Doctor, I need...

It's not that I dislike patients researching their symptoms or their concerns on-line. Actually, the patient with the "petit papier" of  questions is my favorite kind of patient. They are usually well-informed and have questions I enjoy answering. Often it is educational for me because I have to do a little research to be sure my response is accurate. The far end of this pendulum swing is the individual demanding unnecessary tests or drugs. I'll address the medication problem in another blog, today I want to concentrate on tests.

Yesterday I began to write this entry and low and behold the New York Times has an opinion piece by H. Gilbert Welch on this topic appearing in today's issue. I strongly believe prevention is important and put myself forward as a physician interested in keeping my patients well. But prevention is different from finding problems early. Prevention has to do with avoiding lifestyle behaviors that promote illness--bad choices with sexual relations, drinking to excess, smoking, an unbalanced diet, no exercise, etc. Prevention is NOT obtaining every laboratory test known to medicine, getting a "total body scan" or having surgery to remove a body part that is low risk for cancer.

Recently one of my patients, a 32-year-old,  asked for a vaginal ultrasound because she "wants to know her body better down there". What? She suggested that I use the "NPC Guidelines" for ordering the exam. The what? When I Googled that organization the closest I could come up with was the National Phlebotomy Certification. When she was told that insurance would not pay for an ultrasound without symptoms (and that I did not recommend such a thing) she decided that she had some discomfort "down there". I am caught between not wanting to deny a patient a test only to find out later she had something horrible that keeps me talking to attorneys and being annoyed that the insurance company will be paying for an unnecessary test. If she was willing to pay cash for it I would happily order it. But no, no one wants to do that. Our society somehow doesn't put value on piece of mind, unless someone else is paying for it.

The worst-case scenario is the patient who insists on getting a CA125 blood test. You know, the "ovarian cancer test" that makes the email rounds once or twice a year. I've drawn this test on numerous individuals at their request, one time it was elevated. In this particular case she received multiple vaginal ultrasounds over two years, multiple pelvic exams, got an opinion from a gynecologist and an oncologist and ultimately when she stopped smoking for one month (she subsequently resumed cigarettes) the CA125 dropped into the normal range. WAIT--she smokes? Her number one cancer risk is what--maybe LUNG CANCER??? Would it not make more sense to STOP SMOKING????? By the way, the CA125 blood test's purpose is to watch for recurrence of ovarian cancer in individuals who already have the disease but are in remission. It is not a screening test. It's not meant to be a screening test. When you try to make a test into something it is not, people end up with unnecessary tests, sometimes very uncomfortable tests and lots and lots and lots of worrying.

Lifestyle changes -- YES. Shotgun approach to finding early disease -- NO!

The Use and Abuse of Controlled Substances

After you've been in practice for a while you develop different kinds of reputations. Of course you want to be known as a good doctor, a competent doctor, a compassionate doctor. One of the labels physicians learn to avoid early in their careers is that of being a "pain pill" doc. Every new primary care doctor gets a plethora of patients who "need" pain pills and/or addictive anti-anxiety drugs, like alprazolam. If those patients are disappointed you are attributed with another kind of reputation, that of a "hard sell" and those types of patients quit calling.

As practice years accumulate you find yourself in a quandary. Who are the patients truly in pain who need medications, who are the patients who believe themselves in pain but would benefit from less medication and more mental health assistance, who are the true "drug-seekers" and how to tell the difference. It's a lot like the Serenity Prayer, so beloved by AA. Sometimes I need to say the prayer a few times after seeing a particularly difficult patient.

In Kentucky, we use a tool called the KASPER. This way we can see if a patient is going to multiple doctors to obtain controlled substances.  For instance, a few days ago a young woman came to my office that has seen me for years. She is on an amphetamine for Attention Deficit Disorder. This visit was unusual for a couple of reasons. She wanted to increase the dose but had recently been seen in an ER and had been found to have multiple drugs, legal and illegal, in her system. She was pushy, almost demanding, that she have her medication. It made me very uncomfortable so I did a KASPER report. Unknown to me, she had been obtaining the amphetamines from another doctor for a year or more. At least an abuser, at worst she is selling them. I felt used and abused by the patient at this point--angry and disgusted but at the same time sad and disappointed. Hopefully, she will get the help she needs soon, before she ends up in prison.

