My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on Marcus Welby, MD. I didn’t have a motorcycle, but I did have a snazzy SAAB 900.
Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home …
Despite the talk about team-based care, physicians today are isolated
I keep thinking about the dichotomy between covering a lot of ground and getting to the point.
The other day I saw my bosses at one of my clinics stop in their tracks when I suggested that a lot of the things we are measured on as physicians could be turned into standing orders and simply get shifted off my plate. I have just created a letter that anybody can send …
Physicians are problem solvers and artists
I’ve known Pat McCann (identifying information changed) for many years. He carries a diagnosis of COPD and has a preventative and a rescue inhaler, but he has never really had any serious flare-ups.
He fell and broke his hip. Then he went to skilled rehab, one of a half dozen near Cityside Hospital. His stay turned longer than expected because he fell, luckily didn’t break anything, but had to go back …
A diagnosis of pneumonia in a rehab facility: We can do better
Most Saturdays, I join a therapy session down the hall from where I do my walk-in clinic. A patient of mine has a weekly session just before the Alcoholics Anonymous meeting at noon in our big conference room.
Last weekend he told my behavioral health colleague that the people in the AA group who have the most solid recovery seemed to be the ones who claimed to carry a lot of …
The role of hatred in medicine
How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?
So why is the typical “cycle time,” the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?
Answer: Mandated screening activities that could actually be done in different ways and …
Physicians can’t do everything for everybody in every visit
A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.
This “system” often doesn’t work, because of the way medical specialties are divided up.
If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the …
Is primary care an unnecessary roadblock?
Jeanette Brown had lost twenty pounds, and she was worried.
“I’m not trying,” she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:
A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.
That is exactly what happened to my mother some years …
This story happens every week in clinics like mine and it’s got to stop
There is a lot of talk about team-based care nowadays, and I had seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.
But at the same time, there are so many decisions – judgment calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.
I talk to patients all the time …
In the era of team-based care: Some decisions have to be made alone
I haven’t counted how many times this happens every month, but I find it annoying.
I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a prior authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) Read more…
We need RVUs for obtaining a prior authorization
Last week I had a patient with mild kidney disease and a high potassium. I thought that it would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast, and nobody had Kayexalate, the time-tested antidote, in stock.
It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4; his …
A shortage of Kayexalate leads to an ER visit
Driving north in a snowstorm Tuesday of Thanksgiving week I certainly took my time. I left after our Suboxone clinic wrap-up conference, around 7:30 p.m., and arrived at my unplowed driveway in Caribou about 1 a.m.
On the way up, I saw two ambulances, one from Caribou and one from Presque Isle, on their way back home from Bangor. I’ve got a large SUV with all-wheel drive and studded Finnish snow …
Sometimes, the biggest challenge to eliminate health disparities is geography
I’ve huddled since before we used the word for it: You want to be prepared for the patients coming in that day. “Followup MRI” – did they have it and what did it show? “Ankle pain” – do we have X-ray today? “Eye pain” – be sure to check her acuity and put her in a windowless room, and did the new fluorescein strips come in? All fast-paced, to the …
Do huddles really help in primary care?
I have known him for over thirty years. He has been legally blind for the past five.
He tends to be a practical, no-nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said: “I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things,” he began. “I’m seeing children with elfin faces …”
His large, thin hands were in …
A rare condition that often happens to people with very poor eyesight
I am beginning to think that we should not see chronic care patients between Thanksgiving and New Year’s Day. It just makes us look bad.
Our quality metrics make the last blood pressure and the previous diabetic lab test of the year for each of our patients our final report card. We should quit while we’re ahead, in mid-November.
So here we are: The office has Christmas decorations up. There are trays …
We need to be more focused on those patients who find the holidays hard
“Red” McDougall had terrible leg pains soon after going to bed. He did have a bad back, and some mild spinal stenosis, but I hadn’t heard much about that in the past few years. He was dealing with the ache in his legs when he was on his feet too long.
A few months ago he saw his vascular surgeon for a routine followup. He’d had a femoral-popliteal bypass to restore …
When the buck stops with primary care
I guess I should take it as a compliment when patients come to see me after visiting a specialist and ask me a bunch of difficult specialty-related questions.
“Did you ask the specialist that?” I typically ask, and the answer will be a plain “no.”
I’ve seen it in action. Some doctors speak quickly, say a lot, and exude so much authority that it’s hard to stop and question them. There is …
A physician moving back and forth along the Teflon spectrum
“Admission diagnosis: causa socialis”
In my training in Sweden, it was not unusual to admit patients to the hospital for social reasons: an elderly person who could no longer manage at home, a person whose social network fell apart, and so on.
“Social reasons,” causa socialis, was a legitimate diagnosis (Swedes used more Latin than Americans, at least back then). And it was used with only mild grumbling. There was a clear …
Hospitals are no longer an important part of the social safety net. That’s a problem.
Health care is on a different trajectory from most other businesses today. It’s a little hard to understand why.
In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie-cutter quality to the intangibles of authority, influence, and trust. This, …
Health care is on a different trajectory from most other businesses. Why is that?
Many patients who end up in Suboxone treatment have chronic pain. They were originally prescribed other opiates and ended up addicted to them.
Skeptics argue that is just substituting one opiate for another. But that isn’t quite accurate. More on that in a bit.
In my seven years of prescribing Suboxone for opiate addiction, I have often observed how potent a pain reliever this medication is, even in fairly low doses. More …
Suboxone for pain makes sense. Why don’t more doctors prescribe it?
Back when cholesterol target numbers ruled unopposed (before 2013), we all checked fasting lipids every three months. Before 2012, we also checked liver function quarterly in hapless riders on the cholesterol pill merry-go-round. That year the FDA announced there had not been enough reports of statin-induced liver problems to recommend routine monitoring.
I have many colleagues who still do this, and who also routinely monitor routine labs quarterly …
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