A Country Doctor Writes:

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.

He spoke with an aura of superiority, in a slightly nasal voice, and his topic was migraines. It was in the late 70’s, a time when there were few options to treat migraines.

“Most people who claim to have migraines just have simple tension headaches”, he scoffed. And in a move that seemed unorthodox at the time, he disclosed that he himself suffered from “real migraines”, so he knew all about this exclusive disease. He made it sound almost desirable by virtue of how rare it was.

At a Continuing Medical Education course in Boston twenty five years ago, I heard a different neurologist, this one a Dutchman, pronounce that most headaches are in fact migraines.

Today I read in The New York Times that, according to a study (published in Headache fourteen years ago) “primary care providers who diagnose a patient’s headaches as something other than migraine were usually wrong”.

The same article also points out that “sinus headaches” are not a medical reality, and are never diagnosed in Europe. Now that I think of it, I never did hear about this type of headache until I came here.

The whole notion that one explanation for a symptom is somehow more prestigious than another is bizarre, but I see this phenomenon here and there. Also, Americans seem to delight in using technical diagnostic terms instead of describing symptoms to each other or their doctors.

People come into my office all the time with “colitis”, “vertigo”, “eczema” or “bronchitis”, not just diarrhea, dizziness, rashes or coughs. It’s like somehow they don’t need me to do anything except release my power and prescribe for the condition they already know they have. Never mind that the real explanation may be giardiasis, a cerebellar stroke, psoriasis or lung cancer.

One of the reasons for the seemingly increasing prevalence of certain disease is, of course, the drug company ads for medications that come to market for rare or previously untreatable conditions.

Ironically, as an example of that, back at Uppsala University, I remember a cursory mention of Restless Leg Syndrome. “You can prescribe a little diazepam, that usually helps”, was the take-home message. Nobody mentioned that our own neurology professor, Karl-Axel Ekbom, who had retired he same year I started medical school, had described the syndrome, which had been alluded to by Willis in the 1600’s, and nobody seemed to make much of its association with iron deficiency.

It was with the introduction of medications like Mirapex and Requip that RLS rose from obscurity to everyday parlance.

Over the past few months I have encountered several patients who, even though they knew they had migraines, had never sought or been offered preventive treatment. There is much awareness of the many medications that treat attacks, and several of those have been cash cows for the pharmaceutical industry, whereas the preventative medications are generally old and inexpensive generics, which require patience and persistence to work.

With many diseases, and very much so with migraines, knowing the diagnosis and the names of some famous medications to treat it is not enough. How to select and titrate them is what we call the Art of Medicine.

After a Harvard Endocrinology course several years ago, I walked out into the weak afternoon spring sunshine and crossed the street to the Boston Public Garden. Among the multitude of faces of the other flaneurs I was certain I saw scores of people suffering from endocrine diseases – probably undiagnosed, I thought to myself:

I saw tall men with big jaws, typical of acromegaly; stout women with skinny extremities and flushed, puffy cheeks so typical of Cushing’s syndrome; hirsute, heavy set younger women sure to have polycystic ovary syndrome; long-legged beardless men, who seemed classic for Klinefelter’s; and other people I suspected to have Graves’ disease, Turner syndrome, hyperaldosteronism, Addison’s disease, and, oh, so many other obvious endocrinopathies.

Then back home, as the months and years passed, and as the never ending presentations of Chief Complaints continued, my internal search for and classification of possible endocrine diagnoses began to take second place in my hierarchy of what I needed to do.

Yes, Ellen W. does look like she might have Cushing but she has so many issues that it feels a little esoteric to bring this up, too, when her diabetes and mood are out of control, her mother is dying and her husband is still unemployed and her insurance isn’t paying for any of her medicines.

And even if Doreen Fish has primary hyperaldosteronism, she’s already on spironolactone for her low potassium and her blood pressure is okay; a CT scan would cost her so much out of pocket, never mind surgery, and what are the odds she has surgical disease – an adenoma and not just adrenal hyperplasia?

