A Country Doctor Writes:

In these virtual pages I have written about medical mysteries, the frustrations of today’s healthcare, and the human dramas we encounter in the practice of medicine.

Below are updates to three previous posts, one from each of these three categories: “The Great Imposter”, “Calling Mrs. Kafka”, and “Invisible Ties”. Readers who don't remember these posts may want to follow the links to catch up on the beginning of each story.

A TALE OF RED HERRINGS

“The Great Imposter” ended in clinical uncertainty:

“And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.”

The other day I saw Dr. Brown walk Norman Sprague down the hall. Afterward, I asked whatever happened with his possible shingles, gallbladder pain, lung nodules and mediastinal lymph nodes.

“The PET CT looked pretty benign”, said my octogenarian colleague, “and nothing came of that pimple you saw on his back. He still has his gallbladder and Roger White is pretty sure it's sarcoidosis. Interesting, though, that the Lyrica samples you gave him when you thought it was shingles cut his pain at least in half, but the pain is on both sides of the midline…”

“I don't know why it's working, then”, I said.

“Neither do I, but I kept him on it. He's meeting with Roger next week to discuss treatment options, probably steroids.”

“Pretty sure, huh”, I muttered to myself.

A PYRRHIC VICTORY

In “Calling Mrs. Kafka”, I went to bat against the insurance company for Harriet Black. She really did have a terrible case of shingles, and Lyrica was the only thing that really helped her pain; the gabapentin and her regular pain medication had not been enough.

After my call to the surreal Mrs. Kafka in the Prior Authorization department, I asked Autumn to call Harriet and tell her the drug was approved. She was very grateful on the phone. Some time later she came in for her follow-up appointment.

“How’s your shingles pain”, I asked.

“Still pretty bad”, she answered.

“I thought the Lyrica was working pretty well”, I said, confused.

“I can't afford it. The copay is too high”, Harriet said, her voice trailing.

So much for getting a medication approved by the insurance company…

MOTHER AND CHILD

Four years ago, in “Invisible Ties”, I described how Kirk Donner, adopted at birth, went to the State Capital to look for his birth mother after he turned eighteen. He knew she had an unusual name, Suann:

“Kirk took the elevator to the fourth floor. He was alone. As the door slid open, he stepped forward and almost collided with a tall, dark-haired woman with designer jeans and a plain, white blouse. Her eyes met his as he stopped and apologized. They were large and kind. She flashed a smile as he swerved around her, embarrassed and eager to get to the registry.

He walked up to the receptionist and stated his errand with words he had practiced in his mind the whole trip.The clerk handed him a form and as he reached for a pen he saw a stack of similar forms in front of her. Reading the top one upside-down he saw the name: Suann Walker.”

Mother and child made contact soon after that day, and each found peace in knowing what had become of the other. Kirk met his half-sister, also raised by an adoptive family.

Suann and her fiancé attended Kirk’s college graduation in May, and this summer Kirk spent a lot of time at their house while he took a summer course in the southern part of the state.

“Finding her and learning what she is like has helped me understand myself better, it makes me feel more whole”, Kirk has told me.

Many of my vignettes on this blog end with unanswered questions or unstated uncertainties, just like any typical physician’s patient encounters. These updates moved the plot forward in just three cases, but even these are not the final installments in the history of each patient’s own journey. Medicine, even practiced over many years of physician-patient continuity, is but a glimpse into the lives of a few fellow humans.

This week I suddenly felt transported back to my earliest years in medicine back in Sweden. In the last few days I have seen almost a dozen children with rashes. We have a Hand, Foot and Mouth epidemic in our little town, hitting the second and fourth grade children hardest.

One eleven year old boy had looked like an early strep throat a few days ago, but he came back today with subtle red spots on the palms of his hands. He was in the room across the hall from his two-year old cousin, who had a full blown case of HFMD, the worst I have seen all week. His aunt had sore, itchy palms with no rash. I don’t know if it’s a sympathy reaction or if she is next to come down with it.

