said, “but now I can’t even wrestle the rooster.”

On the far side of eighty-years-old, he looked lively and trim, and his weathered face hinted at a smile as his blue eyes peered straight into mine.

“I think these cholesterol pills are hurting my muscles,” he declared. “I don’t think they’re good for me.”

“Is it your back?”

I scanned through his last …

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When something natural does indeed work

The greatest miracle a physician is privileged to be part of

Hans Duvefelt, MD

Physician

January 17, 2014

“Welcome back. How was your trip? Or exile … you were away for a long time.”

“Almost a year,” my nine o’clock patient answered. A woman just over forty, she looked tan and physically strong. Her short hair was peppered with gray, different from the last time I saw her. She had gone abroad on assignment for a magazine and a film production company, and before she left, she had joked …

Hans Duvefelt, MD

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