But then I read the news and I get curious again:

Artificial Intelligence and facial recognition are being used to diagnose or screen for genetic syndromes like DiGeorge and Williams; people are claiming to have identified facial features linked to autism spectrum disorders; psychiatry and general practice colleagues are sending out cheek swabs to help them prescribe psychiatric medications where I am “just” going by experience and intuition; and patients themselves are now looking into their own genetic profiles.

Shouldn’t I try to be more precise in this era of “precision medicine”? Definitely, with all the extra, mandated, ingredients in the primary care visit – screening for depression and alcohol use, clicking off BMI management and tobacco cessation counseling (not just doing them) – it is easy to slip away from just looking at your patients carefully into just glancing at them while also paying attention to the computer screen.

It takes some effort to consistently really look away from the computer, to clear your mind of all its distracting requirements, and to just observe the person in front of you – as if you just walked out of an Endocrinology lecture and looked at the faces of strangers, wondering:

What makes you look the way you look? Do you have a syndrome that guides your health and your appearance? Wouldn’t you, and your doctor, benefit from knowing that?

Medicine Today is Full of Distractions. The secret Behind Resilience is Rising Above Them.

-Yours Truly

The answer to physician burnout is purported to be Resilience Training. That’s like glorifying the natural ability of frogs to tolerate gradually heating and boiling water.

Unfortunately, healthcare today has some toxic ingredients, and physician burnout is directly related to them. Some forms of resilience training I have been exposed to are no more than mental escapes away from medicine, such as art, music and personal relationships.

Those types of activities may in some way, for some people, balance the toxicity that has infiltrated our workplaces, but they don’t change the fact that every day as a practicing physician could be hazardous to one’s mental, or even physical, health.

It’s fine to have a rich and rewarding life outside of medicine, but that doesn’t negate the fact that medicine could and should be a rewarding career and calling in and of itself, too.

There is a different kind of resiliency that should be promoted and cultivated. That is the professional resiliency that comes from embracing the true, timeless and archetypal role of the physician. Every time we make someone feel better, every time we comfort or instill hope, every time we empower a fellow human being to take steps toward a better life, we need to, humbly, celebrate our accomplishment.

Yes, we get points for also clicking the box about what counseling was provided; yes, we get points if we printed the hokey patient education page from the EMR; yes, we need to submit our superbill right away and we’re supposed to finish our documentation within 72 hours. Most of the time I get those things done, even if it is in my barn-office at 5 am or by the fireplace with a glass of wine when everyone else is asleep, but, you know what – I have a job that matters, and I’d rather be doing this than anything else.

And I’m a constant, pesky reminderer about the need to automate some of those mundane clerical task.

Keeping the focus on what really matters is a form of professional resilience. That, ultimately, means more than personal resilience, because the latter could result in some of us leaving our careers because we don’t see the value in what we are asked to do.

Administrators and insurers want a lot from us, but if we don’t listen to and communicate effectively and in a healing manner with our patients, there will be nothing for the big guys to micromanage.

We are the doctors. Let us not forget that.

Of all my patient visits since I came back from my CME trip to Boston, the one that lingers in my mind as I do my farm chores on a sunny day off in mid-May is the young woman I had first met on a bitterly cold evening in February. Her face had been covered with acne, small pustules and red papules, so many of them that they almost touched each other. She had tried every over the counter preparation she could get her hands on to no avail.

I saw her again the other day, beaming, smiling and exuding optimism and confidence. Her face was just about clear and she told me she had just posted a closeup photograph, with NO MAKEUP, on Facebook. She pulled her smartphone from her jeans pocket and showed me.

She is graduating this weekend, and she is ready for her adult life to begin, comfortable in her own skin, as we say in America.

“When I first came to see you, I thought you’d prescribe some other cream that wouldn’t work. But the doxycycline is really working. You remember, at first I got sick to my stomach on my morning dose, but you told me to eat something with it and it worked. Now I’m only taking it at night with supper and look at me!”

A common generic medicine, some common sense advice about skin care, some tinkering with how and when to take the medication, and a young person feels better about herself and ready for summer vacation and a big move out of state in the fall. Not like diagnosing a pheochromocytoma or Fanconis syndrome, but in primary care, even the small victories are important. Every patient deserves to get better if it is at all possible.