Philip Greenspun’s Weblog

We begin with a lecture: “How do people die?” A 55-year-old physician who runs a weekly geriatrics clinic explains why he became a geriatrician. “My father died terribly. He was in months of pain and misery during cancer treatment. At the end of his life he told me he regretted getting treatment. It is my opinion that his doctors did not present him with realistic expectations.” 

He draws a graph of function versus time on the whiteboard, each line representing a single human life. “Seven percent of people die a sudden death, meaning they are highly functioning and die out of the blue.” He draws a horizontal line high on the y-axis until it plummets when the patient dies. “These are the massive heart attacks causing cardiac arrest, the motorcycle accidents with immediate death.” He then draws a downward sloping line. “22 percent of people die of terminal illness — a long steady decline. 16 percent die of organ failure where you have ups and downs, trending down for a long time.” He continues, “So what’s left? 47 percent die of frailty. These are people who are low functioning for a long time.” In summary: “We need to think if we want to flog granny with chemotherapy and LVAD [left ventricular assist device for heart failure] just to set her up for frailty.”

His clinic reviews medications to prevent falls and unnecessary hospitalizations, evaluates prognoses for dementia and advanced chronic diseases, and discusses goals of care, including independence. “One of the most challenging discussions with the elderly is when to stop driving. Remember that the patient never voluntarily gives up driving. It signifies so much for them. A lot of time driving is essential to care for their spouse.” He emphasizes, “It is the doctor’s job to discuss when a patient should stop driving. I remember one time a patient was referred to me and he lived a few blocks down the road from me. He could barely dress himself, but was driving every day to the store. ‘Would you be okay with your son or daughter driving on the same road?’ I don’t understand how physicians are supposed to have these complex discussions with patients with all the EMR [electronic medical record] demands and time constraints, but we have to find a way.” He adds, “A good rule of thumb: if a patient cannot perform the trail-finding test on the MOCA, the patient does not have enough executive functioning and information processing capability to drive.” 

“Our clinic has a three-month back up right now. We’re still working off the backlog that develops during Thanksgiving and Christmas. The family flies in for the holidays only to find that mom has not bathed in months. They say, ‘But she sounded okay on the phone.'”

Farmer Fiona: “I agree with what he is saying about asking patients how they want to die, and that patients are vulnerable to believing best-picture prognosis. But he doesn’t say what we should do to manage unfortunate events. Should patients not undergo catheterization after a heart attack? Not get amputated after a gangrenous diabetic infection? Maybe he wants us to tell patients to keep smoking so they die of a massive heart attack, instead of the long fragility of dementia or pancreatic cancer?” Southern Steve: “Is it worth risking getting dementia to live to 100?”

After lecture, Fiona and I drive 10 minutes to the hospice clinic where we get a tour from a 56-year-old volunteer office manager. He explains: “Hospice sprang up as community volunteer organizations. We used to be able to take patients on fishing trips, meals, shopping. We can’t do that anymore because of the liability of driving patients and all the paperwork involved with insurance. The volunteer tradition is going away, but five percent of a hospice workforce must still be volunteer to qualify for Medicare reimbursement.”

I follow a 48-year-old hospice nurse around the city for three home visits. My first patient (a 35-minute drive away): is an 89-year-old end-stage dementia patient. Before we go in, the nurse explains that family members are “really struggling giving medications (oxycodone and benzodiazepines) because they are afraid of killing her.” She explains to the son, daughter-in-law, two granddaughters, and great-grandson that the doses of pain medications are so low she will be fine: “She needs these medications. We don’t want her to suffer.”

[Editor: The U.S. has 5 percent of the world’s population and consumes 80 percent of the prescription opioids.]

After spending 10 minutes at bedside, including a short prayer led by the hospice chaplain, our patient is agitated. We go to an empty bedroom for a family meeting. Everyone starts crying. The son: “I am not ready to let her go. I freak out about giving her medications if they are going to hasten her death.” Hospice nurse: “She is ready to go. You have to accept that and prepare yourself.”

