Jeanette Brown had lost twenty pounds, and she was worried. “I’m not trying,” she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine: A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight. That is exactly what happened to my mother some years ...

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There is a lot of talk about team-based care nowadays, and I had seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family. But at the same time, there are so many decisions – judgment calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members. I talk to patients all the time ...

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I haven’t counted how many times this happens every month, but I find it annoying. I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a prior authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) 
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Last week I had a patient with mild kidney disease and a high potassium. I thought that it would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast, and nobody had Kayexalate, the time-tested antidote, in stock. It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4; his ...

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Driving north in a snowstorm Tuesday of Thanksgiving week I certainly took my time. I left after our Suboxone clinic wrap-up conference, around 7:30 p.m., and arrived at my unplowed driveway in Caribou about 1 a.m. On the way up, I saw two ambulances, one from Caribou and one from Presque Isle, on their way back home from Bangor. I’ve got a large SUV with all-wheel drive and studded Finnish snow ...

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I’ve huddled since before we used the word for it: You want to be prepared for the patients coming in that day. “Followup MRI” – did they have it and what did it show? “Ankle pain” – do we have X-ray today? “Eye pain” – be sure to check her acuity and put her in a windowless room, and did the new fluorescein strips come in? All fast-paced, to the ...

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I have known him for over thirty years. He has been legally blind for the past five. He tends to be a practical, no-nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said: “I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things,” he began. “I’m seeing children with elfin faces …” His large, thin hands were in ...

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I am beginning to think that we should not see chronic care patients between Thanksgiving and New Year’s Day. It just makes us look bad. Our quality metrics make the last blood pressure and the previous diabetic lab test of the year for each of our patients our final report card. We should quit while we’re ahead, in mid-November. So here we are: The office has Christmas decorations up. There are trays ...

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“Red” McDougall had terrible leg pains soon after going to bed. He did have a bad back, and some mild spinal stenosis, but I hadn’t heard much about that in the past few years. He was dealing with the ache in his legs when he was on his feet too long. A few months ago he saw his vascular surgeon for a routine followup. He’d had a femoral-popliteal bypass to restore ...

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I guess I should take it as a compliment when patients come to see me after visiting a specialist and ask me a bunch of difficult specialty-related questions. “Did you ask the specialist that?” I typically ask, and the answer will be a plain “no.” I’ve seen it in action. Some doctors speak quickly, say a lot, and exude so much authority that it’s hard to stop and question them. There is ...

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“Admission diagnosis: causa socialis” In my training in Sweden, it was not unusual to admit patients to the hospital for social reasons: an elderly person who could no longer manage at home, a person whose social network fell apart, and so on. “Social reasons,” causa socialis, was a legitimate diagnosis (Swedes used more Latin than Americans, at least back then). And it was used with only mild grumbling. There was a clear ...

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Health care is on a different trajectory from most other businesses today. It’s a little hard to understand why. In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie-cutter quality to the intangibles of authority, influence, and trust. This, ...

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Many patients who end up in Suboxone treatment have chronic pain. They were originally prescribed other opiates and ended up addicted to them. Skeptics argue that is just substituting one opiate for another. But that isn’t quite accurate. More on that in a bit. In my seven years of prescribing Suboxone for opiate addiction, I have often observed how potent a pain reliever this medication is, even in fairly low doses. More ...

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Back when cholesterol target numbers ruled unopposed (before 2013), we all checked fasting lipids every three months. Before 2012, we also checked liver function quarterly in hapless riders on the cholesterol pill merry-go-round. That year the FDA announced there had not been enough reports of statin-induced liver problems to recommend routine monitoring. I have many colleagues who still do this, and who also routinely monitor routine labs quarterly ...

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I don’t know how many times a patient has told me, “I was in therapy once, and it didn’t help.” My response is always: “That’s like saying 'I saw a movie once and I didn’t like it'.” That usually breaks the ice just a little. In primary care, we certainly run into a few patients with chronic mental health problems that could use some long-term, in-depth counseling. But usually, patients in my practice ...

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I learned a new word recently: transdiagnostic, which refers to something that is applicable across a spectrum of conditions. It seems that this is becoming an increasingly popular concept in treating anxiety disorders. No wonder. As I researched this word, I read this:

As of 2013, there are twelve anxiety-disorder diagnoses and over twenty-five subtypes and categories of these disorders, with specific treatments for about half of them. Research has ...

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Today I had a followup appointment with a young adult male with severe intellectual disabilities. He is barely verbal. Several weeks ago his caregiver told me that this young man often pointed to his chest and would say “hurt” or “heart,” they weren’t sure which. He also seemed to have gotten pickier about his food, and would literally pick at the food on his plate as if examining it. His ...

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Non-clinicians skip over some of the most necessary underpinnings of doctoring and speak too much about housekeeping issues: blood pressure targets, aspirin use, mass screenings, immunization rates and so on. People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most ...

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Everybody is a stakeholder these days in what we broadly call medicine, or health care. But there is little agreement on what medicine is and what the priorities of the health care “industry” should be. I propose this breakdown of medicine into three separate phenomena. 1. Micromedicine 2. Macromedicine 3. Metamedicine Let me explain: Micromedicine: one on one, real doctoring Doctors from antiquity have served their patients one on one, as individuals. Osler, the father of modern ...

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I saw two patients with a chief complaint of bubbles in their urine this month. One middle-aged woman had eaten some wild mushrooms she was pretty sure she had identified correctly, but once her urine turned bubbly a few days later, she came in to make sure her kidneys were OK. Even though she was feeling quite well, they were not, and she ended up going straight to Cityside hospital for IV ...

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