A Country Doctor Writes:

Marguerite lived on the little hill north of town. You can see her house from the path along the river where I used to walk my beagles. Her tall, turreted Victorian seems to sit right under the constellation of stars in the northern sky I first knew in Swedish as Karlavagnen – Charleswain in Old English, the Plough in British, and the Big Dipper in American.

My house calls at Marguerite Rackliffe’s spanned a period of over ten years. She was already widowed and in her eighties when I began seeing her in her house on Village View Drive. At first, I would visit her every few months, but gradually my house calls became more frequent as her health problems worsened with her advancing age.

Homebound and with no family nearby, she relied on neighbors, acquaintances and hired workers from the community for many of her basic needs. In the beginning, our visits were sometimes more social than medical, but as the years went by, we juggled more and more complex medical issues. Sometimes our visits took place on a spiritual plane; Marguerite was an ordained minister, although she had never had her own church.

I had learned when we first moved to town that Marguerite was a writer. At one time, she had been an editor for a New York book publisher. Now she ran a small publishing company from her home and, by the time I first visited her, from her sick-bed.

I remember the first time I entered her home through the massive double front doors. Inside was a tall, tile floored hallway with a soaring curved staircase.

“I am here, Doctor,” her voice echoed from a large parlor-turned-bedroom. There were books everywhere – in dark floor-to-ceiling bookcases, on a rectangular table, on the mantle and in boxes on the floor.

She was propped up against the tall headboard of an antique bed near the front window, and she had a computer on a stand with the keyboard on an over-bed table in front of her. There were books strewn across the bed.

She spoke with precision and authority as she answered my questions during our review of systems. When I asked her to lie down, she interrupted me and said:

“It is so refreshing to finally hear a doctor say ’lie’ down instead of ’lay’ down.”

“I have to pay more attention, because English is my second language,” I replied.

She had read my column in the local paper and told me she liked it.

“You should write a book,” she said. She continued to say that every so often, and dismissed my excuses about being too busy in my practice. Once, she gave me Dr. Bernard Lown’s book “The Lost Art of Healing”, pointing out that he was a busy doctor and still took time to write.

In every visit with Marguerite, it seemed she gave me more encouragement than I was able to give her. She offered to edit and publish anything I might write, even though her failing eyesight by that time required her to enlarge the fonts on her computer screen to the point where she could only read a few lines of text at a time. There was only so much I could do to control her interrelated medical problems, and I had very little to offer in the way of help for her practical needs.

When I showed concern for her health, she was quick to reciprocate with concern for mine. She spoke of burnout, and gave me her own copy of Thomas Moore’s “Care of The Soul”. Sometimes, she asked if she could pray with me. I sat quietly with her hand holding mine as she prayed for me to have stamina and wisdom in caring for all of my patients. She asked no favors for herself.

We were on a first name basis almost from the beginning, but when she received an honorary doctorate two years before she passed away, she jokingly suggested I must call her “Doctor”.

Every night, walking my dogs, I would turn around after I got to where I could see Marguerite’s house. Most of the time, she would still be up, her computer screen’s bluish light radiating against the night sky. After she passed away, at age 93, I still walked the dogs along my usual route at night. In the beginning I caught myself half expecting to see the light from her computer screen, but her house always lay dark; the only lights near the Rackliffe house were the usual seven brightest stars of Ursa Major in the northern sky.

She has been gone for nine years now, and we have left town for a house in the country. I still do house calls and I sometimes go up Village View Drive. I often think of the decade Marguerite and I shared and how much I learned during those years. My patient became my mentor; her perseverance became my inspiration. She, more than anyone else, showed me how obstacles can make you stronger.

Marguerite’s clear voice still rings in my ears, “I am here, Doctor”. Indeed, she is. I can still feel her presence – praying for my work as a doctor and telling me to keep writing.

My new glasses were years overdue. The eye doctor understood perfectly my request that the focal point and pupillary distance for my iPad reading glasses had to match my habitual reading style – right under my nose. The result couldn’t be more pleasing.

The other day my wife squinted over her iPad and said “I don’t know if I’m getting a cataract or if I just need new glasses. My right eye is blurry”.

“Why don’t you just make a pinhole and find out?” I asked.

She made a fist and peered between her tightly curled fingers.

“Oh, yes, it’s just my glasses!” she exclaimed with relief.