Our next patient with advanced COPD and dementia lives in an upscale continuing care retirement community home. She has a 24-hour home aide who has dressed her in stylish clothing, arranged her hair, and applied makeup. She takes shallow breaths as she stares blankly into space, not acknowledging the two strangers in her apartment. We talk with the 38-year-old home health aide, a relative of family friends who has been taking care of her for two months. The hospice nurse: “You can tell she is going to die soon. She’s ready. It’ll be tonight I think.” She calls the family’s relatives to come to the apartment. (Our patient died three hours later, with her family at bedside.)

Our last stop: an 86-year-old bedbound patient with congestive heart failure living in a beautiful six-bedroom house. A professional 28-year-old home health aide takes care of him (and the bulldog who greets us at the door) five days per week and a neighbor’s failure-to-launch 34-year-old son handles the weekends. We turn him over to look for bedsores; the home aide has done a very good job. When was the last time you pooped? The aide responds that it has been at least six days. The nurse looks at me. Enema time. We roll him over to one side, and perform an enema. He has so much impacted stool we do two. The enema took about twenty minutes. The nurse was surprised that I helped throughout the enema. “Most doctors walk out the door as soon as the thought of an enema pops up.”

I drive back to the hospice clinic for afternoon handoff with Farmer Fiona. Nurses and the palliative care physician are talking about overnight drama between the hospitalist service and palliative care team regarding a terminal cancer patient experiencing poorly controlled pain. “The family did everything right and called the hospice instead of going to the ED. But this hospice does not have flex weekend home visits.” The family brought the patient to the ED, and the medicine service requested the palliative team admit the patient. The palliative care physician: “I told them that we are not admitting the patient. This is a disposition issue that their social workers can manage. We are not in-charge of every hospice patient,” she noted. “We’d be happy to consult on the patient in the morning to provide pain control recommendations, but we are not admitting to our unit. We have limited resources.” (Last week on their service, we sat idle for half the time, sipping specialized coffee drinks made by a volunteer and discussing must-read medical books..)

Thursday morning is a normal day with Doctor Dunker at my family medicine clinic. We had a monthly potluck office lunch featuring homemade apple turnovers. Staffers are comparing their role-specific Bingo cards. For example, Doctor Dunker has a square: “Patient asks for antibiotics before patient is seen by doctor.” The office secretary: “Patient no shows appointment within 24 hours of scheduling.”

I depart after lunch for an afternoon at the travel clinic. The travel clinic, staffed by an infectious disease doctor, is meant as a community resource for individuals traveling for extended periods of time to remote destinations, e.g., six-month mission in Africa or the Amazon. Instead, all four of our patients are going on cruises with limited exposure to dangerous disease beyond an afternoon in Cartagena, Colombia. There is no attempt to hide from the patients that we are primarily looking up information on the CDC web site.

[Editor: Cartagena was where agents accompanying President Obama to the Summit of the Americas used government credit cards for an epic party. See “US Secret Service Cartagena scandal ‘involved 20 women'” (BBC).]

Friday afternoon, we have a class meeting about prevention in primary care. The lecturer, a retired hippie family doctor, discusses the “Pay-for-Performance” era. He reviews a “landmark study” finding that the highest performing practices according to metrics in the UK had no change in patient outcomes compared to poor performing practices. “Despite this evidence, we will see more and more oversight by administration evaluating performance metrics. We’ll soon be telling patients, ‘I need you to get a mammogram, flu shot, etc. because it will improve my clinic performance.'”

[Editor: We learned the same thing in our data-driven medicine class at Harvard Medical School. Except for generating headlines, preventive medicine is of limited value. Popular screening tests, such as mammograms and pap smears, generate so many false positives that patients on balance may be worse off. Flu shots for adults are only weakly correlated with being diagnosed with flu.]

He continued: “One challenge for performance metrics is they address challenges of the past or are out of touch with reality. For example, hospitals get graded on how quickly we start antibiotics for sepsis and pneumonia — the proportion started within 8 hours. This metric is based on studies in the 1990s which showed early administration improved outcomes in sepsis. However, this was on a totally different patient population and different bugs because this was in a day before the pneumonia vaccine existed. There is no evidence administration within 8 hours is beneficial, and instead might cause unnecessary antibiotic administration. You all see that so much, antibiotics are started in the ED for a few hours and then discontinued by medicine service the next day.”

