A Country Doctor Writes:

Andrea Smythe needed something for her depression, but she was leery of medications. Her counselor had recommended trying an antidepressant, and I agreed.

Andrea told me nobody in her family ever took an antidepressant, and none of her friends ever did.

By the time I had dutifully explained about initial nausea, the risk for suicidal ideation and the possibility of inducing a manic episode in undiagnosed bipolar patients, Andrea was squirming in her chair. I didn’t even get to the risk of weight gain and sexual dysfunction before she told me she’d rather do something “natural”.

“Who wouldn’t, after that introduction”, I thought to myself. So we talked about St John’s Wort and other nonprescription alternatives, all less studied but without foreboding government-mandated warnings.

This is the age of informed consent. Anything you don’t say about possible adverse effects can be used against you. That’s why most lawsuits against cigarette manufacturers fail – after all, they warned smokers about the dangers of using their product.

Even when patients agree to take the medication suggested by their physician, the negative expectations can be a hindrance to the beneficial action of the medication – a real nocebo effect. This is the opposite of the placebo effect that some people tend to dismiss as imaginary. Ancient physicians, the fathers of modern medicine and cutting-edge neuro-immunologists all tell us the human body’s ability to heal is helped or hindered by the patient’s state of mind. In many psychiatric diseases this is axiomatic.

I, for one, always look to align my treatment plan with any potentially available placebo force, for lack of a better word.

“Did you ever know anyone who took an antidepressant?” I usually ask. If the answer is yes, I ask which one and how it worked. If the other person is a family member, I not only have a chance for insight into my patient’s positive or negative expectations but also into their genetic predisposition for response or non-response to certain medications.

If the patient believes one medication is more likely to work than another, I would have to feel very strongly about any other medication I might want to suggest in order to pass up all the positive expectations – call it placebo effect if you want – that the patient just offered to the therapeutic situation.

This is where all the practitioners of non-allopathic medicine have several advantages in today’s health care climate; they are not required to warn patients about rare side effects of their treatment, and they are sometimes more able to listen to their patients’ beliefs and preferences without worrying about what insurance companies, managed care organizations or treatment guidelines tell them to do.

The other day I saw a dramatic example of the nocebo effect; Rachel Ruel had been plagued by horrendous attacks of abdominal pain for several years until I started her on a very low dose of metoclopramide, taken only as needed during these attacks. The medication controlled all her dysmotility symptoms and she was finally able to live a normal life. This was long before the 2009 “black box warning” issued by the Food and Drug Administration about the risk for tardive dyskinesia. We talked about the risk for this rare facial movement disorder and Rachel always felt the relief she got from the medication was so significant that she was willing to take the small risk of side effects.

When I last saw Rachel, she had a tooth infection and secondary jaw pain. She had been sure this was the beginning of tardive dyskinesia, so she had not taken metoclopramide at the beginning of her latest attack two days earlier. She was still miserable with abdominal pain. Her unrelated jaw symptoms had escalated her fear of developing tardive dyskinesia, and I was in no position to talk her out of that fear. I had nothing to offer her, except a referral to a university gastroenterologist.

She left my office still fearful and in pain, but she made the least frightening choice she could make in that moment. I am still wondering if I could have handled our visit differently.

Many doctors’ offices have little signs discouraging the use of cell phones. Personally, I find them useful more often than annoying or disruptive.

The other day I saw Mrs. Jonah for a sinus infection. She had lost her private insurance and ended up on Medicaid, the insurance for low-income Americans. When her insurance changed, we had to change several of her medications, because Medicaid didn’t cover what she used to take. Mrs. Jonah told me that one of her new medications wasn’t working for her and the step care on the Medicaid website was confusing. I pulled out my cell phone – not a smart phone for this country doctor, but a waterproof one suitable for working around our little farm.

I know our state’s Medicaid office doesn’t keep you on hold forever, and the people who answer the phone actually have the answers to your questions. Within a couple of minutes I had e-prescribed a new medication to her pharmacy along with an antibiotic for her sinusitis and Mrs. Jonah left the office with a smile and the words “you make things happen”.

I also pulled out my cell phone when Mrs. Gordon’s blood pressure was higher than I had ever seen it and she seemed confused about how many blood pressure medications she was actually taking. The pharmacy told me she hadn’t picked up her lisinopril since February.

Bud Swensen told me his little red pills made him itch, so he stopped taking them. I couldn’t figure out which medication he was referring to. He called his wife on his cell phone and we settled the issue right then and there.

Frank Garr always gives me a hard time if I happen to be running late. That is what happened when I last saw him. He said he was running out of his sleeping pills. According to my records, he should have had a refill left. I called his pharmacy to verify this. He looked demonstratively at his watch and said “I’m deducting this from our fifteen minutes”.

“I’m making this call for you”, I replied.

“Fair enough”, he said.

Norm Parsons was having a terrible time with his rapid atrial fibrillation. His cardiologist in the state capital had really wanted him on a beta blocker because of his mild heart failure. Norm had tried them before and had to stop because of side effects. He was beet red, huffing and puffing, and said “this is exactly what happened last time I tried metoprolol”.

A quick cell phone call to his cardiologist gave me permission to switch Norm to diltiazem, even though it theoretically is less ideal for rapid atrial fibrillation with heart failure. Norm’s e-prescrition for the new medication, my office note and the cardiologist’s documentation of the medication change happened quickly and in real-time.

One thing I don’t do with my cell phone is take incoming calls. I have my phone on “vibrate” and check for missed calls or messages between patient visits. But for straightening things out with pharmacists and colleagues, I wouldn’t want to be without my cell phone.

Muffy Wahl slipped backwards on her icy porch and landed on her right hip. Bruised and sore, she took it easy for a few days but she still went to her exercise class the following Thursday. The petite sixty-three year old was determined not to let a silly little fall set her back, and she did her jumping jacks to the loud, fast music with more determination than usual. She could barely drive herself home afterwards.

After dinner Thursday night she didn’t know what to do with herself; she shifted her weight back and forth, but the pain was just as bad no matter how she positioned herself. Getting ready for bed she noticed the bruises were bigger and now reached around to her groin.

Even flat on her back she was in pain. It was a constant, relentless, nauseating pain unlike anything she had experienced before.

Friday morning she got a call from her twin sister, Mary, who had just been admitted to the hospital with a hip fracture. Muffy promised to go and see her, even though it meant a twenty-mile drive. She took some ibuprofen and drove off to see her sister.

After the two women had visited for a while, Mary noticed Muffy’s pained expression as she shifted her weight in her chair. Mary suggested that Muffy get herself checked out downstairs in the emergency room. Muffy hesitated, still thinking it was just a bad bruise. Besides, she had never had any dealings with St Bartholomew’s Hospital; she always went to Cityside.

Mary insisted, and soon Muffy was downstairs, wearing a hospital gown and being wheeled into x-ray.

“The x-rays were normal and they said it was just a bad bruise”, Muffy told me Monday afternoon in the office “Then they gave me a shot for pain that wouldn’t make me tired. I drove myself home later on.”

“And then…” I asked.

“I noticed the welts Saturday morning. I’ve been in agony all weekend.”

“Welts?”

“Yes, I thought it might have been an allergic reaction to the shot they gave me, but they were only around my right hip.”

“Let me see”, I said.

She exposed the skin around her right hip. There were bruises, red blotches, and the unmistakable blisters of Herpes Zoster – shingles.

“This is shingles. Did anyone look at your skin?” I asked.

“No, they checked how my hip moved and took the x-rays through the hospital gown”, she answered.