Right Appointment, Right Time

One of the not often discussed challenges of our EHRs may be getting patients to the right medical resource at a time most suitable for the medical condition. Our electronic systems whether automated by algorithm or assigned to a person given a protocol have become too separated from medical care itself.  Our schedulers are no longer ourselves or our secretaries trained in the variability of patient needs particular to our offices or even our specialties, which can then be reflected in physician encounters.  Sometimes a medical disorder condition plays out over months, requiring assessment over an interval dictated by the condition.  Some diseases really shouldn't wait for assessment for the next computerized opening three months distant, either because the condition is self-limited, leaving the provider nothing meaningful to assess, or because some anticipated but avoidable deterioration occurs before the next opening.  We have screens, slots, provider names, either open or blocked out or already filled.  

As I transition from retired physician to a seventy-something with long since expired parts warranties, this has become more apparent, though noticed in my working years as we transferred from those wire-bound soft-covered annual scheduling books ordered each year in a different color from a medical stationer to a perpetual electronic module where somebody in a location far remote from either doctor or caller matches where people can be typed onto the screen, often to the disregard of medical need.  These systems do not seem to account for what happens to people with different conditions over set intervals, resulting in avoidable suffering for some, default to providers who are available but really not as experienced assessing a particular condition as somebody else with a schedule already saturated with patients that the less experienced physician could have handled, or in the other direction, premature appointments at intervals too short for the condition to move to its next phase.  I miss that appointment book with its faux leather cover in the custody of an experienced part of the office team who knows what needs attention quickly, and with the authority to inconvenience the doctor, also part of that on-site team, based on experience and mutual professional trust. 

Recently I felt a sudden tear followed by a pop with a grade 8 very sad face on my Fifth Vital sign.  Something tore above my right greater trochanter.  ER, urgent care?  Within a half hour, I could bear weight, guide my wife through checking my range of motion, noted no discoloration.  After a discussion with the on call primary doctor, we concluded that what I needed was an exam by somebody who knew what pelvic and thigh muscles attached to what.  On Monday I called the orthopedic office, knowing that my own doctor had retired since my last visit there.  Remote secretary from a call center offered me an appointment a month later, by which time I would be recovered or disabled. Just having opted out of an ER visit on Sunday disqualified me from any need for their doctor's promptness.  So exam by primary doctor, advice on symptoms and see what a few weeks of the null hypothesis does to the natural process of suspected tendon rupture.  Or perhaps recovery with cancellation of appointment in favor of somebody who might benefit more.

In a similar vein, from diagnosis of iron deficiency to examination of its source took seven months, with a little iron sulfate and some cbc's to see if maybe a different endoscopist in the group should do it in a more timely way than the doc who did my age related screening, though contrary to group scheduling rules.  The great irony came a week later.  Call from the office, I must come in next week to discuss this.  However, what they found evolves slowly over years to decades and I have been on the usual treatment for years.  Urgency of appointment?  Her vacation and endoscopy assignments would delay the office visit six weeks if not done in two days.  I opted to wish her a good vacation and come in person at a less pressured break in her endoscopy assignments.

For primary care, another pseudo-urgent scheduling need.  My wellness assessment was nearing its one year repeat eligibility, so I needed to make an appointment for three months hence right now.  However, I also get medical care for the things she prescribes medicine.  Those are properly assessed at six-month intervals, with a visit a bit overdue now.  But protest from the desk, they cannot do their wellness.  I still need my semi-annual medical care now, not the wellness visit.  That can wait another six months with the next anticipated medical care visit or done independently when OK with Medicare.  But right now, I was already three months overdue for reconsideration of my medicines and related lab work.  They reluctantly agreed.  Some things are better done now, others better postponed.  Which is which depends on the medical situation, not on what open spots the computerized scheduling flags for the remote clerk to insert a patient name.  Alas, being taught to think situations through, the essence of medical school and much of medical care prior to the computer dominance, has been devalued.  There is some harm to this.