Statistics for the week… Study: 7 hours. Sleep: 7 hours/night; Fun: 1 night. Lanky Luke, Sarcastic Samantha, Mischievous Mary, Geezer George, Buff Bri, Jane, and I attend a free concert downtown.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Monday morning: 84-year-old “T-Bone” car accident victim for a hospital follow up. He was admitted to the hospital for seven days with multiple rib fractures and a wrist fracture. A CT of the abdomen showed, in addition to the acute injuries, a dilated common bile duct with the radiologist report stating, “cannot rule out malignancy versus cholelithiasis [gallstones]”. We explain to him the possibilities, and that to determine this we would need to order an endoscopic retrograde cholangiopancreaticography, a procedure in which a scope is placed down the esophagus into the small intestine and injects contrast into the biliary system. “Doc, I was just in the hospital for a week, it took everything out of me. I dont have the strength to get another anesthesia procedure. I’ve had a good life.” We agree with him, and decide to monitor with blood work.

I am beginning to work on the worksheet that we must complete before the end of our six-week rotation. Having asked the three nurses to grab me if anyone needs shots, I get several intramuscular injections checked off by giving flu shots and quadracel vaccinations to children. I also need to perform five EKGs (electrocardiograms). I see a fit 38-year-old nurse who works in the Cardiac Care Unit (CCU) and has experienced feeling faint three times within the last month. Her nursing colleagues hooked her up to telemetry, which showed “an arrhythmia”. I hook up our clinic’s EKG machine’s leads to her, but nothing happens. The three nurses all come in to help troubleshoot. We cannot fix it so we decide to have her return in a few days.

Wednesday morning, Farmer Fiona and I head into the depths of the hospital for an afternoon with occupational medicine (“OccuMed”), a clinic that treats hospital employees for work-related issues. The 32-year-old physician trained with the military before leaving to work in civilian practice. The five patients on his schedule were all no-shows, so we got a 2.5-hour sales pitch regarding the great lifestyle of an OccuMed doctor: “We have no call, our day is like a dermatologist’s.”

His team is responsible for safety protocols at the hospital. He explains the airborne precaution protocol. “OSHA  mandates a standardized nine-question questionnaire with any ‘Yes’ responses requiring a formal physical by occupational medicine. A few years ago we used a slightly different form, and we developed an in-house scoring system to determine need for a physical. Our system was actually more restrictive, requiring almost every employee to get a physical, plus we also do annual physicals on clinical workers. The higher-ups couldn’t understand why we needed to use the OSHA-approved form. What we were doing was actually illegal due to the paperwork discrepancy.” A big smile took over his face: “That’s the beauty of OccuMed. We understand the intersection between medicine, administration, and law. And it’s only getting more complex. We’re the only ones who can do this.”

Lanky Luke, Mischievous Mary, Geezer George, and I head to an impromptu Wednesday beers and burgers night. Geezer George describes the tension between the employee trying to get a work-related pay out and the OccuMed doctor working on behalf of the hospital trying to minimize the problem: “The doctor asked, ‘Could you please bend over and touch your toes.’ The patient responds, “I can’t, it hurts to move my back.’ ‘I know, but just try and touch your toes.’ ‘Okay,’ it’s going to hurt’ As he bends over and attempts to touch his toes, the physician comments, ‘So you can bend over.’ ‘Yes, but it hurts.’ He ended up getting disability.”

Luke recounts his week on inpatient pediatrics. He explains: “We admitted a six-month old with RSV [“respiratory syncytial virus,” a common illness at this age]. The baby presented to an outside emergency room where she was given an intraosseous catheter access [“IO”, a radical drill-through-the-bone procedure with significant risks that was unnecessary for this patient] and medevaced to our tertiary center. The baby was totally fine on arrival. Our attending admitted the patient overnight because the baby was helicoptered in and said ‘The patient has an IO so I guess we should use it.'” Samantha, the PA wife, recounted a similar experience: “We had a patient with chest pain — no troponin or EKG changes — medevaced to our hospital. My attending commented that he would never have been admitted if he’d come into the ED, but he was helicoptered in from six hours away. We let him stay the night under observation.”

