A Country Doctor Writes:

For eight and a half years now, I have chronicled some of the challenges and many of the small victories of my journey toward being the person, and the doctor, I strive to be. I have painted sketches of some of the patients who have entrusted me with their care. I helped some, and failed some. I have described the things that motivate me, and I have quoted the mentors I’ve collected, real and imagined, during my 35 years as an American family doctor.

I have sometimes vented about the silliness we must deal with in health care today. But most of my writing has been about the day to day work and the day to day emotions that define me as a doctor in my adopted homeland.

For an introverted, nearsighted kid from a small town in Sweden, I’ve done pretty well, blending into another country, another culture and another system of health care. I’ve said it before, my education was superb, but I felt a bit constrained in the tightly regulated and culturally unambitious healthcare system I graduated into in 1979.

Healthcare, as many other aspects of Swedish society was steeped in the culture of only being good enough, “Lagom”, a word that makes good enough sound like a virtue.

I was restless and ambitious, and didn’t understand why people in my clinic took their coffee breaks so seriously, or why they seemed to slow down when their 3 pm break was over, even though we were open until five. I couldn’t reconcile the long waiting lists for services and the lack of panic, or at least concern, in my Chief’s eyes when we talked about “the system”.

I was also a little puzzled by the sometimes a bit bureaucratic attitude of my older colleagues toward their patients. They were nice enough, but there wasn’t the spark, the pathos, I had expected to find.

Of course, now I realize they were blunted by years of working in a system that wasn’t as patient focused as they themselves had been when they first started in medicine, just like doctors around me here in America struggle with professional frustration and burnout.

I don’t know enough about medicine in Sweden today to imagine what my life would have been like if I had spent my career there. I do know I have worked harder, made more money, seen more poverty, handled more advanced cases, and played a bigger role in many of my patients’ lives than most Swedish doctors have an opportunity to do.

I discovered a few months ago that one of my classmates became professor of medicine at Uppsala University. For a brief instant I thought, would I have wanted to be in his shoes? But I quickly dismissed the thought.

I am where I am supposed to be, working among the farmers, fishermen and retirees of this small Maine town. They have accepted and adopted me as their own, and I feel connected to every one of them.

My father used to joke that I could almost have been a priest, but my faith wasn’t strong enough, or a lawyer, but I was too honest, so medicine was the only profession open for me.

In a way, as a small town doctor, you actually sometimes perform the priestly duties of helping people forgive themselves and find hope in their despair. And, like a lawyer, you sometimes help your patients stand up against oppressive insurance companies, unfair employers or rigid bureaucracies.

Tonight, as I spend a little extra time with the cats and the goats, as I prepare the evening mash for the horses and clean their stalls for the night, I am thinking about how grateful I am for the life I have chosen.

At age four, I announced I was going to become a doctor, and fourteen years later I knew I wanted to be a small town doctor in America. I don’t know why that became my vision, but it has guided me in many small steps that finally put me in this particular little farmhouse, on this particular plot of land, in precisely this little village in this remote corner of North America.

“Listen, when I was your age, I did the same thing…”

The words came out of my mouth too fast for my frontal cortex to weigh them or to monitor, let alone modulate, the intensity of my delivery.

He was a relatively new patient, 17 years old, scheduled for a well child exam. A tall, athletic young man, he was alone in the exam room. His right arm was in a sling.

“What happened to you?” I asked.

He started telling me about how his right arm got pulled out of its socket a week earlier and how the emergency room had done an X-ray and a CT-scan that were both negative.

There was a knock on the door and Autumn produced the ER note and the radiology reports. The disposition was to see the on-call orthopedist at Cityside within a few days.

“Did you get an appointment with the orthopedic doctor? It says here you were supposed to see him within a couple of days”, I said.

He shook his head, adding “but it doesn’t hurt as much as it did the first couple of days. My dad told me to climb the wall with my fingers like this..”

“I wouldn’t do that until the orthopedist says it’s okay”, I interjected. “Let me call Dr Fazad and see what’s going on with your appointment.”

I pulled my old Motorola from my pocket and called. My young patient looked at the clock on the wall. Dr. Fazad’s office said they didn’t have anything from the ER. “But, he’s under 18 so he needs to be seen by pediatric orthopedics”, the secretary said. “I’ll connect you.”

