Getting it Right

There are many days in primary care when you feeel like you are treading water; nobody gets substantially better as time and disease progression seem to always win over your own and your patients’ efforts.

But sometimes you hit a winning streak. The past few weeks seemed to bring me one diagnostic or therapeutic coup after another.

There was the depressed man who came in smiling and said “I’m shaving again”.

There was the woman who was obviously doubting my assessment that the lip rash she had struggled with for two months was just a simple yeast infection.

I remember another woman with a moist, burning rash in every skin fold of her body. Because she also had some rough patches on her elbows, I suspected she didn’t have yeast at all but a bad case of inverse psoriasis. My seemingly counterintuitive choice of systemic steroids worked like a charm.

I thought back to the man with a stubborn back pain, who couldn’t even tolerate the simple exercises his physical therapist had suggested. Because he admitted to feeling depressed, at least about his chronic pain, I had given him a low dose of duloxetine. The other day, he told me he had felt better already after the first dose; he was spending time with his family again and his back hardly bothered him at all.

Then there was the woman who had fired the doctor who took her off hydrocodone. She certainly had a fair number of orthopedic issues, but her pain was really everywhere. This, along with tender trigger points and her history of poor sleep and profound fatigueabilty, led me to believe most of her pain was actually from fibromyalgia. On two capsules daily of the lowest dose of gabapentin, she had half the pain and double the hours of useful sleep. She was beaming at me the other day and shook my hand with he power of a lumberjack.

I also remember the man who came in depressed and angry with a tale of how everyone around him was withdrawing because of his pricklishness. He fit the criteria for Bipolar disorder, type 2, and between his new mood stabilizer and low dose antidepressant, he was back at work and back in his relationship.

All these small victories added up and gave me a renewed sense of being an effective catalyst through the basic application of observation, knowledge and, for lack of a better word, salesmanship.

It’s not enough to know what to do. How we present facts and formulate treatment plans is part of the therapy. A half-hearted “you might try this” is a lot less likely to work than explaining the diagnosis, describing the mechanism of action behind the symptoms and the medication and even the history behind the treatment.

I believe I made some very good treatment choices, but I also know that what we disparagingly call the placebo effect is always present to a degree, just like the opposite force, the nocebo effect.

I believe that presenting a medication as a very powerful tool that can both help or hurt, and emphasizing the need for skillful dosing and monitoring, you can create expectations and instill hope that helps build the neurobiological foundation for healing. There is more and more literature on that.

And as a doctor with a recent winning streak, I was at least a little bit emboldened over the last few days.

I remember talking with a new patient with longstanding anxiety, who didn’t want medication but seemed at least lukewarm to cognitive therapy. I explained quite a bit about how it works and what the evidence has shown about its effectiveness compared to unstructured forms of talk therapy. Near the end of our visit, he revealed his original intent: He wanted a letter for his landlord so he could get a dog, because he believed that would quell his anxiety.

I love dogs and I worry about people wanting dogs more for their own needs than the dog’s.

I leaned back, looked him in the eyes and said:

I’ll make a deal with you. You start therapy, and I’ll write you a note.

He was silent for a moment, then answered “okay”.

I was on a roll.

9 Responses to “Getting it Right”

  1. 1 meyati June 5, 2018 at 4:28 am

    I so love that.
    Dogs are good. One member of my family was depressed, because she lost her long-time partner. She went to bed and cried and cried every afternoon.

    We found the perfect dog for her at an out-of-state shelter, and brought him home as a comfort dog. At first, she wasn’t too interested and huffy about it. Now they smell each other’s rear ends, run out in the backyard, and Missy is starting to feel good and playful. I know that you guessed it- They are coonhounds. That’s Missy in the pic.

    We’re on a roll and things are getting better here.

  2. 2 Richard Plotzker June 12, 2018 at 10:13 pm

    You don’t give yourself enough credit. What you really did was pay attention to what you observed. In this day when we are pressured to process patients through our exam rooms, something that too often makes all the patients look similar, finding the uniqueness that each person has and the potential to capitalize on that may be a disappearing skill.

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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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