A Country Doctor Writes:

“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?

Friday afternoon, during the last two hours before the long Labor Day weekend, I had two patients with shortness of breath, one who was feeling bad all over, one with a brand new neuropathy and just then I got an urgent fax with an MRI report that a patient I had seen two days earlier had very severe spinal stenosis.

One of the patients with shortness of breath had a stable EKG, an unchanged chest X-ray and a normal blood count. But his oxygen saturation trying to walk down the hall to the bathroom dropped from 91% to 84% and his pulse rose to 137. On exam, he had loud pleural rubs over both lungs. He required some convincing before agreeing to go to the hospital by ambulance. I told him that with his atrial fibrillation and rapid pulse, he was probably trying to compensate for what might just be a viral infection with some pleurisy, but the faster his heart beats, the sloppier and more inefficiently it pumps, which is why he, more than the average person, needed to be in the hospital with everything he had going on.

The patient who felt bad all over looked jaundiced to me and while I waited for his chemistry profile to come back, I went back to my second patient with shortness of breath. Her oxygen saturation was fine both at rest and with a walk down the hall, her EKG was unchanged, her breath sounds and peak expiratory flow were normal and her chest X-ray hadn’t changed from her last one. But she had a new, significant but not critical anemia.

Sitting down next to her, I explained in English while her son listened from his corner of the exam room:

“There are basically three reasons why someone can be short of breath – a weak heart that can’t pump the blood around enough, bad lungs that can’t take enough oxygen from the air and transfer it to the blood, or weak blood with too little hemoglobin to carry the oxygen to all the organs in the body that need it.”

He spoke rapidly to his mother in French, and she nodded in understanding. Then he looked at me and said:

“I’ve never heard anybody explain that so simply before.”

“It really is pretty simple”, I answered. “Someone once said that if you can’t explain something to a twelve year old, you don’t really understand it yourself, or it isn’t worth knowing.”

Madame Theriault refused a rectal exam but agreed to get me some stool cards, the first one the next morning, Saturday. Sadie, the lab tech, had enough blood to send off a B-12, folate and iron studies. We agreed to be in touch Saturday morning and Tuesday. If she gets worse, she will go to the emergency room.

The man who felt bad all over had a bilirubin twice the upper limit, his liver enzymes were elevated and although he didn’t have a fever, his white blood cell count was elevated. I explained to him and his wife that his bile ducts were plugged and he was being poisoned from inside by all that bile and there may even be a brewing infection in his gallbladder. The ambulance had just come back from the hospital, and after they loaded him on the rig, I called the emergency room again and said “I’ve got another one for you”.

The neurosurgeon on duty returned my call just after five. He was able to look at the MRI images as I told him about the patient’s physical exam and his two week history of back pain with sudden urges to urinate or defacate (which in my office note had been transcribed as “deprecate” by the voice recognition software). He told me to have the patient call his office Tuesday morning and they’d get him in to the Wednesday neurosurgery clinic. I called the patient and told him the news. He was feeling quite a bit better on the prednisone I had prescribed. I explained what the MRI report said about how tight his spinal canal and the exit holes for the nerves were.

And, speaking of nerves, I also sat down with the woman with beginning neuropathy and described how it usually starts at the end of the longest nerves. Her big toe is a hair shorter than the two affected toes, so it may be next. We also talked about how better blood sugar control can sometimes make neuropathy better, but not always.

Eight o’clock Saturday morning, I sat with a fifty something man with poorly controlled diabetes. He is a junk dealer, who always fixes his own vehicles.

“Walk me through your day, tell me what you’re eating”, I asked him. After he did, I explained:

“You can keep eating a pretty balanced diet like you’re doing, and take some more pills or even insulin, and we can get your blood sugars down, or you could get more radical with your diet and avoid taking more medicines.”

“Well, I sure don’t want the needle”, he answered. I went on:

“I’ve got my old van out there in the parking lot. It’s a flex fuel thing that’ll run on regular gas or ethanol. If it started to sputter on gas and my mechanic told me to try ethanol, I’d be thinking, like, I’ve been putting gas in my cars for over forty years, and I don’t know anybody who uses ethanol in their car – why me, why should I have to change now, at this age? But, then again, what if my van starts to run better, isn’t it worth switching?”

He shrugged: “So what do I eat?”

“Think of it this way, you’ve already eaten almost all the carbohydrates a person should eat in his lifetime. That’s why people with the right genetic predisposition develop diabetes if they eat more carbs than they can burn right away. Eat protein, and green vegetables; humans can survive quite well on that, just like my van could run on only ethanol.”

Every day I find myself speaking very plainly about how diseases and the human body work. It almost feels like that is the biggest part of what I do. In doctoring, it isn’t enough to know what to do; my job is to help each patient understand their illness and their options for conquering or living with it. Unlike a surgeon, I seldom deliver complete cures that don’t involve a lot of self care in the form of medication or life style changes.

The simple word “doctor” is derived from the Latin “docere”, which means “to teach” and “to point out”. That is what I do, every day, every chance I get. And as health care continues to get more complex with more and more options for every disease, I find myself doing more and more of it, with greater and greater satisfaction the longer I do it. It is a labor of love.