Tag Archives: evidence based medicine

A Modern Country Doc–chart jockeys

–Tom Bibey

In the early 1980s, I made almost all my decisions in conjunction with my patient, together with the specialists we deemed appropriate in a given case. It wasn’t but a few years before modern medical “oversight” or “management” began to assert itself. This started first with government programs, soon followed by big business. Docs were forced to learn a new set of skills to overcome these obstacles to the delivery of care.

Early on, it was a benign process. Every once in a while I’d get a call from old Doc Smith who’d ask about a case. I knew him from State Medical Society meetings. Retired, he’d never made all that much when he was in practice, so I understood his need to supplement his income. I’d even taken over some of his patients, so Doc Smith knew me well. He wasn’t going to scoop me on much over the phone. I had the advantage of being the doc who saw the patient, and we both knew he wasn’t in a position to compete with that. Doc had to call every so often. I understood. He’d call and ask a few questions, and I’d tell him in doctor terms about where to go, and we’d laugh.

By the mideighties the minor nuisance grew to a downright disruption of patient care. I remember a fellow I had followed since I started my practice. I inherited him when a local doc retired. The patient was elderly and had multiple medical problems: several heart attacks, a pacemaker revised several times, bad kidneys, bad lungs, but he was a heck of a nice guy.

My first hospital admission for the patient was for an episode of syncope (they call it “falling out” around here) and the situation was complex, so an extensive workup was undertaken. Both carotid arteries had partial blockage, but the surgeon said that the literature showed that only the worst side of a 70 percent blockage warranted intervention. (Here is a country doc tip for you: if a surgeon doesn’t want to operate, I would take that advice very seriously.) I talked it over with the local cardiologist, we ran everything by the big boys at the Medical Center, and everyone agreed to a treatment plan. With some adjustments in medication, we sent the patient home. Surgery, at least at that time, was not indicated. A week later, he had an unanticipated TIA (near ministroke), which thankfully resolved. Due to the change in circumstances, the surgeons changed their minds and proceeded with surgery to correct his right carotid artery blockage.

The patient did well, and he went home satisfied with the outcome. For him, it was the end of that chapter of his story. For me it was the beginning. Six weeks later, I got a letter from one of the Medicare review boys, who determined the first admission to be unnecessary. I knew my patient could get stuck with the tab, so I began to compose a letter of explanation. Before I could complete it, I had a second letter on my desk from a different review bureaucrat (I call them chart jockeys). This jockey determined the second hospital stay was due to a premature discharge from the first admission. I have a fair amount of education, but I was confused. How can one be discharged too early from an unnecessary admission?

I found it a silly demonstration of the lack of medical sophistication on the part of the reviewers, but I did not anticipate the intense effort required to win this battle. However, I lost the war. Years later I noticed reviewer number one had his name on a government medical complex, and I assure you I will labor in obscurity until the end. I’ll consider myself lucky if I just stay out of trouble. I was the doc for my patient until the end, when he died of plain old, very old, age. Every so often we delighted in laughing at the incompetence of those chart jockeys.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. B talks about the chart jockeys. Today they come in many forms. If the clinic is part of a health system, the chart jockey may be the quality review folks who review patient charts for each clinician looking for patients who are lost to follow up or are out of compliance with recommended treatment. They can be helpful. Thanks to electronic health records (EMR or EHR), we can pull up lists of patients based on diagnosis codes (ICD-9, soon to be ICD-10). As a result, I can look at all of my diabetics and know who has been in the clinic in the last 6 months and what their lab values are.  With diabetics we aim to keep their HGBA1C under 8. (Glycosolated hemoglobin-the measure of sugar molecules on a red blood cell gives us an idea of how well a patient’s diabetes is under control over three months, the life of a red blood cell.) Then the nurse and I can figure out which patients we need to contact and ask them to come into the clinic. In the old days, we waited for patients to come to us. Today we make more efforts to reach out to patients, especially patients with chronic health problems. With diabetes we know that certain medications and checks actually keep patients healthier and prevent or delay kidney failure, loss of vision and amputations.

The chart jockeys can be a nuisance when I have to jump through hoops before I can order a treatment or medication–often call a prior authroization, especially if it is what I know I need to do for my patient. On your rotations you will hear lots of clinicians complain about the paperwork or phone calls that accompany this. It is all an effort to avoid unnecessary treatments, identify fraud and to manage cost. Often it consumes time and energy for staff that interferes with caring for patients.

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Professionalism

–David Loxterkamp

 The family doctor is a hybrid in the field of medicine. We perform the generalist’s role with specialists’ ambitions. We are amateurs (from the Latin amator) who love our labor and shoot more from the hip than from the sights of expert opinion. We still consider medicine a vocation, or calling, and thus remain open to duty that lies beyond the roles for which we’re prepared. And, we remember that professionals are those who profess something publicly about what they believe.

I have listened to the professions of Trappist monks at New Melleray, Gethsemani, and New Clairvaux abbeys. Not only do they commit themselves to the religious life (in the vows of poverty, chastity, and obedience) but pledge to live in one place (the vow of stability) in order that grace, working through community, may move them (by a conversion of manners) closer to God.

Family doctors, too, understand that our high incomes distort our perceptions of the poor; money tests our personal values and stands between patients and their access to medical care. Chastity reminds us to be respectful of the intimacies we guard and faithful to those who are marginalized by the loss of insurance or physical well-being. We remain obedient to a higher authority—the precepts of science and a moral conduct befitting our profession. We realize that patient care is not portable and that the doctor who lives among his mistakes and prejudices becomes a healthier person less prone to severity in the judgment of patients or peers. Lastly, family doctors are inevitably changed by the patients they serve. The merely responsible physician, tempered by mercy and groomed by grace, adds to the stock of moral credibility that has sustained our profession over the millennia.