A minute or two later the pediatric orthopedic clinic wanted to know his name and date of birth.

“No, we don’t have anything on him, but I can see from the ER note that he needs to be seen. We’ll call them later today with an appointment.”

I repeated what they had told me and what I had blurted out before.

“Don’t do any range of motion exercises until the orthopedic doctor tells you to. Usually you need to be in a sling for six weeks with this type of injury.”

His whole body revolted and he got up from his chair.

“Six weeks?!”

“Yes, that’s how long it takes for the tissues around the joint to heal. When I was your age I had the same injury. I was away from home and figured since it popped back in, I must be okay. That’s why I’ve dislocated it twenty more times since then.”

He cringed at what I said.

“You might even want to tie the sling behind your back”, I added.

He gestured toward the loops on his sling that were just for that purpose.

“I say what I say because I wouldn’t want you to have to be guarding that shoulder for the rest of your life”, I said.

I know you usually can’t tell a young person very much – I should have remembered from raising my own children. But I wanted to spare him the complications I suffered from ignoring my injury.

I didn’t tell him about the other medical regrets in my life.

A few years after my shoulder dislocation, my grandfather developed double-sided groin hernias, and I didn’t know then that two simultaneous hernias sometimes means there is a growing tumor inside the abdomen.

When I was already a young doctor, I watched my mother during one July visit stop and catch her breath now and then in the summer heat. I thought she was just suffering from the heat, and didn’t consider paroxysmal atrial fibrillation. She had to have a stroke before that diagnosis was made.

I hope he follows my advice.

The pressures of time, the complexity of our patients’ needs and today’s documentation requirements can easily make a medical provider feel less than generous these days. We must counteract that in order to carry on as healers.

All day long, I am conscious of the time as I work my way through my long list of fifteen minute encounters. But I am also conscious of the fact that the more pressure I feel, the less empathic I can become, and the less effective I am in building and maintaining the relationships that lie at the root of my ability to care for my patients.

It is only because of those relationships that I am in any way able to tell a fellow human being what to do; it is that relationship that allows me to reassure someone in just a few words with only my demeanor and the tone in my voice.

I can only cover so many issues and help solve so many problems in fifteen minutes, and I have long been aware that some of those minutes need to be time spent nurturing the relationship that allows me to be my patient’s doctor, not just any doctor.

I have made it my golden rule to always be realistic about the size of the agenda of every patient encounter, but to also always give something extra that the patient didn’t ask me for. By thinking and working like that, I have found myself less frustrated at the end of each day, more energized and, I believe, more effective in my craft.

That extra effort with each patient can take different form: Sometimes I personally bring a wheelchair bound patient back out to the reception area, sometimes I show an animal lover a picture of my horses or miniature goats, sometimes I tell a child a story of when I was their age, and sometimes I just give a more detailed explanation of a medical issue and tell the history behind the medication or treatment I am recommending.

It’s like when you give or get a humble gift that is wrapped really neatly with carefully chosen matching paper and a hand-made instead of stick-on bow.

It isn’t calculated this way, but not only does that little extra in every visit help create a more healing atmosphere in the medical encounter, it also creates an emotional bank account so that in those situations when I do have to rush or when I can’t deliver the help my patient was hoping for, they are more likely to still understand that I am only doing the best I can.

A few days ago, The New York Times had an article about the Munich academic and expert in Chinese medicine, Dr. Paul Unschuld, whose name translates as “innocence”. What struck me was that this expert apparently doesn’t believe all that much in the pharmacological effectiveness of traditional Chinese medicines, but sees the classic writings of the Yellow Emperor as an instrument that brought a certain enlightenment and pragmatism into Chinese medicine and culture.

Dr. Unschuld indicates that he believes traditional Chinese medicine can be effective in certain situations, but that it is also an expression of the Chinese way of thinking. The article states:

“For Dr. Unschuld, Chinese medicine is far more interesting as an allegory for China’s mental state. His most famous book is a history of Chinese medical ideas, in which he sees classic figures, such as the Yellow Emperor, as a reflection of the Chinese people’s deep-seated pragmatism. At a time when demons and ghosts were blamed for illness, these Chinese works from 2,000 years ago ascribed it to behavior or disease that could be corrected or cured.

“It is a metaphor for enlightenment,” he says.

