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.

We need more behavioral health treatment in primary care

Hans Duvefelt, MD

Conditions

November 8, 2018

I don’t know how many times a patient has told me, “I was in therapy once, and it didn’t help.”

My response is always: “That’s like saying ‘I saw a movie once and I didn’t like it’.”

That usually breaks the ice just a little.

In primary care, we certainly run into a few patients with chronic mental health problems that could use some long-term, in-depth counseling. But usually, patients in my practice …

Transdiagnostic therapies in primary care

Hans Duvefelt, MD

Conditions

October 30, 2018

I learned a new word recently: transdiagnostic, which refers to something that is applicable across a spectrum of conditions. It seems that this is becoming an increasingly popular concept in treating anxiety disorders.

No wonder. As I researched this word, I read this:

As of 2013, there are twelve anxiety-disorder diagnoses and over twenty-five subtypes and categories of these disorders, with specific treatments for about half of them. Research has …

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Transdiagnostic therapies in primary care

When patients can’t tell you their symptoms

Hans Duvefelt, MD

Physician

October 24, 2018

Today I had a followup appointment with a young adult male with severe intellectual disabilities. He is barely verbal. Several weeks ago his caregiver told me that this young man often pointed to his chest and would say “hurt” or “heart,” they weren’t sure which. He also seemed to have gotten pickier about his food, and would literally pick at the food on his plate as if examining it. His …

Primary care does what Google can’t

Hans Duvefelt, MD

Physician

October 14, 2018

Non-clinicians skip over some of the most necessary underpinnings of doctoring and speak too much about housekeeping issues: blood pressure targets, aspirin use, mass screenings, immunization rates and so on.

People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most …

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Primary care does what Google can’t

Medicine is a word with 3 meanings

Hans Duvefelt, MD

Physician

October 9, 2018

Everybody is a stakeholder these days in what we broadly call medicine, or health care. But there is little agreement on what medicine is and what the priorities of the health care “industry” should be.

I propose this breakdown of medicine into three separate phenomena.

1. Micromedicine
2. Macromedicine
3. Metamedicine

Let me explain:

Micromedicine: one on one, real doctoring

Doctors from antiquity have served their patients one on one, as individuals. Osler, the father of modern …

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Medicine is a word with 3 meanings

It’s the physician’s job to think of worst-case scenarios

Hans Duvefelt, MD

Conditions

October 3, 2018

I saw two patients with a chief complaint of bubbles in their urine this month.

One middle-aged woman had eaten some wild mushrooms she was pretty sure she had identified correctly, but once her urine turned bubbly a few days later, she came in to make sure her kidneys were OK.

Even though she was feeling quite well, they were not, and she ended up going straight to Cityside hospital for IV …

A case of instant gratification in primary care

Hans Duvefelt, MD

Conditions

September 25, 2018

Few things in primary care give patient and doctor mutual and instant gratification.

It’s been a while since I reduced a “nursemaid’s elbow” or a spontaneous shoulder dislocation other than my own, or a finger dislocation, but those all count.

I once wrote about curing deafness in a man with a movement disorder by flushing ear wax more or less on the run as he bobbed around the exam room. That …

Real doctoring means mitigating the fear patients have

Hans Duvefelt, MD

Physician

September 24, 2018

It’s been said in the world of business that people only buy two things: good feelings and solutions to problems. In medicine, the single most important factor that brings patients through our doors isn’t a “toward” kind of desire, but an “away” one — away from feeling bad.

More specifically, it is pain and fear that most often cause patients to call and ask for an appointment. They hopefully leave with …

Behold the power of clinical triads

Hans Duvefelt, MD

Conditions

September 18, 2018

A few weeks ago, I saw a patient with shortness of breath during my Saturday clinic. He had been short of breath for a few weeks, and on a couple of occasions, he had also experienced mild chest pain. He has known aortic stenosis, moderate according to his last echocardiogram two years ago.

My brain kicked into autopilot, and I asked: “Have you fainted or passed out recently?” It was a …

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Behold the power of clinical triads

The problem with telephone messages in primary care

Hans Duvefelt, MD

Conditions

August 21, 2018

Sometimes I wonder if I am wired differently from other doctors, in terms of what I remember on my own and what I need some help with.

The other day I got a “medical call” that simply said, “Mr. Brown called to report his blood pressure is 120/80.”