In practice, I would see hospital consults for hyperparathyroidism or elevated TSH or diabetes in various stages of evolution.  Everybody reappeared on my office schedule within two weeks.  The asymptomatic calcium will not change in that interval, the response to the levothyroxine started or adjusted in the hospital will still be in transition when they appear in the office, and the end organ situation of their diabetes was addressed in the consultation.  Had that same diabetic been evaluated in my office, the next visit would be two months, not two weeks, and scheduled by my own front desk on my instruction with me personally two doors away if any special consideration was needed.  As these already resolved hospital consults fill up the slots, transmitted from a remote central site by somebody who cannot challenge what she is told to do, then link to my office scheduling module, that same number of people referred by their physician calling that call center are told that I can see them in two months, irrespective of whether they have the need to reconsider chronic lab results that eventually need to be brought closer to accepted targets or whether they are symptomatically hyperthyroid or hyperglycemic.  Offices of my frequent referrers know who to call to correct the unreasonable.  The City Health Center or other clinic sites for the uninsured tend to accept the reality of central scheduling, same as their network with their computer system utilizes.

To be fair we have a lot of patients who benefit from our care.  Systems that process people through quickly, including electronic central scheduling from a few dedicated operators able to distribute patients to the right office without diverting things that clerical staff at the patient care sites need to do for the patients at their desks right now, have made care more efficient.  Yet, there are also times when understanding the natural cycles of disease or the distress that symptoms bring to people even when their lives or mobility are not in immediate danger, needs to take priority over the algorithms.  It used to happen, and physicians on-site still have a measure of authority to make care timely when it should be, but our modern systems are really designed to process people in and out of care with efficiency, not with thought.  But ultimately top medical care really depends on the patients' conditions being evaluated at the right stage of their evolution, modified for urgency, by the person best trained to do this.  Our electronic central scheduling systems seem to do this efficiently, though not quite in the best way.

Reversing Mask Mandate

When the new drug gets promoted by the detail men, we doctors nearly always heed that sage, time-tested advice, don't be the first to prescribe it but don't be the last. Few of us are pioneers or risk takers.  Few of us are incorrigible laggards either.

Two years into Covid 19, vaccines available and effective, my synagogue remained the only place I attended other than medical facilities which maintained a no mask = go away position.  The CDC position came out in March 2022 that Covid risk had decline sufficiently that 90% of the American public lived in places that did not warrant madatory face covering.  In the ensuing six months, people's external airways have remained mostly uncovered in public places, indoors and out, without a worrysome spike in hospitalization, though more equivocal data on interpersonal viral transmission.  

My congregation assembled a committee now of three physicians, though once four, all active or retired office based physicians, chaired by an experience biological scientist with Board of Governors experience.  We have met periodically since the days following the first vaccine release at a time when Covid was a more fearful illness with high mortality.  Every precaution needed to be made mandatory, even if contrary to political druthers of anti-vaxxers and anti-maskers, rare but not absent among our membership.  Deadly Covid ran its cycle, followed by significant surges of delta and omicron subsets which infected some of our older members despite vaccination but caused no ICU admissions.  Still every Saturday morning, all people in our sanctuary remain masked, with the exception of the man in the front by himself chanting the liturgy, and then only when by himself and chanting.  For our Holy Days, far more attended and much longer than any weekly service, we had mandatory masking with an outdoors mask break two consecutive years.  I went outside, breathed more comfortably for a few minutes, chatted with others which I did not do when inside, took my time getting back, and when the indoor mask got to me, took it upon myself to go back outside for a personal mask respite.  The reasoning:  we did it last year and it would be disruptive to do something else on short notice.  Somehow, our committee has its impromptu meetings hurriedly called a few days before the congregational Board needs to take a formal position. 

By the Holy Days I found myself, a minority view congregant and physician committee member, masked out, VP'd out by people of less skill unable to move from the default position, and already rationing my Saturday mornings in attendance by a reasonable personal algorithm.  I don't know if anyone else also stays home unless invited to participate in some way, but our need for ten men to conduct a full service has become less secure, even failing to materialize at all once or twice.

Like any decision, it entails risk.  All medical studies elaborate the undesired outcomes of research participants, whether receiving a new drug or a new surgical intervention.  While a risk tolerance of nil sounds attractive, the reality is nobody who puts their retirement savings in a guaranteed no risk of loss investment will accumulate enough to retire.  Yet the Rabbi, now moved on, wanted no risk, meaning masks for everyone, vaccinations for everyone, data for no one.  My committee also has a worthy clinician who serves primarily as a nursing home director.  Our congregation is on Medicare primarily, but we are not frail.  And one more email contact, the chairman and one doc again tried to slip the status quo under the door, citing the deadline of the Board meeting.

