Back in 2019 I wrote a piece titled “A Science of Uncertainty and an Art of Probability”. My readers know I like to play with words and I guess many people would think that probability is a science and constantly dealing with uncertainty is an art. I chose reversing the expected words just to illustrate the tension between those two concepts. That particular post has had more views every single following year than the year I published it. It’s like the Energizer Bunny, it keeps going and going.

In frontline medicine, uncertainty is a constant and my own way of dealing with it is to think out loud and explain how I arrive at the conclusions I’m drawing in each visit or communication as a “case“ in primary care isn’t usually a one time deal but can evolve between visits and incoming test results.

There is such a fine balance between admitting uncertainty and instilling confidence. Not enough of either one and you’re dead in the water with your patients. The way to do this is to share your thinking and also volunteer, without bragging, the background knowledge that makes you arrive at the conclusion you arrive at. I once wrote a piece about just that, titled “Clinical Depth: Knowing More than the Minimum”.

So here are those two reflections:

Yes, I was raised in Sweden, but no, I’m not a Socialist. But the irony is that “free” healthcare there is more clearly understood to be directly financed by local(!) taxes that can go up if people in that region consume more healthcare. Here, nobody really knows what anything healthcare related actually costs, or who pays how much, so how can we really care about the cost of healthcare?

Here, most health insurance is financed by employers, and I don’t believe the average American worker is lying awake at night worrying that his family’s medical bills will eat into the corporate profits of his employer. And even if American workers bear some of the costs of their health insurance, the relationship between how much healthcare they consume and how much their portion of the insurance premium or copays/deductibles will go up is less than obvious, depending on who else is insured in the same risk pool as each particular worker’s employer sponsored insurance.

The Swedes have, in spite of their minimal churchgoing, a set of ethics that relates their personal choices to the impact they have on society as a whole. They recycle batteries instead of throwing them away, they worry about air pollution – so much that it is illegal to idle your car for more than 60 seconds, for example when the bridge over the canal in my home town opens to let a tall ship through. My former countrymen also care deeply about how waste in the healthcare system can affect the availability of healthcare for vulnerable people.

Another thing they are more sensitive about than we are over here is corporate greed. The examples on this side of the Atlantic are so many, and occur so frequently that we soon forget each individual case. What we do retain is the regrettable sense that healthcare is a dirty business where someone is always taking advantage of someone; providers cheat Medicare, insurers cheat patients, drug companies cheat them all.

What we need in this country is a moral wake up call, whether that comes as a crisis or a disruptive innovation. It is obvious that Government regulation and oversight has done relatively little to reduce the “Wild West” behavior and mentality of the big players in our “industry”.

The first thing we need to do is scrap the concept of health insurance, because insurance is when something expensive but unusual and infrequent is paid from a pool of money that a lot more people pay into than withdraw from. In America today, everybody draws from that pool of money, even for things that are completely predictable, like having a baby or even an annual physical (except if you have Medicare, and then you get a Wellness Visit, but that’s another story). That means every single transaction of healthcare in this country becomes a profit center for one or more types of middleman, who most of the time adds little value but draws handsome revenue from what they do.

If we are trying to cover everybody for everything, let’s call it what it is, Socialized medicine. But are we ready, today, for a society where we all stop and consider the common good before we ask for that MRI, “just to know what’s going on”, or where drug prices are negotiated between a “single payer” like CMS or each State Health Department and the drug companies?

I believe the citizens of my adopted homeland prefer to have more freedom of choice than a Socialist system usually offers, and I believe that by having both the ability to choose and the responsibility to pay for services, we can make the healthcare value equation come out more even.

And, I’m sorry, but if we reign in the excesses of insurers and drug companies, American patients may act more responsibly, but as long as patients have the feeling that gauging, fraud and abuse continue to be rampant in the industry, there will be no loyalty between patients and “the system”.

Then, our only hope will be a post-apocalyptic Direct Primary Care model, which is just as American as the corporate model. Come to think of it, maybe even more so…

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.

Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)

DISEASE PREVENTION AND SCREENING

You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.

My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.

I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.

What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.

(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)

Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.

All that is very different from the stilted pseudo-comprehensiveness of medicine in America today.

First, those in power think that we can cover each patient’s presenting concern AND all appropriate health screenings, immunizations and other public health issues, along with the latest protected-minority-and-political-correctedness inquiries, in our typical fifteen minute visits.

“They”, whoever they are that decide coding standards, Patient Centered Medical Home standards, Meaningful Use standards, EMR workflows and the general purposes of life in medicine, have, in their inscrutable wisdom, decided that all of these items are best addressed by administering standardized, “validated” questionnaires every time we see each patient, just like even a patient with a dozen prescription medications is supposed to get a complete medication reconciliation every time they walk through the door, even for a hangnail. At twenty seconds per medication, that would take up four of our precious fifteen minutes, just for starters.

“But not all of this has to be done by the physician”, goes the refrain. “Team members, practicing at the top of their license, can do this”.

Right, have a medical assistant who never took a day of pharmacology reconcile medication lists, and trust that they know that Compazine is prochlorperazine, Trilafon is perphenazine, Phenergan is promethazine, and Thorazine is chlorpromazine. And, that metoprolol tartrate is a 12 hour drug, while metoprolol succinate is taken once every 24 hours and that bupropion comes in short, intermediate and long acting varieties.

And, right, keep telling me that a two or nine item questionnaire administered in rapid-fire fashion during check-in will outperform a trusted physician leaning forward, asking a long term patient “how are you feeling?”