Thursday: I spend 30 minutes talking with a fit 64-year-old who had bilateral total hip arthroplasties (replacements) over a decade earlier. After a tooth extraction, he was admitted for a 5-day ICU admission for sepsis in both of these artificial joints. He underwent two surgeries and a 50-day rehab stay. He is now doing a 3-week antibiotic holiday to confirm no infection before a revision. He is back home, but is not allowed any weight bearing on either leg.

The next clinic patient is a 35-year-old female, BMI 32, with a history of depression and polysubstance use disorder (alcohol, benzodiazepines, and cocaine) presenting as a new patient due to worsening shortness of breath. She explains she drinks a few beers on the weekend, but has been sober from other drugs for the past three years. She is also very upfront about being incarcerated for the past three years: “I was selling cocaine and meth.” My attending: “I always find it ironic when a drug user includes incarceration years as part of their sobriety time.” We order an echo, but strongly suspect she is drinking causing an alcohol-induced cardiomyopathy. We discontinue her seroquel, which might help her lose some weight, order an echo, and instruct her to stop drinking alcohol.

We are required to attend an Alcoholic Anonymous (“AA”) meeting as part of this rotation.  Wildflower Willow and I select a Thursday evening meeting through the AA online portal (there are more than 10 within a 20-mile radius every night). The leader asks the 35 attendees if anyone new would like to introduce themselves. Older people tend to be sober and say “I am an alcoholic” while the members who are our age are more likely to be active users and say “I am alcoholic and an addict”. Willow: “I didn’t like it, it felt like we were sent to the zoo to learn from the freaks firsthand.”

Friday morning: “Medicine” grand rounds on gastrointestinal bleeding at the hospital, then head to the clinic around 9:00 am. I burn several actinic keratosis  (“AK”, a common precancerous skin lesion) off with cryotherapy. Doctor Dunker lets me do two punch biopsies on a patient with numerous nevi (moles) on his back. I grab supplies, including local anesthesia, suture, drapes, needle driver, and forceps. The next step is to draw lidocaine and epinephrine into a syringe and inject to anesthetize the nevi sites until a “wheal” forms.

Doctor Dunker sees that I am comfortable getting the supplies, so he lets me do an excisional biopsy on a later patient whose previous punch biopsy pathology results showed a squamous cell carcinoma in situ, but with “positive margins” (i.e., the cylindrical punch biopsy did not remove the entire lesion). Steps: acquire supplies, prep the site with iodine, use a sterile marker to outline a 1cm margin around the lesion, incise with scalpel until reached subcutaneous fat, cut tissue with scissors, place into tissue container, suture wound close. Doctor Dunker: “Great job. Haven’t seen anyone hand-tie in quite awhile.” (As opposed to “instrument tying” using a forceps and needle driver.) This was my first time doing surgery on a conscious patient.

The last patient of the day: 47-year-old overweight female on birth control presenting for an annual wellness visit and mentions foot pain when walking. The ankle appears swollen and slightly inflamed. Although the patient does not report any worsening shortness of breath, our concern is she may have a deep venous thrombosis of the lower extremity (“DVT”, a clot in the leg, which can throw small chunks into circulation until they reach the lung). Alternatively, it could just be a sore muscle. Following the standard protocols, which are heavily biased toward defensive medicine, Doctor Dunker decides to send the patient to the ED. “Every doc will get burned by a PE [pulmonary embolism]. I wonder how many CTs it takes to diagnose one PE? How many CTs to save one life for a PE?”  (After a no-doubt multi-thousand dollar bill to the insurance company, and a whopping deductible cost for this rare privately insured patient, the hospital determines that there is no DVT.)

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Week 2 on family medicine rotation. Monday morning begins with a one-hour lecture by a 53-year-old talkative palliative care specialist (“helping patients learn how to live with serious illnesses”).

Palliative care was recognized as a speciality by the American Medical Association in 2008. “The profession has exploded since insurance realized that palliative care consultations save money. The problem is we don’t have enough fellowships to meet the demand.”  She would like her colleagues to be involved with CHF, COPD, cancer treatment, dialysis, and dementia when a patient has a life expectancy of less than 18 months. She adds, “We are far behind Canada with integration of palliative care into medical management. For example, palliative care specialists are typically at every Canadian dialysis and heart failure clinic.” Why is the U.S. lagging? “Political motivation,” she responded. “Palliative care became known as the ‘Death Squad’ created by ObamaCare.”

