Telemedicine is on its way in.

I have nightmares already.

I am already seeing people taking "supplements" and "natural medicines" made by hand around here, from a physician in another state or sent from other countries.

One patient is treated by a doctor in another country. The patient won't give me information. The patient won't show me the "medicine". I insist on laboratory work and the person is extremely anemic. A ferritin is the lowest I've ever seen. They still won't show me the medicine or the notes. I finally say that I cannot care for this person without sharing information. It's a black box. I want the other providers notes, or switch doctors. The patient switches.

Now, multiply that by telemedicine all over the US, across state lines. Will there be clinic notes? Will I be able to get my hands on them? Good luck! There are 500 different electronic medical records. We ask people to bring EVERY pill (or tincture or herb or vape) they are taking to the first visit. About half do. The other half bring the prescriptions only or don't bring any of it. "I am on metoprolol." There are three different formulations and about 5 strengths of each. And the person doesn't know. "I take vitamin E." "How much?" "What do you mean, how much?" "How many micrograms?" "Whatever the store sells."

It is sold by Walmart or the Food Co-op so it must be safe. Yet the same person says, "I don't believe in prescription medicines." and "I don't trust Big Pharma." Um, it's Big Pharma that is making the supplements and vitamins. Oh, and they LOVE people not trusting prescription medicines. They don't have to prove anything about the supplements except that the ingredients are "generally regarded as safe". I suspect sterilized dirt and dust bunnies are generally regarded as safe.

I am starting to request other provider notes: the chiropractor, the naturopath, the cash only MD with a website selling tons of pills. All the notes. I review labs ordered by an alternative provider. "Are they going over these with you?"

"No." The person looks confused. Labs were DONE. So it must be OK.

"You have multiple vitamin levels that are high: some twice the upper limits of normal. Are you still on those vitamins? We don't know the levels that are toxic. We can't do a clinical trial where we give people more and more until they are poisoned." I say. Though each year my pocket drug book adds more upper limits of dosage. Vitamin D now says maximum of 4000 mcg daily. They sell 10,000 mcg drops. Or people have vitamin D in four different supplements. And haven't read any of the labels. I guess we are figuring out the toxic levels. Go consumers!

And then I read this: "Volpp describes the link between customization and experience by citing Amazon. “I do think one of the areas in which health care delivery could really improve is if we did a better job of aligning with patient goals. At Amazon, they have this very nice mass-customization model that uses all the data they have about you and people like you to figure out what to offer you. That’s what we could aspire to do in the future in health care — and maybe we could even do it better by integrating this with clinical evidence to determine what people should be offered.” Oh, great. We will spy on people and buy Big Data from the internet and then custom offer stuff to patients. Ha, my on-line spies know that you will TOTALLY want a pill that helps with sleep deprivation so you can stay up internet surfing until 2 am and then go to work at 6. GREAT. Or you are highly suspicious of hormone replacement but a female libido supplement, you'd go gaga.

I have people showing up from naturopaths with testosterone twice the upper limits of normal which raises their blood count and puts them at risk for heart attack and stroke. I had one going into renal failure from mushroom pills, from the Seattle mushroom guy. He sells on line. I have people arriving on thyroid supplements from naturopaths, no labs in two years, they are hyperthyroid. This can damage the heart. "I don't take levoxyl, I take a natural thyroid." Ok, it has to be extracted from pig or cow or sheep. That means it goes through a laboratory and there is a process to extract it. How do you define "natural"?

I do telemedicine. With the University of Washington medical center. Telepain and PACC. But both are formal and controlled. I fill out a form, year of birth and no name, standardized and present the patient on live telemedicine. The panel discusses recommendations and sends me a list. I try to implement what they recommend. This is not some provider in Ohio prescribing something to my Washington patient over the internet. It is going to be a huge awful worse mess. We still need single payer and one electronic medical record so that everyone can carry all their information around on a card. Other countries have that. We are too ruled by hubris and greed and magical thinking.

Back in residency in the early 1990s, I did two rotations in the Veteran's Hospital. The charts were paper. There were a few Veterans who would work the system. They knew what to say to get admitted, were in the ICU for chest pain, laboratories done every 6 hours to rule out a heart attack. Meanwhile we would be scrambling to call whatever hospital they'd been in before, please send the records, please fax them, because we don't want to do another treadmill if this person has had five treadmills this year....

People come in saying that their physical therapist said they should have an MRI. Their chiropractor said they need a brace. Their friend thinks they need their head checked. I say that I would be happy to review the notes from the other provider or that provider can call me.

A patient asks, "Why didn't my new cardiologist do a treadmill? A cardiologist told me years ago that I would have a heart attack in my 70s. Don't I need a treadmill?"

I go over the note with the patient. "Medicine changes. Let's go over the note." We do. The cardiologist says what I say: no signs of heart disease, work on the risk factors. "Are you exercising?" No. "Are you taking any time off?" No. "Are you sleeping well?" No. "Have you reduced alcohol?" No. I am exasperated. "So you are going to keep doing what you are doing until you DO have heart disease. How is a treadmill going to help with that? It is not going to prevent the heart attack. Taking care of yourself and changing your risk factors will." We negotiate a start of an exercise plan and a follow up visit. Because doing the work prevents the heart attack, not getting a test!

People are nuts. They are sold. They want the magic pill and the magic test, the more expensive the better, but they don't want to change their habits. I wish that they would stop trying to buy the pill that reconnects them with nature. Go for a walk instead. Outside. No earbuds, no dog, no friend, just you alone in nature. Look and listen. Reconnect. Because you can not do it with a pill....

theme song: Stuck in the middle with you

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