And, right, tell me how much a woman with pneumonia appreciates being cornered for her overdue Pap smear when she’d rather just get an antibiotic and some cough medicine and crawl back under the covers for a few days.

And, right, tell me the local pastor is going to be forthcoming with a medical assistant he also sees in the second pew from the back of his church every Sunday as she probes his alcohol habits while pumping up the blood pressure cuff.

And, right, that new patient with anxiety and heart palpitations is going to feel much more reassured after her EKG and careful history and physical and a thorough discussion about whether or not she would want to be resuscitated if her heart were to stop suddenly.

Doctors have been doctoring for thousands of years and we have learned a few things along the way. Medical progress usually comes to practicing physicians via scientific research and from the major teaching institutions.

Since when do we really think it will come to us from bureaucrats, statisticians and other nonmedical sources?

Now, with studies to support their use in anxiety, we are pressured to prescribe them, since they, unlike benzodiazepines, are said to “get to the root of the problem”. But do they get to the causes of either anxiety or depression?

Even before Prozac, my medical school courses in psychiatry, back in Sweden, taught the distinction between endogenous depression, treatable with the tricyclic antidepressants of that era, and exogenous depression, which only the Americans chose to treat with drugs. The Swedish opinion was that depression due to external factors should be treated by addressing those external forces or the patient’s cognitive-behavioral reaction to them.

Depression, along with other mood disorders, has earned the alternate name of “chemical imbalance”, even though we really don’t know all that much about the chemistry inside the blood-brain barrier. The new moniker does help justify choosing medication over exploring the psychological reasons behind the symptoms, though. Never mind that the efficacy of medication alone is only marginally better than placebo. And never mind that therapy along with medication has a much better success rate than medication alone. We truly are just treating symptoms empirically with these drugs. Worse still, our understanding of how our current medications work is very incomplete. For example, fluoxetine and sertraline are said to treat depression by inhibiting re-uptake of serotonin in synapses of the brain. Yet, in Europe there is a drug, tianeptine, that instead enhances serotonin re-uptake, and it also helps depression, so two opposite drug mechanisms seem to bring about the same clinical result.

Psychiatrist Steven Reidbord blogs about how more and more diseases have been snatched away from the psychiatrists’ realm as science pinpoints their causes. He concludes that there will probably always be conditions with unknown or uncertain neurobiological mechanisms that only psychiatrists, with their tolerance for uncertainty, have the patience to treat.

Today, in primary care, urology and many other specialties, symptoms are what we treat all day long, it seems. From overactive bladder and erectile dysfunction to myofascial syndrome, restless legs, neurodermatitis and insomnia, we have the drugs but not quite the understanding of how and why they work. In many cases, several possible mechanisms seem to lie behind each symptom.

The old-fashioned notion of “syndrome” applies here; we recognize clinical constellations of symptoms, but we often don’t have a straightforward cause isolated. We have empirically established treatments that work at least some of the time, but we often don’t know why. In many cases, clinical syndromes are relegated to the sidelines, even when there are available treatments, unless those treatments are brand-name drugs. More than once, pharmaceutical companies have made obscure syndromes, such as Restless Leg Syndrome, famous in order to promote a new drug, even if the drug is not always effective, as it doesn’t quite seem to address the root cause of the disease.

This reminds me of the medical school professor, who during morning rounds on his top floor ward at Uppsala Academy Hospital dismissed many patient concerns with the words “I treat diseases, not ailments”.

Times sure have changed.

Today, ailments are honorable to treat. We talk about improving or enhancing quality of life. Ailments are also now big business. Myrbetriq, for overactive bladder, costs $250 per month; Viagra, for erectile dysfunction, $28 per pill; Lunesta, for insomnia, $280 per month, to name just a few examples.

In this era of genetic and neurobiological advances, we are sometimes naively optimistic about the depth of our understanding. We like to think that we have moved beyond treating symptoms, but even when we prescribe statin drugs or stent blocked coronary arteries, we are not even attempting to address the causes of coronary artery disease, for example.

So, maybe only a select few subspecialists among us can say that they only treat diseases and not ailments, or symptoms; most of us do a lot of it. For every new scientific breakthrough, there seems to be a handful of empirical discoveries of something that sometimes works, even though we don’t know why.

Dr Reidbord is not alone in living with the uncertainty of treating symptoms of unknown cause; welcome to the world of primary care.

(I put “patients” in quotation marks, because I wonder if we should use that word for people who aren’t sick…)

In many cases, we have ended up with disease-like names, and drug based treatments, for these risk factors. In reality, many other things besides drugs can modify these risks, but our “scientific” paradigm mostly recognizes double blinded trials of medications and undervalues other approaches.

Cholesterol and heart disease are prime examples of how simplistic and ignorant we have been and how “medicalized” our thinking has been:

While extremely high cholesterol sometimes is a genetically determined abnormality, for example Friedrichsen’s hyperlipidemias, garden variety high cholesterol is a laboratory abnormality that evolves and can change according to a person’s diet and lifestyle.

For decades now, we have treated “high” cholesterol with statin drugs, and we now have statistical “proof” that they reduce a person’s risk for strokes and heart attacks. This is the case even for people with “perfect” cholesterol, but the absolute risk reduction isn’t as impressive as the relative one. After all, half of next to nothing isn’t as impressive as half of a very large number.

