Johnny can’t play!

Another day in the office, another appointment.  This one turned out to be unique.

Johnny, 8 years old, plays hockey, but he seems to have lost his stamina, can’t finish a whole game.  I have seen this before.  My son’s soccer team captain lost his mojo and couldn’t finish a game, left the team and returned 100% after his doctor diagnosed exercise induced asthma.  So, I did have one example to suggest that.  Johnny’s history and my exam of him and his heart and lungs were normal.  The next step could have been blood tests, ECG, CXR, all normal, then referral to pediatric cardiology or pulmonology.  That is also the lazy and uninteresting way out!  It’s also a great way for a health system to make money, so it’s common, but IMO completely unnecessary, wasteful, and poor stewardship, but I digress…

I told his parents I thought he might have exercise induced asthma.  That condition is detected by demonstrating that lung function declines by 20% or more after at least 10 minutes of exercise, preferably peaking at 20 minutes, and responds to inhaled bronchodilator, i.e., a short acting albuterol inhaler or nebulizer treatment.  It also responds to doing nothing except stopping the exercise and resting until the reaction subsides.  The theory is that exercise dries out the airway, the the asthmatic reacts to that drying.  No allergens needed!

So, what to do?  

“Let’s make another appointment shortly for Johnny to come here, get his lung function tested, go running 20 minutes outside, and then retest him.”

Done.  For the follow-up, Dad brought Johnny dressed for running.  It’s Western Washington.  It was raining lightly.  As usual!  Johnny’s baseline lung function can be simply measured with a $12 peak flow meter I had in each exam room for monitoring and detecting asthma.  His baseline was normal.  20 minutes later he came in after running, soaking wet.  His Dad sent him out in the rain while waiting for him.  His lung function as measured by peak flow had dropped 25%.  He was feeling fine, just winded, so I did not bother with adding a nebulizer albuterol treatment.  I could easily justify it, but it would add an unnecessary NEED for a machine to recover, in his mind, scare the young man, and add to the cost (and my income).  I didn’t do it.  Instead, I gave him a peak flow meter and an instruction sheet on using it properly, and showed him how.  I also demonstrated how to use an inhaler correctly using a “pretend” inhaler I also had, and then I gave him a prescription for a short acting albuterol inhaler.  Most importantly, instructions to use 1-2 puffs 20 minutes BEFORE the game starts, to block that reaction from happening.  The medication is good for 4-6 hours, and is used by nearly every person with asthma.  

“Let me know what happens, and monitor your peak flow before games and off and on to find out YOUR normal.”

Step one in managing what may turn out to be a bigger asthma problem was done.  The goal is to find one’s own normal, and monitor peak flow regularly, with a dropping peak flow to trigger use of the bronchodilator inhaler at 80% of normal, and if that one is used more than a few times a week, to add a corticosteroid inhaler.  Today, the combination is recommended as the FIRST line of treatment, but not back when I met Johnny.

Now I waited for feedback.  That is NOT done in the urgent care or ER.  They have zero continuity.  This was one of OUR families.  They already knew that followup could be easily arranged then, if not in 2024 as I write.  Access then was often same day or next day for urgent appointments.

So, the next event was an urgent request for them to come in, granted, right now!!  That surprised me!! I expected to find Johnny short of breath and in trouble.  I knocked on the exam room door, walked in, and found his parents, Johnny, and his brother all relaxed and grinning.  Johnny was in his hockey uniform.

“We just wanted to thank you! Johnny just scored 8 goals and won the hockey game!”

My favorite stories make me look good.  This one could be done just this way by any family doc with residency training, a good work environment, a cheap peak flow meter, and motivation to make things cheap and simple.  Your average family practitioner.  It’s not that special.  However, getting it coded right for reimbursement by insurance??  Another reason fee for service doesn’t work for family practice.  When you do the same thing every day in some less creative and complex specialty, coding is not that hard.  In family medicine, one never knows what the next patient will bring in, and much of the time we have to remember the option to bill by the time spent, which is not nearly as lucrative as billing for a procedure.  Freezing a wart in two minutes is a cryosurgical procedure, and paid better than a complete physical then.  Do docs think about this all the time?  When primary care in Washington has shrunk to 5.1% of the healthcare dollar from 9% when I started, when corporate speedup and productivity goals for employed physicians have become the norm, along with awful hospital-based electronic records systems, burnout, and loss of autonomy, conscious or not, economics drives what happens.  I wish it were otherwise, but healthcare has never been less of a right or a public utility and more of a business than now.  We can rebuild it, but it will take change at the roots, not a tweak.