Sometimes I have to be assertive.  I assembled the actual data, both for efficacy of vaccines for which a policy can be deduced, and some editorials on masking, which have no data.  Then I asked for the formality of a meeting with presentation of data, attended by the congregational President with an opportunity for a Board determination of actual policy within the coming week.

Our goal has to be to keep people from getting hurt.  True of safety in the parking lot, fixing some loose carpeting that is still not entirely flush with the floor beneath it, and not infecting each other while we worship.  While people could assume their own risk by coming unvaccinated, they could also claim their own risk by driving in the parking lot after drinking too much schnapps at our Kiddush following weekly services.  No go on either.  We have an obligation to avoid people being harmed, so immunizations needs to stay and that iffy carpeting cannot languish forever either.

Masks are more philosophy than data.  In our community we have a branch of the State University dedicated to post-retirement education.  Those in attendance seem more frail than those in our sanctuary.  Yet, the University, which has a reputable epidemiology department, lifted the mask mandate but not the vaccine mandate this semester.  That seems our best model, one that merges prudent risk, don't be first or last, and special populations needing special consideration.

We met as a group, three physicians, scientist chairman, congregational president.  We each presented our positions, mine being the one with citations and philosophy, both medical and Jewish.  We are not permitted to burden people unnecessarily, a condition called Tircha, but we are obligated to protect people.  By now the masks are a burden.  My other two colleagues acceded. So within the next few weeks, we will be like all other local congregations and like the community at large.

That's not always a good thing.  Israel's argument for Samuel appointing a king was mostly that the other nations had one.  Torah allowed one, but did not mandate it.  We got one optimal one, still including restoration of that dynasty in our daily prayers, though probably better delaying its resumption.  But for protection of people, not being an outlier is really the way to go, no matter how easy it may be to default to what we did last week.

Reversing Endocrine Racism

 About ten years ago, the Endocrine Society selected ethnic disparities as its Annual Meeting Theme.  Working as the lone endocrinologist serving an inner city population, the subject generated appropriate enthusiasm on my part, though more on the flight to that meeting than on flight home.  Disparities of diseases were discussed, senior professors lamented the under-representation of minorities in their clinical trials recruitment, some desired broader ethnic representation in the workforce while leaving no offense to the very fine people we already had.  No surprise on our aggregate professional scorecard.  I returned to my patient cohort wondering about my own lapses, as wanting all patients to benefit maximally from clinical encounters is shared by virtually all physicians.  Unfortunately no way of making an accurate  personal appraisal and no specifics of what to seek out in my own patient encounters.  Nor anyone to coach me.

When Hizzoner Mayor Koch used to ride the NY City subways solo, he would randomly ask riders how he's doing as Mayor.  Some would tell him what they thought the candid truth.  In the ten years since that Annual Meeting, Covid along with more formal outcome studies on disparities in common endocrine disorders provided our specialty disappointing progress from what that themed meeting aspired to achieved.  African-Americans and Hispanics still lag behind accessing emerging diabetes technology, the most reliable insulins are farther our of financial reach for many people now than ten years ago, as Covid forced acceptance of virtual remote site medical encounters groups most devastated by the pandemic were the least able to take advantage of this new resource, our workforce, while still admirable, reflects the ethnic distribution of college graduates who took the pre-med requirements and got an A or B in Organic Chemistry, which is a whole lot different than the mix of patients who depend upon our skill and our kindness.  That ten year interval does not seem to have generated much in the way of pilot projects of great promise.  And publicly expressed antagonisms have become more harsh, not less.