But, and we know all this although we don’t talk enough about it, since non-statins like ezetimibe (Zetia) can also lower cholesterol without giving anywhere near the same degree of risk reduction, it’s not really about the cholesterol reduction at all. Every day I rattle off to patients that the statins stabilize and prevent rupture of cholesterol plaque, prevent plaque buildup in the first place, prevent blood clots via a mechanism different from aspirin and prevent contraction of the little muscles in the walls of coronary arteries that cause coronary spasm. And I explain that although we know these mechanisms exist, we can’t measure their effects in patients. I also mention that in older persons, a Mediterranean diet causes about the same risk reduction as statin drugs do in middle aged people. It lowers cardiovascular mortality by 30% compared with the old standard low-fat diet.

The new lipid guidelines have a calculator that provides a ten year cardiovascular risk. That helps people by providing a risk number they can relate to, but then the “experts” arbitrarily decided that people with 5 or 7.5% ten year risk should be on low or high dose statins, respectively. The only problem is that all men over 67 or so should be on drugs. Common sense gets in the way of adopting that one, at least in my book. When age as a risk factor outweighs the truly variable measures, like blood pressure, shouldn’t we modify or scrap our disease paradigm?

Another example of a questionable “disease” is osteoporosis. The average woman’s bone density enters the osteoporosis range somewhere around age 80, and the average 60 year old woman has osteopenia. The universally accepted “T-score” compares everybody to a 20 year old. The “Z-score”, on the other hand, compares women to individuals their own age. [UPDATE 2026: MY LOCAL RADIOLOGY DEPARTMENTS NO LONGER REPORT Z-SCORES.] Today’s guidelines suggest labeling the average baby boomer woman as having a disease, also many women with better than average bone density. So we are told they are candidates for more or less scary but certainly not innocuous medications.

That reminds me of my residency days, when I would get my hand slapped if I didn’t put every postmenopausal woman on estrogen, because she was obviously estrogen deficient, and we even had the blood tests to prove it. The theory was that since older women had more heart attacks than younger women and the biggest difference(?) between them was their estrogen levels, all we had to do to wipe out heart disease in postmenopausal was to prescribe them a lifetime supply of estrogen.

What happened, as the Women’s Health Initiative demonstrated, was that older women on estrogen plus progesterone (to protect from overstimulation of her uterus lining and subsequent endometrial cancer) had MORE heart attacks, strokes, breast cancers and blood clots than those who allowed their natural aging process to continue.

Today, the same thinking takes place with men and testosterone as the pharmaceutical industry continues its quest for the fountain of youth.

The ultimate question is to what degree aging is a disease and whether it should be the priority of the medical professions, pharmaceutical industry and our insurance system to fight it.

Rummaging through medical textbooks and notebooks from medical school in my library the other day I rediscovered a compendium that I had almost forgotten. I was one of the editors of this 256 page down and dirty guide for what to do when starting your internship. After I moved to this country, I learned that there already was such a book over here, called the Washington Manual. But back in Sweden in 1979, I was one of the editors or what we should have called the Uppsala Manual.

In Sweden, you can work as a physician, although under supervision, during the last two years of medical school and many of us had done that in different specialties. I had worked in nursing homes and in urgent care. My urgent care shifts were in a side wing of a small emergency room a short distance from Uppsala, where I lived. My shift started Friday 6 PM and ended Monday morning 6 AM. The triage nurses would decide which patients needed to see the emergency room for all the services they offered and which patients could be seen in the urgent care clinic next to it.

I loved that job.

Many of us in my medical school class got together to create an intern’s pocket size reference guide for what to do in common situations. This was based on what we learned in medical school and what we learned in our early practice positions. After I moved to this country, I found that there were a few similar books published by commercial publishing companies here, but there was no such thing available in Sweden when we graduated from medical school in 1979.

Looking at this book today, there are some striking differences in approach, partly based on evolving understanding of disease processes and also, of course, because of new imaging possibilities and new pharmaceuticals to treat disease.

In a future post I will give some examples that may seem quaint or even odd reading them now, 45 years later.

Most people know about head lice, pubic lice, scabies and bed bugs, maybe even chiggers. A few search the web and know of other conditions, like Morgellons(whatever they really are) and demodex, which is a much more common mite than I would have guessed.

I’m trying to formulate a strategy for helping those who know more and will not accept the possibility that they just have dry, itchy skin. But, I’m thinking I might just make them worse if I tell them what my own research is telling me.

I think I’ll have to start with a reminder about everybody’s intestinal flora, our biome. There are many trillions of organisms living inside us.

Obviously, the bacteria in our intestines help us digest our food. We couldn’t live without them. Minor troubles caused by them might be our moods and appetite or cravings. Major troubles from unwanted intestinal bacteria includes diarrhea and death from dysentery or clostridium difficile.

Having said that, I guess I’ll go on to say that a lot of people have mites, but they’re too small to be what they’re seeing. And when it comes to some mites, they’re impossible to eradicate.

Demodex, also called face mites, live in our hair follicles and some sources say most people have them. Usually they cause no trouble. They may have a role in skin conditions like blepharitis, conjunctivitis, chalazions and also rosacea, sometimes referred to as adult acne. Treatment, when someone has many of these mites and bothersome symptoms, is usually only topical. Cliradex may be the best one but ordinary Tea Tree Oil, which it is derived from, is also effective.

As I’ve been reading up on face mites, I haven’t come across anything good they do for us. So I think I may be speaking for most of us when I say that I’m grateful for my intestinal flora for helping me get the nutrition out of the food I eat. And, those bacteria are, well, in my gut and not in my face, which is where my demodex freeloaders are literally hanging out.

It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.

When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.

What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.