Both of us medical providers, and both of us lifelong photographers and former dark room enthusiasts, we started talking about everyday optics. We speculated whether younger primary care clinicians still use pinholes to distinguish between eye diseases and simple refractory errors, for example when doing a quick vision check on a patient with eye pain who left their glasses at home.

The pinhole test is one of those examples of low tech, bedside – or, rather, exam room – assessments, that have been around for generations. So much of medicine today is complicated and dependent on technology. And there is more and more being written about point-of-care testing with smartphones and miniaturized gadgetry that people might be forgetting some of the basics that almost don’t require any equipment at all.

The other day I saw a patient with tension headaches. I had him look at a poster across the exam room through my ophthalmoscope. Switching between the neutral and the plus one diopter built-in lens, he could read with both through his left eye, but only with the neutral lens on the right, suggesting he may be a little farsighted in his left eye. I referred him for a formal refraction.

Maybe it’s the Boy Scout in me that finds it interesting to still use my earliest medical school lessons, my common sense and everyday tools to evaluate patients.

For example, I still use my tuning fork a lot. I love explaining the Webber and Rinne tests for conductive hearing loss to my patients.

I use my regular blood pressure cuff to record a palpatory blood pressure at the ankle for a quick ABI, or Ankle Brachial Index, in patients at risk for peripheral vascular disease.

One of my pet peeves is using the peak flow meter when evaluating asthmatics. Every hospital emergency room I have seen checks oxygen saturation as a routine vital sign. But a low oxygen saturation is a very late warning sign in asthma – almost immediately before needing intubation. A peak flow meter is a much simpler tool than an oximeter. In fact, all the guidelines I have seen recommend using peak flow meters at home, so why not at the doctor’s?

And, of course, that universal symbol of the medical profession, the stethoscope is more than an identification symbol:

I regularly listen for bruits over the carotid arteries and have found a few critical stenosis cases. I also listen for the kidney arteries and sometimes the femoral arteries in the groin.

There is a growing movement among medical educators to bring bedside clinical exam skills back into focus, instead of just being part of the introductory courses, somewhere between the history of medicine and applied Mendelian genetics. Abraham Verghese and others, as recently as a few weeks ago in The Journal of the American Medical Association, emphasized the importance of mastering both clinical exam skills and the use of technology.

It was here in North America that Osler revolutionized medical education by bringing it from the lecture halls to the hospital wards. But today’s medical students and residents spend only a small fraction of their workday in the presence of their patients. It is my hope that that will change, and that medicine will strike a healthier balance between hands-on bedside assessment and hands-off high tech testing.

I enjoy new technology, but direct observation by a skillful physician isn’t necessarily inferior to the latest gadgetry. My iPhone can tell me what the weather is where I live, but if I get soaked when I step outside in the morning, I won’t need to check the weather app to verify my observation.

Talking with an insurance doctor, who denied a vertebroplasty for my patient with a spontaneous compression fracture, I started thinking about the dilemma of defining what a doctor-patient relationship is.

A couple of years ago a local doctor with a dwindling private practice joined an Internet medical site that promoted drugs like Viagra and offered online consultations with physicians who prescribed the medications when they felt it was appropriate. The State Medical Board disciplined the doctor with a warning, a stiff fine and a permanent blemish on his record.

The charge was “prescribing without a physician-patient relationship”.

It struck me as ironic that providing a treatment long distance gets you in trouble with the Medical Board, but denying treatment to patients you have never met or communicated with in any way is perfectly acceptable. It might even qualify you for a bonus?

The managed care industry, on its own, redefined the doctor-patient relationship many years ago, and now the Internet and the Government are continuing the transformation.

In 1999, writing about the inherent conflict between being someone’s doctor and in reality also working for the insurance companies, Goold and Lipkin conceded that the doctor-patient relationship is still something very personal:

“The doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided.”

Curiously, they then went on to create a breakdown of how doctors build trust during the medical interview, as if they might somehow be able to replicate it without the doctors’ involvement.

Today, of course, medicine has become less personal. Teams of doctors, PA’s, NP’s, nurses, medical assistants and health educators are engaging with patients during and in between visits. Patients are trying to get used to this kind of group health care, and are often expected to quickly open up and establish trust in these new “team members”.

Sometimes the teams are introduced as being physician-led, sometimes as being part of a trusted health care organization. The problem with some of the newly created entities, like Accountable Care Organizations, is that they are still completely unfamiliar to patients.

