What I put in a patient’s chart is protected by HIPAA, the privacy law in this country. That law doesn’t apply to ChatGPT from what I understand and that doesn’t seem right to me.

ChatGPT knows the identity of my patient and their medical history, their test results and medications. I have only used the app for writing purposes just to see what it can do, but I don’t see any consents or privacy warnings when I do that. I actually suspect ChatGPT could “learn” and then share my ideas or concepts that I asked it to flesh out for me.

I think the use of AI for medical advice when health information is entered into its vast data base needs to be regulated or at least should require informed consent about what could possibly happen to individual patients’ otherwise protected health information.

Old drug with new application, and obviously this particular formulation is patented by Abbvie.

https://en.wikipedia.org/wiki/Pilocarpine#:~:text=Pilocarpine%20was%20isolated%20in%201874,the%20South%20American%20plant%20Pilocarpus.

https://eyewiki.org/Vuity

First, a side comment about languages. I was taught British English and there, a T is a T and a D is a D, but in American English that distinction is minimal. So this headline, when spoken, could easily give the illusion that I ride horses. I have horses, but I just keep them and spoil them, I do not ride them. But that is a side issue. The relevance here is that since I was sick most of February with a little horse farm, I still had to do all the heavy manual labor that goes with it.

I did not get much writing done during February because of my prolonged influenza (in spite of my vaccination) and its slow recovery. I was not able to fully disengage from my work during my illness because we are a fairly lean outfit here in Maine. That took a lot out of me.

So please accept my apologies and know that I have several pieces percolating and started that will be published in the coming days.

So I did not fall off the face of the earth, and I did not lose my desire to share my experiences and reflections as a country doctor in this fairly remote area. Stay tuned.

His first major work, published 1843 in Danish under the pseudonym Victor Eremita (suggestively similar to the Danish word for hermit, eremit), was titled Enten/Eller, Either/Or.

It contrasts aesthetic, his word for hedonistic, versus ethical views of life and states neither is all good, and whatever we choose, we will have to deal with the anxiety of our choices. The hedonist tries to escape their guilt by more hedonistic acts while the ethicist feels anxious by whatever degree of self-denial they have.

In the end he points out that the human condition is messy and unfair and we have to accept its unfairness and absurdity with a sense of humor.

I was surprised by his claim that living an ethical life would create anxiety. It’s easier for me to see that hedonism can lead to anxiety and attempts to sink deeper into their pathology (which Nietzsche saw as the new way of ruling the word). Link to my piece about that below. Meanwhile, I’m thinking of writing about anxiety and my lack of it on my personal Substack soon.

Hans’s Substack

Beyond Good and Evil: Nietzsche Foresaw the Übermenschen of Today

I have been with Blinkist for many months now and really enjoy listening to their book summaries when I’m resting or driving. Sometimes, after listening to a summary there, I will buy the book on audible or in print. This is what happened after I listened to Nietzsche’s…

Read more

a year ago · 5 likes · Hans Duvefelt, MD

It was 10 minutes before 5 on this Thursday afternoon. I called the oxygen company and they answered in a cryptic way “Medicare only pays for 36 months, that is correct“.

“So what do people do“, I asked, “go without? Die?”

“We don’t take their equipment away“, the woman at Lincare said.

“You just don’t get paid then”, I asked.

“Correct“, she answered.

I love it when I learn something new about the practice of medicine. But most of the time when I learn a new aspect of how the “system” works, it just feels bewildering because it makes no sense. Wouldn’t anybody think that the rent per month would go up so as to cover the service and maintenance during the 3 1/2 years that go by after the 18 months of Medicare payments stop?

It occurred to me to check if today, here on Substack, there is any interest in occasional posts on this theme. Comments are welcome. Click on the screenshot to get to this post from January 2019.

We only got his urine test done a couple months ago, near the end of 2025. When I did his wellness visit the other day he had received a urine cup from his insurance company. I told him that it would be kind of silly to do that test now because he had it just a couple months ago. He should really have it toward the end of the year. If he doesn’t do it by then I will get dinged, but if he does it now it’s going to be fine and it wouldn’t serve any medical purpose. This is a common dilemma in today’s medicine. Do we do things that make medical sense or do we do things to chase? What in the industry is called “star ratings“?

So here’s a question for my colleagues: Would you have done the urine test now just to get the points or would you do it a year from when you did your last one?

In my first year of blogging, 2008, I wrote about a patient I had with Charles Bonnet syndrome, and in 2018 I wrote another piece on the same topic. The syndrome occurs in people who are blind or severely visually impaired, and involves seeing elf like Small, childlike, figures, often playing outside in the yard. The BBC article describes very similar and consistent reports by people who consume certain presumably psychedelic mushrooms in various parts of the world.

Very thought provoking that such different circumstances can produce very similar syndromes across countries and cultures.

https://www.bbc.com/future/article/20260121-the-mysterious-mushroom-that-makes-you-see-tiny-people

Wordpress links to my articles:

https://acountrydoctorwrites.blog/2008/09/24/visions-of-little-people/

https://acountrydoctorwrites.blog/2018/11/22/the-elfins-return-2/

Substack links:

P.S. Long after I first published The Elfins Return, I realized that elfin is an adjective and not actually a noun. Oh well, English is my second language.

-Max Lucado

“We have neuroplasticity on our side. In other words, your brain can rewire itself at any age, creating new pathways that override old patterns. When you deliberately interrupt a negative thought spiral and choose a different mental direction, you’re not just changing your mood – you’re physically reshaping your brain, one thought at a time.”