Whether you are treating patients, coaching athletes, raising children or housebreaking puppies, the most effective way to bring about change is just about always incremental. We need to keep that in mind in our daily clinic work. Small steps, small successes create positive feedback loops, cement relationships and pave the way for bigger subsequent accomplishments.

Sometimes I avoid the biggest “problem” and work with patients to identify and improve a smaller, more manageable one just to create some positive momentum. That may seem like an inefficient use of time, but it can be a way of creating leverage for greater change in the next visit.

I actually think the healthcare culture has become counterintuitive and counterproductive in many ways; it helps me when I focus intensely on the patient in front of me, forgetting my list of “shoulds” (target values, health maintenance reminders and all of that) and first laying the foundation for greater accomplishments with less effort in the long run.

I once wrote this about how I try to start each patient visit. And in my Christmas reflection several years ago I wrote about the moment when a physician prepares to enter an exam room:

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

It’s all about the patient, the flesh and blood one in front if you in that very moment and what he or she needs most from us today. In physics I learned that you get better leverage when your force is applied a greater distance from the fulcrum. In human relationships and in medicine it is the opposite; the closer you are, the greater leverage you achieve.

Today, an “admin” day, I took a call from his wife. They switched insurance January 1 and could no longer use the medical supply company they had been dealing with for years. He was running out of colostomy supplies. I promised to try to find another supplier, knowing there are fewer and fewer companies that deal with that in Maine. I told her I would call her back when I located one.

45 minutes later I was able to call her back with the report that she would have to have them shipped from an out-of-state company operating nationally, and the three that I had found in my search had very mixed reviews by their customers.

This took a huge amount of time, but there was no way I could delegate this on a Friday afternoon. My own Health Advocate is out until Tuesday and the other two were doing home visits with and for their provider.

So my patient and his wife will research these companies and get a message back to me tomorrow, Saturday with their choice of vendor so I can put in the order.

I think I invented the term Metamedicine back in 2014. Here is that post. Note that the ICD 9 diagnostic codes have been replaced by ICD 10 since then.

https://acountrydoctorwrites.blog/2014/07/24/medicine-is-easy-but-metamedicine-is-hard/

I don’t think we know yet if our chronic lifestyle diseases like obesity, diabetes and heart disease will increase, decrease or stay the same. But it is certainly bewildering to see us step back in time when it comes to infectious diseases.

If large numbers of Americans lose their health insurance, their food stamps or even their jobs, more bad things will happen to the state of health in this country. For example, how can people eat healthier on a smaller food budget?

With cutbacks and eliminations by Executive Order of the institutions that monitor disease trends and guide interventions, will we even know what’s going on? Will we have competing/alternate views of the reality we live in? That trend started before our regime change. Did the mRNA vaccines ultimately help lessen the severity and mortality of Covid, or would the virus have mutated in a benign direction anyway? I, for one, believe they helped, but that’s not what everyone believes.

And whatever one thinks of abortion, gender identity and the other LGBTQ societal trends that have evolved over many years, I find it almost mind blowing that the clock has been turned back to such a degree in so little time, not by consensus but by small voter margins and politically appointed Supreme Court Judges in today’s extremely polarized political climate.

As a physician, I have always avoided talking politics in my patient encounters, but that is becoming harder and more and more ethically problematic right now.

Happy New Year 2026 – or is it?

I had to search far back in the medical record for the referral. It was sent in January of this year, almost a year ago. The virtual fax contained about 25 pages of some brief notes and messages and a lot of laboratory reports.

Before opening that fax, I went into the lab section of the medical chart and there was a mildly elevated PSA result from January. This made me think that the reason for the referral was the elevated PSA, possibly indicating a significant prostate problem.

Quickly going through the 25 pages in that fax I did not see the PSA level. And the fax did not contain a headline to indicate the purpose of the referral.

Two things are striking about this incident. One is the lack of brevity in the referral our office sent out. The other is the lack of urgency on the part of the urology office in getting back to us questioning what the purpose of the referral was.

As far as our referral, I think it’s crucial to say what the main problem or question is. The other important thing is not to send too much information.. In our state just about every hospital laboratory uploads their results to a statewide database where any doctor can look up those results. This makes faxing lab test and x-rays almost unnecessary. Not all practices upload their office notes, though, so we have to be cognizant of that.

Everybody is pressured in today’s healthcare environment. There’s so much to do and so little time. Everywhere in our society, the attention span is dropping. I found it mind blowing that the urology office took nine or 10 months to raise the issue of what the referral was for, but I’m not completely surprised. They say that you have eight seconds to make a first impression when you meet somebody and in writing, everybody’s looking for a catchy headline. I mean, who would read a novel or even a short story with no title?

I think brevity in medical communications is a virtue. American healthcare today has all kinds of documentation requirements that don’t necessarily speed up the handling of medical issues. Unfortunately, the referral letter and the specialist response have almost gone by the wayside. They used to be valuable exchanges between colleagues, dictated, printed on fancy stationery and signed in ink. EMR’s don’t always accommodate for that type of exchange.

Let me go back and look at what I’ve written about referral letters before…

Norm and Clara Anderson chose Dr. Wheeler as their family doctor once they had made the decision to relocate to Maine and raise their family away from the big city. The process of choosing a doctor reminded them of working out where to live. That was twenty years ago, and Dr. Wheeler has seen them and their two daughters through childhood illnesses, one heart attack, two cancer scares, Clara’s bouts of depression and irritable bowel syndrome, and their youngest girl’s struggles with migraines. A graduate school student near Boston now, Holly still checks in with Dr. Wheeler when she visits her parents. The Andersons sometimes reflect that Dr. Wheeler is like a pastor and a friend, and not just their family doctor.

