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.

The surprising reason behind an early refill of alprazolam

Physician
October 2, 2015

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart …

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The surprising reason behind an early refill of alprazolam

Are your patients uncomfortable with a scripted physical?

Physician
July 21, 2015

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One of the ghosts in every exam room is the institution that pays many private doctors over ten million dollars, the authority that determines that you can order a BNP (brain natriuretic peptide) to look for heart failure in patients with shortness of breath but not when they have leg edema. You know who I’m talking about: Medicare.

Medicare is not only …

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Are your patients uncomfortable with a scripted physical?

A rare case in a rural doctor’s office

Conditions
May 2, 2015

I see some odd things in my clinic. One recent diagnostic dilemma was a man in his late fifties with shortness of breath.

He had been born with a ventricular septal defect and had undergone surgery for this in his infancy. During his lifetime, he had seldom gone to doctors and always thought he was in fairly good health, maybe just of a weak constitution. A smoker since age 13, he …

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A rare case in a rural doctor’s office

Stay away from doctors: From a patient who listens

Physician
April 26, 2015

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Earnest Tipp was very overdue for his blood pressure follow-up. Almost a year and a half overdue, as a matter of fact. The last few times I had refilled his medications, I had added “needs follow-up” to the signum on his scripts.

The other day I finally saw him in my schedule. I thought about him all morning. A tall, muscular 90-year …

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Stay away from doctors: From a patient who listens

With the EMR, you have to work backwards from the superbill

Tech
April 6, 2015

Sometimes, after crafting an important or complex plan of care with a patient, I say: “Let me type all this into the computer so that, in case I run into that big bull moose up on Vaillancourt Hill on my way home tonight, the next doctor who sees you will know what we were thinking today.”

Patients sometimes squirm or laugh nervously at that, but then they usually indicate understanding and …

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With the EMR, you have to work backwards from the superbill

What this patient needs for a normal blood pressure

Physician
March 22, 2015

Dwight Frost had all the risk factors, plus he had already had a stroke several years ago. His blood sugars were too high, his lipid profile was near the top of the class, he still smoked a cigar now and then, and his blood pressure hovered around 200. He also seemed a little vague about which medications he actually took and which ones he didn’t.

He spoke rapidly with a slight …

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What this patient needs for a normal blood pressure

Today’s EMRs: Extra work with uncertain benefits

Tech
February 28, 2015

The other day I ordered a CT scan with contrast on a patient with an apparent mass on his neck. I explained about the need to get a blood test to make sure his kidneys could handle the iodine contrast. Because our lab was closed, I had to print a requisition for him to bring to the hospital lab.

Printing a requisition from our EMR is a multi-step process that involves …

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Today’s EMRs: Extra work with uncertain benefits

Which drugs are on formulary? A little help, please.

Meds
February 23, 2015

The letters are usually four pages long and begin by saying that my patient has received a temporary supply of the medication I prescribed.

Next, there are general paragraphs about how the drug either isn’t on their formulary or the quantity exceeds the plan limits. None of these letters contains a reference to an online formulary physicians can access to compare covered alternatives.

Then there are several cumbersome explanations about the appeal …

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Which drugs are on formulary? A little help, please.

A career in primary care means you are comfortable with uncertainty

Physician
February 6, 2015

Primary care is a messy business. Nobody has just one simple problem, and no patient has all the typical symptoms for their diagnosis. Most don’t even tell us everything that’s going on. And most don’t follow their treatment plan completely. But this may be OK, since we often change our minds about what is right or wrong in the practice of medicine.

Knowing what constitutes success in front line medicine is …

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A career in primary care means you are comfortable with uncertainty

A house call is worth a dozen tests. And then some.

Physician
January 28, 2015

Flossie Marks used to complain now and then about shortness of breath on exertion. She never had chest pain and, after all, she carried firewood from the basement to feed the wood stoves and fireplaces in her large Victorian house. At 81, who wouldn’t be a little short of breath doing that?

Last summer, she finally sold the house where she and Eli had raised four children and hosted nine grandchildren …

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A house call is worth a dozen tests. And then some.

What if the president worked like doctors today?

Physician
January 11, 2015

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Perhaps doctors should be more like the president.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the president needs in order to manage his, and all …

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What if the president worked like doctors today?

Bureaucrats think a doctor is a doctor. They’re wrong.

Physician
December 28, 2014

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I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that health care is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1. …

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Bureaucrats think a doctor is a doctor. They’re wrong.

Primary care: No system can replace human effort and commitment

Physician
December 23, 2014

It’s been thirty years since Dr. Pete shook my hand on graduation day and slapped my back, his gravelly voice mumbling a wisecrack that couldn’t quite hide his emotions. I was the first foreign medical school graduate in our small residency program and he had trusted me, just as I had trusted him, through three years of hard work and many challenges.

Our residency program was only a few years old, and my …

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Primary care: No system can replace human effort and commitment

Medicine is complex, but doctoring is viewed as being simple

Physician
December 14, 2014

I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.
– Rudyard Kipling

Medicine has become a very complex, multifaceted science, ranging from pharmacogenetics to psychoneurobiology. Doctoring, however, is increasingly viewed as so simple that you don’t actually have to be a doctor to know how it should be done.

What else could explain why IT people tell doctors what “workflows” …

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Medicine is complex, but doctoring is viewed as being simple

Physicians are treating the well, and nurses are treating the sick

Physician
December 2, 2014

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A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could …

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Physicians are treating the well, and nurses are treating the sick

When the art of medicine gets lost in the business

Physician
November 25, 2014

Andy was new to me. He told me he had seen several doctors over the past few years for various pains in his right arm.

Some months ago, he had right shoulder pain that went away on its own, but for the past few weeks, he had pain in the middle of his upper arm. Last year he had tennis elbow and forearm pain for many months.

A slender, middle aged man, …

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When the art of medicine gets lost in the business

When checklists become chokelists

Physician
November 2, 2014

Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s …

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When checklists become chokelists

Team-based care needs to be more than a buzzword

Physician
October 6, 2014

Team-based care is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the team can bill for their work.

Few people seem to be concerned with the simple but essential question of how physicians spend their time and how medical offices are paid. As a primary care physician who doesn’t do any major procedures, and who in 2014 is essentially paid fee …

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Team-based care needs to be more than a buzzword

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