A Country Doctor Writes:

Friday noon, in typical fashion, I seemed to have an emergency on my hands. This time, it was an ocular one.

Philip Brown had driven 35 miles in a steady snowfall to see me. Four days earlier he had been to the Cityside Emergency Room for modest pain and a couple of small blisters on the right side of his forehead. They diagnosed him with shingles and put him on an antiviral. Now he had 48 hours of severe, burning pain in his forehead, where at first there had been only mild discomfort, as well as a new, piercing pain and profuse tearing in that eye.

“Well, we’ve got two things to take care of”, I began. “The pain can be managed with the same medication you took when you had that pinched nerve in your back last year, but we have to figure out exactly what’s going on with your eye.”

He grimaced and struggled to open his eye. With his left eye he could see 20/30 but with his right only 20/200. His squinting eye had a mixed injection – redness that extended all the way to the limbus, or corneal margin.

“Let me get some more equipment to examine your eye with”, I said and headed to the procedure room for the Wood’s light and some fluorescein strips to look for signs of zoster ophthalmicus, the dreaded dendritic fluorescence you can see when the virus attacks the cornea.

I reached for the eye tray on the top shelf in the cabinet over the large stainless steel sink. My heart sank as I fumbled around among its contents. The fluorescein strips were gone.

I knew exactly what had happened. The half full box had December of last year printed as the expiration date. I remember thinking the last time I used them that we needed to order new ones. The ordering of supplies is done by one of the younger nurses at the other end of the clinic.

“Autumn, have you seen the box of fluorescein strips?” I asked, but she hadn’t.

I returned to Philip with the bad news: “I’m going to have to refer you to an eye doctor today, because we ran out of the stuff to look for shingles in the eye. Who do you usually see?”

“Dr. Pomeroy.”

I looked at my watch.

“An hour from here, in good weather.”

“With good eyesight”, Philip added.

Just then, there was a knock and the door opened. A triumphant Autumn handed me the box of fluorescein strips.

“They were on Sally’s desk, ready to be thrown out”, Autumn said. “I left a note for her not to get rid of the old box until the new one comes in.”

Moments later, I knew that Philip didn’t have shingles of his cornea. What he had was a peripheral superficial corneal abrasion at twelve o’clock, caused by a curled eyelash. With the eyelash out of the way, his eye stopped tearing and his pain was instantly reduced by half. On his second trip to the eye chart, he scored 20/25 with his right eye.

With prescriptions and instructions taken care of, I went back to my office, opened my thermos and ate my sandwich.

Just then, Sally, back from her lunch, came in.

“What’s this about the fluorescein?”

I swiveled around and looked up at her.

“Let me tell you a story about how, with outdated equipment, I saved a man from pain and agony and a dangerous two hour round trip in a snow storm…”

Gordon Grass had fallen three times. He said he was always lightheaded.

A slender chain smoker with nicotine-stained fingertips, he didn’t go to doctors much. He was on a blood pressure pill, though, started years ago by a colleague over in Danderville.

I looked at his vital sign display in my EMR. His blood pressure had never been high in the years that I had known him. In fact, sometimes it was on the low side. His typical systolic blood pressure was 130-134, but occasionally it was in the 100-110 range.

His exam was unremarkable when I saw him a couple of weeks ago. I listened carefully for bruits in his carotid arteries, did a standard neurological and ENT exam and even took out my tuning fork to check his Weber and Rinne; everything was normal.

Sitting on my stool opposite Gordon in the drafty, north facing Room 4, its old windows rattling as a powerful nor’easter pounded on the brick walls of the former hospital, I pulled the portable blood pressure cuff stand closer and tightened it on Gordon’s right arm. Sitting, his blood pressure was 136/68, and standing, it was 122/60.

“I think we should stop your blood pressure pill and see how you do”, I said. Gordon said he was happy to get rid of them, and we agreed to check his blood pressure and his symptoms in a couple of weeks.

I knocked on the door to Room 1 and entered the sun-drenched room across the hall from where I had seen him two weeks earlier.

“Feel that solar heat”, I said as he squinted in the warm, bright yellow room. “How are you doing?”

“Better, not as lightheaded.”

I looked at his vital signs. Autumn had entered his blood pressure when she checked him in: 112/62.

“Your blood pressure is lower than last time”, I mumbled, adding “I have read that the effect of hydrochlorothiazide can last for months after you stop it.”

Instinctively, and without speaking, I pulled the wall mounted sphygmomanometer down from the concrete wall between Gordon’s chair and the exam table on his left, tightened it around his arm and pumped up the cuff. Listening carefully as I released the pressure, I, too, recorded a lower blood pressure than last time: 116/60.

“I like the cuff we used last time better, but let me check your right arm also with this cuff”, I said and stretched the tubing across to his right arm. There, his blood pressure was 132/78.

“Hmm, let me check a few things again”, I said and ran my fingers along his neck, his collarbones and in his armpits. I put my stethoscope in my ears again and listened to his carotid arteries and his lungs.

Finally, I took both his wrists and found each radial pulse with my index fingers. I took a deep breath and relaxed. Then I sat quietly as my fingertips registered his pulse, bom-boom, first in his right wrist, and, a split second later, in his left.

