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.

Having a medical license doesn’t mean you’ve mastered the art of medicine

Hans Duvefelt, MD

Physician

October 2, 2017

“The fool doth think he is wise, but the wise man knows himself to be a fool.”
– William Shakespeare

I learned about the Dunning-Kruger effect at a medical conference recently. It certainly seems to apply in medicine. So often, a novice thinks he or she has mastered a new skill or achieved full understanding of something complicated, but as time goes on, …

A doctor goes without a white coat. Here’s how his visits changed.

Hans Duvefelt, MD

Physician

September 25, 2017

Something very interesting happened to my patient visits when I changed my office attire.

My clean long cotton lab coats, hanging on the back of my office door, suddenly all seemed dingy when I set out to change lab coat about a week ago. I decided to pretend it was Saturday.

On Saturdays, I usually wear a pocketed button-down shirt instead of one of my usual Jermyn Street ones. I skip the …

Alarm fatigue is problem. Here’s a pragmatic solution.

Hans Duvefelt, MD

Physician

August 30, 2017

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite …

A lesson learned after seeing a tick-borne illness

Hans Duvefelt, MD

Conditions

August 16, 2017

It was late afternoon. The woman who had seen my colleague, Dr. Wilford Brown, a few days earlier was sitting in my exam room. Her chart note read like a typical unnameable virus: headache, body aches, fatigue, low grade fever. She had always seemed like a level-headed resolute woman, but she had called three days in a row for medical advice because she felt so poorly. And it all sounded …

The health care quality debate has a myopic view

Hans Duvefelt, MD

Physician

August 10, 2017

Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answer doesn’t matter anymore.

If you ask a patient with a given symptom, like tremor, lameness or a skin eruption, only a few questions and then conclude that they have …

When an erythrocyte sedimentation rate leads to a serious diagnosis

Hans Duvefelt, MD

Conditions

August 1, 2017

In Sweden, back when I trained, three blood tests were the “routine labs” done at most doctor visits: hemoglobin, white blood cell count, and erythrocyte sedimentation rate. I’m trying to remember, but I don’t think everyone waited an hour to see the doctor, so they must have used a modified rapid sedimentation rate.

The “sed rate,” or “sänkan” as we call it, was invented by Robin Fåhraeus, a relative of one …

A hidden reason for electronic prescribing of controlled substances

Hans Duvefelt, MD

Meds

July 18, 2017

As of July 1, pharmacies in Maine cannot honor paper or telephone prescriptions for controlled substances, from OxyContin down to Valium, Lyrica, and Tylenol with codeine.

EPCS, or electronic prescribing of controlled substances, is a double security step in the prescription process built into EMRs, electronic medical records. It involves another password entry and the use of one-time passwords from a small number generator issued to each prescriber.

It has been said …

A more careful examination would have saved her expensive procedure

Hans Duvefelt, MD

Conditions

June 28, 2017

“Noncardiac chest pain” was Laurie Black’s discharge diagnosis. Her chest CT angiogram didn’t show a pulmonary embolus, her troponins were negative for a heart attack and her nuclear stress test was negative for coronary ischemia.

“So what do you think it was?” she asked while I read through her hospital discharge summary.

“I don’t know. Show me where the pain was,” I answered.

“It started on my back, on the left side, and …

Failure is a constant possibility in medicine

Hans Duvefelt, MD

Physician

June 9, 2017

He had been in for a physical the day before.

Like so many people, he seemed to have this need to run half a dozen minor bodily symptoms past me, while I worked my way through the agenda of screening colonoscopy, whether or not to test his PSA, calculating his ten-year cardiovascular risk, talking about alcohol use, screening for depression and so on.

I remember his left leg pain. He had had …

Why we shouldn’t pigeonhole patients into groups

Hans Duvefelt, MD

Physician

May 30, 2017

I was scheduled to attend a medical director’s retreat the other day, but because of a horse emergency the day before, I had to stay home, so I offered to skip the retreat and see patients instead.

