THCB

Categories

Tag: Hans Duvefelt

All the Lonely People: Primary Care isn’t a Team Sport Anymore, We’re Only Interacting with Our Computers

BY HANS DUVEFELT

In spite of all the talk these days about health care teams and in spite of more and more physicians working for bigger and bigger healthcare organizations, we are becoming more and more isolated from our colleagues and our support staffs.

Computer work, which is taking more and more time as EMRs get more and more complex, is a lonely activity. We are not just encouraged but pretty much forced to communicate with our nurses and medical assistants through computer messaging. This may provide more evidence of who said or did what at what point in time, but it is both inefficient and dehumanizing.

Why do people who work right next to each other have to communicate electronically? Why can’t my nurse simply ask me a question and then document “Patient asked whether to take aspirin or Tylenol and I told her that Dr. Duvefelt advised up to 2,500 mg acetaminophen/24 hours”. It would be a lot less work for me, even if I have to sign off on the darn thing.

Continue reading…

Truthfully, the Physician Shortage Doesn’t Exist!

• 1

BY HANS DUVEFELT

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. (Sinsky et al, 2016)

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

Continue reading…

Two Cases of a Cool Skin Condition (Erythrocyanosis, Pernio or Chilblains, Anyone?)

BY HANS DUVEFELT

A month ago an oncologist called and asked me to see one of my heart failure patients whose chronically swollen legs seemed unusually blue but not cold.

Before I could get him in to see me, he ended up seeing a colleague, who called me up and said the man’s legs were cool and there was no Doppler in that office to check for pedal pulses. The man was sent for an urgent CT angiogram with runoff.

The test was perfectly normal. He had clean arteries.

When I saw him, the legs were less blue than they must have been and they felt OK but he had what looked like a shingles rash around his right elbow. There was some surrounding swelling and redness, so I prescribed an antiviral, an antibiotic and prednisone and arranged to see him back.

My diagnosis was erythrocyanosis. I have never seen a case but my instinct when I saw him was that this was a peripheral thermal regulation problem. So, a little bit of searching on the Internet gave me the diagnosis.

In follow up, the legs looked fine and the elbow rash was drying up nicely.

None of my research suggested a reasonable treatment option for his condition. But he was getting better so I didn’t have to worry about it at that moment.

Continue reading…

Two Patients With More Than One Diagnosis

BY HANS DUVEFELT

I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.

We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.

My purpose in writing about these cases is to show how disease, the enemy in clinical practice if you will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.

Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.

A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.

Continue reading…

Practicing at the Top of Your License is Not an Option for Primary Care Physicians

BY HANS DUVEFELT

You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).

You also don’t really need a medical degree to enter data into an EMR.

And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!

And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…

Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!

Hans Duvefelt is a physician, author, and writer of “A Country Doctor Writes.”

I Love Explaining Medical Things

BY HANS DUVEFELT

A lot of people don’t know much about how the body works. One of my jobs as a physician is to explain how things work in order to empower my patient to choose how to deal with it when the body isn’t working right.

On my blog I have written about this many times, for example in the 2010 post GUY TALK:

Guy Talk

One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.

Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.

I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.

Continue reading…

Dear Patient, If You Have to Treat a Cold, Know This:

BY HANS DUVEFELT

Americans hate being sick. There are too many cold medicines out there to remember by name. But there are really only a handful of different drug classes to consider.

In order to choose any one of them, be clear about what you want to accomplish. It’s actually very simple.

1) Make my cold go away faster: Zink, echinacea, visualization/manifesting, sauna, prayer (may be mostly placebo effect ).

2) Stop my nose from running (including post nasal drip): You’ll want the crud to leave your body as soon as possible, so turning off the drain pipe that your nose has become can increase the risk of stagnant mucous in your sinuses becoming secondarily infected. But intermittent use of a decongestant (pills like pseudoephedrine, diphenhydramine or nasal sprays like Afrin) can help you look healthier than you are for an important Zoom meeting.

3) Make my nose run and relieve the pressure in my sinuses: Lots of fluids, room humidifier/vaporizer, shower steam, nasal steroid spray, guaifenesin (Mucinex) or even nasal lavage (Nettipot), but I personally have reservations about that one.

Continue reading…

The Dangers of EMR-Defaulted Prescription Stop Dates

By HANS DUVEFELT

It happens in eClinicalworks, I saw it in Intergy, and I now have to maneuver around it in Epic. Those EMRs, and I suspect many others, insert a stop date on what their programmers think (or have been told) are scary drugs.

In my current system all opioid drug prescriptions fall into this category. For a short term prescription that might perhaps be a good idea but for a longer-term or occasionally needed prescription it creates the risk of medical errors.

In Epic there is a box for duration, which is very practical for a ten day course of antibiotics. If I fill in the number 10 in the duration box, the medication falls off the list after 10 days. This saves me the trouble of periodically cleaning up the list.

Continue reading…

A Country Doctor Reads: What if Burnout Is Less About Work and More About Isolation? (NYT)

BY HANS DUVEFELT

This weekend I read a piece in The New York Times that put a slightly different slant on what burnout, in the case of physician burnout, is or is caused by. We have heard theories from being asked to do the wrong thing, like data entry, to “moral injury” to my favorite, “burnout skills“, when you keep trying to do the impossible because people praise you when you pull it off.

Tish Harrison Warren’s piece is a dialog between her and psychiatrist/author Curt Thompson. He focuses on isolation as a driver of burnout:

Assume that if you’re burned out, your brain needs the help of another brain. Your brain is not going to be OK until or unless you have the experience and opportunity of being in the presence of someone else who can begin to ask you the kind of questions that will allow you to name the things that you’re experiencing.

The moment that you start to tell your story vulnerably to someone else, and that person meets you with empathy — without trying to fix your loneliness, without trying to fix your shame — your entire body will begin to change. Not all at once. But you feel distinctly different.

I’m not as lonely in that moment because you are with me. And I sense you sensing me. That’s a neural reality.

Continue reading…

Health Care Through the Back Door: The Dangers of Nurse Visits

By HANS DUVEFELT

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

Continue reading…