In the old days, every physician was considered qualified to educate patients and families about the logistics and prognostics of different care options, e.g., whether to agree to surgery or proceed with intubation in a terminal disease. Now the conversation gets punted to a credentialed separate specialty: “We also investigate the reasoning behind a family’s decision, we sometimes just listen but we can also use evidence-based methods to guide a patient to a more informed decision,” she explained. “For example, a 27-year-old polysubstance user got into a car crash. The ICU team doesn’t want to intubate because they fear it is unlikely the patient will ever be extubated. The mother wants the whole nine yards. We came in to talk to the family for goals of care and learned that the mother’s insistence was driven by a fear that the son was going to Hell. We coordinated chaplain services and eventually the mother agreed that it was time to let the son pass away.” (Hospitals have a substantial financial incentive to bring in palliative care specialists, who can bill more per hour than an internal medicine (hospitalist) physician.)

Roughly 80 percent of the time, she is discouraging patients from opting for expensive yet low-value procedures. In some cases, however, it is the palliative care doctor who pushes for a procedure: “A 38-year-old male had multiple life-threatening injuries including spinal cord compression and blunt abdominal trauma leading to a partial colectomy and colostomy after an industrial work accident. He was in constant pain. His neurosurgeon recommended against spinal cord decompression due to the high risks of surgery. We recommended he undergo it even though it would likely worsen life expectancy because the family and patient could not bear to see him in so much pain.”

Farmer Fiona and I happen to be assigned to palliative care for Monday, so after the lecture we head over with the attending to the palliative care team room. Each of us sees two patients. I sit in on a family meeting concerning a heavily sedated 69-year-old male with COPD and congestive heart failure in the ICU. The family has been debating for three weeks whether to stop the pacemaker that is keeping the patient alive. The wife is tearful, but says it is what he would want. “He wouldn’t want to live like this in the hospital.”

[Editor: It is always the spouse who wants to pull the plug, citing a never-committed-to-writing desire to be dead rather than sick, and the kids who want to keep a parent alive. Keep that in mind when setting up a health care proxy.]

After the meeting, we call the cardiology service. Some providers and device manufacturer representatives are hesitant about stopping the life-saving device. “One of the cardiologists on the service refuses to do these types of procedures,” says the attending, “but the one on tomorrow understands.” The manufacturer rep pushed back, but eventually relented after discussion with the cardiologist. We scheduled the shut down for the next day. This would allow the family from out of town to be present for the patient’s final hours. 

I join the attending for a new patient in the neurotrauma ICU. The 67-year-old male recently had a car accident and was coded for 10 minutes until a pulse came back. We don’t know anything about neurosurgery and haven’t talked to the patient’s neurosurgeons, but we have read some notes in Epic and supposedly have expertise in how to break bad news to patients. We had a (necessarily) vague conversation that might have helped the family formulate some questions for the neurosurgery team and most definitely helped the hospital collect revenue from Medicare.

Tuesday: family medicine clinic. The first patient is a 43-year-old father of two and aircraft mechanic for UPS presenting for an annual checkup. We discuss indications for statins given his 10-year cardiovascular risk above 7.5 percent. We prescribe Lipitor and counsel regarding smoking cessation. He mentions job-related back pain. Doctor Dunker performs a brief strain/counter-strain OMT technique. “What I really need is a massage from my wife.” Doctor Dunker jokes:,”Want me to write a doctor’s note?”

During annual visits, we evaluate USPSTF (United States Preventive Services Task Force, a panel of experts appointed by the Department of Health and Human Services) Grade A/B screenings and CDC vaccine recommendations. We often have a discussion about the new shingles vaccine, Shingrix. Our office does not carry the vaccine, which costs $100 at a local pharmacy and Medicare Part A or Part B do not cover this. Patients on whom taxpayers are spending $10,000 or more annually balk at the idea of paying $100 dollars to cut their risk of getting shingles from 33 percent to about 1 percent.

