A Country Doctor Writes:

Even though I had been up until midnight, I was awake before my 5:10 alarm and out the door just after 7:30. Somehow I felt more energetic and more philosophical at the same time. All day, I felt more generous, and less pressured than I had all week, even though my schedule was jam packed and the phones kept ringing.

I had happened to read about a patient who switched doctors after what she described as a near miss due to inattention by her long time family doctor. The physician is known far beyond her service area as a competent and caring doctor, and I was surprised by what I read. The essence of the patient’s complaint was that the doctor didn’t listen to her concerns. Reading the account of the doctor’s actions left me with the impression that this doctor was pressed for time and had, at least temporarily, lost her ability to engage, acting far below her usual standards. Possibly she was suffering from some degree of burnout.

My thoughts before falling asleep were about how fine a line we sometimes walk between working at full capacity and being stretched too thin. Often the difference lies within ourselves.

Driving to work I delighted in the warm sunshine and thought about my first patient of the day, a Hospice patient with Alzheimer’s Disease, one of my regular housecall patients. His wife is such a diligent caregiver, and the two of them have done well in spite of their family living so far away.

I also wondered about Mr. Donnell, the man I had slipped out to see a couple of days earlier. His warm, swollen and exquisitely tender knee had looked like a typical gout attack and since he had a remote history of gout, I had put him on a short course of steroids and some pain medication. I had asked Autumn to call him the next day to see how he was doing, but she must not have remembered. As I was driving up “Moose Alley”, I remembered my broken promise and decided to swing by his house on my way back from my scheduled home visit.

Mrs. Thurlow, met me at the front door of their tidy little home. I could tell from her face that there had been a major change. Her husband had stopped eating, and was barely taking fluids. He was also becoming increasingly restless. The hospice nurse had already used her authority to start some of the “comfort pack” medications. Together, Mrs. Thurlow and I went through her husband’s medications and stopped everything nonessential. I wrote down the changes on a prescription pad and asked her to call me after noon with an update.

As I left, my first office visit was already due to begin, but I still stopped in at Jack Donnell’s. I felt unfettered by the clock and thought more about the purpose of my workday. He waved from his perch by the kitchen window.

“Well hello, young man, how are you”, he grinned with nicotine stained teeth.

“That’s my line”, I said. “How’s that bum knee of yours?”

It took me less than five minutes to make sure that my diagnosis had been correct and that he was on the mend and I was back in the car. I arrived at the office less than fifteen minutes late.

Throughout the day, I found it easier than on some other days to feel connected with each one of my scheduled patients and keep the focus on them, and not on the peripheral things that sometimes fill my awareness: the schedule itself, the EMR, the insurance paperwork, the number of prescriptions to authorize. I found myself thinking more about the patients needing the medications than the work aspect of renewing them in the system.

I offered Autumn to contact more patients myself than I usually do. On days when I feel more pressured, I rely more on the electronic messaging system and give her instructions on what to tell the patient. This is one of the things my colleague downstate had done when the patient really needed to hear directly from her doctor.

I spoke with Diana Brooks about her continued side effects after we had stopped the medicine I thought was the culprit and I personally made sure she was on board with stopping her amlodipine and restarting her valsartan-hydrochlorothiazide.

I also grabbed the phone and told poor Jimmy Forthmeyer that his D-dimer from yesterday was positive, so he did need to have that ultrasound done of his leg to look for a blood clot. I already knew he would have to take the bus to the hospital for the test and it doesn’t run every day, so I had to e-prescribe an injectable blood thinner for him. I arranged for him to pick it up at the drugstore and bring it to the office so we could show him how to give himself the daily injection until the ultrasound. When Jimmy showed up without the medication, saying “I guess it needed a prior authorization or something”, I grabbed my cell phone and called the pharmacy from the exam room. “Try the brand name, Medicaid sometimes prefers brand over generic”, I told the rookie pharmacist. Sure enough, the brand name went through, so Jimmy had to hoof it back over to the pharmacy and get the prefilled syringes. Good thing it was a nice and sunny day outside.

George Hincks still hadn’t heard about his follow-up with the visiting pain specialist, even though his second MRI, this one with sedation, had been done a month ago. Again, I grabbed my cell phone and called the Specialty Clinic. “Dr. Brooks is here today, and he has a cancellation at 3:30. Can Mr. Hincks be here by then?”

And so it went. I don’t mean to say that I don’t usually reach out, connect and engage with my patients, but I often feel more on guard than I did today, and today I felt unfettered by the system and more directly connected to the souls who have entrusted me with their care.

I still got just about all my chart notes done in real time and when I left the office at 5:20, I felt energized by my day and was able to fully notice and again delight in the warm sunshine I had enjoyed on my drive to work almost ten hours earlier.

Over dinner, Emma and I talked about how we can choose to approach life with a sense of lack or with a sense of abundance. This is a choice we all have, and it determines the course of our lives. Think of yourself as an overworked, powerless cog in the big healthcare machine and all you will feel is frustration and exhaustion; give generously of your gifts of healing and comfort, view the system as peripheral to your higher purpose, and feel the reward of your engagement with each patient renew you and replenish you.

“What you did today was practice mindfulness, and out of that grows compassion and healing, both for you and your patients”, Emma said. She told me about a book she was reading by Thich Nhat Hanh, “Living Buddha, Living Christ”, where he compares mindfulness in Buddhism, the Holy Spirit in Christianity and Jewish piety.

“This book gave me a different and much deeper understanding of mindfulness – it is not just being aware of everything in the moment, but putting a sense of sacredness into everything you do”, she said. “You might want to read it, too.”

It is almost eleven o’clock. My index fingers tap quietly on the virtual keyboard of my iPad. The goats are chewing their cud and making contented little grunting noises. My white Arabian horse dunks her hay in the pink bucket hanging on her stall wall and eats with smacking lips. The night sounds fill the air in the barn through the screen windows. One week after Midsummer it is dark outside here, unlike in Sweden, but the fireflies are out, painting short lines against the night sky.

I am content; tonight I view life with a sense of abundance. I know that there will be days when there are more things weighing on my shoulders than I can carry without feeling pressured, but I must not let those days flavor my whole outlook on the life I have chosen.

I close up the barn and walk the short distance back to the house. Just like last night, Emma is probably asleep already. Tomorrow is Saturday and I can look forward to two days of farm chores in the sun.

Emma is asleep, but she emailed me this quote while I was down in the barn:

“A mind committed to compassion is like an overflowing reservoir – a constant source of energy, determination and kindness. This mind can also be likened to a seed; when cultivated, it gives rise to many other qualities, such as forgiveness, tolerance, inner strength, and the confidence to overcome fear and insecurity.”

Dalai Lama