The AMA publishes guidelines to help doctors make decisions about prescribing these medications. So does the KMA (although these were last published in 1996--given that Kentucky is a state know for it's drug pipeline, it might be time to update them). These are helpful. The other skill doctors learn to listen to is their gut feelings. Unfortunately one's intuition may be swayed by prejudices deep in the subconscious--the place where racism, sexism, ageism, and other cultural influences hide and haven't yet been flushed out by thoughtful self-analysis.

So I turn to another William Osler quote, "Medicine is a science of uncertainty and an art of probability." Add a little wisdom to that and I will hope to make the right decision.

À la recherche du temps perdu

À la recherche du temps perdu is a novel I have wanted to read for years. One volume of it sits and mocks me on a bookshelf in my bedroom along with the other thirty or forty books I would really like to read. In English,  Remembrance of Things Past by Proust is a classic novel about involuntary memory--the act of remembering events in the past brought on by something in one's present. This weekend was filled with "memory", dealing with the beginning consequences of my mother's worsening memory as well as the remembrance of when she had this issue involving her mother, and the fear of my own children dealing with the same in the future.


Like all physicians, the issues that I face at home are frequently the same issues my patients face in their lives. Having many patients around the same age that I am, my empathy can be very acute, even painful. Sometimes I am caring for both the declining parent as well as the child, usually a daughter or daughter-in-law. Over the years I have watched Alzheimer's disease take away the intellect and independence from a patient and helped the caretaker deal with the grief as mom or dad is whittled away to nothing. It's a painful, frightening process, well-illustrated by William Utermohlen's portraits, as he traveled this dark path.

The most frustrating part of the dementia process is the frequent refusal of patients to take any of the meds that help slow the process down a bit. No cure, but sometimes a medication will keep the patient at a plateau of functioning for a period of time longer than if the patient takes no medication. Typically, it is a very hard sell. Perhaps some of the problem is that no one wants to admit it exists. Agreeing to take the medication means they have to face a fear-provoking diagnosis. My own mother becomes vehement in her refusal to take anything. She won't even let me help her get a medical alert necklace or bracelet in case she falls. What is with that? The reasons vary from "they are ugly" "my friend had one and when she fell she was out of range" to "I'll take care of it". Meanwhile I feel as helpless and frustrated as the caregivers I see in my office every week.   


Some days, the Serenity Prayer is the only thing that keeps me sane.

Weight loss

Sometimes the bane of my medical practice day is talking to patients about weight loss. I hate it. They hate it. I dread it. They dread it. My medical assistant tells me how a patient will get on the scale and sigh, then say "Dr. Nieder is going to yell at me." Now truth be told I do NOT yell. But I do try to be consistent with my advice and not ever let an obese patient leave the office without hearing that they would be better off to lose weight. With the overweight patients I try to encourage them to stop gaining weight now before it's too late.

It's not as painful with the patients who understand that one can't gain weight on air, that too much intake and not enough exercise is why they are gaining weight. And it is harder to lose it as the years mount up. In my twenties if I wanted to lose five pounds I would just not eat much for a couple of days. For the last ten years I've been battling the same ten pounds. Five pounds will disappear with lots of effort and the minute I let my guard down, BOOM, the pounds have returned. It's very frustrating. Losing five pounds takes a month of concentrated effort and I HATE IT! It is unimaginable to think of needing to lose 100 pounds.

So I can commiserate with patients who are frustrated but what I can't do is go home with them or go to the grocery store with them. Honestly, it would be a helpful and educational thing to do, for both of us. I stand in line behind 220+ pound people at Kroger's and look at the contents of their baskets. What do I see? "White mushy bread??? 4 cases of soft drinks. Hot dogs (eeeww!) Whole milk. Hamburger helper. Canned vegetables. Cap'n Crunch (I LOVE Cap'n Crunch but I NEVER buy the stuff). Potato chips. No fruits or vegetables unless they are in cans, no whole grain anything, lots of processed foods and all dairy products are full of fat. Seriously?

Yes, it's hard for me to lose those five pounds but I suspect the glass of wine in the evening, the french fries I had for lunch, the con queso I had for dinner last night or the peppermint bark cookie I ate for a late night snack may have contributed to the problem. Your hormones, your thyroid and your mother-in-law did not cause your weight gain. Your diet did. Your lack of activity made it worse, but it is what you put in your mouth that caused the problem. The sooner you can face that and move on, the easier it is on everyone. Tell me that you know you need to lose weight and that you are your own worse enemy and I can empathize. Tell me that you NEVER eat anything, that you've been starving yourself for years and it's very hard for me to help you. No controlled study has ever backed up any claim that people gain weight on air.