Dr. Brockman is part of a big group of orthopedic surgeons now, and Mountain Memorial has merged with Countywide Health Systems. Uncle Will’s children know that Dr. Brockman still does top-notch work, because his outcomes are posted on the Internet.

Dr. Wheeler also works for Countywide Health Systems these days. He sometimes jokes that he is a healthcare factory worker now, and the Andersons get to rate him every year in Countywide’s patient satisfaction survey. Asked if they thought Dr. Wheeler delivered high quality care, they answered unequivocally yes.

Dr. Wheeler gets graded on how many of his patients reach targets like immunization rates, blood pressure levels and average blood sugars. He also gets graded on how many of his diabetic patients are prescribed ACE inhibitors, and how many men with heart disease, like Norm, are taking aspirin and beta blockers.

The Andersons understand the importance of these quality metrics but they are confused about why Dr. Wheeler’s diagnostic skills aren’t on his report card. He was the one who diagnosed Clara’s IBS after two of her previous doctors failed to do so. He also found Clara’s pheochromocytoma, the very rare tumor that presented as a slight vibration Norm could feel when he put his arm around Clara’s waist in bed at night. He also seemed to know the diagnosis the instant Norm arrived at the clinic with his heart attack, even though his only symptom was nausea and even though Norm had passed a stress test for work the month before.

Clara thinks Dr. Wheeler has worked miracles with Holly, her youngest daughter. She was a shy and insecure girl with crippling bouts of vomiting. Dr. Wheeler diagnosed the spells as migraines, tried and succeeded in preventing them with medications and he gave Holly a sense of control over them by helping her identify her triggers. He seemed to spark a scientific talent in Holly that is now becoming her career and life passion.

On TV the other night, Norm and Clara saw the Chief Executive of Countywide Health Systems talking about the future of healthcare. He pointed to statistics from their surgery department that outperformed every other health system in the region. Then he spoke of primary care. He showed the rates of compliance with dozens of guidelines, and he pointed out that the new systems Countywide had begun to put in place throughout all of its primary care offices were going to bring quality in primary care to new and even higher levels.

The executive went on to say that healthcare cannot rely on mom-and-pop individual doctors offices or exceptional efforts by superclinicians to deliver the quality healthcare America needs now and into the future. Just like in aviation and manufacturing, process design and quality measurements are the key elements that will raise quality standards and eliminate human error as well as unnecessary variability in healthcare.

Next up on the evening news was an in-depth story on the corporate culture within General Motors that allowed faulty ignition switches to be installed in millions of cars over so many years.

The next story was about the Veterans Administration scandal over forged waiting lists that had tried to cover up the long waits for access to healthcare in the VA system.

Right before the weather was a piece about how long it has taken this country to recover from the collapse of the banking industry and the fines paid by some of the top banks in recent years.

“I wonder how all this corporate medicine and process design talk will affect Dr. Wheeler. They may not think they need superclinicians, but I’m grateful we’ve had one for the last twenty years”, Clara said and turned to her husband.

I was wrong. There is a Thanksgiving Sunday in the Lutheran Swedish state church (shows you how much I attended when I was living there). It takes place in early October and is a celebration of the harvest. In the old days farmers would bring wheat, potatoes, carrots, rutabagas, apples, and other crops to share with the less fortunate in their congregation or village.

Since moving to America, I have more and more embraced Thanksgiving. This year, I even have two Thanksgiving celebrations, one with my lady friend and her large extended family in Van Buren on Thanksgiving Day and one in Bangor on Saturday, when we will join my children and grandchildren for a belated Thanksgiving because my daughter works on Thursday.

I just reread some Thanksgiving reflections that I originally published in 2016 and 2017. I’m linking to them below. Other than the chronology of how long I’ve been here and so on they still describe pretty well how I feel about my life and my choice of living in this country and doing the work I’m doing.

Because healthcare is so much about public health, prevention and chronic disease management these days, diagnostic acumen is an underestimated skill in my opinion.

Diagnosis is the foundation of sick care, the oldest iteration of the practice of medicine. Half a century ago, many specialties involved more diagnosis than treatment. Neurology seemed to have very little in the way of treatment to offer back then, for example.

When I was a first year medical student, our university hospital didn’t yet have a CT scanner; the brain CT was introduced in Sweden the following year. The full body scanner came to Sweden in my third year.

So a thorough clinical history and bedside physical examination were the fundamental tools in the diagnostic process. I learned lung auscultation from a couple of old pulmonologists with experience evaluating tuberculosis patients. They were experts at percussion, the almost forgotten technique of listening to the sound created by tapping on the chest wall. People said they could draw a picture that predicted what a patient’s chest X-ray would look like.

We certainly have better imaging capabilities now, but so many diseases don’t show up in pictures. Take movement disorders, headaches, even chronic belly pain. Symptom history and simple observation and examination have not become obsolete.

In our everyday practice, we see diagnoses play many different roles for us as medical providers, for our patients and for the organizations we work within as well as for insurance companies and ultimately Uncle Sam.

A DIAGNOSIS CAN OPEN DOORS

A patient of mine with chronic respiratory failure on oxygen 24/7 was bothered by thick sticky phlegm. Maximum doses of guaifenesin did not help her raise much of it. I wanted to try an old nebulized medication called acetylcysteine. It required a prior authorization. The diagnosis I assumed would qualify her was chronic respiratory failure with hypoxemia, J96.11. The prior authorization was denied. I managed to find a list of diagnoses that would cover this medication. It turned out that the much less ominous ICD 10 code for unspecified emphysema, J43.9, got it approved.