“This is the first time I’ve diagnosed this condition in thirty five years”, I began.

I explained Subclavian Steal Syndrome to Gordon; how a blocked artery under his left collarbone causes blood to be shunted from the right carotid artery, across the brain, and downward through the left carotid and into his circulation-deprived left arm, stealing some of the blood that was supposed to fuel his brain.

“There are two ways you can get this condition”, I said. “One is similar to any blocked artery from smoking and all the other causes of poor circulation, and the other is something constricting the artery from the outside, like a cervical rib or a tumor of the lung”.

Gordon made a silent gesture to the pack of Pall Mall cigarettes in his breast pocket.

“Yes, them, either way”, I said. “Let me order some tests…”

A few days later, the Chief of Radiology called me: Subclavian Steal, no tumor.

Next week, Gordon meets with a cardiovascular surgeon to discuss a bypass of his blocked subclavian artery, because he is still symptomatic, even without his blood pressure pill.

A Country Doctor and his horse, Thanksgiving 2012

Equanimity eluded me the other day after a string of challenging visits that each ran over its allotted 15 minutes. There was the man with a nonhealing lip ulcer that might be cancer, the elderly woman who decided to stay with her abusive husband, and the depressed pain patient whose lumbar steroid injections had not helped.

“Can I see you for a second”, Autumn said, peeking her head in after a discreet knock on the exam room door. She told me that Mauritz Blair in Room 1 had already left his room twice to express his dissatisfaction with my running late. I looked at my watch – only twenty minutes behind schedule.

“He said he’ll give you a few more minutes”, Autumn said. I shrugged and went back in the exam room with my waiting pain patient.

“I’m sorry about the interruption”, I said as I sat back down on my stool.

A few minutes later, I crossed the hall to Room 1. Mauritz Blair had been in a couple of weeks before with a longstanding, strange pain in his upper abdomen. I had ordered tests, which were all normal. I needed to come up with the next step in his workup. I wasn’t sure what to do next.

I knocked on the door and entered. Mauritz stood in the middle of the room with his arms crossed and turned an angry stare in my direction.

“What’s going on”, I said.

“Where have you been? I’ve been standing here without hearing any sign of life in this office for a long time. I was beginning to wonder if you were even here.”

I felt my indignation rise and heard myself blurting out:

“I’ve been seeing patients all day. Do you really think I’d keep you waiting on purpose? I had patients with big issues that needed some extra time. I’ve done that for you sometimes. Don’t you think I always do my best?”

He uncrossed his arms in surprise and I composed myself, trying to rescue the visit that had started with the two of us suspicious of each other.

I motioned toward the two chairs in the room and we sat down next to each other. I showed him the printouts of his tests and explained what each one meant.

“This could be what’s called Splenic Flexure Syndrome”, I began, and went on to explain the condition and some strategies to treat it. He listened quietly and I never did get a sense whether he thought my assessment and plan were reasonable.

“Why don’t you try these things for a couple of weeks, then we can follow up and see how they worked”, I said and entered my follow up request in the EMR.

He left without making another appointment.

That visit hung over me the rest of the day and after supper I confessed to my wife that I had failed in a visit by reacting with selfish indignation instead of trying to understand a frustrated patient. He could have been more worried than I realized, he could have had something else bothering him, or simply just been in a hurry. Just because he is retired, that doesn’t mean he doesn’t have time pressures just like I do.

I found myself, not for the first time, openly confessing to my wife that one of the few things about myself that I take too seriously is my commitment to my patients and my profession. I admit my procrastination at home, my vanity, my bad posture and all my annoying habits, but I have trouble accepting that some patients don’t think I try hard enough.

My wife listened patiently to my monologue. Then she spoke. I expected her to quote something from her Buddhist readings, which she did. But she first told me something evangelist Joel Osteen had said:

Only 25% of people really like you no matter what. 25% won’t ever like you. 25% like you conditionally, and 25% don’t like you unless you work at it. If you expect better odds, you’re unrealistic.

The Buddhist wisdom she shared about equanimity, one of the immeasurable qualities, was:

Equanimity in Buddhism means to have a clear-minded tranquil state of mind – not being overpowered by delusions, mental dullness or agitation. For example, with equanimity we do not distinguish between friend, enemy or stranger, but regard every sentient being as equal.
The near enemy is indifference. It is tempting to think that just ‘not caring’ is equanimity, but that is just a form of egotism, where we only care about ourselves.
The opposite of equanimity is anxiety, worry, stress and paranoia caused by dividing people into ‘good’ and ‘bad’; one can worry forever if a good friend may not be a bad person after all, and thus spoiling trust and friendship.
A result which one needs to avoid is apathy as a result of ‘not caring’.
Equanimity is the basis for unconditional, altruistic love, compassion and joy for other’s happiness and Bodhicitta.
When we discriminate between friends and enemies, how can we ever want to help all sentient beings?
Equanimity is an unselfish, de-tached state of mind which also prevents one from doing negative actions.

“If one tries to befriend an enemy for a moment, he becomes your friend.

The same thing occurs when one treats a friend as an enemy.