Mixed in with the rest of them was a two year old from out of town with a sketchy immunization history and a bad case of chickenpox, and a handful of children with colds and worried parents. One little boy with a runny nose had one single macular lesion on his thumb – too soon to tell whether he is coming down with Hand, Foot and Mouth disease or not.

Working acute care in Sweden, I saw a lot of rashes, and in those days we did not have all the immunizations we have now. I remember feeling pretty confident with my differential diagnosis of rashes – measles, German Measels, scarlet fever, things we don’t see much of anymore. Scarlet fever, associated with streptococcus infections, was common then but is rare these days. We also saw enough post-streptococcal nephritis that I routinely brought strep patients back for a urinalysis after their sore throat had resolved.

I remember the varied reactions among parents during the small epidemics I witnessed in those early days. Most parents took things in stride, expressing gratitude that their children got their “normal childhood diseases” over and done with. Some parents even sought out chickenpox cases in their neighborhoods and had chicken pox parties in order to have some control over when their children got the disease. I just read somewhere that the Swedes still aren’t immunizing children against chickenpox, apparently for cost reasons.

When I worked in student health here in the U.S. in the late 1980’s, we had a measles epidemic at the university. Because the students had been immunized as children, they tended to get milder and atypical forms of the disease. I remember being called in to see my colleagues’ cases all the time as the local expert on the rashes of “childhood diseases”.

Hand, Foot and Mouth disease was first described in New Zealand (or Australia by some accounts) in the 1950’s. I don’t remember running into it often back when I used to see measles and German measles. I remember just calling it a coxsackie virus rash. Recently I have read that the Swedes call the disease “höstblåsor”, or “autumn blisters”. I do remember seeing more “herpangina”, which looks the same and is also caused by a coxsackie virus, but is limited to the mouth.

There is no widely available vaccine against Hand, Foot and Mouth disease, and antiviral drugs are ineffective against it, but it tends to be a very benign illness. Some of the eleven viruses that can cause the disease are more aggressive, and in other parts of the world, for example Vietnam, the disease can more often be associated with neurological complications, from minor twitching to convulsions.

The way our society reacts to the mild form of the disease that we usually see is interesting. People worry about second graders missing a week of school – something I have a little trouble with. The economic burden of working parents missing work is a valid concern, but with so few “childhood diseases” left to contend with, a week of reading, watching movies or playing games at home isn’t the end of the world.

Our few remaining “childhood diseases” take the time they take to get through, and we have no shortcuts. They offer us an opportunity to understand that we can’t control everything in our lives.

Hand, Foot and Mouth disease usually only strikes once, so unlike the common cold, it has not become big business for purveyors of useless remedies, and unlike influenza, we have no big-ticket disease modifying drugs, so we are left to practice good home care, humility and the ancient art of just “being sick”.

America’s favorite mid-century pediatrician, Dr. Benjamin Spock, wrote the following about the “childhood diseases”:

“There are only two things a child will share willingly — communicable diseases and his mother’s age.”

You have to think fast in medicine. Not that most doctors handle life and death emergencies all day long, but even seemingly mundane clinical situations require a lot of rapid gathering of data, processing of applicable information and attention to detail in formulating a plan.

I have always been bemused by the so called E&M (evaluation and management) coding that dictates payment by requiring documentation of how doctors think. Ironically, the AMA defines this work and thereby has been a major contributor to physicians now spending more time on documentation than on doctoring. The documentation, even with EMR templates, takes infinitely more time to complete than the thought processes that go into clinical work. Even our preliminary observation of a patient, before any history taking occurs, is something instant, that in a novel might fill a whole first chapter, or in a homeowners’ insurance inventory might go on for pages. We can take in details of a new face or a new place in the blink of an eye; this is something all of us experience. Doctors, by nature of their profession, hone this ability in Sherlock Holmes-like fashion.

Not that I follow sports, but I can imagine a pro golfer or star soccer player could go on for quite a long time describing all the millisecond judgments that go into every aspect of their game. But the difference is they don’t have to. It seems they get paid according to their results, and not by their stated mental work behind those results. In fact, most fans’ appetite for hearing all the details behind the action shots is probably rather limited.

