A Country Doctor Writes:

I have published well over 500 posts on A Country Doctor Writes since I started blogging over ten years ago. Right now I am pretty much posting something new twice a week. But I thought I’d put a “rerun” of an older post up every day (or almost every day) for the next year to allow frequent visitors to see older posts that would take lots of WordPress Infinite Scrolling or scrolling down the “Archive” to get to. The one I am pinning to the front page today is called “The Power of Words“.

He seemed like his usual self, strong willed and irreverent, with his gravelly voice and nicotine stained fingers, and as always tied with clear plastic tubing to the oxygen concentrator on the back of his wheelchair.

He is a DNR, Do Not Resuscitate. But during his last hospitalization he ended up intubated and on a ventilator for several days.

His daughter gave her version of what happened and the discharge summary was less clear cut. So I turned to him and asked:

“So what happened? How did you end up on a respirator as a DNR?”

He answered “I said HELP ME, and that’s what they did”.

“I think the doctors panicked when he said that”, his daughter concluded.

“And would you want that to happen if you say HELP ME again?”

“No.”

“So when somebody can’t breathe, there are sometimes only two options, sticking a tube down their throat and hooking them up to a respirator or giving them morphine to treat the agony and anxiety of the process.”

I glanced over at his daughter and then looked him straight in his eyes.

“So, let me make sure I hear you right. If you can’t breathe and say HELP ME, does it mean machine or morphine?”

“Morphine”, he said, emphatically.

I’m glad we had this talk. This very plain talk.

Driving north in a snowstorm Tuesday of Thanksgiving week I certainly took my time. I left after our Suboxone clinic wrap-up conference, around 7:30, and arrived at my unplowed driveway in Caribou about 1 AM.

On the way up, I saw two ambulances, one from Caribou and one from Presque Isle, on their way back home from Bangor. I’ve got a large SUV with all wheel drive and studded Finnish snow tires. They don’t, but they passed me and blew up clouds of snow behind them as they did. I also met an ambulance careening south toward Bangor down I-95 with full lights on.

I had an appointment for a telephone interview with a journalist for the next evening to talk about the challenges of rural medicine.

Distance is certainly one of them.

Not long ago I met a patient who, after a routine knee surgery, developed a lot of swelling as his hemoglobin dropped precipitously. Two hours passed before it was clear he needed emergency vascular surgery. The Presque Isle hospital has sometimes had a vascular surgeon and sometimes not. This was during a “sometimes not” time.

The Bangor vascular doctors accepted the transfer. The patient was on IV fluids, received blood and drugs to keep his blood pressure up, but it was a snowy night. Neither helicopter nor fixed wing aircraft could fly, so there was no other choice besides ground transport.

Seven hours after the original injury, he was in the OR. Circulation to his lower leg was restored, but today he still has problems with it. If Presque Isle had had a vascular surgeon on staff, if the weather or time of year had been different, he would have fared better.

There is one full time neurologist north of Bangor, no full time gastroenterologist, no neurosurgeon, no endocrinologist, no nephrologist, no dermatologist and the list goes on. Some specialty services are available as once a month or so visiting doctors to each hospital’s “Specialty Clinic”.

There is a lot of talk among my kind of primary care clinics about eliminating “Health Disparities”, and I often hear about cultural and economic differences in access to care. But here, the biggest challenges are geographic, sometimes compounded by something as uncontrollable as the weather.

When I interviewed for my 1981-1984 Family Practice residency, I really liked what I saw in Bangor, but it seemed so far north. I instead chose Lewiston, 100 miles to the south.

As life played out, I now work near Bangor part of the week and 200 miles north of there the rest of the time. And I now think of Bangor as “south”.

I told the journalist some of these things on the phone the night before Thanksgiving as I drove from Van Buren to Caribou long after dark. I also told her that practicing primary care in a remote, rural area lets me use my training and my skills more than where there are specialists on every street corner.

I canceled my plans to challenge the tail end of the snowstorm by driving back “downstate” for the holiday after just three hours of sleep the night before and a full day of clinic work. I got an early start the next day instead. You can’t make exact plans during northern Maine winters.

I have known him for over thirty years. He has been legally blind for the past five.

He tends to be a practical, no nonsense man. The other day, he seemed restless and very concerned as he lowered his voice and said:

“I don’t want you to come to the conclusion that I’m crazy, but I’m seeing things…” he began, “I’m seeing children with elfin faces…”

His large, thin hands were in his lap. I put mine on his and said “I know what that is. You’re not crazy. This is something that often happens to people with very poor eyesight. It’s called Charles Bonnet Syndrome, and it was actually described in 1760 by a Swiss philosopher who observed it in his grandfather who was going blind. It’s like the brain fills in the empty spaces, and for reasons we don’t understand, much of the time it tends to be with elfin like children. They’re usually friendly and jovial and there’s nothing threatening about them.”