Perhaps time for a rethink.  Earlier this year, the Endocrine Society assembled an expert panel to explore the challenges of America's ingrained racism which, at least in part, keeps certain groups of Americans from partaking of the best our specialty has to offer.  [Eradicating Racism: An Endocrine Society Policy Perspective 

Ruban Dhaliwal, Rocio I Pereira, Alicia M Diaz-Thomas, Camille E Powe, Licy L Yanes Cardozo, Joshua J Joseph

The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 5, May 2022, Pages 1205–1215, https://doi.org/10.1210/clinem/dgab896] 

 Like most formal position papers the goals are noble, the assessment of the challenge thorough, and parts that I might have hoped would be part of the move forward did not make it to the text.  As doctors, we look at our measures to achieve best outcomes.  The first thing that stands out is the stated need to eradicate the effect of racism.  As doctors this impedes our effictiveness.  As people, eradicating racism is undertaken to enhance the world.  The paper opted for the medical goal of better outcomes rather than addressing this as a fundamental demerit in how our world is structured.  In that perspective medical outcomes are a form of collateral damage that can be reduced even when the imprint of how different subsets of people are thought to think and react is probably more intractable. 

 Endocrinologists, and physicians in general, do quite well sifting through histories of how we got to where we are, whether doing a comprehensive consultation on a new patient, looking at the trajectory of how our current treatments flowed from what the previous generations of endocrinologists did, and in a social framework looking at where we were and its path to where we aspire to be.  Disease outcomes are fairly easily extracted.  But to improve, the committee recognizes that some cooperation is needed from payers and others who also want good care for their beneficiaries which sometimes conflict with the financial obligations to their shareholders, with minority patients caught in middle.  

Medical care depends highly on its workforce.  The Endocrinology community has always surrounded me with worthy colleagues.  Our training programs go out of their way to assure that its graduates are ready to pass their exams and take responsibility for their patients and for undertaking productive research.  But the position paper questions, with some validity, whether it is the best work force and whether we put the right incentives in place so that those most interested in reducing disparities have the resources that they need to do it.  Perhaps more importantly, do those who direct their careers that way receive due recognition, or will they always score lower on the Endocrinology Prestige Meter than those who advance molecular biology or medical technology?  It is a very valid question.  At the 2012 meeting themed to disparity, the plenary invitations still went to those most productive in the lab.  To some extent funding reflects what is valued or what is judged of greatest future potential.  There are some training grants to address this.  It is still unlikely that research efforts to explore the social structures of endocrinology will acquire parity with efforts to delve into the molecular mechanisms of the diseases we treat.

As much as a diverse, inclusive workplace has become a widely accepted goal of healtcare instututions, major corporations that thrive or fail by their innovation, and the universities that generate the talent, the pool of people from which the talent emerges is really a skewed subset of the larger community.  While medical school, residency, and fellowship is not available to everyone, even to many who would make terrific colleagues, the care of patients needs a lot more people than just specialized technical talent.  They correctly recognize that the people patients and research subjects connect to best to are people they feel are most like them.  And patient care is a team enterprise.  Opportunities to expand this presence by bringing aboard research coordinators, office staff, and others who are very much part of the Endocrinology workforce but not permitted to be as visible or as representative as they could be.  This may be one of the more measurable initiatives that brings a huge contribution to the goal of better outcomes.

Policy statements have what is there, but also what is not there.  Some of the candor seemed to be either absent or less conspicuous than I think it could have been. The statement gives major emphasis to education.  Hard to be a doctor and oppose education.  But it takes more than education to be effective, which is why we do a lot more practical work than classwork after the basic science years of medical school.  In the area of public policy and attitudes, it is not always education that generates desired outcomes.  Seat belts had their opposition for decades until states started fining drivers on the road unbuckled.  Teaching people about Covid immunization does not eliminate anti-vaxxers or even physicians who  cater to them.  In the more sensitive areas of Civil Rights, there were lectures galore of the social and financial benefits of open public accommodations but restaurants and hotels often continued to exclude minorities until a legal mandate required they have access.  I would question how much progress can really be made in the absence of mandatory conduct, something very absent from the statement and its recommendations.  

As a fellow I was made to carry a small ruler in the breast pocket of my white coat because endocrinologists measure everything.  Measurements and pilot projects are essential to progress.  I don't know what an Endocrine Society Skunk Works would look like or what they would fund.  Surely the intent of the themed meeting fell short of its intent, thus the revisit, but what failed and why needs to be part of the assessment.  So does what succeeded, but the trajectory of progress in those ten years did not make the current policy statement, which I think is incomplete without it.  For a specialty dependent on measurement of our patients' progress and our own, I might have expected within the proposal some benchmarks to monitor progress along the way to avoid another ten year interval between meaningful initiatives.