Doctor Dunker recounts several patients that have permanent life-altering complications from shingles, namely postherpetic neuralgia. “I had a retired nurse commit suicide because of the intense pain. It is just like trigeminal neuralgia.” (Also known as the “suicide disease”, trigeminal neuralgia is a chronic pain disorder with recurrent episodes of intense, unexpected jolts of pain on one side of the face that last for a few seconds.)

I sit in on a visit for a 68-year-old female active smoker with congestive heart failure (CHF) who does not understand her disease. She arrives with a “care coordinator,” a nurse with extra training whose job is to prevent hospital readmissions and reduce the chance that the hospital will get dinged by Medicare under the Readmissions Reduction Program (RRP). She has had two CHF exacerbations requiring readmission due to a lack of understanding of her medications and when she should take her “fluid” pill to avoid becoming volume-overloaded. I use her chest x-ray from the most recent admission to explain why she’s becoming short of breath and  say that we will likely need to increase her metoprolol dose to control atrial fibrillation and keep her heart rate below 110 beats per minute. Her INR (international normalized rate, a measure of blood clotting when on Coumadin) from today’s in-house blood draw was increased. I told her that the hospital’s latest amiodarone prescription may be responsible. I feel like I am getting the hang of outpatient medicine!

Thursday afternoon: playing around with Epic and notice an InBasket message, which I hadn’t realized we have access to. Who would send me something in this? It is a request from Doctor Dunker that I look up ectopic kidney (kidney located in the pelvis). I do research on UpToDate.com and present findings to Doctor Dunker to help him prepare for a meeting with a family and their newborn. I explain the main considerations in management of ectopic kidney are: (1) risk of hydroureter/hydronephrosis,  (2) association with other congenital anomalies, and (3) increased risk of urinary tract infections

Doctor Dunker takes responsibility for his patients, a contrast to the hospital’s poor continuity of care. For example, on Friday morning, we see a 72-year-old female who was admitted to the hospital the previous week for a GI bleed. The patient was stabilized on IV fluids and 2 prbc. The EGD showed no abnormalities, but because the patient stabilized a colonoscopy was not performed. She now has to wait several weeks for an elective colonoscopy. After several thousand dollars in hospital bills, still no answer. No ownership.

[Editor: It’s not all bad. Via the above incident, the hospital obtained “ownership” of several thousand tax dollars via Medicare!]

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night. Twelve classmates drive 30-minutes outside town to a new, dog-friendly brewery.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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We pick up our hero’s story in January 2019, halfway through Year 3.

Orientation begins at 7:00 am. Our clerkship director, a 58-year-old family doctor, explains that we are expected to write at least two notes per day at our assigned clinic. “Get used to the SmartPhrases [canned templates within Epic, with fields such as patient age ready to be auto-filled] your team uses. Half the note is just for billing, which makes it frustrating to find information even in my own notes, let alone others’. But we have to work with it.”

He describes the distinction between family medicine and general practice. “General practitioner developed bad connotations because it was basically a physician who did not complete a residency. You were considered a general practitioner (GP) in your third year of medical school. My dad delivered babies by himself as a fourth-year medical student. Family Medicine fought back against this confusion by becoming the first society to require a board examination.”

The orientation was followed by a lecture on geriatric polypharmacy (drug interactions and the consequences of our pharma-happy medical system). A geriatrician (family doctor with geriatrics fellowship) in her 50s: “More than 12 percent of the US population is over 65. An estimated 50 percent of these folks take more than five medications. Polypharmacy has serious consequences; 30 percent of hospital admissions are estimated to be from adverse drug effects.” Why aren’t the hazards of over-pharma better known? “There are a lot of studies looking for a primary discharge diagnosis of ‘adverse drug reaction’ as an ICD-10 code. They will miss a situation in which the adverse drug reaction caused the primary problem, e.g., a patient falls from too many anti-hypertensives and breaks her hip.” 

She describes Beers Criteria, a list of potentially inappropriate medications in the elderly that can lead to falls, fractures, gastrointestinal bleeds, delirium, and overall increased risk of death. “We’re trying to get away from the lady that takes a few Xanax every night for 40 years,” she exclaimed. She described analgesia in the elderly. “Too often we avoid giving opioids because of the stigma, but they are frankly one of the best options to manage pain in the elderly. The alternative of NSAIDs [e.g., Advil] causes serious GI bleeds and destroys the kidneys.”