In medicine today, unlike the worlds of Sir Arthur Conan Doyle or Sherlock Holmes, we don’t quite have the option of using the richness and nuances of our language to document our observations. Our words must be chosen from a dictionary of “findings” that correspond to numerical codes used as underpinnings of our EMRs. Our patients can’t be “uncomfortable”, “squirming”, “braced”, “forced”, “pensive” or even “vague”; we must choose between “in acute distress” or “not in acute distress”.

Our language is no longer ours; we must speak like accountants. But when we do, will accountants understand us any better than when we speak like doctors? I suspect that by speaking their language, we risk having our powers of observation, ability of analysis and skill of formulating a clinical plan reduced to something with less depth than what it is, regardless of the number of details we provide.

When we encounter patients we have seen a long time ago, our own notes can fail to give us the instant familiarity of past medical records, and when we see our colleagues’ patients, we struggle more to get to the essence of the clinical notes.

By accepting to describe our work in this foreign language, Accountanese, we have deprived ourselves of some of the tools of our trade, the shorthand that soccer teams might use to synchronize their game. We have lost the nuances of language we need to describe complex processes and multidimensional clinical scenarios involving patients of flesh and blood. So we fumble around, choosing more and more words from our pick lists, none of them quite the right one, while our notes get continually bigger and less and less precise.

We are more or less trusted to care for the lives of our patients, but we are not trusted to bill honestly for whether we just did an easy visit or a complex one.

Maybe I should ask my tax accountant for an itemized bill for his preparation of my income tax filing; all he sent me was a note, stating:

“Preparation of 2013 form 1040. $180″

I would never get away with anything that brief.

“Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you are the one getting burned.”
Buddha

“I came to realize that if people could make me angry they could control me. Why should I give someone else such power over my life?”
Ben Carson, M.D.

“Depression is rage spread thin.”
Santayana

“Depression is the inability to construct a future.”
Rollo May

The other night I got an email with a survey from the AMA. I don’t recall ever getting one from them before. Not that I have been all that involved with the politics of healthcare; I joined the AMA when I was a senior resident, a newcomer to American medicine, and bought life and disability insurance through them.

In all the years of change and upheaval in American medicine, I have never been asked my opinion on what I need in order to do my job well or how I feel about my chosen profession. Until now, that is. And now, they skipped over any questions they might have had about what I need; they went straight to the more ultimate questions:

The AMA wanted to know if I’m burned out or depressed and if I hate my EMR. They also wanted to know if I am contemplating changing practice location, dropping out of medicine, retiring or committing suicide.

And I had somehow gotten the impression that the AMA was one of the drivers of change for the last thirty years. But maybe I was misinformed.

Clearly, the questionnaire indicates that the medical establishment is quite worried about its constituency.

In “Bitter Medicine” I wrote about how outside forces have distorted the traditional doctor-patient relationship. I also wrote about how doctors need to see their patients as suffering kinfolk and doctoring as having a higher purpose.

The four years that have passed since that piece have been years of increasing physician dehumanization through “Meaningful Use” and other bureaucratic mandates. I have seen more signs of anger and bitterness in doctors and there has been a great deal written about physician depression and suicide.

But what is this anger really, what is the nature of this depression, what are their consequences, and is there a way out?

In psychodynamic theory, Abraham postulated in 1911 that depression can be self-directed anger in people with narcissistic vulnerability. Freud linked depression to anger at oneself after a perceived or actual loss of a person one felt ambivalent toward.

Brenner, while I was in medical school, saw depression as resulting from symbolic castration or more or less actual disempowerment. Aggression towards the person who causes the feelings becomes self-directed instead out of fear of the other person.

Physicians, or rather, people who choose to become physicians, often think of themselves as more dedicated and perhaps even smarter than other people. We carry the world on our shoulders and sometimes feel we are different from other people. These are essentially what psychologists describe as narcissistic personality traits. I believe many of us are vulnerable to and apt to react with strong emotions to real or perceived rejection or loss of power, such as what has happened in our profession in the last 30 years.

