A Country Doctor Writes:

My mother, who lives in Sweden, has been suffering from gout again. It has been a few years since her last attack. She told me on the phone this morning that the medicine her family doctor prescribed didn’t seem to be working. Last time she had an attack a covering physician had given her an anti-inflammatory medication, naproxen. When she saw her regular doctor the other day, he read her chart and voiced his disapproval of his colleague’s choice of treatment that time.

“You should not be taking naproxen when you are also taking a blood thinner”, he declared. “I’ll give you something else.” 

Four days later there was no sign of improvement. I asked what medication her doctor had put her on. “A-L-L-O-P-U-R-I-N-O-L 100 mg”, she spelled from the bottle.

I advised her to stop taking it and explained that allopurinol isn’t indicated for acute gout, but instead is used to prevent attacks. It can often precipitate an attack when first started.

Her doctor is a board certified generalist, who works part time at her neighborhood clinic and does research part time. From what I have heard, he is a decent fellow, who generally takes good care of my mother’s health issues. In this case, however, I felt compelled to intervene.

“Why don’t you call tomorrow and ask for some prednisone,” I suggested. “That’ll stop the attack fast and it won’t upset your blood thinner. Then, when everything has settled down, you might be able to start the allopurinol.”

I don’t remember how nervous Swedish doctors are about short-term use of steroids, but not using allopurinol for acute gout is fairly basic.

I did some more thinking this afternoon. One does need to be careful judging others with regards to what is basic knowledge as opposed to esoteric. I don’t know quite how old my mother’s physician is, and I know the diseases he encounters in my mother’s urban clinic in Sweden are vastly different from what I see in rural America.

I went to medical school before AIDS/HIV, hepatitis C, fibromyalgia and many of the diseases that now fill the workdays of many of my colleagues, and I work in an area without much ethnic diversity. I have only had one patient with AIDS, and I haven’t seen a gun shot wound in a decade. I remember thinking when I took the test to renew my Family Medicine board certification a few weeks ago that the choice of questions was not representative of what I see most days in my practice.

Perhaps we have arrived at a point where physicians’ knowledge base even in primary care isn’t universal.