A Country Doctor Writes:

“I am not on call”, Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know”, I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54 year old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see an optometrist for glasses. I’ve called every hospital within 50 miles and there is no ophthalmologist on call over the long weekend. You helped me once before with a case of dendritic keratitis when you were on call.”

I also remembered Memorial Day weekend last year, I was in the same situation during my Saturday clinic. A young boy, whose mother had just joined the board of our health center, came in with eye irritation. He had a small rust ring very close to the center of his cornea. I had dug out plenty of them, with a special spatula or even with the tip of an 18 gauge needle, but this was a child, who might not have beeven fully cooperative, and the location was critical for his future near vision.

Cityside Hospital had no ophthalmologist on call for that long weekend either, and all my calls to ophthalmologists in the surrounding area were fruitless. He got in to see an eye doctor the Wednesday after the Monday holiday and it turned out that he actually also had a small metallic corneal foreign body. Everything turned out okay, but the wait was uncomfortable and at least a little risky.

A corneal rust ring, even a foreign body, can usually wait a few days, but if this woman had what I thought, acute angle closure glaucoma, I wouldn’t want her to wait that long to see an eye doctor.

“I think she’s got acute glaucoma”, I said.

He was silent. I continued:

“She’s got mixed injection, no foreign body, no fluorescein uptake and I can see her left fundus clearly but I can’t get a focus on her right fundus no matter what lens I dial in on the ophthalmoscope.”

He was silent again for what seemed a very long time. Then he said:

“I live an hour away, but I happen to be in town. If you have her walk out your door right now, I’ll meet her at my office in, what, 25 minutes?”

“She’ll be there. Thank you so much.”

I haven’t heard yet what he found, and I haven’t wanted to bug him, but I am anxious to hear what the final diagnosis was. I do know that an urgent slit lamp exam was necessary.

One postscript:

When I sent my emergency eye patient off with her office note and insurance information to see Dr. Stoltz, her husband said:

“You’ve done well by us. I came in and saw you once with a cauda equina syndrome.”

I didn’t remember him, but he must have had a critical enough pressure on his lower spinal nerves to also have warranted an urgent referral to a specialist.

Disease strikes at inopportune times.

When I read a case report in a journal or whenever a patient comes in to see me about a new symptom, all my senses are tuned in and I know there is a diagnosis to be made.

But on regular clinic days with “routine” follow ups, I find myself not being as tuned in as I would like to be. I know my patients well; we are all growing older together. They change gradually over the years, just as I do. A couple of times last year I have found myself surprised and ashamed that someone else made a new diagnosis in a patient I was seeing on a regular basis.

Stella Sanders world had shrunk since her boisterous husband died a couple of years ago. She had never learned to drive, so without Roy to take her places, she had become virtually housebound. Her spinal stenosis had gone from moderate to severe, and she couldn’t take care of her home in the way she had always prided herself in. She admitted she was depressed, but didn’t want to take an antidepressant and wouldn’t hear of seeing a counselor. Her whole demeanor had changed. She never smiled, and she was less animated in all her facial expressions and body movements.

It was her neurosurgeon who saw it. He had nothing to offer for her spinal stenosis, but he suggested she talk to me about the possibility of her having Parkinson’s Disease.

I saw her again the other day, and on Sinemet she looks almost like her old self again.

Fred Nystrom’s health had been declining for years, and after going through both an operation for a fractured hip and emergency bowel surgery for perforated diverticulitis last year, he never recovered his old level of functioning. He came back from rehab the second time using a walker. Two months later he was still using it. His affect was flat and he couldn’t keep track of his medications the way he had a year earlier. His enlarged prostate seemed to bother him more and more, and he moved too slowly to always make it to the bathroom.

It was my partner, Dr. Wilford Brown, who made the observation that Fred had dementia, gait disturbance and urinary incontinence – the classic triad of normal pressure hydrocephalus. Fred is going in to have a shunt placed to drain his ventricles at the end of this month.

Our challenge is, in the hustle and bustle of everyday practice, to look beyond the issue at hand often enough to “see the big picture” in each patient, and at the same time keep a constant vigil for small changes that could mean a new disease is evolving.

