Daily Archives: February 17, 2023

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If it don’t fit, don’t force it

Templates in primary care medicine suck.

Why? The problem with templates in primary care medicine is they focus on getting a specific list of questions answered for something like ear pain or back pain. They miss the weird stuff. They miss the outliers.

I hated the templates when we got our first electronic record in the early 2000s. The doctors who liked computers spent a year picking the system. Then they trained all the clinics for one week and we all went live. One of the biggest problems was that they liked computers and talked the language. We didn’t. We quit asking questions within a week, because when we asked a question it 1. Was a user problem and 2. They treated us like we were stupid and 3. They answered in Geek, which we did not understand.

We quit asking questions. The nurses and I all filed for workman’s comp because our shoulders locked up. Our shoulders hurt. We figured out how to get the stupid thing to work. Every doctor and nurse and PAC and nurse practitioner worked to figure it out on our own.

Two years later, they set up some standards for use. We resisted again, because they gave us orders in Geek and anyhow, we had no respect for them and we didn’t care. Change what we were doing? After no support for two years? Good luck!

It took me two years and three months to get the system to write what I considered a good clinic note. I had contacted an outside specialist three months in and asked how our notes were.

“You want me to be honest?” he said.

“Yes.”

“They suck. They are useless.”

“That’s what I thought.” I went on fighting the system and hating it. I won, eventually. Parts of my note continued to suck, but I figured out how to work around the stupid templates and put in some REAL information.

Now wait, you say, is the template totally useless?

In some situations, like emergency rooms, it may be very useful. It helps keep a harried ER team with four people from a car wreck from missing something. And if you are an ENT, otolaryngologist, you do see a lot of ear and mouth and throat things, so templates may help. But I think they are terrible for primary care.

They are good for billing, though. If you have all the boxes checked, the insurance company pays, and you can move on to the next victim. The insurance companies pay more if you see more people in a day. That is why our administration said, “See people for one thing per visit.”

However, that is not ethical. Say it is a 70 year old diabetic with atrial fibrillation on coumadin with a bladder infection. You cannot just say bladder infection and slap them on sulfa. For one thing sulfa screws up the coumadin and puts them at risk for bleeding. For a second, diabetes can affect kidney function and so can age and you have to adjust antibiotic dose for lower kidney function. For a third, if their glucose levels are out of control, the infection may not be controlled by an antibiotic. It’s not one thing. And the average patient has 4 chronic disorders in a study way back in the early 2000s. That means some people have none, some people have eight or more and most people have 3-5. Hypertension, diabetes, toe fungus, chronic shoulder pain, heart disease, the list goes on and on.

In any visit, I am alert for the things the DON’T fit. One time I am doing a new patient visit for back pain and note that she is hoarse. I bug her about the hoarseness. She admits it is continuous and has been there for two months. I do two referrals, because continuous hoarseness can be laryngeal cancer.

When she returns, she thanks me. She has vocal cord polyps, not cancer, but needs laser surgery. “You didn’t have to do that but you did.” she says. And do I feel good about not ignoring it? The visit went over time, but I’d rather go over time than miss laryngeal cancer, right?

We were taught to let the patient talk. Open ended questions. They’ve done studies that doctors cut people off from telling their stories very very quickly. If you let people talk, sometimes they say something that doesn’t fit the template, and we have to pay attention. Sometimes a comment or a couple comments are the clue, the key, the thing that doesn’t fit. Don’t force it into the template. Pay attention instead.

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The very serious group of people is a county medical meeting, 2014.

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Diagnostic quest

Some diagnoses take months or even years. How can that be?

A patient comes to me with right shoulder pain. His pain is “out of proportion to the exam”. His shoulder exam does not fit with a rotator cuff tear, he has good range of motion, it is weird. I hospitalize him and ask orthopedics to see him.

The orthopedic surgeon agrees with me. It is not a musculoskeletal shoulder problem. We do xrays and labs. We do a chest xray as well as a shoulder xray because on the right side of the body, the recurrent laryngeal nerve goes down to the diaphragm and then returns to the shoulder and neck. So sometimes shoulder pain on the right is referred pain from a problem or tumor or pneumonia at the base of the lung.

His chest xray is normal.

We are having trouble controlling his pain even with morphine.

I call the general surgeon. My patient has some small lymph nodes in his supraclavicular spaces. We actually have lymph nodes all over, but many are hidden deep in muscles or under bone. We can feel them in the neck, the supraclavicular space, under each arm and in the groin.

The surgeon says there isn’t anything large enough to biopsy.

I call the oncologist in the next county. We are too small a rural hospital and do not have an oncologist at that time. I say, “I think he has cancer, but I can’t find it.” The oncologist listens to the story. He agrees. We do a chest and abdominal CT scan and some blood tests. The patient has had his colonoscopy. Nothing.

I send the patient to the oncologist’s bigger hospital. They can do some tests that I can’t. A bone scan and a PET scan.

The oncologist calls me. “I think you are right, but we can’t find it yet. Send him back when there is something to test.”

My patient goes home with pain medicine.

He then calls me every week or two. “It still hurts,” he says. “Please come in and let me do another exam,” I say. “No,” he says and hangs up. I am a Family Practice physician so his partner is also my patient. She comes in and rolls her eyes. “He complains, but he won’t come in!”

At last he shows up in the emergency room and now he has enlarged supraclavicular lymph nodes. The general surgeon biopsies them. It is an undifferentiated carcinoma. That means we don’t know where it is from. We don’t know the primary.

The oncologist says, “Send him down, so we can do the tests again.”

The patient is at home and refuses.

I call the oncologist back. “He’s refusing.”

“Oh.” says the oncologist. “Well, we can treat it with chemo blindly. We can try to figure out the primary and treat it more exactly. Or he can choose hospice.”

Ok, yes, three choices. I call and leave a message to go over the choices with him.

He comes up with a fourth choice: he refuses to talk to me at all.

I call his partner. “Yes,” she says, “He’s grumpy.”

“We are happy to help with whatever choice he makes.” I say.

“I’ll tell him.”

He continues to refuse to talk to me or the oncologist. Eventually he goes back to the emergency room and goes to hospice at the local nursing home.

I tell the oncologist. He comforts me. “Yes, sometimes we are pretty sure there is a cancer, but it has to get big enough to find.”

I am not comfortable with that but medicine is way more complex and messier than people realize. Sometimes it is really nice to have a patient with something where I know what it is AND it can be treated. Appendicitis. Gallstones. Strep throat.

But sometimes it is complicated and can take months or even years. Stay present and keep checking in.

Diagnostic quest.

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The boat is returning to the water after work in our boatyard. Healed and seaworthy.

For the Ragtag Daily Prompt: quest.