The reality of today’s patient encounter is that some of the preciously short time we have allotted is spent fulfilling the requirements of the healthcare system that may or may not directly benefit each patient. That leaves little time for diagnosis and treatment, and even less for relief of suffering. And, of course, if we are trapped in our own suffering, we cannot help relieve that of our patient.

Physician anger and depression may, ironically, be as great an obstacle to good patient care as the Government mandates, insurance company obstacles and Health Information Technology shortcomings we doctors are so upset with.

Venting our frustration with the system is a waste of our patients’ appointment time. At most, we may need to briefly explain what can and cannot be done in the minutes we have together. And harboring feelings of depression or helplessness distracts us from the necessary engagement with each patient.

There may be ways for physicians to effect change of the system, but the place for that is not the exam room. There is also the possibility of opting out of the system. But for all of us who choose to stay, every patient encounter with a fellow human being deserves our full attention and genuine compassion.

Thinkers from all different religions and schools of thought have all said the same thing: We have a choice whether to cultivate our anger or not. Most tell us we can’t suppress it, because it has a way of expressing itself in other ways, even as illness.

Physician anger or depression that stems from powerlessness, like all anger, has an antidote. Borrowing from Buddhist thought, the antidote is love and the path is mindfulness.

Thich Nhat Hanh writes:

He also says something that points out Westerners’, including Western doctors’, emphasis on formal education compared with cultivating our well-being. Hearing about divorce rates and alienation of other family relationships among physicians, these words should make us stop and think. Not that we should have forgone our education, but why do we think our life, well-being, and our relationships don’t also require effort and time?

“Getting a university degree may take you six or even eight years, and that is quite a long period of time. You may believe that this degree is important for your happiness. It might be, but perhaps there are other elements that are more important to your well-being, and to your happiness. You can work on improving the relationship between you and your father, your mother, or your partner. Do you have time for this? …You are willing to put aside six years for a diploma; do you have the wisdom to use just as much time to work out a relationship? To deal with your anger?”

Our anger demands attention, but not encouragement. Like Buddha’s hot coal, it hurts the one who carries it. When we are angry, like many of us are with the system, we need to examine our anger. Are we angry more or less because we can’t have our way? Are we angry because we think health care politics need to change? In the first case, our anger is only hurting us; in the second, it needs to be turned into political action.

We need to stop banging our heads against the wall. Yes, our tools aren’t as good as we would like, those who pay us don’t know enough about what we do, and the Government is fixated on form without function.

But did Hippocrates have top-notch equipment, did Albert Schweitzer have all the resources he needed, and did Michelangelo always have the right paints and brushes? Sure, we could all do better if only….but we’re just wasting our breath, using up valuable time and watering the seeds of anger and depression if we harbor such thoughts in the exam room or at home. We can take them to the political arena, but we must not let them poison our patient care, our home life or our souls.

Autumn’s 17 month old nephew from out of town had been visiting with us in the office the other day. He sat in his mother’s arms as Autumn showed her sister, April, around the clinic. We had made brief eye contact then. He had the hesitant look of quiet amazement as he looked around our busy office. I minimized the EMR on my big computer screen and showed him the picture of my white Arabian horse standing next to me, all bundled up in my thick leather jacket with a blaze orange vest over it. Dylan’s eyes locked on to the screen as the two women talked. They stayed locked on and he didn’t seem to register my attempts to make contact. After a few minutes, April signaled she had to be going. Autumn and I both waved and Dylan strained his neck, gaze still fixated on my computer screen as his mother turned around and stepped into the hallway.

Friday, Dylan was in my schedule for fever and vomiting. Both his mother and father were there and Autumn was in the room with them.

Dylan didn’t appear to be all that sick. I sat slouched on my stool while I took the history and then slowly moved closer to the exam table and began to examine Dylan in his aunt’s arms.