Another area of untapped potential not discussed beyond a polite slap at our insurance payers are the potential partnerships to be pursued.  The Endocrine Society, to which I loyally pay dues even in retirement, is the most diverse of the advocates for patients with hormonal disorders, though hardly the only one.  If diabetes care lags behind, I suspect the American Diabetes Association leadership is just as taken aback by the ourcomes of the patients we share.  There is a thyroid association, an organization of bone experts, potential gynecological overlap, and experts in our end organ meltdowns of heart and kidneys.  Eliminating racism either for its own sake or directed to optimal medical outcomes means seeking alliances.  Perhaps our best partner might not be another health agency but a think tank that has experience creating researched and enforceable policies.  Moreover, not all great allies need to be congenial.  A lot of us are forever grateful to the most notorious curmudgeon in our fellowship program who gave us that tough love that we needed when nobody else would.  While the work force needs to be diverse, so too the committees that explore solutions.  Not all diversity committes reflect that.  They should, lest recommendations emerge from professional echo chambers.  The most disagreeble, unwelcome input, when learned, offers insight not easily acquired elsewhere.  And every outcome has a why, an investigation typically more gratifying than the outcome itself.  Bask in successes, as there have been many, but recognize what has not gone along the desired path.  Opponents can be either resources or threats.  Either way, they are still part of medical care and development of meaningful initiatives.  

All worthy projects, indeed all that we have from medical advances to technology to the trajectories of our social structions, always begin with somebody imagining what might be possible, then assembling a process to make it happen.  Eradicating racism, which has been an ongoing American blight, has to start with proposals for doing it, anticipating what success might look like in terms of more equitable medical care and better congeniality, then outlining a means of pursuing it.  I think the Endocrine Society deserves support for the effort.  While it seems incomplete, even vulnerable in some ways, it is an initiative that deserves high priority as well as some introspection of ourselves as people and as a profession.  Impediments not previously encountered will invariably arise, as they do with all transforming initiatives, but addressing those snafus is really part of the success.  

Topical Treatments

Skin has a big absorptive surface, as does mucosa.  My daily pill case and PRN's now exceed what should be altering my chemical innards so I've taken to topicals.  For a recent road trip, I gathered Voltaren, Lidocaine, and Ben-Gay into a soft tossable plastic bag along with a bottle of naproxen, none of which I used despite some soreness.  As I cope with rhinitis, this time infectious, fluticasone has come to the rescue. What I found most helpful has been the OTC Voltaren, now the drug of choice for DJD if limited to an area where it can be applied.  My right shoulder hurt enough to limit use of my right arm.  The stuff only works if taken on schedule, which I did bid for about a week, resulting in a fully useful shoulder with scant residual discomfort.  My right knee could be doing better but my commitment to the schedule did not hold.

Back pain calls for the PRN forms of lidocaine.  I have two areas, one midback and persistent, largely at the edges of what I can reach and a more classical lumbar area.  Lidocaine gives very temporary analgesia, enough to get on a treadmill.

Not to ignore Ben-Gay, its role has been for exercise induced myalgia.  Intermediate efficacy but attracted Priscilla the Cat who started licking the fingers used for application.

No systemic effects, currently off all.  Useful when needed.

Wellness Invitation

Threescore and ten has arrived.  Not been there long enough to make any judgment of whether granted the vigor to make it to fourscore.  I wonder why the English translations of the Psalms always present in this way as the Hebrew just uses 70 and 80, but there must have been some type of reverence for advancing age.  Without reverence but with steady payroll deductions, Medicare has also arrived, mostly a pretty good plan with the supplement that I have.  Realities brought me to a new primary physician and I periodically touch base with a cardiologist, soon to be declared well enough to latch on to her NP.  I think I am well enough.  Symptoms are some blend of nudgy and insidious.