With more than fifty calls in my inbox and no memory of what the issue was with Mr. Brown’s current blood pressure, I replied: …

The many ways to describe chest pain

Hans Duvefelt, MD

Conditions

August 15, 2018

There are at least 50 words in the Eskimo languages for snow, 25 in mainstream Swedish, and supposedly 180 or so in the Sami language of the nomadic inhabitants of the northernmost parts of Norway, Sweden, and Finland.

But there are even more words than that for “chest pain” among my patients, many of whom do not consistently or fully comprehend the English phrase, “If you have chest pain, call 911 …

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The many ways to describe chest pain

Changing the treatment plan when covering for another doctor

Hans Duvefelt, MD

Physician

August 8, 2018

I was a little taken aback when Dr. C. changed my patient from warfarin to one of the novel anticoagulants. And one I seldom use, at that.

I have only worked with her for about three years, and we seem to come from the same mold: seasoned family docs with a penchant for teaching and patient empowerment. I had not imagined she would step in and completely change my treatment plan …

The double-edged power of the medications we prescribe

Hans Duvefelt, MD

Meds

July 30, 2018

My patient, a rugged sixty year old with massively muscular forearms, gray chest hair at the V of his denim shirt, and a voice that suggested years of liquor and unfiltered cigarettes, lowered his voice and leaned forward.

“I’m not usually scared of anything, but for three nights now, ever since I started taking the Levaquin for this pneumonia, I have had the most horrific nightmares. I can’t even talk about …

How urgent care rejuvenates this primary care doctor

Hans Duvefelt, MD

Physician

July 25, 2018

I volunteered to work Saturdays. And to do walk-ins. And to take all comers, not just our patients.

It has been an interesting journey.

Some clinics put their newest, least experienced clinicians on the very front line of doing urgent care. Here, it’s the opposite. I’ve got 39 years under my belt, and I see everything from sore throats to people who left the emergency room in the middle of a workup …

Balancing stewardship and entitlement in health care

Hans Duvefelt, MD

Policy

July 23, 2018

Today’s news is full of commentary about work requirements for Medicaid. Is work a prerequisite for health care or is health a prerequisite for work?

Not to complicate things, but can we even agree on what health care is? I don’t think we can, and it largely falls back on what we want to share in paying for.

A patient with an ugly skin lesion can have it removed if it might …

Both physicians and CEOs need time to think

Hans Duvefelt, MD

Physician

July 18, 2018

I’ve always likened the job of a primary care physician to that of a chief executive officer of a small business. Family doctors manage the “business” of delivering and coordinating care for more than a thousand patients at an average cost, in the United States, of $8,500 per year: an $8 to $12 million business. Because the actions or inactions of the PCP impact the need for, and cost of, …

The satisfaction of Suboxone treatment

Hans Duvefelt, MD

Physician

July 17, 2018

My second foray into Suboxone treatment has evolved in a way I had not expected, but I think I have stumbled onto something profound.

Almost six months into our in-house clinic’s existence, I have found myself prescribing and adjusting treatment for about half of my medication-assisted treatment (MAT) patients for co-occurring anxiety, depression, bipolar disease and ADHD as well as restless leg syndrome, asthma, and various infectious diseases.

Years ago, working in …

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The satisfaction of Suboxone treatment

The freedom to admit someone because it was the right thing to do

Hans Duvefelt, MD

Physician

July 10, 2018

The most high-powered rotation in my medical school was endocrinology. There, you got to see things most doctors never come close to diagnosing themselves. Uppsala University’s Akademiska Hospital served as a referral center for the Swedish population north of Uppsala, an area the size and shape of California.

Back in the seventies, laboratory testing wasn’t as sophisticated as it is now. We didn’t have CT scanners even at the major hospitals, …

How today’s EMRs are like self-driving cars

Hans Duvefelt, MD

Tech

July 6, 2018

Drivers are distracted klutzes and computers could obviously do better. Self-driving cars will make all of us safer on he road.

Doctors have spotty knowledge and keep illegible records. EMRs with decision support will improve the quality of healthcare.

The parallels are obvious. And so far the outcomes are disappointing on both fronts of our new war against human error.

I remember vividly flunking my first driving test in Sweden. It was early …

The art of medicine is needed to prevent migraine headaches

Hans Duvefelt, MD

Conditions

June 28, 2018

He spoke with an aura of superiority, in a slightly nasal voice, and his topic was migraines. It was in the late 70s, a time when there were few options to treat migraines.

“Most people who claim to have migraines just have simple tension headaches,” he scoffed. And in a move that seemed unorthodox at the time, he disclosed that he suffered from “real migraines,” so he knew all about this …

Hans Duvefelt, MD

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