I think this is a fairly random ruling by Medicare. But little things like that fill our days. Knowing what diagnosis covers what in terms of qualifying for a test or treatment is part of a bigger phenomenon that I call metamedicine. Another example of metamedicine is that even though heart failure can typically cause shortness of breath and/or swelling of the legs, Medicare pays for the blood test BNP that we use to diagnose and quantify heart failure only if there is shortness of breath; leg swelling will not cover it.

A DIAGNOSIS BRINGS MONEY TO PROVIDERS AND INSURANCE COMPANIES

Because so much chronic care is managed and measured, it has become increasingly important to predict how costly each diagnosis is per year. This requires a degree of specificity when choosing the ICD 10 diagnostic codes. The more severe ones give you more “points“. And Medicare does not retain the codes over time. Each year they need to see a claim with active condition codes in order to predict their expenses. And now more and more they pay providers either directly or by making them earn or not earn bonuses if the cost to care for a patient is higher or lower than anticipated.

A diagnosis of depression with no indication of it being severe gives you no brownie points and no extra money in your pocket. Diabetes with complications is more profitable than diabetes without complications. And if we don’t assume that a person‘s mild to moderate chronic kidney disease is actually secondary to their diabetes, we lose an opportunity to score.

A DIAGNOSIS CAN SAVE YOUR LIFE OR MAKE YOU MISERABLE

Low-dose CT lung cancer screening and mammograms are examples of screening tests that may prevent getting a diagnosis too late for any hope of cure. Screening for Alzheimer’s disease isn’t likely to open doors to any radical and successful treatment. Some people might modify their disease trajectory by lifestyle changes, but how many of us would want to live the rest of our lives with the knowledge that we will come down with a disease like that? The benefit of prostate cancer screening has been debated for decades and one thing I learned in my training that still seems to hold true is that you may have to treat around 35 men for prostate cancer to actually save one life. The downside of treatment side effects, and also knowing that you have a cancer, even if most people don’t die from it, is something we may not be able to predict the effect of when we decide whether to screen or not.

A DIAGNOSIS CAN ELIMINATE THE SUFFERING OF UNCERTAINTY

For most clinicians, it can seem obvious that an annoying symptom that has lasted for decades is quite likely something harmless. That’s not how all patients see it. So many times I have found that an appropriate diagnosis or explanation of why they feel what they feel helps people stop worrying. As a primary care provider, we have to live with ambiguity and uncertainty, but that’s not how all human beings are made up. The closer we can come to a reasonable medical explanation of a symptom, the more we can help our patients get on with their lives and help themselves navigate their symptoms by developing an understanding of what makes them feel better or worse.

DIAGNOSTICIAN MAY BE AN EMERGING NICHE SPECIALTY

One of the greatest compliments I ever had, actually more than once, was “he is a brilliant diagnostician”. Maybe AI can help clinicians with less training make more accurate diagnoses as technology moves forward. But, now there is talk of making American medical school three years instead of four, even before medical AI is completely ready for prime time.

My Swedish medical school training was 5 1/2 years. After that, I did a two year rotating internship and then a three year family practice residency in this country. I have been a board certified family doctor for 41 years. I do love a medical mystery and have to confess that following treatment algorithms for chronic diseases all day long can be pretty boring. So at this stage of my career, it would be nice to be the in-house diagnostician who helps point patients care in the right direction. Maybe with an increasing percentage of primary care providers having shorter and increasingly even online training, diagnostic physician will become a new niche specialty?

Read Lilian White’s essay here:

I read an interesting and a little provocative article in JAMA this weekend, Critical Thinking for 21st-Century Medicine—Moving Beyond Illness Scripts by Richard M. Schwartzstein, MD; Alexander A. Iyer, ScB.

In the opening paragraph, they describe diagnostic errors this way:

Most diagnostic errors involve common diseases the physician did not consider rather than rare diseases the physician did not remember; they are thinking errors, not knowledge deficits.

They then start out describing how much of medical education views diagnosis as relying on pattern recognition. They describe it as “Illness scripts”, trying to match up the patient’s presentation with differential diagnoses and then ranking these by probability. AI uses pattern recognition and can be very good at it. But the authors advocate using a more pathophysiological way of reasoning. This sounds to me like taking a step away from the knee jerk rattling of differential diagnoses and envisioning what the processes are inside the body that could cause a given symptom, before naming a plausible diagnosis.

They continue:

Educators can cultivate adaptive expertise by focusing less on pattern recognition and more on teaching learners to engage in critical thinking, starting from foundational principles of human biology and pathophysiology. In particular, instead of asking trainees to move directly from a patient’s clinical presentation to differential diagnoses, educators can push trainees to develop testable, intermediate hypotheses that explain a patient’s presentation in terms of pathophysiological processes.

I can think of two cases in my career that I have written about, where I pondered what could be happening inside their bodies and arrived at the correct diagnosis, albeit not instantly. Both were patients with shortness of breath whose final diagnosis wasn’t one of the commonest, but certainly not esoteric, Two Red Herrings from 2011 and An Uncommon Cause of Shortness of Breath from 2021.

My next post here on Substack will be another reflection on DIAGNOSIS - and that one will be an early and late career collaboration with Lilian White, MD.

I think that title is brilliant. I also think it is depressing – when did doctors offices stop being solution shops? Because they weren’t always production lines. Rereading my piece, I don’t believe much progress has been made in shifting the framework for how a medical practice works.