She added, “When you get a few years under your belts, you’ll start to notice pharmaceutical tricks. When a commonly used drug is about to go generic, the company will conduct a clinical trial with a dose that cannot be obtained from a combination of pills already on the market. For example, Aricept [donepezil], medication used in Alzheimer’s dementia despite minimal clinical benefit]  comes in 10 mg and 20 mg. Before the patent expired, Pfizer conducted a trial at 22 mg. It didn’t work, but if it had, they would’ve sought FDA approval for the 22 mg level, and then insurance would have paid only for the FDA-approved dose, otherwise it would be an off-label [uninsured] use.  Same thing happened with Claritin.” She concluded: “Learn the rules, so that you may break them properly.” She requires us to conduct a polypharmacy review of an elderly patient during our rotation.

[Editor: See a March 11, 2001 New York Times story on Schering-Plough keeping Claritin from becoming an inexpensive generic via dosage tweaking leading to patent extensions: “The Claritin Effect; Prescription for Profit”.]

Farmer Fiona, a 26-year-old from rural America who is interested in rural family medicine, and I are paired for our weekly nursing home days. Fiona texts the attending who tells us to meet him at the assigned nursing home at 1:00 pm. I rush through lunch at the gas station burrito shop, but need not have hurried since the doctor does not arrive until 1:30 pm. He assigns us two patients each, one admission and one follow-up. After 45 minutes, we reunite with the attending and present our patients in a conference room. My 65-year-old patient has been in and out of the rehab facility twice after pancreatitis hospitalization complicated by an abscess formation requiring laparotomy (cut open abdomen). He is experiencing worsening nausea two days after discharge from the hospital. He has no peritoneal signs (inflammation of abdominal wall), or systemic signs of infection (fever, tachycardia). We prescribe Zofran and plan to re-evaluate him the next day for possible transfer to the hospital for imaging. We then round on 5 patients in skilled nursing, and 5 patients in the long-term care section of the assisted living complex.

Tuesday morning I drive 45 minutes into the countryside to a family medicine clinic that will be my primary home for six weeks. Work starts at 8:30 am, so I get more sleep than during the surgery and internal medicine rotations. The office has three physicians, one of whom works 2.5 days per week and spends the rest of the time with her children. It isn’t difficult to craft a work-life balance when a nice house near the clinic costs $250,000 and a full-time doc is earning $220,000/year. I will be working only with the two full-time physicians. We are able to perform lab draws (in-house A1C, CMP) and electrocardiograms, but no onsite x-ray.

Doctor Dunker is a 41-year-old member of a traditional Anabaptist group. He has seven home-schooled children, a beard that flows down to mid-chest, and dresses like an Amish farmer. He comes in at 8:30 am on the dot wearing a pressed white shirt with baggy black pants and a black vest. He expects the nurse (also in traditional garb, including bonnet) to have prepped his first patient and will put his black hat on the desk, don a white coat, and go into the exam room within a minute of arrival. Jane and I won’t be able to complain about working hard in medical school; Doctor Dunker had two young children to care for during his medical education.

He cares for a village, about 3400 patients spanning several generations of families, twice as many patients as the other full-time attending in the practice. About half are from his traditional community, many driving two hours from the rural area in which he formerly practiced, and some making all-day drives from other states. “They just keep having children, and I can’t say no.” He has learned to have low expectations for M3s: “Things are crazy around here, I actually requested to not have a medical student this block. I know this isn’t your fault. Today, you’ll just follow me. We’ll figure a way to make it work. I still want you to get comfortable with doing great outpatient encounters.  I just can’t get behind on my patients because I have to leave on time.”

The typical day has acute visits and medication follow-up visits scheduled in 15-minute blocks while new patients and annual visits are scheduled for 30 minutes. We are supposed to take a lunch break from 12:00 to 1:30 pm (oftentimes interrupted by 1 or 2 fill-in appointments) and are done at 5:00 pm. On two days per week, Doctor Dunker stays late and sees patients until 7:00 pm.