From the ancients to Jung to modern science, we understand that our thoughts can change how our brains work.

Maybe a thought to consider as a possible New Year’s resolution?

Abstract:

Clonazepam, first used for seizure disorders, is now increasingly used to treat affective disorders. We summarize the use of clonazepam to improve the management of depression. Clonazepam is useful for treatment-resistant and/or protracted depression, as well as for acceleration of response to conventional antidepressants. Clonazepam is at this time recommended for use in combination with SSRIs (fluoxetine, fluvoxamine, sertraline) as an antidepressant, and should be used at a dosage of 2.5-6.0 mg/day. If clonazepam is effective, a response should be observed within 2-4 weeks. It is significantly more effective for unipolar than for bipolar depression. Low-dose, long-term treatment with clonazepam exhibits a prophylactic effect against recurrence of depression. Although the mechanism of action of clonazepam has not yet been established, some investigators have been suggested that it involves enhancement of anti-anxiety effects, anticonvulsant effects on subclinical epilepsy, increase in 5-HT/monoamine synthesis or decrease in 5-HT receptor sensitivity mediated through the GABA system, and regulate in GABA activity.

https://pubmed.ncbi.nlm.nih.gov/19330803/#:~:text=Although%20the%20mechanism%20of%20action,receptor%20sensitivity%20mediated%20through%20thehttps://pubmed.ncbi.nlm.nih.gov/19330803/#:~:text=Although%20the%20mechanism%20of%20action,receptor%20sensitivity%20mediated%20through%20the

Researchers at Sweden’s Karolinska institute did a 12 year longitudinal study of the sense of smell and the mortality data of more than 2500 participants with an initial average age of 72. The researchers used a 16 item odor identification test and classified the participants into three groups: Anosmic (0-6 correct answers), Hyposmic (7-10 correct answers) and Normosmic (11-16 correct answers).

At both their 6 and 12 year follow-ups the anosmic group had almost 70% higher relative risk of mortality than the normosmic group. For each wrong answer, the mortality increased 5-6%.

Interestingly, the only causes of mortality involved were neurodegenerative deaths (mostly Alzheimer’s disease), respiratory and cardiovascular diseases. There was no association with cancer mortality.

So, maybe it’s time to reintroduce the first item in the neuro exam we all learned in school...

https://jamanetwork.com/journals/jama/fullarticle/2833992

Abstract

Clonazepam, first used for seizure disorders, is now increasingly used to treat affective disorders. We summarize the use of clonazepam to improve the management of depression. Clonazepam is useful for treatment-resistant and/or protracted depression, as well as for acceleration of response to conventional antidepressants. Clonazepam is at this time recommended for use in combination with SSRIs (fluoxetine, fluvoxamine, sertraline) as an antidepressant, and should be used at a dosage of 2.5-6.0 mg/day. If clonazepam is effective, a response should be observed within 2-4 weeks. It is significantly more effective for unipolar than for bipolar depression. Low-dose, long-term treatment with clonazepam exhibits a prophylactic effect against recurrence of depression. Although the mechanism of action of clonazepam has not yet been established, some investigators have been suggested that it involves enhancement of anti-anxiety effects, anticonvulsant effects on subclinical epilepsy, increase in 5-HT/monoamine synthesis or decrease in 5-HT receptor sensitivity mediated through the GABA system, and regulate in GABA activity.

https://pubmed.ncbi.nlm.nih.gov/19330803/#:~:text=Although%20the%20mechanism%20of%20action,receptor%20sensitivity%20mediated%20through%20the

These two parents described how they wake up at night, sometimes to go to the bathroom and sometimes anyway. Then they listen for the sounds from their adult child’s room. No sound makes them think their child is dead, Loud snoring makes them think he is sleeping drunk with outstretched arms, and yet, probably safe. What their subconscious minds seek in reassurance is quiet snoring, their sign of normal sleep in their loved one, who, right now, is lacking self determination to carry on and live through their next step in their recovery.

I like to write about more personal interests and reflections, but I don’t want to distract from the medical focus on A Country Doctor Writes, so here is the link to my personal Substack:

https://hansduvefeltmd.substack.com/

Of course, we still need to deal with patients who have pain, but assessing pain is not straightforward, much less numeric. We need to understand the significance, the symbolism and the psychological components of what people view as pain. Narrative medicine, if you will.

This abnormality turned up again the other day, and I finally stopped in my tracks and said to the patient, “I often see this happening when my patients go to the emergency room, but after a little while it normalizes most of the time. It has to be some sort of stress reaction. But we will check your level again just to make sure”.

When I Googled it, everything fell into place. All the stress hormones lower potassium. It’s not their major effect or reason to exist, but that’s how it works. I don’t know if it serves any bigger purpose. But we should definitely not assume that patients under stress with low potassium need lifelong replacement therapy.

Buprenorphine, with or without naloxone (as in Suboxone) comes in consistent strength, doesn’t induce the kind of euphoria the other opiates cause, doesn’t cause depression with long term use and doesn’t cause respiratory depression (stopped breathing) anywhere close to what other opiates do.

In fact, the risk of dying from an opiate drug overdose is reduced by 50% once somebody is prescribed buprenorphine.

https://acdw.substack.com/p/a-quick-and-easy-way-to-save-lives

So it’s a little bit like nicotine patches, which can keep you from inhaling the slowly lethal effects of cigarettes.

This may be a little provocative, but it’s no joke. Comments are welcome…