One frightening thought that comes to me when I think about the healthcare climate today is that medical practices may be becoming even more like production lines than they were a few years ago. Today’s solution shops seem to a large degree to be freestanding non-provider entrepreneurs. I see them position themselves between the medical practices and the payers/insurance companies with promises to get better results or more savings by data mining, analyzing and influencing provider behaviors and performance.

I also see niche medical practices who provide specialized services, like supporting or even managing the care for patients with respiratory illness, obesity or other high Total Medical Expense (TME). For pulmonary patients, they typically provide phone support, video coaching of inhaler techniques, etc.

There are also companies that analyze insurance claims for prescription refills and send reminders to PCPs that a heart disease patient hasn’t filled their statin drug that should have run out two weeks ago. Such things lead to lower quality scores for us, even if the patient was in the hospital with a serious infection and got their cholesterol from the hospital pharmacy, for example.

Those types of middlemen, or whatever you want to call them, seem to be where the action is today, while many medical practices struggle with high costs, low reimbursements, staff shortages and burnout.

The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.

The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.

(Writing this piece, I came across the news item that the Hotel Rossiya, once the biggest hotel in the world, was demolished in 2006.)

From that first morning on, everything I encountered felt dim, dark and repressive. I saw with my own eyes that Sweden’s degree of uniformity was nothing compared to the Soviet Union’s, which some of my classmates, communists and former Viet Cong supporters, had spoken well of before we got there.

During our stay I saw dilapidated hospital wards and surgical suites with antiquated medical instruments in scarce supply, which we couldn’t even all see because of a lack of scrubs and booties. We saw bare-bones ambulances staffed with underpaid specialist physicians, neurologists for stroke victims, for example. I thought being a doctor in the Soviet Union seemed like one of the most depressing things you could end up doing for a living.

I yearned for the freedom and optimism I had seen back in 1971, when as an exchange student I fell in love with America and a girl I met in my high school sociology class.

During my high school year here, I got the impression that almost everybody in America had a personal ambition, like making music, writing a book or starting a business. I saw a service mindedness I had not seen in Sweden, where years later I saw the epitome of that in a restaurant near the Arctic Circle that closed for lunch (for the staff) from 12 to 1 pm every day.

In America I also got the impression that the rules of society were not exactly cut in stone the way there were in Sweden. Due dates seemed a little flexible, rules seemed to have countless exceptions; even spelling of the American language seemed to offer a few individual choices.

Doctors in America were mostly in private practice. I didn’t see much of American healthcare that year, except the afternoon reruns of Marcus Welby, MD that I devoured. It ran from 1969 to 1976 and it solidified my vision of being a primary care doctor in America.

Fast forward twenty years, to 1991, the year the Soviet Union collapsed. The Planned Economy proved itself to be an unsustainable daydream of the social engineers of communism.

That year I had lived in this country for a decade. My work in a Federally Qualified Health Center, part of a safety net that offered subsidized or free care to people without health insurance, had shown me the inequalities and health hazards of “the other half” of American society. I felt proud to be part of such a clinic, providing equal access to everyone.

During the ensuing two decades, the Federal agencies that paid our grants and provided our preferred reimbursement rates started to micromanage what we did and how we structured our work. My original liberated experience of American healthcare turned into a sense that the bureaucrats mistrusted doctors and administrators of FQHCs so deeply that they had to structure our work for us.

The crowning event was when we all more or less had to earn recognition as “Patient Centered Medical Homes”, which at first sounded like we needed to make our practices Marcus Welby-like. Instead, PCMH was not really about nimbly meeting your patients needs but about creating rigid protocols that in fact made it hard to improvise. This was followed by many other initiatives that to a small or larger degree lacked firm anchoring in the reality of front line medicine and became virtual shackles for medical practices.

This hampering of improvisation in how you meet individual patients needs felt strangely familiar, and brought back memories of that cold December morning in Moscow:

Tea or Coffee, but not both.

Save one same day slot and qualify for easy access recognition, double book freely and fail the access parameter (no “protocol”).

And then when Uncle Sam wanted our “data”, presumably for better central planning some day, we were given grants to computerize our patient records with numerous qualifiers about how to use these computers. “Meaningful Use” broadly sounded like a good idea, except the technology was immature.

One example: Patient information about their medical condition, if generated by the EMR software, often amateurish and rudimentary, gives us Meaningful Use brownie points, but high quality handouts from sources like Up to Date, Harvard or the Mayo Clinic don’t count.

Another Federal shackle: Uncle Sam wants us to deliver comprehensive care, which includes screening for a growing list of clinical and societal issues, like depression, alcohol use, domestic violence, sexual orientation, food insecurity and so forth. If we don’t do all this, we lose brownie points. Consequently, we hesitate fitting infrequent visitors into our clinic schedules, because you can’t possibly do all that in a single visit for a sore throat, so we look better if that patient goes to a walk-in clinic – one ding on the Access parameter instead of numerous dings for all the other ambitious comprehensiveness requirements

I am sorry to report that the well meaning bureaucrats of the Central Planning Office are making American Primary Care feel more and more like the Soviet Union of Lenin and Marx where people mattered as populations, perhaps, but not as individuals. That is not the way Americans think. They don’t want to be told what to drink with their breakfast and they don’t want to be told what the agenda is for their next doctor’s visit.

Collapse or profound disruption seems inevitable.

Joey seemed different from other babies early on to his previous provider. His doctor was Barbara Brennan, my good friend and colleague, who ended up giving up her career as a doctor because of her own health. Her early office notes, referral letters and the various specialist reports read like a medical mystery novel.