Autumn and April commented from the beginning on how difficult Dylan usually is to examine. I plodded along slowly without any protests. I checked his neck for enlarged lymph nodes and carefully pulled the stethoscope from the pocket of my long white lab coat.

“I don’t believe that he’s okay with you doing that”, his mother said as I listened to his heart and lungs. I squeezed his belly very gently as I told his mother that his lungs sounded nice and clear. His abdomen was absolutely soft and he didn’t seem bothered by my palpation.

Next, I slowly pulled my pocket otoscope from the holster on my belt. Dylan watched intently as I unfolded the instrument.

“See how this works”, I said in a low voice and turned the light on. I aimed it first at my left hand and wiggled the light a little. Dylan’s eyes followed my movements. When I aimed the light at the Disney figure on his shirt, he looked down, and his chin touched his chest. Slowly, I reached past the exam table and pulled an otoscope tip from the wall dispenser. “Let’s check your ears”, I said while I attached the otoscope tip.

Dylan’s eyes followed every move I made. I aimed the light at my own hand again, then I quietly reached over and looked in his ear while I very carefully pulled just a little at the tip of his outer ear. As he started to tighten his muscles I let go and pulled away. “That one looks okay”, I said as April and Autumn stood next to Dylan with wide eyes and open mouths.

His other ear looked fine, too. He didn’t tense up at all this time. I said “let’s check your mouth” and cocked my head up a little to be able to look through the lower portion of my bifocals. Dylan also looked up a bit, and his jaw muscles relaxed. Gently, I touched the sides of his mouth and opened mine a little. He opened his mouth in the same fashion and I pulled lightly on his jaw and his mouth fell wide open. I got a quick look at his tonsils and I could see that his mucous membranes were moist and normal in color.

“He looks fine. I think he just has a viral infection, so as long as he keeps taking in fluids and doesn’t develop any other symptoms, he should be okay”, I reassured his parents.

“He’s never let anyone examine him without fussing or crying”, April said. “I know”, Autumn chimed in. “He’s always been impossible to examine.” Turning directly to me, she continued: “I always knew you were good with kids, but this was truly amazing!”

“I also tame wild horses”, I said, overcome by an uncharacteristic impulse of flamboyance.

As I thought about my words, it seemed that the analogy is obvious. People talk of the “techniques” they use when dealing with mistrusting, unbroken rescue horses, sullen teenagers or toddlers with fear of doctors, but I never thought of any of it as technique. Approaching another creature requires genuine respect and connection, and it can’t be completely taught or analyzed.

After I ended up with my rescued Arabian princess and got to know her by just hanging out with her, sitting quietly in the barn cold winter evenings and sultry summer nights, she has come to trust me, and I her. When she was ill and too despondent to return from the frozen pasture during her first ice storm, I trundled out to her with halter and lead rope for the very first time, and she followed me willingly back to the barn.

Later, I have read about just this way of relating with horses, not by dominating them, but by earning their trust and respect. Carolyn Resnick calls it “The Waterhole Rituals”. The first and most crucial step is to place yourself near the horse without fixating on it, and enter a frame of mind that is peaceful and gentle. If you just do that, any horse will seek you out to make your acquaintance.

Approaching a sick child, or just a fearful one, requires the same frame of mind. There may be techniques to learn, like listening to the lungs right away, before any crying starts, and saving the throat exam for last, because if the child does start crying, you’ll see the throat anyway, and without effort. But those are superficial and secondary considerations. The kind, gentle and healing presence isn’t something you need schooling to learn. It is just a matter of having your heart in the right place. I also think it is important to connect on a level some people may refer to as “energy”; Dylan, the amazed visitor from another world, that of a gentle and curious seventeen month old, responds better to a quietly plodding softspoken “energy” or demeanor, while some older children with mischief in the back of their minds relax and connect better with a grandfatherly doctor with a twinkle in his eye and a joke up his sleeve.

As my practice has matured, I see fewer children than I used to, but I cherish the opportunities I do have to see young children. It’s like dusting off your old bicycle and going for a spin – you never forget how to do it.