“Right, these are. I’m so glad to hear this is not some psychosis.”

“It’s a hallucination, but not a psychosis”, I reassured him. I printed up an article and gave it to him to show his friends and the staff at the Senior Citizens Home.

A few days later I heard how appreciated the article was.

This was only the second time in my career I have seen this condition. The first time I had no idea what it was but a family member of that patient brought in a printout of an article they had googled. That was ten years ago and I wrote about it in my first year of blogging.

Apparently up to 10% of people with visual acuity under 20/60 have this syndrome, and it tends to go away when vision is completely lost.

This little incident evoked two distinct feelings for me. The first one was the comfort, confidence and gratitude that I could instantly reassure my longtime patient that what he was experiencing has happened to other people and has a name and a long history. The other feeling was equally profound and mixed with all kinds of emotions:

My patient was once my neighbor, and my soon to be 35 year old son was often hanging around his yard, checking out his motorcycle, convertible Mustang and garden tractor. My son did look like a little elfin at that time. Maybe it was him that he was “seeing”.

I guess I should take it as a compliment when patients come to see me after visiting a specialist and ask me a bunch of difficult specialty-related questions.

“Did you ask the specialist that?” I typically ask, and the the answer will be a plain “no”.

I’ve seen it in action. Some doctors speak quickly, say a lot, and exude so much authority that it’s hard to stop and question them. There is also the fact that on a first visit there isn’t yet much of a doctor patient relationship.

As a long term family doctor, I’m probably viewed as more approachable and less intimidating and therefore end up getting the questions that didn’t get asked in the consultation.

I think a lot about this balance of ours – when and how to engage deeply and with a large “contact area” and when to appear close without engaging or attaching too much. Still remembering when the Teflon frying pan technology, first patented in 1954, took Sweden by storm in the sixties, I use the metaphor “Teflon doctors”.

I consciously move back and forth along this spectrum. In line with my effort to be the kind of doctor my patient needs in a particular situation, I think there are times when I should “stick” and times when I need to be like Teflon.

When a patient hesitates tackling an important issue or feels desperately depressed or disconnected, it is my role to “stick” tight and help them stay with their task or avoid drifting emotionally. But on the other hand, there are times when I don’t let anything stick to me.

The other day when a patient started listing all the minor to moderate aches and pains he’d been saving up for his once a year routine physical, I mentally took a step back and, sensing he was looking for pain medications, said:

“If you have specific pains or orthopedic issues, I or an orthopedist can look into them, but my first duty in a physical is to go over the big health risks you may be facing at your age. Today I will focus on if all your pains are part of a bigger picture, some underlying disease, or if your body just has a lot of wear and tear.”

When patients are suffering in large or small ways, doctors risk feeling like they “own” the patient’s problem. We never do. We are guides, supports, experts and even friends, but we should never shoulder a patient’s problems for them, no matter how much love and empathy we feel for our patients as fellow human beings. Taking over their problem weakens them and creates an unhealthy dependence.

Being “Teflon Doctor” and still helping the patient is an art to cultivate. It involves putting the patient at the center, by saying things like, “how do you feel when…” and “what have you found to be helpful when…”

Sometimes we come across patients who are like Velcro, another product of my childhood, patented in Switzerland in 1955. Perhaps a more common word doctors use for such patients is “sticky”. Fancy talking doctors call them “Frontal lobey“. This is because people with frontal lobe lesions can exhibit symptoms like inability to make decisions and lack of the ability to interact, feel joy and express spontaneity.

One review of the function of the frontal lobe puts it this way:

“The evolution of the human frontal lobes lies at the very essence of the characteristic behavior of humans. Everyday traits that define our existence, both socially and as individuals, have important substrates in the frontal lobes: humor, intuition and insight, deception and truthfulness, optimism and skepticism, affection and hatred, and inspiration. One of the great tragedies for patients and their families is a disease of the frontal lobes that destroys the distinctive personality around which a whole life has been built.”

All doctors have known patients who have difficulty moving forward or away from a minute topic or medical history item, who keep coming back to a thought, often kept on a list of concerns, and who seem unable to grasp a bigger picture.

What I tend to do in order to move forward with patients like that is to “chunk it down”. I try to create smaller steps, descriptions, decisions and interventions. But it is hard work and it almost always takes more than fifteen minutes.

Unless you’re a better Teflon Doc than I am…