Doctoring, In Simple Terms

Friday afternoon, during the last two hours before the long Labor Day weekend, I had two patients with shortness of breath, one who was feeling bad all over, one with a brand new neuropathy and just then I got an urgent fax with an MRI report that a patient I had seen two days earlier had very severe spinal stenosis.

One of the patients with shortness of breath had a stable EKG, an unchanged chest X-ray and a normal blood count. But his oxygen saturation trying to walk down the hall to the bathroom dropped from 91% to 84% and his pulse rose to 137. On exam, he had loud pleural rubs over both lungs. He required some convincing before agreeing to go to the hospital by ambulance. I told him that with his atrial fibrillation and rapid pulse, he was probably trying to compensate for what might just be a viral infection with some pleurisy, but the faster his heart beats, the sloppier and more inefficiently it pumps, which is why he, more than the average person, needed to be in the hospital with everything he had going on.

The patient who felt bad all over looked jaundiced to me and while I waited for his chemistry profile to come back, I went back to my second patient with shortness of breath. Her oxygen saturation was fine both at rest and with a walk down the hall, her EKG was unchanged, her breath sounds and peak expiratory flow were normal and her chest X-ray hadn’t changed from her last one. But she had a new, significant but not critical anemia.

Sitting down next to her, I explained in English while her son listened from his corner of the exam room:

“There are basically three reasons why someone can be short of breath – a weak heart that can’t pump the blood around enough, bad lungs that can’t take enough oxygen from the air and transfer it to the blood, or weak blood with too little hemoglobin to carry the oxygen to all the organs in the body that need it.”

He spoke rapidly to his mother in French, and she nodded in understanding. Then he looked at me and said:

“I’ve never heard anybody explain that so simply before.”

“It really is pretty simple”, I answered. “Someone once said that if you can’t explain something to a twelve year old, you don’t really understand it yourself, or it isn’t worth knowing.”

Madame Theriault refused a rectal exam but agreed to get me some stool cards, the first one the next morning, Saturday. Sadie, the lab tech, had enough blood to send off a B-12, folate and iron studies. We agreed to be in touch Saturday morning and Tuesday. If she gets worse, she will go to the emergency room.

The man who felt bad all over had a bilirubin twice the upper limit, his liver enzymes were elevated and although he didn’t have a fever, his white blood cell count was elevated. I explained to him and his wife that his bile ducts were plugged and he was being poisoned from inside by all that bile and there may even be a brewing infection in his gallbladder. The ambulance had just come back from the hospital, and after they loaded him on the rig, I called the emergency room again and said “I’ve got another one for you”.

The neurosurgeon on duty returned my call just after five. He was able to look at the MRI images as I told him about the patient’s physical exam and his two week history of back pain with sudden urges to urinate or defacate (which in my office note had been transcribed as “deprecate” by the voice recognition software). He told me to have the patient call his office Tuesday morning and they’d get him in to the Wednesday neurosurgery clinic. I called the patient and told him the news. He was feeling quite a bit better on the prednisone I had prescribed. I explained what the MRI report said about how tight his spinal canal and the exit holes for the nerves were.

And, speaking of nerves, I also sat down with the woman with beginning neuropathy and described how it usually starts at the end of the longest nerves. Her big toe is a hair shorter than the two affected toes, so it may be next. We also talked about how better blood sugar control can sometimes make neuropathy better, but not always.

Eight o’clock Saturday morning, I sat with a fifty something man with poorly controlled diabetes. He is a junk dealer, who always fixes his own vehicles.

“Walk me through your day, tell me what you’re eating”, I asked him. After he did, I explained:

“You can keep eating a pretty balanced diet like you’re doing, and take some more pills or even insulin, and we can get your blood sugars down, or you could get more radical with your diet and avoid taking more medicines.”

“Well, I sure don’t want the needle”, he answered. I went on:

“I’ve got my old van out there in the parking lot. It’s a flex fuel thing that’ll run on regular gas or ethanol. If it started to sputter on gas and my mechanic told me to try ethanol, I’d be thinking, like, I’ve been putting gas in my cars for over forty years, and I don’t know anybody who uses ethanol in their car – why me, why should I have to change now, at this age? But, then again, what if my van starts to run better, isn’t it worth switching?”

He shrugged: “So what do I eat?”

“Think of it this way, you’ve already eaten almost all the carbohydrates a person should eat in his lifetime. That’s why people with the right genetic predisposition develop diabetes if they eat more carbs than they can burn right away. Eat protein, and green vegetables; humans can survive quite well on that, just like my van could run on only ethanol.”

Every day I find myself speaking very plainly about how diseases and the human body work. It almost feels like that is the biggest part of what I do. In doctoring, it isn’t enough to know what to do; my job is to help each patient understand their illness and their options for conquering or living with it. Unlike a surgeon, I seldom deliver complete cures that don’t involve a lot of self care in the form of medication or life style changes.

The simple word “doctor” is derived from the Latin “docere”, which means “to teach” and “to point out”. That is what I do, every day, every chance I get. And as health care continues to get more complex with more and more options for every disease, I find myself doing more and more of it, with greater and greater satisfaction the longer I do it. It is a labor of love.

4 Responses to “Doctoring, In Simple Terms”

  1. 1 Cheryl Lord September 5, 2016 at 11:29 am

    Allan and I always read your blogs, Hans. Very interesting and well written. Miss you guys!!

  2. 2 marc lippman September 5, 2016 at 11:34 am

    as an aging physician myself i am completely engrossed by your blog. it seems so unfortunate that many of regret deeply the fact that we are leaving medicine i[ or at least physicianhood ] n worse shape than we found it. in your most recent article i think you are quoting : Ernest Rutherford:

    “A theory that you can’t explain to a bartender is probably no damn good”

  3. 3 si September 5, 2016 at 12:57 pm

    Beautifully explained, brilliant thinking, I love it. Now. How do we get more doctors to do this????

  4. 4 janet pina September 6, 2016 at 2:59 am

    I like the comment about patient who had already eaten his lifetime share of carbs. I am 82. By eating low carb for almost two years I have lost over 40 pounds and reduced my blood glucose from 105 to 97. I have had neuropathy in both feet for several years, dating back to when my blood glucose hovered at 100 for years. Neuropathy is uncomfortable but not painful. Hoping drop in blood glucose will halt progress of nerve disorder.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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