On an ordinary day last month, I saw patients for eight and a half hours. I addressed a dozen computer messages, took four or five calls from outside providers and held innumerable curbside conversations with medical assistants, case managers and colleagues.

I didn’t get to any of the 100+ lab results or 50+ documents in my electronic inboxes. Consequently, the care for several dozen of my patients didn’t move forward.

Many of them didn’t get the news that their blood tests, mammograms or CT scans were normal; some never got scheduled for follow up visits to discuss options based on their mildly abnormal studies; a few didn’t get their highly abnormal tests acted on. Others didn’t get their annual eye exams logged in their diabetic flow sheet.

This happened because I am the official bottleneck by virtue of the “work flow” dictated by our electronic medical record.

My last office note might say “Follow up to review results”, but if I am late getting through my inbox, the clerical task of scheduling that appointment doesn’t happen.

It’s a little bit like having me answer our clinic’s telephone, or, a presumptuous analogy, the President opening the Government’s mail and then forwarding each item to the proper cabinet secretary.

Because every piece of data in a medical office has an ordering provider or a provider of record, it seemed like an EMR no-brainer to send everything to that person. But I think someone forgot that the current primary care business model is based on each medical provider cranking out as many visits per day as is humanly possible. That makes desk work a money losing activity.

With all the talk about having everyone in the medical office work to the top of their license, I think it is high time we turn the virtual mail sorting work flow on its head:

Have non-providers check incoming reports and lab test against existing treatment plans with cut-offs for when to interrupt providers, and give the provides more time to provide care and make medical judgements. A lot of information comes in to the primary care office just so we can maintain a record of patients’ care. It isn’t necessarily imperative to have the physician read a seven page specialist report to find one relevant medication change that needs to be updated in a patient’s record. That is what we used to call secretarial work in the old days, but that word and concept, dear Health Care Industry Comrades, seems to be taboo these days.

So, back to my reality: Last night, after cleaning the horse stalls, I spent almost two hours going through my backlog of reports. At least I was able to do my work from home, in the company of my horses, but I keep feeling that on a daily basis I am making up for a system that isn’t all that well designed.

Theresa Miller is one of the hardest working women I know. She doesn’t come in to the office very often. She no longer needs my prescription for her heartburn medication, as it costs less for her to buy it over the counter these days.

Today I saw her for a preoperative clearance. She had decided to finally get her chronically sore shoulder operated on. She had injured it many years ago, and in spite of the heavy physical work she does, she has managed to live and work with her pain and limited range of motion until now. She never took a pain pill in all the years I’ve known her.

“I figured as things slow down for the winter, it’s time to deal with it. I’ve got ten more years before I’ll want to be done working, so it’s an investment”, she said as I opened up her record in our EMR.

I asked all the usual questions about chest pain, heart palpitations, shortness of breath on exertion and so on. Her answers were quick, to the point and full of her typical down to earth determination.

As I listened to her lungs, I remembered the first time I met her and her husband. They had moved to our area from Connecticut earlier the same year. He had become ill with cancer, and I had agreed to do a housecall one Saturday after my morning clinic. He died at home a few months later, and I saw Theresa only occasionally after that.

“You know”, she said after I removed my stethoscope from her chest, “sixteen years ago last weekend was the day you came to se Ron. It was Thanksgiving weekend.”

I hadn’t remembered that it was just this time of year.

“We talked about it this Thanksgiving, among the family, how unique that is, to have a doctor do housecalls like that”.

“Around here it isn’t”, I said. “Maybe Maine is a kinder, gentler place than Connecticut.”

“That’s what my sisters just said”, she answered.

Sixteen years ago, I thought to myself, I was a father of teenagers, the millennium was almost new, Y2K never really happened, the World Trade Center still towered over New York, and life seemed almost innocent that Thanksgiving. Except for the newly diagnosed cancer in the man who had so recently brought his wife to Maine for a better, gentler life, away from the hustle and bustle of the big city.

Life in medicine is never without sorrow. Today had a twinge of it, too.

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.