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.

When primary care handles the consequences of psychiatric medication prescribing

Hans Duvefelt, MD

Physician

January 13, 2020

If my hypertensive patient develops orthostatism and falls and breaks her hip, I fully expect the orthopedic surgeon on call to treat her. I may kick myself that this happened, but I’m not qualified to treat a broken hip.

If my anticoagulated patient hits his head and suffers a subdural hematoma, I expect the local neurosurgeon to graciously treat him even though it was my decision and not his to start …

A physician shares the computer screen with patients

Hans Duvefelt, MD

Physician

January 9, 2020

I ran late the other morning. My first patient, an internal transfer, was already waiting. Booting up my laptop seemed to take forever.

Usually, I try to poke around at least a little in the EMR before I enter the exam room, even when I know the patient well in order to remind myself of what we are supposed to do in today’s visit.

I decided to walk in cold because I …

Most medical offices are hopelessly old fashioned

Hans Duvefelt, MD

Physician

January 4, 2020

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch — and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course, that’s not how banks operate. There are small ongoing charges (or margins off the interest they …

Happiness has become a selfish pursuit

Hans Duvefelt, MD

Physician

December 30, 2019

Earlier this month Ross Douthat wrote a piece in The New York Times titled “The Age of American Despair” where he posed the question “Are deaths from drugs and alcohol and suicide a political, economic or spiritual crisis?”

Douthat writes:

The working shorthand for this crisis is “deaths of despair,” a resonant phrase conjured by the economists Anne Case and Angus Deaton to describe the sudden rise in …

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Happiness has become a selfish pursuit

Physicians have to inspire their patients

Hans Duvefelt, MD

Physician

December 25, 2019

The Swedish word for physician is läkare, which literally means healer. That seems a lot more glamorous than the American word physician, which is derived from physic, the old fashioned laxatives that were thought to rid the body of poisons and impurities. But we are actually the healers a lot less often than we think.

The more we learn about how the body works, the more we have to admit that …

Experience and in-depth knowledge can empower you with an appreciation for nuances

Hans Duvefelt, MD

Physician

December 17, 2019

In medicine, contrary to common belief, it is not usually enough to know the diagnosis and its best treatment or procedure. Guidelines, checklists, and protocols only go so far when you are treating real people with diverse constitutions for multiple problems under a variety of circumstances.

The more you know about unusual presentations of common diseases, the more likely you are to make the correct diagnosis, I think everyone would agree. …

Doctors shouldn’t be horse whisperers

Hans Duvefelt, MD

Physician

November 27, 2019

I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications, according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes-related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant …

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Doctors shouldn’t be horse whisperers

How this physician does less in primary care and accomplishes more

Hans Duvefelt, MD

Physician

November 19, 2019

So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.

It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood …

Why doctors need to be chameleons

Hans Duvefelt, MD

Physician

November 6, 2019

Doctors need to be true to themselves, but at the same time, they must be chameleons.

A doctor fills certain roles in the lives and stories of patients. It is a two-way relationship that looks different to each person we serve throughout every workday and even in the most casual interactions we have.

Some patients need us to take charge for a while because they’re exhausted; others need us to listen quietly …

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Why doctors need to be chameleons

Why physicians should adopt the role of guides

Hans Duvefelt, MD

Physician

November 5, 2019

The family doctor used to be almost the only source of medical information patients had access to. Now, few people need us to bring them the latest news. It’s there for everyone to see. There’s even too much of it.

Today, our role is to help make sense of it all. In order to do that, we must possess and project authority, but we have no reason to put ourselves on …

Why primary care will soon only treat chronic conditions

Hans Duvefelt, MD

Physician

November 4, 2019

In most other human activities, there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Health care spans from one extreme to the other. Think code blue versus diabetes care.

Primary care was once a place where you treated things like earaches and unexplained weight loss in appointments of different lengths with documentation of different complexity. By doing both in the same clinic over the lifespan …

Physician office notes should have an executive summary

Hans Duvefelt, MD

Physician

October 9, 2019

I have advocated before for putting a visit synopsis at the beginning of each visit note. I have called that the aSOAP note. I think that works immensely better than APSO notes that only rearrange the order of the elements. The reason I say that is that in today’s EMR notes, it’s too darn hard to find the story. If a note is half a dozen pages or …

The answer to physician burnout isn’t resilience training

Hans Duvefelt, MD

Physician

September 27, 2019

The answer to physician burnout is purported to be resilience training. That’s like glorifying the natural ability of frogs to tolerate gradually heating and boiling water.

Unfortunately, health care today has some toxic ingredients, and physician burnout is directly related to them. Some forms of resilience training I have been exposed to are no more than mental escapes away from medicine, such as art, music, and personal relationships.

Those types of activities …

When physicians fear for their lives

Hans Duvefelt, MD

Physician

September 12, 2019

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave, and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the …

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When physicians fear for their lives

The sensitive topic of physical contact during exams

Hans Duvefelt, MD

Physician

August 29, 2019

Touch is a sensitive thing. No pun is intended here, but whether and how we touch our patients deserves our careful thought and deliberation.

So much interpersonal contact these days is virtual, with emojis, abbreviations and whole words thrown around as substitutes for human contact. Think XOXO and, “hugs and kisses.” And when people do touch in our health care environment, it is often with gloves, even for simple fingerstick blood …

When Medicare stops covering a test without warning

Hans Duvefelt, MD

Physician

August 19, 2019

There are two versions of “the conversation” we have with men: One is for teenage boys, and it is about wet dreams, sexually transmitted disease, unwanted pregnancy and at one point also about testicular self-examinations. Those have now been edited out of the script, which makes sense to me since I have seen only three cases of that in forty years of practice, all but a couple of them diligently …

A doctor survived a day without a computer. Here’s how he did it.

Hans Duvefelt, MD

Physician

August 9, 2019

It wasn’t even nine o’clock when the screen on my laptop suddenly froze. From that moment until my last patient left the building, my clinic had no internet.

For my part, the day went pretty smoothly, mostly because of some of my own work habits. It also helped that it was a warm, sunny day, and my schedule was on the light side. Others have frowned at my old-fashioned work habits, …

Too many “experts.” Not enough family doctors.

Hans Duvefelt, MD

Physician

August 6, 2019

It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification

There are personal and executive coaches, wealth advisers, marketing experts, closet organizers, and all kinds of people offering to help us run our lives.

In each of these fields, the expectation is that the provider of such services has his …

Instead of speed, focus on the value of each patient encounter

Hans Duvefelt, MD

Physician

August 1, 2019

In business literature, I have seen the phrase “getting paid for who you are instead of what you do.” This implies that some people bring value because of the depth of their knowledge and their appreciation of all the nuances in their field, the authority with which they render their opinion or because of their ability to influence others.

This is the antithesis of commoditization. Many industries have become less commoditized …

The art of off-label prescribing

Hans Duvefelt, MD

Meds

July 10, 2019

Some drugs are used for indications beyond their original FDA approved ones that make complete sense. I mean, if old seizure medications help nerve pain, it might be reasonable to try new ones for the same purpose if everything else fails.

Sometimes the broader use of a medication leads to additional FDA approved indications. One good example is bupropion, Wellbutrin, for smoking cessation. It even got a new name for that indication, Zyban, …

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The art of off-label prescribing