Joey didn’t reach his developmental milestones; his eyes didn’t seem right and he had an unusual, broad grin, which he always flashed. By age two he was diagnosed with Williams Syndrome, a rare genetic disorder that affects one in 7,500 newborns.

Joey, in typical fashion for Williams Syndrome children, is extremely gregarious, even with strangers. He is a favorite with the nurses. He isn’t potty trained, cannot make three word sentences, and cannot make age-appropriate drawings.

His parents elected to give him the 4-6 year-old shots yesterday, and he protested loudly. Immediately afterward, he wanted to kiss the nurses.

Yesterday afternoon I saw Marguerite Brown, an eighty-three year old woman with stubborn blood pressure and skin problems. Two months ago she had told me that her daughter, Molly DeLorme, had been diagnosed with inoperable cancer. I have been Marguerite’s doctor for ten or fifteen years, and never realized that her daughter was the woman who wallpapered our house a couple of years ago; after all these years practicing in this community I am still finding out that people I have known for years are related to each other.

Last week I had seen Molly’s obituary in the paper. The same issue of our local paper had a little “In Memoriam” piece about a six-year-old patient of mine, who was killed by falling logs several years ago. His parents are still struggling with their loss.

Marguerite Brown was somber, naturally, as I entered the exam room.

“Why did Molly have to die, why couldn’t it have been me?” she asked, rhetorically.

Tonight I answered telephone calls from my adopted children. Both of them are dealing with the consequences of choices they have made in the past. I have wished for a long time that I could have spared them what they are going through right now, but I am wise enough to know that most of us have to learn things for ourselves, and cannot learn from the mistakes of our parents.

I can imagine the heartache of Joey Lafleur’s parents as they imagine what his life will be like, growing up with Williams Syndrome. I can imagine their grief as they think about all the things he will never do.

We must all remember that our children are only loaned to us. We have a natural desire to see them grow up to be healthy and happy, and more often than not I think we hope they will be a lot like us. Our task and privilege as their parents is to see them for who they are, and help them reach their potential.

A youngster with Down’s or Williams Syndrome can be more capable of receiving and returning the love of their parents than a child without genetic challenges, and a healthy child can be killed in a freak accident in the matter of seconds. The wisest parents cannot protect their children from making their own mistakes, and even the elderly often have to grieve the loss of a child.

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 recliner in the tack room in our horse barn, writing on my iPad and listening to the barn animals chewing their hay.”

I saw his eyes soften. He no longer had a hundred head of cattle, but he was still Farmer Carr, and he loved animals.

I had been working on my post “This is America, You Don’t Have to Do Anything”, and I kept thinking about Farmer Carr. He had been hospitalized with pneumonia and when I saw him in followup he was weak, pale, short of breath and tachycardic; his resting pulse was 125 and after I had him walk down the hall, he reached 145. His EKG showed sinus tachycardia. His oxygen saturation was in the low 90’s, which wasn’t bad, but he had a little swelling and tenderness in his left calf, so a blood clot was a possibility. His white blood cell count was elevated, and his chest X-ray had some hilar fullness and some streaking in the mid right lung. I didn’t have access to his hospital X-ray, but even if I did, he looked like there was more going on than a slow-to-resolve pneumonia. He agreed to return to the hospital for reevaluation, and I called ahead and sent my records.

I remember, working on my post, hoping I would get a call from the hospital, and my mind wandered further back in time to call nights over the years when I had wished the opposite – that no one would call me.

When I started working at our clinic thirty years ago, one year out of residency, our town had a volunteer ambulance corps without Advanced EMTs, and it was the on-call doctor’s duty to meet the ambulance at the scene of car accidents, cardiac arrests and other calls that could use skilled care during transport to the hospital. It was also our duty to open the office, with no staff to help, for emergency cases that requested that we do so.

I remembered cleaning a facial road rash on a mean looking leather clad motorcyclist from Massachusetts in the middle of the night. He was twice my size, and he didn’t like the way I caused him pain picking out the pavement residue from his scraggly chin.

I remembered treating allergic reactions and asthma attacks with injectable medications, alone with the patient in the clinic.

I remembered the times I had to do CPR, in a motel room off Route One, in a trailer at the end of a dirt road and in the jalopy town ambulance with howling sirens over icy and snowy roads.

I remembered the sense of dread on call nights when anything could happen. I remembered trying to quiet my crying infant son late at night, with the little black Motorola beeper on my belt, and every cell in my body knowing that at any moment the shrill beeping might tear me away from him and out into the night to face situations I might or might not be able to handle with little equipment and little assistance.

Times have changed. We have a professional ambulance service. The hospital has full time hospitalists and we don’t open the office at night anymore. Some people miss the old days when we were available for emergencies right here in town, but most know that medical technology and the standard of care have advanced over the thirty years that have passed. A normal EKG doesn’t rule out a heart attack anymore, and no one rules out a fracture in a trauma case without X-rays anymore.

We are still available to triage and coordinate care after hours. And with remote access to our EMR I can even send a patient summary to the emergency room from my iPhone. Primary care doctors don’t try to do everything themselves anymore. But we take our job of coordinating care seriously.

Oh, I almost forgot: Farmer Carr’s CT scan didn’t show a pulmonary embolus, just an almost resolved pneumonia; his pulse was normal in the ER and when I saw him back today at the emergency doctor’s request, he did look a lot better.

“Today, you’re able to walk and talk at the same time”, I pointed out as we walked down the hall a ways together.