Automation being what it is, I received a message to take advantage of a Wellness Assessment, paid by Medicare at no cost to me.  While I recently had a semi-annual visit with my primary doctor, my focus deviated a bit from the expected purpose of the follow-up.  When I telephoned the office concerning whether I needed to see the doctor or her surrogate again, I was told that Medicare's Wellness program differed from their usual office visits.  Not knowing what it entailed, I made the appointment for about a month hence, then proceeded to the www to determine what might be in store.  Apparently the purpose is to look at risks and to some extent resilience.  I wish I felt better but don't feel badly.  Cognition checked as part of a research protocol, so I did pretty well.  Mood could be better.  And one day I will stumble over clutter at home and fracture something or fall down the stairs.  I don't have a lot of medicines or a lot of providers.  I can be an ROS + if the detail is sufficient, though.  I don't engage in hazardous activities.  Vision good.  Hearing good.  Weight seems to be declining, I assume in response to some dietary changes of a few months back.  I'm mostly well.  See if she concurs.

License Renewal

That biennial season has arrived.  Licenses from both states are about to expire.  Since retirement, I've paid no serious attention to CME other than renewal at the next cycle to keep the option of locums open.  It is no longer open.  My Board Certification and DEA similarly expire in the coming calendar year, with no interest whatever in maintaining either.

But license renewal remains an option.  Pennsylvania can be something of a nuisance, 100 hours of cme, 40 category 1, twelve hours risk management, two hours opiate, two hours child protection.  They offer a retired physician license for $360 with just the opiate and child protection modules.  Since the Commonwealth extended the deadline, I could do that but it doesn't seem like money well spent.

Delaware seems more user friendly, a straight 40 hours Category 1 and a child protection module.  That I can do. Fee $425 but it keeps me part of the local team, so I need to consider this.

So far I've paced myself, about 1h online CME a day, all endocrinology or related.  I sort of enjoy doing some of this.  It adds structure to my day.  I do not cut corners.  I now know the hot themes: CGM for type 1 DM, SGL2 inhibitors for heart and kidney protection, long term data on bariatric surgery.  And there's always Covid-19.  Never a shortage of things to engage me.  But for sure, some of this is more difficult for me to learn now than it would have been were I still seeing patients and doing consultations.  Yet I don't regret stopping.

Enrolling as a Research Subject

About a year ago, I volunteered for a study at the state university examining cognitive decline as people age.  Appropriately, they recruited subjects from a table set up in the lobby at the Osher Lifelong Learning Institute.  Being always on the prowl for something to do, I offered my contact information, underwent screening and was assigned as a healthy control.  I attended two on-site sessions, getting a university parking ticket at one that I successfully challenged.  I read my own uncontrasted cranial MRI which freaked out the technicians a bit, but never got the formal radiology interpretation.  On exercise testing they measured oxygen consumption but neither I nor my physician ever got results.  They did psychometric testing which my self-interpretation would suggest limitations of spatial orientation and maybe some immediate memory. My honorarium arrived in due time.

OLLI has gone virtual due to Covid-19 but the computerized face pages still recruit us for university studies.  I followed the link, somebody contacted me, and ran a miniscreening.  They performed over the phone a mini-mental status exam, where I had great difficulty repeating the words I had just heard, both immediately and a few minutes later.  All else seemed intact, but the deficit qualified me for the next stage.

My professional research experience, despite an endocrinology fellowship, was quite minimal.  I had written an NIH Training Grant Proposal as a program requirement, did not get selected, and really graduated without understanding stages of clinical studies until I became a subject who had to give consent.  The current project has an honorarium far larger than the last one and is subdivided into two main grants and some lesser offshoots.  While I thought the first screening qualified me, that was not the case.  I underwent a second more detailed screening, including my wife's presence part of the time to provide information about me while I was sent someplace else.  Then the exam, a more detailed mental status exam with a language component, much like we were taught in neurology class in medical school to assess a mixture of dementia and aphasia.  I did a lot better, even the repeating of words.  As I listened to the dozen or so words being presented, I did not think of them as isolated words but as categories: gemstones, animals, and dwellings.  By classifying them, I was able to repeat a lot more of them this time than last, so I may not qualify for a memory impairment study, though had I not categorized the words and just tried to remember them as words, I probably would.  Is it a short term memory deficit that's compensated but still a deficit?  The person administering the questions couldn't tell me.  But it's not a functional deficit.  While the first study kept my scores hidden from me, the consent on this one requires them to disclose them to me.

But if I am demented at all, it's pretty subtle, exposed only by testing for that purpose.