Especially striking, Dr. Unschuld says, is that the Chinese approach puts responsibility on the individual, as reflected in the statement “wo ming zai wo, bu zai tian” — “my fate lies with me, not with heaven.” This mentality was reflected on a national level in the 19th and 20th centuries, when China was being attacked by outsiders. The Chinese largely blamed themselves and sought concrete answers by studying foreign ideas, industrializing and building a modern economy.”

I often think about how our perceptions about disease are culturally rooted and how physicians not just deliver treatments but are in a position to nudge our patients’ views of how health and disease come about.

It seems to me we are now in the middle of a big transition that echoes the Yellow Emperor. In his era, demons and ghosts were blamed for causing disease, and he pointed out how much our own lifestyle lies at the root of illness. In the last hundred years, our culture, with its tremendous scientific and technological advances, embraced the notion that our diseases come from invading bacteria, random gene mutations and other causes completely beyond our control. The promise of modern medicine has been that we can understand and counteract these forces through science, with more and more counteractive interventions. But as our treatments get more and more powerful, we have seen many of them cause ripple effects that cause other types of discomfort or disease. Now, we are instead seeing serious research into the relationships between illness and our psychological state, our harmony with our own gut bacteria, our low level exposure to dust and dirt we thought were harmful, our dietary choices and our physical activity level. We are beginning to see ourselves as no longer the hapless victims of outside forces, but products of our own day to day living choices.

I have written about the Yellow Emperor before in a 2013 piece that was also published on The Health Care Blog:

Every now and then the title of a book influences your thinking even before you read the first page.

A little samurai discipline and restraint could help most of us…

One of the new requirements for Patient Centered Medical Home recognition is tending to patients with chronic illnesses, like diabetes, by making sure we document, before the deadline, what their self management goals are.

Here is my original post from 2011 about when doctors decide to change the subject:

Mrs. Blouin was new to our practice. Her previous doctor, in the next town up the road, had left the area just over a year ago. Her presenting complaint was “Wants Reclast infusion”.

Reclast is a once-yearly $1,200 intravenous infusion for osteoporosis, primarily for patients who cannot tolerate the older treatment alternatives.

I have many misgivings about osteoporosis treatment, and have not yet prescribed Reclast. It has a long list of drug interactions and side effects, and it is still very new.

It didn’t take me long to realize that there were other issues afflicting Mrs. Blouin. She was fatigued, her blood pressure was very high, she had no idea what her cholesterol was, and she had a foreboding family history of cancer and heart disease.

Dr. Greyson’s notes mentioned her blood pressure being up a bit, ongoing fatigue, breathing problems and several other symptoms. Reading through them, I wasn’t sure how osteoporosis came to be the predominant concern.

“How did you and Dr. Greyson come to focus on your bones?” I asked.

“I don’t know”, she answered. “I guess he thought they were really that bad.”

“It sounds like we need to look at the whole picture right now. You couldn’t get your infusion now anyway without some fresh bloodwork. We might as well see if we can find out why you’re tired, check you for anemia and thyroid problems. We could also check your cholesterol if you’d like. And I’d like to check your blood pressure one more time, since it’s higher today than it was last year at Dr. Geyson’s.”

I had moved the focus of our visit away from what Mrs. Blouin had come to see me for. So had Dr. Greyson, but in the opposite direction.

Physicians change the subject of patient visits all the time. Sometimes we do it because we feel there is a more pressing issue than the one a patient came to see us for, like correcting a high blood pressure or screening chronically ill patients for depression, which may be a barrier to achieving better health. Other times we may be guilty of shifting the attention away from a symptom we are unfamiliar or uncomfortable with in favor of something we find easier or more satisfying to deal with. Sometimes we may avoid or postpone issues that aren’t easily solved in a fifteen-minute-visit.

I sometimes hear patients say about other doctors: “He didn’t seem concerned about my symptoms”. Some people may say that about me too; I know I don’t pay as much attention to arthritis pain and old sports injuries as some patients might expect when they come in for physicals and have unmet screening needs for cancer and cardiovascular risk that I feel a need to cover in my half-hour with them.

But where do we draw the line? When is it fair to change the agenda for a patient visit and when is it not? When are we doing the right thing by steering our patients toward issues they may not have thought of as priorities, and when are we doing the wrong thing by not making them equal partners in their own health care?