It would have been almost an entire day hearing about trauma informed care and the lifelong impact of adverse childhood events. As a primer, the conveners of the seminar emailed a “dear doctor” letter …

Xylocaine and Lyme disease: A deer tick story

Hans Duvefelt, MD

Conditions

May 24, 2017

It was a small deer tick, hidden by the crus helix, embedded in the cymba conchae, the crevice just above the ear canal of my seven-year-old patient halfway through my Saturday clinic.

He was worried that it would hurt. His parents hadn’t wanted to try removing it on their own. I had a hard time even seeing the small tick as it was sitting at an angle where I saw it …

The doctor shortage is worse than it has to be

Hans Duvefelt, MD

Physician

May 17, 2017

Now, I’m just a country doctor, but I have to say I find it very hard to understand why folks in this country, on one hand, keep talking about a doctor shortage in primary care and, on the other hand, keep piling sillywork on those of us who are still here.

The net effect is that the doctor shortage is going to be a whole lot worse than it has to …

Help people let go of struggling and move toward valued living

Hans Duvefelt, MD

Conditions

May 12, 2017

She didn’t seem obviously depressed as I entered the room.

“So, we have you taking a good dose of both antidepressants now,” I said. “How are you doing?”

“I feel about the same.”

“Have you done anything lately that could have made you feel a little better?”

“I’m not sure …”

“I’ll give you some examples. They can be different things for different people. It could be reaching out to a friend, helping a neighbor, …

The evolution of prior authorizations

Hans Duvefelt, MD

Physician

May 8, 2017

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each …

Read more…

The evolution of prior authorizations

I doubt this patient’s other doctors listen

Hans Duvefelt, MD

Physician

April 28, 2017

The patient, I surmised, was the one in the wheelchair with nasal oxygen and an unhealthy red color of her cheeks. The younger woman in the room with her looked like she might be a daughter.

I introduced myself. I had been right about the other woman being her daughter.

It was Saturday clinic, urgent care at our country doctor practice, and the plastic holders with “express check-in” history forms and a …

Removing jargon: Why are physicians singled out?

Hans Duvefelt, MD

Physician

April 12, 2017

My voice recognition software insists on typing “when needed” when I say “PRN,” and the other day I saw an orthopedic note that said, “before meals joint.” I was sure that the straight-laced orthopedic surgeon did not intend to tell the world anything about anybody’s cannabis use. Instead, it was obvious he had spoken the words “AC joint,” meaning acromioclavicular (on top of the shoulder). But AC can also mean …

EMRs should be like rental cars

Hans Duvefelt, MD

Tech

April 12, 2017

When a new doctor joined our clinic, she spent a week learning our electronic medical record. She had used two other systems before, so she was no stranger to EMRs, but that’s how different they can be.

That’s crazy!

EMRs should be like cars, which range from the likes of Smart, Mini Cooper, and Skoda to Mercedes Maybach, Rolls Royce, and Porsche. They range from simple to sophisticated, from nimble city cars …

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EMRs should be like rental cars

What on call used to mean

Hans Duvefelt, MD

Physician

March 28, 2017

“I was surprised when the emergency doctor at Cityside Hospital said he was going to call you to discuss my case,” Farmer Carr said when I saw him today. “I figured you’d be asleep at that hour.”

I smiled as I recalled the cell phone call that had come in at 9:30 the night I had sent him back to the hospital for a reassessment.

“No, I was sitting in my camping …

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What on call used to mean

Let’s pay doctors like we do athletes

Hans Duvefelt, MD

Physician

March 24, 2017

Think about it; athletes aren’t the ones who document their performance. It’s other people that keep the score. That’s a whole science in itself. People talk for hours after the game or tournament is over about how each athlete did this or that in whatever way they did it, and the numbers are in many cases captured by extremely sophisticated electronic equipment.

Physicians work hard to diagnose and treat their patients, …

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Let’s pay doctors like we do athletes

What do you do when a patient’s illness strikes an inopportune time?

Hans Duvefelt, MD

Physician

March 21, 2017

“I am not on call,” Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know,” I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54-year-old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see …