People want a "kick start" with pills which occasionally I will acquiesce to. Nine times out of ten, this helps them to lose about five pounds and then they stall out, quit the pills because they are also not the quick fix they'd hope for and five months later they've picked up another five to ten pounds.

After 20+ years of practice I can agree that diets really don't work. Only life-style changes do. Or sometimes, a gastric bypass or similar surgery. When patients ask what the best way to lose weight is, I tell them Weight Watchers because it is a lifestyle change. It is the most successful weight loss program I can attest to after all the years I've been in practice. People who stick to it, lose. Not 20 pounds a month. Sometimes not even five pounds. But consistently over months, the weight comes off. Add a good six days a week exercise program and suddenly people feel great and look great. BUT, it is HARD work. Very hard work. Of course most good things in life are hard work.

To email or not to email...

Using email to communicate with patients is controversial both inside and outside of medicine. Not only have recent articles in medical literature addressed this but the Wall Street Journal published a very recent Yes/No opinion discussion on it. There are multiple issues involved--security, HIPAA compliance (which can involve hefty fines if one is found non-compliant), ensuring that patients understand the parameters for email use, concerns about liability, and time constraints among the biggest that come to mind.

The AMA has published guidelines for physicians that want to use email in their practice. Most of them are common sense suggestions but some are burdensome and difficult to communicate during an already foreshortened visit thanks to the time constraints most doctors have in practice. For instance, I am supposed to "Request that patients put their name and patient identification number in the body of the message." My patients have no clue what their identification number is. I could request their date of birth but at this point they get my email address from my staff or from my business card and there are only five or six people who utilize it. I do print all communication out (since I don't yet have an Electronic Medical Record) and so far I have had no trouble identifying who I'm talking to...Another recommendation is "Instruct patients to put the category of transaction in the subject line of the message for filtering: prescription, appointment, medical advice, billing question." With only a very few people out of my population of 3000 are asking for this type of communication, it's ludicrous to create a strict policy with emails.

It is amusing that the development of these guidelines was prompted by request of the Young Physicians Section of the AMA in 2000 (and it hasn't been updated since 2002). It's amusing because "young" people these days hate email. They use social media, eschewing email as much as possible. That's a topic for another day but I understand that point of view. Email is cumbersome by contrast to Facebook messaging or texts even though it is more professional.  Also of interest is a separate publication by the AMA on the Ethical Use of Email with patients. Also very common sense kind of recommendations but I venture to guess most physicians have no idea this advice is on the AMA site.

So what's my feeling on using email? Well, as I mentioned above, I don't use it with very many people so at this point it is not a big issue. I find that the majority of individuals do not abuse the privilege and have short, to-the-point messages requesting refills or clarification of some minor medical question. The patients are in all ranges of ages, from early twenties to mid-seventies. If the question is too lengthy, I ask them to make an appointment. As mentioned above, I print out almost all emails and put them in their paper charts (what's wrong with that remark!) Emails do not take the place of phone calls because I reserve phone calls for more lengthy explanations of lab results or other tests where I need to be sure the patient understands what I am saying. Really bad news is only given in person, so that's not an issue. So far it's been a helpful supportive tool. It is possible that I'll change my mind as things evolve, or perhaps a social media site will take the place of email entirely. 

In the meantime, those patients who do utilize email to communicate with me really seem to appreciate the opportunity and don't abuse it. It seems like another good tool for bettering patient communication and that's a plus.

E-prescribing

Seriously, any problem reading this?

Unsurprisingly to me, a recent study published by the Journal of the American Medical Informatics Association (http://health.usnews.com/health-news/family-health/articles/2011/06/30/e-prescribing-doesnt-slash-errors--study-finds) determined that there were the same number of errors with electronic prescribing as with written prescription. Same number, but the errors were different. Unsurprising to me because now that I've been e-Prescribing for more than five years I actually make MORE errors on-line than I do when I write them out. Of course this is partly due to the very strict Catholic sisters who oversaw my writing development in the 60's, ensuring that my penmanship was legible. If you don't believe me, ask any of the east-end Louisville pharmacists who have to fill my prescriptions. They LOVE them because they can read them.