Therefore, by understanding the impermanence of temporal relations, Wise ones are never attached to food, clothing or reputation, nor to friends or enemies…” (The Buddha)

(http://viewonbuddhism.org/immeasurables_love_compassion_equanimity_rejoicing.html)

Sir William Osler put it this way:

“Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaint.”

As I quietly pondered all this, my wife said:

“Maybe in the exam rooms, somewhere near where the patients sit, you could hang on each wall…”

“A clock”, my mind raced to fill in. I had resisted that impulse for thirty years.

“….a picture of P.”, she said, referring to my Arabian rescue horse, who taught me patience with animals and showed me how to build trust by quietly sharing each other’s territory.

She’s right, if I can carry more of that patience with me into the pressure cooker of my workday, I may be more able to walk in the footsteps of Sir William, if not the Buddha.

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, Meaningful Use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30 minute physical or “wellness visit” (not the same thing) visit once a year for every patient chews up 750-1,000 hours. Total “contact” hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick – less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people – blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating Chronic Diseases Leaves Little Room for Diagnosing and Treating Acute Illnesses:

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing Evidence Based Medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in-clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like RiteAid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITTP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience. Equally true, Nurse Practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called “doctor shortage”, this is what sometimes happens:

In many states, Nurse Practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.

SO, WHO SHOULD DO WHAT IN PRIMARY CARE?

I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But, “out of the box”, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950’s.

My point is that in today’s healthcare system, we are often asking the providers with the least training to see the unsorted clientele in “sick-call” while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned Nurse Practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived “doctor shortage” may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the “sick-call”, and Nurse Practitioners more of the “maintenance“ of modern healthcare.

Let’s really talk openly about who should do what in primary care today!

Andy was new to me. He told me he had seen several doctors over the past few years for various pains in his right arm.

Some months ago, he had right shoulder pain that went away on its own, but for the past few weeks, he had pain in the middle of his upper arm. Last year he had tennis elbow and forearm pain for many months.

A slender, middle aged man, he had no unusual hobbies and denied injuries or neck symptoms. He was visibly uncomfortable as we talked and kept his left hand tightly gripping his right upper arm, held close to his chest.

He had full movement of his neck and normal sensation to touch of both arms and hands. His intrinsic hand muscles were not atrophied. In fact, his grip was stronger than mine.

I asked him to abduct his shoulder forward and to the side, which he did without pain, even when I resisted his movements – a sign of an intact rotator cuff.

When I asked him to place his right arm over his head, he volunteered that he sometimes slept with his arm in that position as it offered some relief from his otherwise unrelenting pain.

I excused myself with the words “let me get my wiring diagram”. Returning with my tattered paperback copy of Mumenthaler’s pocket neurology textbook from the early seventies, I showed him its picture of the cervical dermatomes.

“You have a pinched nerve in your neck, the fifth cervical nerve, and some of the pains you’ve had before sound like they could have been from the sixth nerve also”, I told him.

His eyes widened. “You know, I did fracture my C-5 twenty seven years ago in a skiing accident, but I’ve never had any issues with my neck since that year”, he said.

We talked about what his options were. Because the pains had come and gone before and had only been severe for a relatively short time, and because his muscle strength was intact, I explained that a short course of steroids might help, at least in the short run. I also offered him pain medication.

“I’ll take the steroids but I’ll pass on the pain relievers. I hate the idea of taking those things”, he said emphatically.

I went over the dosing and side effects of the prednisone and said “if ten days of this doesn’t help, I would go ahead with an MRI”. He nodded agreement and we set up a follow up appointment eleven days later.

Day ten was a Monday. Among the weekend faxes from the hospital that landed on my desk that morning were two emergency room reports about Andy.

The first report, from late Friday night, told of how his pain had escalated steadily since he saw me. They had done plain X-Rays, which showed bone spurs and narrowed disk spaces from C-4 to C-6. They gave him some 5 milligram Percocet, which helped his pain, and sent him home with a prescription for 10 milligrams every 4-6 hours as needed and instructions to keep his follow up appointment with me.

The second ER visit, eighteen hours later, was for nausea and vomiting. The five milligram tablet Andy took in the ER Friday night was just right, but the ten milligram tablets, which he had dutifully taken every four hours, were too strong.

“Did you try breaking the pills in half?” I asked when I saw him back in the office.

“I guess I could have, but I didn’t really think of it”, Andy answered.

“I feel terrible that you ended up going to the ER twice”, I confessed, “because I should have told you that if the prednisone hadn’t done anything after three or four days, it probably wouldn’t work at all. If I had, you would have known before the weekend that you needed to let me know.”

“Ah, that’s all right”, Andy said, but I kept thinking about how the most accurate or clever diagnosis is of little use to a suffering or fearful patient if you aren’t clear enough about what seems like a straightforward plan to you, but not to a patient who never had the experience of being sick or taking medications before. As doctors we assume all patients will make the necessary judgement calls on their own.

I failed Andy and the first emergency room doctor failed him, too. We rattled off our standard instructions without making sure he understood what to do if our treatment plan didn’t work.

That’s the Art that sometimes gets lost in this business.