The first visit is a joint annual check up for an Anabaptist couple in their 70s. We start with a routine health check and filling out a Medicare annual form ($35 in extra revenue) that asks how long it takes the patient to “get up and go” (should be under 20 seconds to rise from sitting, walk 10 feet, turn around and sit back down), domestic violence screening, and dementia screening test with Mini-Mental Status Exam (MMSE, including a three-word recall and drawing a clock). The wife asks: “By the way, one more question. Our granddaughter is pregnant and needs a note to take five-minute breaks at Walmart when she gets short of breath. Could you do that?” He was silent for a second. “I cannot confirm or deny that she is a patient of mine or her situation.” The couple laughed, “Oh, Doc. We know she is pregnant, she told us, and we’re ecstatic. Her boyfriend, hopefully fiance, is a great guy and all about her. And by the way, you’re a terrible liar!” Doc Dunker: “If she is a patient, I will reach out to her.” As the old couple leaves, they comment approvingly on the Christian artwork.

We see a 12-year-old girl for eczema. Last visit, Doctor Dunker had ordered a compounded steroid cream. However, Medicaid had rejected the order, even though it is a generic medication. “This can be so frustrating. They reject what I order, but won’t offer an alternative.” He adds, “Finding a medication that Medicaid will pay for is like whack-a-mole.”

Doctor Dunker: “The next patient is quite interesting. Interview the patient when she arrives while I see the roomed patient.” A 37-year-old female former nurse, local but not Anabaptist, presents for a one-month follow-up after discharge from a stroke rehab program. After a routine dental procedure and despite being generally healthy, she contracted subacute bacterial endocarditis (heart valve infection). The infected valve threw clots into her arteries, one to her middle cerebral artery causing a stroke, and one to her left leg causing gangrenous necrosis. Her left leg was amputated above the knee. She was in rehab for a month, with follow-up physical and occupational therapy appointments.

The patient is way out of my league. I don’t know what questions to ask about the post-stroke recovery process. Fortunately, Doctor Dunker knocks on the door. The patient and her husband brighten, “Doc look at this. She attaches her prosthesis to the left lower extremity stump, and walks to the door. “Oh my God. Wait here.” He calls the nurses and front desk staff. “Everyone come here and watch.” People cheer as she walks down the hall.

When the commotion subsides, she explains her challenges going forward. “Insurance won’t pay for any more PT or OT [physical or occupational therapy]. My husband and I have worked too hard to go for the Medicaid spend-down, but we just can’t afford these $150 sessions out of pocket. I wish we had known what we know now. We had only 10 sessions for PT and OT. If we scheduled them back-to-back, they count as one, but we scheduled the first few at separate times so it counted for two seperate uses.” Doc Dunker: “Let me see what I can do.” He calls our care coordinator, who gets her another 10 PT and OT sessions from charity care.

[Editor: when a hospital reports “charity care”, it is at the fictitious list prices that are often 10X what an insurance company would pay. “How Much Uncompensated Care do Doctors Provide?” (NBER, November 2007) concluded that “uncompensated care amounts to only 0.8% of revenues” and that physicians actually were “earning more on uninsured patients than on insured patients with comparable treatments.”]

The next patient is a 69-year-old male, accompanied by his daughter, for worsening hallucinations associated with Lewy body dementia (LBD). LBD is characterized by early vivid visual hallucinations followed by progressive decline in cognitive function. He called 911 at 2:00 am because he thought his wife had stopped breathing (in fact, she passed away 10 years earlier). This is the fourth time he has called 911 for a hallucination. He describes how he sometimes sees large beetles (“size of my hand”) crawling on him at night. My attending describes this phenomenon where objects appear bigger or smaller than reality as Lilliputian, dubbed the “Alice in Wonderland” syndrome. The patient is quiet throughout the interview, clearly embarrassed about his behavior. Afterwards, we just sit in the room for a few seconds. “So sad, his body is fit but his mind is failing him. He knows right now he has a problem. This can be the most devastating period of the dementia.” (Robin Williams who committed suicide at 63 suffered from the “terror” of LBD.)

[Editor: Williams was also being pursued by two alimony plaintiffs. New York Daily News: “Paying out over $30 million

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