Many patients are worried that either too much or too little is shared between the members of the health care team: Too much and they feel their privacy threatened, too little and they worry their diagnosis or care will be incomplete.

In my opinion, each patient’s personal physician really needs to be the glue that holds together these new teams of health care workers. If physicians are not promoted as team leaders in this reorganization of patient care, patients will be tossed around in a haphazard fashion, where the care will be tangential – focused on what each team member needs to document for their own job security, but with no one to sit down and work through the hard decisions that inevitably arise when you are treating people, not numbers.

This role requires physician confidence and enthusiasm. It requires trust between doctors and their employers that they are working with the same vision. It requires a new view of the physician as more than a revenue producer; very soon we will not be bringing in more revenue simply by seeing more patients and charging correctly for our work.

Private practice physicians were once each at their own epicenter of a very fragmented, individualized health care system. The American insurance system reduced us to line workers in the big health care machine. Costs went up, quality went down, and now the Government is asking for Accountability.

The role of physicians is set to evolve again, from well paid widget makers to managers – of care, of staff, of resources.

Are we up for this new role? Do we also remember the ancient role of the physician? And can we bring it with us into the future?

The principles behind the physician’s role haven’t, or shouldn’t have, changed. Even the AMA, in its Code of Medical Ethics, speaks of the moral imperative in the doctor-patient relationship this way:

“The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.”

Accountability implies a moral or ethical foundation. If today’s doctors, working in today’s evolving health care system, are to retain the moral and ethical principles of our profession, the organizations they work within must adhere to similar principles. If the implied message is that health care wasn’t living up to the highest possible standards before, can an entire industry be made ethical?

I have just brought back a good message from the land of 102°:
God exists.
I had severely doubted it before:
but the bedposts spoke of it with utmost confidence,
the threads in my blanket took it for granted,
the tree outside the window dismissed all complaints,
and I have not slept so justly for years.
It is hard now to convey
how emblematically appearances sat
upon the membranes of my consciousness;
but it is a truth long known
that some secrets are hidden from health.

John Updike, “Fever”, 1963

Dustin Pelletier is an extremely busy and engaging eight-year old. He wasn’t at all his usual self when I saw him a few Mondays ago. He had been hospitalized while he and Holly, his mother, were Downstate visiting his grandparents. He seemed to come down with a headache and stomach flu and proceeded to pass out three times within the span of an hour. The doctors pulled out all the stops; CAT scan of his head, spinal tap, and all kinds of lab tests – all normal.

Dustin seemed unengaged in the visit. He barely answered my questions. He still had a bad headache. He seemed to look somewhere over my left shoulder as I examined him. Dustin hadn’t had an EEG, so I ordered one, and he had a heart murmur I hadn’t noticed before. I decided to schedule an echocardiogram and repeat his labwork.

I told Holly to bring him right back in if he seemed to get any worse. That she did, at 4:45 the very next day. This time Dustin was somnolent, barely rousable.

“Could he have gotten into something?” I asked.

“I can’t imagine”, Holly answered.

“We’ve got to get him to the hospital”, I said.

I told the ER doctor about my observations, mentioned my worries about something inhaled or ingested.

The next morning Holly called. She described all the normal tests Dustin had had and how he was discharged with strict orders to call me for a follow-up appointment the very next day.

“But, you know”, Holly said, “the instant we got into the car, Dustin shook his head and looked all around. Then he said ‘Aaah, it’s good to be back’. And from that moment he’s been himself again!”

Driving home Friday night, my adjustable leather seats seemed strangely stiff and uncomfortable. Stepping out of the car, the ground seemed further down from the running boards than usual, and my knees creaked and seemed to have a slight extension deficit. The house seemed cold to me, and I asked Emma if she minded me turning off the air conditioning.

The next seventy-two hours have been a jumbled blur of chills, sweats, bodyaches and stomach rumblings. At one point I remember lying on the floor, waking up, and staring at the claw foot of a chair leg right in front of me. Once, I woke up and couldn’t figure out where I was.

I remembered a poem by John Updike, Fever, but couldn’t muster enough strength to get up and find it, so I retrieved it online with my iPhone. That, too, exhausted me. I slept most of today, too.

If I have what my young patient had, I hope the moment will come soon when I, too, will shake my head and say:

“Aaah, it’s good to be back”.

But, first, I’ve got to lie down for a while.