Having said that, the study did imply that most electronic prescription errors are correctable IF the software is properly designed. In my own practice, using  an Allscripts product, I make certain errors on a regular basis (sigh):

1. The script is sent to the wrong pharmacy. This is a software error I have bugged Allscripts about for a couple of years now, but it falls on deaf ears. The default setting is to send the prescription to the local pharmacy. There should not be a default, the physician should have to choose either a mail order pharmacy or the local one. This happens weekly and the patients are angry when their medication doesn't show up in the mail (they ignore the reminder call from the local pharmacy). Ultimately, when the medication never shows up in the mail, my office gets an irate call from the patient wanting to know why Dr. Nieder sent the script to the wrong place and now they won't get their meds on time and they will have to pay extra for a 30 day supply (or more likely--go without). But for some reason Allscripts doesn't think this is a problem...
2. It's the right medication but the wrong dose. I often look on the medication list in the chart to choose the dose and if it's not been properly updated the patient gets the wrong number of milligrams. This is usually an easy thing to fix by cutting the pill in half or doubling it, but annoying none-the-less. Hopefully this will improve with electronic medical record documentation...then again, GIGO.
3. The prescription is sent from my computer but never makes it to the pharmacy. This typically occurs with mail order pharmacies. I don't know why it doesn't go "through" and Allscripts hasn't yet provided the physician with an adequate way of knowing when it doesn't make it. Hopefully communication processes will improve and I'll see a little flag on my desktop someday as a notification. As it is, the patient calls and informs us, we go through a lengthy process in the system trying to see what went wrong and then resend it, crossing our fingers that THIS time it works. Yet another situation where the patient will go without or get a temporary supply at the local pharmacy until their medication is mailed.

Ultimately e-prescribing will be a safer alternative for prescribing medications but it isn't quite there yet. It irritates me that there is not a board of prescribing doctors that routinely report to the Allscripts software development group to help make the process more physician-friendly. Instead the company relies on a "Client Connect" on-line community. If you're at all tech-savvy you know that this process is only as good as the people "patrolling" it and since these are not physicians, clinical issues may not be obvious for the IT guys to "get" what the fix needs to be. I've already had this experience talking to the support people with Allscripts.

Soon, I won't just be electronically prescribing, I'll be documenting like many of my colleagues. Something I'm not looking forward to because so far, none of my peers have been happy with the process or the result, all of them have been frustrated and few see the light at the end of the tunnel as anything but a train...

How tired am I of hearing "the Little Clinic"?

OK, I get it that patients are too busy with their lives to "make" time to see me during the day. That's why I have Tuesday evening hours. But those hours aren't enough when one is sick on another day of the week and need to get better IMMEDIATELY. So enter the "Little Clinic". Physicians have finally taken it to heart that not everyone with an upper respiratory illness should get an antibiotic (in fact, MOST people with URIs don't need an antibiotic) thus slowing down the development of superbugs. Unfortunately the "practitioners" (and no, I don't mean doctors) who work at the "quickie mart" brand of medical care offered at drug stores, grocery stores and discount department stores, apparently didn't get the message. If I had a quarter for every patient who got an antibiotic at those places, I'd be happily supplementing my income. Meanwhile my patients are mystified that the amoxicillin or z-pack they got for their cold just isn't "doing the trick". By this they mean that they are still sick after three days.

Who is overseeing these people? I resent that my patients are getting inadequate care and I resent the systems that are bringing this poor care about--employers that won't allow patient sick days (which is what "allowed time off" is--a way to avoid paying sick time), employers that insist their employees work when they are ill, insurance companies that encourage the use of "physician extenders" because they can pay less for that kind of care, entities (like drug stores and grocery stores among others) that are offering poor care so that they can take another slice of the health care dollar, and patients who think a z-pack will cure every respiratory illness.

"One of the first duties of the physician is to educate the masses not to take medicine."
William Osler

Starting a Blog

My daughter does it. (http://panamowa.blogspot.com/). My friends do it. I tried to start one on my hobby, cooking, but somehow it just never got going. Suddenly it hit me--since vocal complaining about the health-care system doesn't seem to accomplish anything, perhaps writing about my patients struggling to care for themselves and their families in a system nearly incomprehensible to anyone outside of it will at least ease some of the angst. Yes indeed, maybe there is a blog in all this just waiting to come out.

As if my life isn't busy enough. But learning a new skill isn't usually easy, isn't always fun but usually worth the effort. To quote Osler, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”

So with not a little bit of trepidation, let's see where this pathway takes me.