 What I am trying to describe is a doctor who is more than the sum of his or her parts, more than a tally of screening tests and minor procedures and patient encounters scored over the course of a career. We might more easily see that a rabbi or minister is not only master of ceremonies but a person praised as a man of God. We know that a teacher is more than a conveyor of facts and proctor of exams but someone dedicated to the channeling of curiosity in the pursuit of truth. So, too, family doctors, who through the blur of ICD-9 and CPT codes will finally rest in those relationships that define and sustain their work.

(Excerpted from A Vow of Connectedness: Views from the Road to Beaver’s Farm, The Country Doctor Revisited (KSU, 2010) and Family Medicine (2001) used with the permission of the author)

 Dr. Loxterkamp wrestles with big issues. He does not use the word, but the physician is a healer– he/she takes a vow much like a monk or holy man. Medicine is more than science, but the art. There is an understanding between the patient and the physician that the physician will practice in the best interest of the patient, not simply for his or her own reward. Dr. Loxterkamp believes that physicians are called to something greater than simply an occupation.  What are your thoughts on this? In today’s production and profit oriented health care systems is this even possible?

 Dr. Loxterkamp admits that in family medicine we often shoot from the hip.  That may be heresy in the world of evidence based medicine. We have reflected on this in other posts–balancing the art and science, balancing the evidence and what makes sense for the patient. How do you see the health professionals you work with blend what the evidence tells us and caring for patients where there is no evidence to guide us? Are we shooting from the hip? Is there more to it than this or are we fooling ourselves?

 Dr. Loxterkamp suggests that in small communities we “live among our mistakes.”  In small communities we cannot hide. What does it mean to live among your mistakes?  How does one reconcile that a medical mistake may harm someone?  Perhaps after all we are our own worst critics? Sometimes community members can be quite forgiving of the doctor’s foibles and even look past what might be poor care because they value their relationships with the physician.  How does a physician stay honest to the profession and his oath to care for his/her community despite the current incentives in health care, depite the fact that we are human and will make mistakes?

Read Dr. Loxterkamp’s entire essay in Family Medicine

Welcome to Elma

–Mitchell L. Cohen

Dr. Cohen, who practiced family medicine for five years in rural Washington, describes a typical day’s roster of patients to the third year medical student spending the month with him:

First on the schedule is a forty year old log truck driver coming in to get his physical for his license. I never knew how many log truck drivers were in this county until I started working here. Here’s a thirty two year old female with chest pain that’s probably either her asthma, anxiety, or both. She smokes way too much tobacco and marijuana. Then there’s a depressed patient with fairly newly diagnosed diabetes, high blood pressure, and elevated cholesterol. It’s so frustrating. He just doesn’t seem to care, but I know a lot of this is the depression. The next guy you’ve got to meet. He is eighty nine and coming in to talk about his gout. He’s a retired veterinarian and tells some pretty amazing stories. Just ask him about serving in Italy in World War II. A tough case of ADHD in a kid in foster care is next. We’ll do a skin biopsy on the next guy. His dad is one of my patients in the nursing home. Really sad; rapidly advancing dementia.  He’s having a tough time watching his father go through so much. 

Then it’s lunch time. Do you like Mexican food? Good. For lunch we’ll walk on over to this great Mexican place on the next block. The owners and most of the employees come here for their medical care too. I highly recommend the spinach enchilada.

In the afternoon we’ll start with a pregnant patient of mine. I delivered her last baby. I also take care of her parents and grandparents. We have quite a few third and fourth generation families in the practice. My partner holds the record for a five generation family, but then the great-great grandparent died and it went back to four generations. This guy here always comes in to get his ear wax cleaned out. Ahh, fascinating stuff there! Here’s a guy in his mid-forties with low back pain and, and, oh by the way, he’s seventy pounds overweight, smokes, and uses walking to his mailbox as his form of exercise. These visits are painful for both of us. Anyway, dispersed among all of those there are a few well child visits, other pregnancy appointments, some of these might be Spanish speakers. How’s your Spanish? I spent two years of my CME time learning Spanish. I am passable, unless it gets complicated, then I use a phone translator—but as you’ll learn, the visit fee hardly pays the cost. Then of course, more high blood pressure and diabetes, and the rest we’ll figure out when we take a look on the other side of the door.  Looks like about twenty-two patients total—pretty typical day.

Remember, you’re here to learn about rural medicine. Get to know the patients. Let them tell you about their families and what they do for a living. You’ll see that so much of what they tell you relates to their medical illnesses in ways that you haven’t ever considered. This is one of the intangible benefits of family medicine and it is best brought out in rural areas. It doesn’t appear in any proficiency scores or quality measures, but the continuity of care we provide for generations of families allows us to tailor modern medicine to fit their needs. This is the art of medicine. 

(Excerpted and used with permission, published in The Country Doctor Revisited, KSU, 2010)

Today we talk about the value of evidence-based medicine, knowing the best practice for your patient’s disease and situation. Research and science have their place in caring, but so does the art. Dr. Cohen describes the art as letting the patients tell you about their families, what they do for a living and about their lives and then comes the art—you adjust the science to make it work for them and their unique situations.  I am thinking of one of my new diabetic patients. If I want to get quality credit for my diabetes management I need to have the BP well controlled, the Hemoglobin A1C under 8, the LDL under 100, and the patient needs to take an ACE/ARB (like lisinopril) and aspirin. If I addressed all that with him during our first visit he would have been drinking out of a fire-hose—not fun for anyone. So little by little we examine the various issues and negotiate what he can and cannot do.

What has surprised you about the patients you have encountered on your rotation? Where have art and science intersected? How has your teacher/preceptor’s knowledge of the patient over a number of years informed the diagnosis and treatment?